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18,248
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Discharge summary
|
report+addendum
|
Admission Date: [**2174-7-26**] Discharge Date: [**2174-9-12**]
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is an 82-year-old male
patient with remote myocardial infarction who has had
increasing shortness of breath and fatigue over the past year
with recent increase in symptoms. He has also had bilateral
arm pain. He has had a recent echocardiogram in [**Month (only) 958**] of
this year which revealed 3+ mitral regurgitation, moderate
aortic insufficiency, pulmonary hypertension and ejection
fraction of 50%. He was admitted to [**Hospital1 190**] on [**2174-7-26**] for a cardiac catheterization.
PAST MEDICAL HISTORY: Remote myocardial infarction, prostate
cancer treated with radiation therapy, arthritis, urinary
incontinence, gastritis, cataracts and hard of hearing.
MEDICATIONS: Lasix 40 mg po q d, Zoloft 25 mg po q d,
Isordil 20 mg qid, Plendil 2.5 mg q d, Protonix 40 mg po q d,
Timolol 5 mg q d, Alprazolam 0.25 mg tid and Aspirin 1 po q
d.
ALLERGIES: The patient states allergies to Vioxx and
Levofloxacin.
PHYSICAL EXAMINATION: On admission to the hospital, the
patient's vital signs were stable with a pulse of 57, sinus
bradycardia, blood pressure 125/50. The patient was alert
and oriented, in no apparent distress. Coronary exam was S1
and S2, regular rate and rhythm, noted for a systolic
ejection murmur grade [**3-1**]. Lungs were clear to auscultation
although diminished bilateral bases right greater than left.
Patient's abdominal exam was benign. He had posterior tibial
pulses 2+ on the right, 1+ on the left with no dorsalis pedis
pulses palpable and no peripheral edema.
LABORATORY DATA: Upon admission to the hospital were
unremarkable with an exception of a creatinine of 1.7.
HOSPITAL COURSE: The patient was taken to cardiac
catheterization lab on [**2174-7-26**] which revealed a left
ventricular ejection fraction of 25%, 3+ mitral
regurgitation, a 60% osteal left main lesion as well as three
vessel coronary artery disease and severe pulmonary
hypertension. Cardiothoracic surgery consult was obtained
the following day and subsequently the day after that the
patient was also seen by another cardiothoracic surgeon. The
patient was felt to be an appropriate candidate, albeit high
risk for cardiac surgery. On [**2174-7-29**] the patient was taken to
the operating room by Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] where he
underwent an aortic valve replacement, a mitral valve
replacement, both were tissue valves, as well as coronary
artery bypass graft times three. Postoperatively the patient
was dependent upon Levophed, Milrinone, Dobutamine,
Amiodarone, IV drip. He was atrially paced. He was on IV
Propofol for sedation. He required full ventilatory support.
The patient initially had low cardiac indices by
thermodilution measurement, however, was noted to have a
better index by FICK. The patient was transfused some blood
products over the first night.
During the first 48-72 hours postoperatively the patient
remained on Levophed drip due to hypotension, Milrinone due
to low cardiac index and Dobutamine as well. The patient was
started on some Lasix due to low urine output as well as low
dose Dopamine. The patient was on an insulin drip due to
blood sugars that were elevated. The patient's Dobutamine
and Dopamine were weaned off during this time. Postoperative
day #4 the patient was started on Ceftriaxone due to gram
positive bacteria noted in his sputum. The patient also was
noted to be in atrial fibrillation and was cardioverted and
given increased dose of Amiodarone. On [**8-3**] an
electrophysiology consult was obtained due to persistent
atrial fibrillation. It was their recommendation to
discontinue Digoxin, increase his oral Amiodarone dose and to
cardiovert once he was fully loaded with Amiodarone.
Hyperalimentation was started on [**8-3**], also due to patient
having elevated residuals with attempt at tube feeding the
patient enterally. On [**2174-8-4**] the patient was extubated and
reintubated after a short period of time due to respiratory
failure. The patient was noted to have Klebsiella in his
sputum and also was back in atrial fibrillation. The next 48
hours the patient was noted to have abdominal tenderness, his
tube feed was discontinued at that time, the patient
underwent abdominal ultrasound which showed sludge in the
gallbladder, however, no fluid, no stones, no sign of
obstruction. The patient was noted to have pancreatitis by
laboratory values as well as abdominal tenderness. The
patient proceeded to have a worsening cardiac index and was
increased on his Milrinone. Gastroenterology consult was
obtained, it was also their thought that the patient had
pancreatitis and recommended a repeat ultrasound over the
next few days. The patient was continued to be followed by
the electrophysiology service due to his atrial fibrillation
as well as the GI service due to elevated amylase, lipase and
bilirubin. It was the GI service's recommendation to
continue the patient npo and to continue total parenteral
nutrition during this time as the pancreatitis was still a
problem for him. The patient had a left pleural effusion
drained on [**8-8**] which was postoperative day #10. Milrinone
was weaned off and the patient was begun on Heparin due to
atrial fibrillation. The following day the patient had a
transesophageal echocardiogram due to persistent atrial
fibrillation to rule out clot. Prior to cardioversion there
was no clot noted and the patient was cardioverted to a slow
junctional rhythm and subsequently ventricularly paced his
epicardial wires.
The following day, postoperative day #12, the patient was
seen by general surgery in consultation, Dr. [**First Name8 (NamePattern2) 333**]
[**Last Name (NamePattern1) **], who was consulted due to abdominal pain,
increasing white blood cell count and persistent metabolic
acidosis. Recommendation at that time was made for abdominal
CT scan to rule out necrotizing pancreatitis or another
intra-abdominal process. The CT scan was essentially
negative for pancreatitis, for abscess or for gallbladder
disease. Infectious disease consult was also obtained due to
persistent white blood cell count and it was their
recommendation to continue Zosyn as well as to initiate
Vancomycin. Renal medicine consult was also obtained in this
time period. Due to increasing creatinine and decreasing
urine output, it was renal's recommendation to maximize his
hemodynamics and follow his urine output closely as well as
his laboratory values. On [**2174-8-12**] the patient had recurrent
atrial fibrillation. He was, at that time, felt to be in
adult respiratory distress syndrome as well as significant
chemical pancreatitis, was maintained on npo status on total
parenteral nutrition. The patient had a right chest tube
placed for pleural effusion and the Ceftriaxone was changed
to Ceftazidime at the request of the infectious disease
service. The patient was begun on Neo-Synephrine for some
hypotension. On [**2174-8-13**], on postoperative day #15, a
surgical Intensive Care Unit consult was obtained and the
patient was transferred to the Intensive Care Unit service at
that time. It was their recommendation to continue sedation
and full ventilatory support due to his acute respiratory
distress syndrome, to maintain his npo status and continue
total parenteral nutrition due to his pancreatitis, to
continue Neo-Synephrine as needed for hypotension and to
treat the patient with volume expanders/colloids prn. On the
following day the patient was begun on neuromuscular
blockade, was started to facilitate
ventilation and the patient was discontinued from his
antibiotics at this time. The following day he was resumed
on Ceftazidime and Cipro at the recommendation of the
infectious disease service. The patient's creatinine was
rising. Over the next few days and on [**2174-8-16**], the patient
was begun on CVVHD at the recommendation of the renal
medicine service. The patient still remained 100% paced with
a slow ventricular rhythm underlying. Over the next five
days, the patient was maintained with CVVHD. The patient was
begun on IV Vasopressin due to persistent hypotension and on
[**2174-8-21**] was noted to be back in atrial fibrillation with a
controlled ventricular response as well as stable blood
pressure on his Levophed and Vasopressin. The patient was
continued on IV Amiodarone also. Patient's tube feeding was
resumed at Peptamen 10 ml per hour. On [**8-23**], postoperative
day #25 the patient received a hemodialysis treatment since
he was somewhat more stable hemodynamically and it was felt
that the patient should not be fully heparinized in order to
tolerate CVVHD. Patient remained in atrial fibrillation over
the next few days with a controlled ventricular rate. On
[**2174-8-24**] dermatology consult was obtained due to a new rash
that was noted. It was their opinion that this was
dermatitis due to stasis as well as edema and that they did
not have recommendation for specific treatment. Also on this
day a post pylorus feeding tube was placed in interventional
radiology. The patient also underwent a
stimulation test which did reveal some degree of adrenal
insufficiency and the patient was started on Hydrocortisone.
Over the next few days his tube feeding was increased and the
patient had begun to tolerate this well. An endocrinology
consult was obtained on [**2174-8-26**] due to question of adrenal
insufficiency as well as diabetes management. It was their
recommendation to slowly wean the steroids off and to
continue blood sugar control on an insulin drip. On [**2174-8-27**]
the patient continued on hemodialysis treatments, however,
over the next few days his urine output began to increase, he
was started on a Lasix drip and received no further
hemodialysis treatments. From [**9-1**] into [**9-2**] the patient was
placed on pressure support ventilation, he was requiring less
sedation, he was more stable from a ventilatory status as
well as oxygenation and it was felt appropriate at this time
to let him start to wake up and begin to breathe on his own.
His Levophed had significantly decreased and it was weaned
off on [**2174-9-2**], although he remained on very low dose
Vasopressin IV drip.
Over the next few days the patient had bilateral pleural
effusion. He was begun on Diamox due to increasing metabolic
alkalosis and his Vasopressin was continuing to be decreased.
On [**2174-9-5**] the renal medicine service had signed off the case
due to the patient's continued decrease in creatinine and
increasing urine output. The patient had been weaned off all
pressors at that time. The patient had been off antibiotics
and was hemodynamically stable. He was afebrile and a
rehabilitation screen was obtained. The patient also was
started on some free water replacement both enterally as well
as intravenously due to hypernatremia as well as an elevated
BUN. On [**2174-9-7**], although the patient had progressed
significantly with ventilator weaning, he still remained on
pressure support and had not been off the ventilator at any
point in time, it was felt most appropriate to place the
percutaneous tracheostomy due to continued ventilator support
which was anticipated to be required over the next few weeks.
On [**2174-9-8**] the patient went to interventional radiology
department where a feeding tube was placed into the proximal
small bowel for continued nutritional support. The patient,
this time, was more awake and alert and responsive and
continued with a slow pressure support wean.
The patient's condition today, [**2174-9-9**], is as follow:
Temperature 99.2, pulse 65 in atrial fibrillation,
respiratory rate 18. The patient remains on pressure support
ventilation with 12 of pressure support, 50% FIO2 and 5 of
PEEP. The patient's blood pressure is 134/56, his most
recent blood gas is PH 7.44, PCO2 33, PO2 125 with oxygen
saturation of 100%. Sodium 145, potassium 3.5, chloride 114,
CO2 20, BUN 33, creatinine 1.0, blood glucose 138. [**Name (NI) **]
PT is 15.3 with INR of 1.6, PTT 31.1. Physical exam,
neurologically the patient is alert, moves all extremities
although weakly, and follows commands appropriately.
Cardiovascular, the patient remains in atrial fibrillation
with a ventricular response in the 70's, his lungs are clear
to auscultation bilaterally, although diminished in bilateral
bases. Abdomen is obese, soft, nontender, non distended with
a feeding tube in place. Extremities are warm with palpable
pulses.
DISCHARGE MEDICATIONS: Epogen 40,000 units q Monday,
Combivent meter dose inhaler 4 puffs q 4 hours around the
clock, Protonix 40 mg per feeding tube q d, potassium
chloride 40 mEq per feeding tube tid, Reglan 10 mg IV bid,
Amiodarone 400 mg via feeding tube q d. The patient is to be
begun today on Coumadin due to continued atrial fibrillation.
He is to have a target INR of 2.0 to 2.5. Other medications
are Tylenol prn, Dulcolax suppositories prn as well.
Th[**Last Name (STitle) 33066**] electrolytes should be monitored twice weekly
until he is stable and should be monitored for decreasing
urine output as well. Patient should follow-up with his
primary care physician, [**Name10 (NameIs) **] [**Name11 (NameIs) 17996**], upon discharge
from rehabilitation facility as well as his primary care
cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The patient is to follow-up
with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **], also upon discharge from the
rehabilitation facility. For any further cardiac surgical
issues, Dr. [**Last Name (STitle) **] [**Last Name (Prefixes) 2546**] office can be called at
[**Telephone/Fax (1) 170**].
DISCHARGE DIAGNOSIS:
1. Coronary artery disease, status post coronary artery
bypass graft.
2. Mitral regurgitation, status post mitral valve
replacement.
3. Aortic stenosis, status post aortic valve replacement.
4. Respiratory failure, status post percutaneous
tracheotomy.
5. Atrial fibrillation.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2174-9-9**] 17:46
T: [**2174-9-9**] 21:30
JOB#: [**Job Number **]
Name: [**Known lastname 17621**], [**Known firstname 394**] Unit No: [**Numeric Identifier 17622**]
Admission Date: [**2174-7-26**] Discharge Date: [**2174-9-13**]
Date of Birth: [**2091-11-20**] Sex: M
Service:
ADDENDUM: On [**2174-9-12**], the patient had
implantation of a DDI atrioventricular pacemaker for
bradycardia. The procedure was without complications. The
patient has been stable in atrioventricularly paced rhythm
since the procedure. He received perioperative vancomycin.
He remains hemodynamically stable and has had no other issues
since the previous dictation. The patient will be discharged
in stable condition to a rehabilitation facility.
DISCHARGE MEDICATIONS:
Epogen 40,000 units q. Monday.
Combivent metered dose inhaler four puffs every four hours
around the clock.
Amiodarone 400 mg per gastrostomy tube q.d.
Coumadin 5 mg per gastrostomy tube h.s. (The INR is to be
checked in two days and the dose adjusted p.r.n. for a target
INR of 2 to 2.5.)
Protonix 40 mg q.d.
Reglan 10 mg q.d.
Tylenol p.r.n.
Dulcolax p.r.n.
Potassium supplementation p.r.n.
DISCHARGE DIAGNOSES:
Coronary artery disease, status post coronary artery bypass
grafting of five vessels with aortic valve replacement and
mitral valve replacement.
Respiratory failure, status post tracheostomy.
Atrial fibrillation and bradycardia, status post
atrioventricular pacemaker placement.
CONDITION/DISPOSITION: The patient is discharged in stable
condition to a rehabilitation facility.
FO[**Last Name (STitle) 6646**]P: The patient is to follow up with Dr. [**Last Name (Prefixes) **],
Dr. [**Last Name (STitle) 17623**] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 681**]
Dictated By:[**Last Name (NamePattern1) 1257**]
MEDQUIST36
D: [**2174-9-13**] 13:33
T: [**2174-9-13**] 13:47
JOB#: [**Job Number 17624**]
|
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"518.5",
"584.9",
"427.89",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.24",
"35.21",
"88.57",
"37.23",
"96.72",
"39.61",
"36.12",
"36.15",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
15514, 16363
|
15099, 15493
|
13847, 15076
|
1782, 12629
|
1092, 1764
|
137, 642
|
665, 1069
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,864
| 198,741
|
16905+16906+16907
|
Discharge summary
|
report+report+report
|
Admission Date: [**2196-6-4**] Discharge Date: [**2196-6-13**]
Date of Birth: [**2196-6-4**] Sex: M
Service: Neonatology
HISTORY: [**First Name5 (NamePattern1) **] [**Known lastname 47617**] was the 715 gram product of a 24-1/7
week gestation delivered to a 33-year-old primigravida, blood
type O positive, antibody negative, hepatitis surface
antigen. This pregnancy was achieved by IUI conception with
first trimester bleeding secondary to hematoma, which
resolved. Pregnancy was then uncomplicated until seven hours
prior to delivery when mother noted uterine stiffness and
abdominal pain thought to be prolonged [**Last Name (un) 47618**] Hicks
contractions. Due to persistent symptoms, came to Antepartum
triage, where her maternal blood pressure was 77/44. Fetal
heart rate estimate to approximately 60, no fetal movement.
Baby delivered by a STAT C section and emerged with no
respiratory effort, no movement, heart rate less than 100.
Intubated with a 2.5 ET tube with heart rate rising to
greater than 100. Improvement in color, but only with
occasional gasping respirations. No other movement. Apgars
are signed one (one for heart rate), 3, 3, 3 all with two
points for heart rate and one point for color. At 1, 5, 10,
15, and 20 minutes respectively. [**Hospital **] transferred to the
Newborn Intensive Care Unit for further management of extreme
prematurity.
PHYSICAL EXAMINATION ON ADMISSION: Weight 715 grams. Head
circumference 23 cm. Heart rate 144. Overall appearance
consistent with known gestational age. Anterior fontanel is
open and question slightly full. Eyes fused. Palate exam
deferred. Orally intubated. Breath sounds bronchial,
symmetric. Regular, rate, and rhythm without murmur, 2+
femoral pulses. Abdomen is benign without hepatosplenomegaly
without masses, three vessel cord, normal male genitalia for
gestational age, normal back and extremities. Hips deferred.
Skin not pale. Fair perfusion. No tone or spontaneous
activity.
HISTORY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: [**Last Name (un) **]
was intubated in the Delivery Room for management of
respiratory support. His initial vent settings were 40/5, a
PIP of 40, a PEEP of 5, respiratory rate of 30. He weaned
over the next 12-24 hours with three doses of surfactant for
management of respiratory distress syndrome, and was then
placed at about 24 hours of age. Infant noted to have bright
red blood coming via his ET tube, which diagnosed a pulmonary
hemorrhage, at which time he was transferred to high
frequency ventilation. He remains stable currently on high
frequency ventilation with a MAP of 10, a delta-P of 16.
His most recent arterial blood gas was 7.30, pCO2 50, pO2 50,
total CO2 of 26, and base deficit 1. He most recently had
bloody secretions from his ET tube on day of life six, which
prompted a second course of Indomethacin.
Cardiovascular: Initially required normal saline boluses x2,
and was placed on a dopamine with a maximum of 4 mcg/kg/day.
On day of life #1, the infant presented with pulmonary
hemorrhage. Cardiac examination was consistent with patent
ductus arteriosus findings, audible murmur, full pulses,
widen pulse pressures. Infant was treated empirically with
Indomethacin at that time.
On [**6-10**], infant presented again with pulmonary
hemorrhage, and decision was made to treat with Indomethacin
as there was a loud murmur. The infant completed his
indomethacin course, and had an echocardiogram performed on
[**6-12**], which demonstrated a large patent ductus arteriosus
with continuous left to right flow with increased pulmonary
venous return. At this time, infant was restarted on
indomethacin awaiting recommendations from Cardiology for
ligation.
Fluid and electrolytes: His birth weight was 715 grams. He
was initially started on 100 cc/kg/day. His max fluid intake
was 180 cc/kg/day to maintain neutral sodium balances. He is
currently receiving 130 cc/kg/day of parenteral nutrition and
interlipid via UVC. His most recent set of electrolytes were
on [**6-12**]. Sodium was 133, potassium was 4.3, chloride was
99, total CO2 was 23. He has been NPO throughout his
hospital course.
Gastrointestinal: Infant was started on phototherapy at
delivery. Infant was bruised. His peak bilirubin was on day
of life four at 4.8/0.5. He continued on double phototherapy
with his most recent bilirubin level on [**6-12**] of 3.8/0.8.
Hematology: His hematocrit on admission was 47.1. He has
received a total of four packed red blood cell transfusions
to replace blood out. His most recent hematocrit was on [**6-10**] of 35, and his most recent blood transfusion was on [**6-11**] at 15 cc/kg/day. His blood type is A+, Coomb's negative.
He also had thrombocytopenia with a platelet count on [**6-6**] of 62. He received 10/kg of platelets at that time.
Platelet count began to fall again in concurrence with the
initiation of a second round of indomethacin. He received
another 10 cc/kg platelets at that time. His most recent
platelet count on [**6-12**] was 135.
Infectious Disease: A complete blood count and blood
cultures obtained on admission. Complete blood count was
benign. Blood cultures remained negative at 48 hours, but in
light of his clinical course, decision was made to treat the
infant empirically for a seven day course which he completed
on [**6-11**].
Neurologic: Head ultrasound findings on day of life 0 within
normal limits. Head ultrasound findings on day of life two
had a left IVH. A repeat on day of life four had bilateral
IVH with slight increase in the ventricular size. His most
recent was on [**6-10**] with the same examination findings.
He is appropriate for his gestational age, and
.................
Psychosocial: A social worker has been involved with this
family. The contact social worker is [**Name (NI) 18945**] [**Name (NI) **]. She
can be reached at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Guarded.
DISCHARGE DISPOSITION: [**Hospital3 1810**].
PRIMARY PEDIATRICIAN: Not yet identified.
DISCHARGE DIAGNOSES:
1. Premature infant born at 24-1/7 week gestation.
2. Status post respiratory distress syndrome treated with
three rounds of Survanta.
3. Early onset chronic lung disease.
4. Status post rule out sepsis with antibiotics.
5. Patent ductus arteriosus.
6. Status post pulmonary hemorrhage x2.
7. Bilateral Grade II-III IVH.
8. Thrombocytopenia resolved.
9. Anemia.
10. Hyperbilirubinemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Last Name (NamePattern1) 38294**]
MEDQUIST36
D: [**2196-6-12**] 23:49
T: [**2196-6-13**] 06:34
JOB#: [**Job Number 47619**]
Admission Date: [**2196-6-4**] Discharge Date: [**2196-6-25**]
Date of Birth: [**2196-6-4**] Sex: M
Service: Neonatology
HISTORY OF PRESENT ILLNESS: Baby boy [**Known lastname 47617**] is a former 24
and 7 week male delivered prematurely due to placental
abruption. He is currently 21 days old.
The mother is a 33-year-old primigravida. Prenatal screens
revealed O positive, antibody negative, hepatitis negative,
group B strep unknown, with intrauterine insemination
conception. Noted to have first trimester bleeding secondary
to "hematoma" that resolved. The pregnancy was then
uncomplicated until seven hours prior to delivery when the
mother noted uterine stiffness and abdominal pain, thought to
be prolonged [**Last Name (un) 47618**] Hicks contractions. Due to the
persistence of symptoms, came to the triage area at [**Hospital1 1444**] where maternal blood pressure
was 77/44. Fetal heart rate was estimated to be about 60
with no fetal movement. The baby was delivered by STAT
cesarean section. The infant emerged with no respiratory
effort, no movement, heart rate less than 100, and intubated
with a 2.5 endotracheal tube with heart rate rising to 100
with improvement in color but only occasional gasping
respirations. No other movement. Apgar scores were 1 at one
minute and 1 for heart rate and 3 at 3 minutes and 3 at 10
minutes and 3 at 15 minutes.
The infant was transferred to the Newborn Intensive Care
Unit. Obstetrician reported that the uterus was filled with
blood with maternal postoperative hematocrit of 27.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed birth weight was 715 grams (10th
percentile), head circumference was 23 cm (10th percentile),
and length was 31.5 cm (10th percentile). Current weight is
894 grams, length is 32 cm, and head circumference is 23 cm.
Initial respiratory effort was none, blood pressure was
47/25, with a mean of 33, followed by 37/17, with a mean of
23, and received a 10 cc/kg bolus. Overall appearance
consistent with known gestational age. Anterior fontanel was
soft, open, slightly full. Eyes were fused. Palatal
examination deferred, orally intubated, subsequent intact.
Breath sounds bronchial and symmetrical. A regular rate and
rhythm without murmurs. Femoral pulses were 2+. The abdomen
was benign with no hepatosplenomegaly. No masses. A
3-vessel cord. Normal male genitalia for gestational age.
Normal back. External hip examination deferred. Skin was
pale with fair perfusion. No tone or spontaneous activity.
Admission dipstick was 19. Received a 2 cc/kg D-10 bolus and
was started on D-10-W infusion. First venous blood gas was
6.96/53.
HOSPITAL COURSE BY ISSUE/SYSTEM:
1. RESPIRATORY ISSUES: The infant was started on the
conventional ventilator 40/5 at a rate of 30. Over the first
24 hours the infant was weaned down to a weight of 23/5 and a
rate of 18. Transitioned to the high-frequency ventilator
with a delta P of 4, mean arterial pressure was 12. He has
remained on the high-frequency ventilation since that point.
On [**6-24**], his settings were mean arterial pressure of 13,
a delta P of 24, with an oxygen requirement of 35% to 55%.
He had gas on [**6-24**] of 735/46, was noted to be labile, and
will be transitioning to the conventional ventilator for
transition over to the [**Hospital3 1810**] for a patent
ductus arteriosus ligation.
2. CARDIOVASCULAR SYSTEM: The infant has had a persistent
murmur. Initially required two normal saline boluses and was
started on dopamine which he required until day of life two
when it was discontinued. He did receive indomethacin on day
of life one for presumed patent ductus arteriosus. He did
demonstrate some symptoms of a pulmonary hemorrhage which
resolved after transitioning over the high-frequency
ventilation.
He had a persistent murmur which has been followed by
Cardiology including an echocardiogram. He was treated with
three course of indomethacin with a 5-day course on the last
third course which was completed on [**2196-6-16**]. The plan
was to go to the operating room. Because of issues of
infection, the operating room date was postponed until his
blood cultures were negative. Last echocardiogram on [**6-23**]
showed a large patent ductus arteriosus with a 2-mm to 3-mm
right-to-left flow, a left aortic arch. Baseline heart rate
was 150s to 160s, blood pressure was 50/32, with means in the
30s. He is currently on low-dose dopamine because of concern
for renal failure. Dopamine at 60 mg in 50 cc of D-10-W
running at 2.5 mcg/kg per minute.
3. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The infant
initially had a umbilical artery catheter and a umbilical
venous catheter line in. A central peripherally inserted
central catheter line was placed on day of life 10. This was
removed because of concerns for infection on day of life 20.
The tip of this was sent for culture which has remained
negative to date. He currently has two peripheral
intravenous lines. He has been receiving parenteral
nutrition D 12.5% and limited protein because of renal issues
of 1 g/kg per day. He has 3 mEq/kg per day of sodium, and no
potassium in his intravenous fluids.
Electrolytes on [**6-24**] were 128, 5.8, 87, and 18. Repeat
electrolytes on [**6-25**], prior to the operating room, were
pending at the time of this dictation. Dextrose sticks have
been stable in the 123 to 119 range. Total fluids are at 120
cc/kg per day. He was receiving enteral feedings which were
introduced on day of life 18 of trophic feeds at 10 per
kilograms. These were discontinued on day of life 20 when he
was noted to have a heme-positive meconium stool. KUB was
reassuring, but feedings have been held in preparation for
the operating room.
3. GASTROINTESTINAL ISSUES: The infant did require
phototherapy for hyperbilirubinemia. He was under double
phototherapy with a peak bilirubin of 4.2/0.3 on day of life
two. He is currently under single phototherapy with a
bilirubin on [**6-24**] of 3.2/0.9. Previously bilirubin also
under single phototherapy was 3.2/0.7 on day of life 18.
4. HEMATOLOGIC ISSUES: The infant's blood type is A
positive, Coombs negative. He has received approximately
nine blood transfusions to date; the last one being on [**6-24**] and [**6-25**] for a hematocrit of 31.5. He received 20
cc/kg divided in two with a Lasix [**Location (un) 6002**] in between. He
also required a platelet transfusion. His initial platelet
count was 201,000. Platelets drifted down to 62,000 on day
of life two. The infant received 10 per kilograms of
platelets. Again, on day of life five, his platelets drifted
from 90,000 to 72,000; and he received another 10 per
kilograms of platelets. His last platelet count on [**6-22**]
was 173,000. Complete blood count at that time revealed
white blood cell count was 35.9 (52 polys, 5 bands, 5
metamyelocytes, and 3 myelocytes) and hematocrit was 34.
5. INFECTIOUS DISEASE ISSUES: The infant initially had a
sepsis evaluation with a white blood cell count of 21.8 (18
polys, 4 bands, 64 lymphocytes) and platelet count was 204,
and hematocrit was 47.1. He was started on ampicillin and
gentamicin, and a blood culture had been sent at that time.
Because of the severity of illness, he was treated for seven
days with ampicillin and gentamicin. He had gentamicin
levels of 1.6 and 2.9. The dose was adjusted. He then had
levels of 1.3 and 9. He had a lumbar puncture with 35 white
blood cells, 6095 red blood cells, protein was 197, and
glucose was 82,000. He subsequently, on day of life ten, had
another complete blood count sent with a white blood cell
count of 55 (38 polys and 16 bands), platelet count was 128,
hematocrit was 31.2, with an I to T ratio of 0.22. Blood
culture grew out Staphylococcus aureus. He had subsequent
positive blood cultures with Staphylococcus aureus and was
treated with vancomycin and gentamicin which subsequently was
switched to oxacillin and gentamicin.
Because of persistent positive blood cultures, Infectious
Disease Service was consulted. At that point in time, his
last negative culture was on [**6-17**] on oxacillin and
gentamicin. He has shown symptoms of renal failure. He did
have a normal renal ultrasound but had a blood urea nitrogen
peak at 42 and a creatinine of 2.3. Urine output has been
greater than 2 cc/kg per hour.
Infectious Disease Service recommendations were to continue
oxacillin, and we have added cefotaxime (which the organism
is sensitive to). He currently is receiving cefotaxime 45
mg intravenously q.24h, and his oxacillin was discontinued on
[**6-24**].
Lumbar puncture on [**6-24**] revealed 3 white blood cells, 13
red blood cells, 0 polys, 42 lymphocytes 58 monocytes, and
negative Gram stain. As stated above, the peripherally
inserted central catheter line tip has remained negative.
6. NEUROLOGIC ISSUES: Initial head ultrasound on [**6-4**] was
within normal limits. A repeat head ultrasound on [**6-6**]
showed a left intraventricular hemorrhage with no
ventriculomegaly with serial ultrasounds that have been done
since then. On [**6-8**], he had increased ventricular size.
On [**6-10**], there was no change. On [**6-13**], there was a
decrease in ventricular size bilaterally. On [**6-17**], it was
again slightly improved. On [**6-22**], there was no change.
The plan was to continue to follow serial head ultrasounds.
The baby received Fentanyl as needed for pain control. He
had a two doses on [**6-23**] and two doses on [**6-24**].
7. SENSORY ISSUES: Audiology screening has not been done at
this date.
8. OPHTHALMOLOGY EXAMINATION: First examination will be due
the week of [**2196-7-13**].
9. PSYCHOSOCIAL ISSUES: The parents visit daily. They are
quite involved in [**Last Name (un) 47620**] care and are appropriately anxious
about his current clinical condition and long-term issues.
CONDITION AT DISCHARGE: Condition on discharge was guarded.
DISCHARGE DISPOSITION: Discharge disposition is to the
[**Hospital3 1810**] operating room for a patent ductus
arteriosus ligation.
PRIMARY PEDIATRICIAN: Primary pediatrician not determined at
the time of transfer.
CARE RECOMMENDATIONS:
1. Continue nothing by mouth with intravenous fluids of
D-10, D-12, and half Was with maintenance electrolytes at 120
cc/kg per day.
2. MEDICATIONS: Continues on his cefotaxime 45 mg q.24h.
with a dose due at 1545 on [**6-25**], Fentanyl as needed,
dopamine 2.5 mcg/kg per minute.
3. STATE NEWBORN SCREEN: Initial screening sent on [**6-7**]
after a blood transfusion. A repeat screen sent on [**6-23**]
and was pending at the time of this dictation.
4. IMMUNIZATIONS: None to date.
DISCHARGE DIAGNOSES:
1. Premature 24 and [**1-12**] week male.
2. Respiratory distress syndrome.
3. Methicillin-sensitive Staphylococcus aureus sepsis.
4. Status post pulmonary hemorrhage.
5. Patent ductus arteriosus.
6. Intraventricular hemorrhage.
7. Renal failure.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Last Name (NamePattern1) 36251**]
MEDQUIST36
D: [**2196-6-24**] 23:02
T: [**2196-6-25**] 02:55
JOB#: [**Job Number 47621**]
Admission Date: [**2196-6-4**] Discharge Date: [**2196-7-4**]
Date of Birth: [**2196-6-4**] Sex: M
Service:
Please see previous dictated summary for detailed history.
Briefly, [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 47622**] was the former 715 gram product of a 24
and [**1-12**] week gestation pregnancy, born to a 33 year old,
Gravida I, Para 0 woman. She was admitted with a concealed
abruption and delivered by stat cesarean section under
general anesthesia. Apgars were one at one minute, three at
five minutes and ten minutes and three at 15 and 20 minutes.
He required intubation in the delivery room.
He was admitted to the Neonatal Intensive Care Unit for
treatment of prematurity. His course has been complicated by
severe lung disease, symptomatic patent ductus arteriosus,
pulmonary hemorrhage and intraventricular hemorrhage. This
dictation covers the period from [**6-24**] through [**2196-7-4**].
HOSPITAL COURSE: 1.) Respiratory: [**Last Name (un) **] returned from a
patent ductus arteriosus ligation on [**2196-6-25**]. He was
initially on conventional ventilator but then changed to the
high frequency oscillatory ventilator. He had increasing need
for escalating support. His mean airway pressure was between
18 and 20. Oxygen requirement was between 30 and 100%. His
blood gases showed respiratory failure with carbon dioxide in
the 80's with pH as low as 7.0. His trache aspirate
was positive for pseudomonas and he continued treatment for
presumed pseudomonas pneumonia.
2.) Cardiovascular: As noted, [**Last Name (un) **] had a patent ductus
arteriosus ligation performed on [**2196-6-25**]. He continued to
have a murmur postoperatively. A repeat echocardiogram was
performed on [**2196-6-30**] which showed no patent ductus
arteriosus, qualitatively good by ventricular function. A
prominent ridge between the left atrium appendage and the
left upper pulmonary vein, more prominent than usual, and a
thrombus could not be excluded. No other vegetations or
thrombi were noted. [**Last Name (un) **] required extensive blood pressure
support with Dopamine as high as 18 mcgs per kg per minute.
He received multiple volume and colloid transfusions in
support of his blood pressure.
3.) Fluids, electrolytes and nutrition: [**Last Name (un) **] continued fluid
restriction to 120 to 130 cc per kg per day. His most recent
weight was 996 grams on [**2196-7-4**]. Serum electrolytes were
initially notable for hyponatremia postoperatively which
corrected by day of life 26 on [**2196-6-30**].
4.) Infectious disease: A previous blood culture had grown
staph aureus. Due to the severity of illness, he was
recultured on [**2196-6-29**] and that blood culture grew coagulase
negative staphylococcus epidermis. Vancomycin was added to
his initial treatment with Cefotaxime and on [**2196-7-2**], his
antibiotics were changed to Vancomycin and Zosyn and he
remained on those through the remainder of his Neonatal
Intensive Care Unit admission. He continued to have shifted
CBC's with white counts of 24,000.
5.) Hematology: [**Last Name (un) **] received several red blood cell
transfusions and several platelet transfusions. The etiology
of his low platelet count was not identified. PT and PTT
were obtained on [**2196-7-3**] and were within normal limits.
6.) Gastrointestinal: [**Last Name (un) **] continued to require treatment
for unconjugated hyperbilirubinemia with phototherapy. His
serum bilirubins persisted in the 8 to 9 range. An abdominal
ultrasound was unremarkable showing only an enlarged gall
bladder.
7.) Neurologic: Pain management was provided with a Fentanyl
drip and frequent boluses.
8.) Social: Due to his persistent critical status and the
escalating cardiovascular and respiratory support, the NICU
team and [**Last Name (un) 47620**] parent's discussed how best to rpovide his
care. After requesting a second opinion from a neonatologist
not involved in his crae, the team met with [**Initials (NamePattern4) 47620**] [**Last Name (NamePattern4) 47623**].
Everyone one agreed that redirection of his care to comfort
measures was in his best interests. All were in agreemient
with this.
[**Last Name (un) **] was extubated and sedated and placed in his parents
arms, where he expired at 19:15 hours on [**2196-7-4**]. He was
pronounced by Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) **] who also notified the medical
examiner. Autopsy declined. Obstetric team notified.
CONDITION AT DISCHARGE: Expired.
DISCHARGE DISPOSITION: Expired.
DISCHARGE DIAGNOSES:
Prematurity at 24 weeks gestation.
Respiratory distress syndrome.
Chronic lung disease.
Staph aureus bacteremia.
Staphylococcal epidermis bacteremia.
Patent ductus arteriosus, status post two courses of Indocin;
status post patent ductus arteriosus ligation.
Pulmonary hemorrhage.
Intraventricular hemorrhage.
Unconjugated hyperbilirubinemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By: [**First Name11 (Name Pattern1) 22866**] [**Last Name (NamePattern1) **], RN, MS, NNP
MEDQUIST36/D: [**2196-7-5**] 12:22/T: [**2196-7-5**] 04:36
JOB#: [**Job Number 47624**]/
|
[
"776.1",
"038.11",
"770.3",
"V30.01",
"765.02",
"769",
"774.2",
"772.13",
"771.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.83",
"99.15",
"96.04",
"03.31",
"38.93",
"38.92",
"96.72",
"38.85",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
22636, 22646
|
22667, 23339
|
19038, 22587
|
17007, 17499
|
2043, 5952
|
9504, 16714
|
22602, 22612
|
6938, 9470
|
1437, 2014
|
5977, 5987
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,351
| 113,963
|
6117
|
Discharge summary
|
report
|
Admission Date: [**2142-7-20**] Discharge Date: [**2142-7-27**]
Date of Birth: [**2065-8-22**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
Bronchoscopy
Intubation (prior to admission)
Intensive care unit monitoring
History of Present Illness:
Ms. [**Known lastname **] is a 76 yr old woman with h/o HTN, DM, CHF on
digoxin, Afib on coumadin, who presented to [**Hospital3 **] for
altered mental status. Pt was last seen acting normally at
4:30pm, at which time she reported feeling dizzy and went to lay
down. Around 7pm, she was found by her husband laying on her
right side, moaning and unresponsive. No tremors or bladder or
bowel incontinence noted. She was brought by EMS into the OSH ED
for evaluation. There she was reportedly nonverbal but combative
and received ativan 2mg IV x 2. CT head was negative for
intracranial hemorrhage. CXR was significant for a RLQ pneumonia
and pt was given levofloxacin 750mg IV. A digoxin level was
checked which was elevated to 2.8; K was 5.7. She was given 2
vials of digibind and intubated under succinylcholine with
propofol for sedation prior to transport for airway protection
due to diminished gag reflex in the setting of altered mental
status. ABG 7.4/41/111 on AC 500/12/70%/5.
In our ED, VS: T 97.3, HR 41, BP 154/49, O2sat 99% on AC at TV
500, rate 14, PEEP 5, and FiO2 100%. Her CXR showed a sizeable
RML infiltrate, and vanco dose given with 500cc NS. EKG showed
HR in low 40s. 3 vials of digibind drawn up. Toxicology was
consulted and recommended holding further digibind at this time
unless pt drops blood pressure as may overcompensate and affect
her baseline therapeutic level of digoxin. She was transferred
to MICU for monitoring.
On the MICU floor, pt report is intubated and sedated. Per her
husband, she had no fevers, chills, cough, or shortness of
breath suggestive of pneumonia; no choking or coughing with po
intake; no recent sick contacts or hospitalizations. Pt eats
small meals throughout day; husband did not note any recent
change in po intake. She did not complain of any vision changes,
N/V, abd pain, diarrhea, headache, confusion, or hallucinations.
Of note, was seen in Cardiology clinic the day prior with
discontinuation of propanalol and clonidine.
Past Medical History:
A fib on coumadin
Diabetes mellitus
Hypertension
Congestive heart failiure
H/o TIA 15 years ago with sx described as a weak arm and slurred
speech.
Gout
GERD
L-TKR
Social History:
Patient lives with her husband. She is a former manager with
[**Location (un) 23944**] Farms, now retired. H/o 2 cigarettes/wk for "years"
but quit years ago. Occasional EtOH. Denies illicit drug use.
Family History:
Mother with possible CAD
Physical Exam:
ON ADMISSION
GEN: Sedated, occasionally agitated
HEENT: NCAT, intubated, mucous membranes dry
LUNGS: CTA anteriorly
HEART: RRR, S1-S2 nl, II/VI SEM radiating to carotids
ABD: BS+, soft, ND, hepatomegaly
EXTREM: No edema, pulses 2+ b/l
NEURO: PERRL, opens eyes, moves all extremities, withdraws to
noxious stimuli.
ON DISCHARGE
GEN: NAD, pleasant, alert and orientedx4
HEENT: NCAT, PERRL, EOMI
LUNGS: CTAB except crackles in right middle lobe, much imporved
HEART: RRR, S1-S2 nl, II/VI SEM radiating to carotids, also
II/VI systolic murmur at apex
ABD: BS+, soft, ND,
EXTREM: No edema, pulses 2+ b/l
Pertinent Results:
Outside Hosptial prior to admission:
WBC 17, Plt 264
N 86.7, L 6.8, M 5.1, E 1, Bas 0.4
Na 134, K 5.7, Cl 100, Bicarb 25, BUN 49, Cr 1.9, Gluc 208
AST 55, ALT 46, AP 84, TB 0.6, DB 0.1, TP 9, Alb 4.2
CK 106 Trop T 0.03
ProBNP 2664
TSH 3.61
Ferritin 86.6
Vit B12 1219
Dig 2.83
.
[**2142-7-20**]
WBC-14.8*# RBC-3.62* Hgb-12.1 Hct-34.7* MCV-96 MCH-33.4*
MCHC-34.8 RDW-14.2 Plt Ct-258 Neuts-87.3* Lymphs-8.5* Monos-3.8
Eos-0.2 Baso-0.2
PT-38.2* PTT-34.7 INR(PT)-4.0*
Glucose-165* UreaN-49* Creat-1.9* Na-140 K-4.6 Cl-103 HCO3-25
AnGap-17
ALT-40 AST-43*
Calcium-9.7 Phos-3.4 Mg-2.3
CK(CPK)-96 CK-MB-NotDone cTropnT-0.02*
Lactate-2.8*
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011 Blood-TR
Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG
Urobiln-NEG pH-7.0 Leuks-NEG
RBC-[**4-5**]* WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0-2
Eos-NEGATIVE UreaN-557 Creat-38 Na-86
DISCHARGE LABS
[**2142-7-27**] 05:25AM BLOOD WBC-7.9 RBC-2.87* Hgb-9.3* Hct-27.5*
MCV-96 MCH-32.4* MCHC-33.7 RDW-14.2 Plt Ct-335
[**2142-7-27**] 05:25AM BLOOD Glucose-98 UreaN-31* Creat-1.3* Na-140
K-3.8 Cl-108 HCO3-23 AnGap-13
[**2142-7-24**] 05:50AM BLOOD proBNP-[**Numeric Identifier 23945**]*
[**2142-7-26**] 06:34AM BLOOD Calcium-8.5 Phos-3.1 Mg-2.4
[**2142-7-24**] 05:50AM BLOOD T3-74* Free T4-1.1
[**2142-7-23**] 06:05AM BLOOD TSH-8.9*
[**2142-7-23**] 06:05AM BLOOD VitB12-GREATER TH
.
[**2142-7-20**] 10:47 am Influenza A/B by DFA Source: Nasal swab.
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2142-7-20**]):
Negative for Influenza A viral antigen.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2142-7-20**]):
NEGATIVE FOR INFLUENZA B VIRAL ANTIGEN.
URINE NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN
EKG:
Sinus bradycardia with first degree atrio-ventricular conduction
delay.
Non-specific QRS widening with left axis deviation and diffuse
repolarization abnormalities. Compared to the previous tracing
of [**2141-12-23**] cardiac rhythm is now sinus mechanism with A-V
conduction delay.
CHEST (PORTABLE AP) Study Date of [**2142-7-20**] 12:52 AM
1. Right perihilar pneumonia or hemorrhage.
2. Left retrocardiac atelectasis or aspiration.
3. Moderate cardiomegaly, without pulmonary edema.
KNEE (AP, LAT & OBLIQUE) RIGHT Study Date of [**2142-7-22**] 2:46 PM
The bones are diffusely demineralized. Degenerative changes are
present predominantly in the medial compartment where there is
joint space
narrowing and subchondral sclerosis. Minimal osteophyte
formation is also
noted in the patellofemoral compartment. No discrete fracture is
evident and there is no evidence of dislocation. An equivocal
small suprapatellar joint effusion is demonstrated as well as
extensive vascular calcifications within the soft tissues.
CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2142-7-24**]
1:09 AM
1. No PE.
2. Diffuse septal thickening, small bilateral pleural effusions,
cardiomegaly, and ground-glass opacities in the dependent
portion of the upper and lower lobes. The constellation of
findings is most compatible with CHF.
3. Subcentimeter hypodensity in the right lobe of the thyroid,
for which
further evaluation with ultrasound can be performed on a
non-emergent basis.
TTE (Complete) Done [**2142-7-25**] at 1:51:57 PM FINAL
The left atrium is moderately dilated. The right atrial pressure
is indeterminate. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is moderate regional
left ventricular systolic dysfunction with hypokinesis of the
septum and inferior walls. The remaining segments contract well
(LVEF = 30-35 %). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size is normal with mild global free wall
hypokinesis. The ascending aorta and arch are normal in
diameter. The aortic valve leaflets (3) are moderately
thickened. There is severe aortic valve stenosis (valve area
0.8cm2). No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild to moderate ([**2-2**]+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is high normal. There is a no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
regional systolic dysfunction c/w CAD. Severe aortic valve
stenosis. Mild-moderate mitral regurgitation.
Brief Hospital Course:
76 yo female with PMH of atrial fibrillation admitted with
confusion and found to have digoxin toxicity, pneumonia and
acute renal failure.
# Digoxin toxicity: Digoxin levels elevated in toxic range with
bradycardia and PR prolongation. Likely in setting of
hyperkalemia from acute renal failure from dehydration, possibly
secondary to pneumonia. No recent medication changes other than
discontinuation of propanolol and clonidine, which do not affect
the metabolization of digoxin. Patient was monitored on
telemetry with frequent EKGs and labs for hyperkalemia. Her EKGs
remained stable. She remained hemodynamically stable with
gradually improving HRs. Toxicology was consulted and
recommended holding off on digibind unless HD unstable or EKGs
worsened. This did not occur and no further digibind was given.
Digoxin was 1.0 on [**7-24**] and mental status resolved to baseline.
Will defer to outpatient provider regarding restarting digoxin.
Once bradycardia resolved patient was restarted on Metoprolol
without any unstable hemodynamics.
#Hypoxemia. The patients oxygen requirements increased to using
a non-rebreather mask on [**7-23**]. It is likely that this was due to
CHF exacerbation (supported by BNP > [**Numeric Identifier 389**] and findings on CT)
as furosemide was being held vs effusions present on CT likely
secondary to the pneumonia. PE was initially considered and
ruled out by CT angiogram. The patient was gradually diuresed
and her respiratory status improved, though this was also likely
contributed to by treatment of pneumonia. Discharged on
2-3L/min NC with stable oxygen status to be weaned at nursing
facility.
# Altered Mental Status: Likely [**3-5**] digoxin toxicity although
may also have delirium in setting of infection. Was intubated at
OSH for airway protection, however, after bronchoscopy here (See
below) she was extubated without difficulty. CXR notable for
large right middle lobe infiltrate concerning for pneumonia.
Less likely neuro process; no h/o of seizures, CT head negative
for acute changes. Digoxin toxicity and pneumonia were treated
as described elsewhere and mental status improved to baseline.
# Pneumonia: Large RML (right middle lobe) infiltrate and
leukocytosis suggestive of infectious process although patient
was afebrile and asymptomatic per husband. [**Name (NI) **] likely
ventilator-acquired pneumonia vs aspiration from altered mental
status. Received levofloxacin and vanco prior to arrival on
floor. In setting of digoxin toxicity concern for QT
prolongation, she was changed to Azithromycin/Clindamycin due to
a PCN allergy. After legionella antigen returned negative,
azithro was discontinued. She underwent bronchoscopy and
cultures which grew oropharyngeal flora. Blood cultures were
negative. On [**7-21**], she spiked a fever and antibiotics were
changed to ceftriaxone. She again spiked on [**7-23**] and coverage
broadened by changing antibiotics to cefipime and vancomycin.
She should complete a 8 day course for ventilator associate
pneumonia. Vancomycin is being dosed Q24 hours for renal
insufficiency but will be monitored at her nursing facility
should her renal function improve.
# Acute renal failure: Cr elevated above baseline here 1 year
ago of 0.9. BUN/Cr ratio suggested prerenal etiology, likely in
setting of pneumonia. Creatinine improved with IVF. Renally
dosed meds. Held ACE-I. On [**7-23**], the patient was found to have
increased oxygen requirments and was placed on a non-rebreather
mask. In the setting of respiratory distress and concern for PE
vs decompensated heart failure, the risks of renal insult were
outweighed by the need for CT-angio with IV contrast and
diuresis. Pt received N-acetylcysteine course and cautious fluid
resusitation. Upon discharge, Cr 1.3 and Lisinopril continuing
to be held with possible restart at her nursing facility.
# CHF - acute on chronic, systolic: Prior TTEs not in system; EF
unknown prior to admission but appeared dry here when first
admitted and received gentle IVF. Held lasix in setting of
dehydration. Also initially held beta blocker and ACE inhibitor
as PR prolongation and ARF. When patient developed new O2
requirment, Lasix was restarted for diuresis. TTE obtained at
that time revealed AS and EF = 30-35%. Continued to hold ACE
inhibitor for hospitalization but beta blocker was restarted and
patient was continued on statin, fish oil and ASA.
# Atrial Fibrillation: Held digoxin, metoprolol and amiodarone
in setting of digoxin toxicity as did not want to contribute to
nodal blockade given bradycardia. INR was supratherapeutic on
admission and coumadin was held. Warfarin restarted on [**7-22**] and
INR has been therapeutic. Metoprolol was restarted and she
remained rate controlled during the rest of her admission.
Amiodarone and Digoxin were not restarted.
# Hypertension: Held metoprolol and lisinopril as above.
Continued amlodipine for BP control. Restarted metoprolol, but
contiue to hold lisinopril for ARF.
#Aortic stenosis: classified as severe on echocardiogram.
Diuresed gently as patient was preload-dependent. Remained
hemodynamically stable. Advised to manage as outpatient
# Swollen righ knee: Seen by rheumatology, whose assessment was
polyarticular gout flare. The joint was aspirated and crystals
were noted by Rheum fellow but not in final report. Synovial
fluid with neutrophilic infiltrate. Cultures negative. Acute
gout flare was treated with indomethacin and colchicine.
Indomethacin was discontinued the following day given ARF. The
patinet improved and has not complained of joint pain since
[**7-24**]. Colchicine discontinued on [**7-27**]. Continued home dose of
Allopurinol.
# Urinary incontinence: Detrol and oxybutynin were discontinued
on suspicion that they might contribute to AMS. The patient now
reports feeling that she is able to adequately control her
bladder, and we will defer to outpatient provider regarding
these medications.
# History of TIA: No evidence of bleed on OSH CT head. Continued
ASA. Therapeutic on warfarin and statin therapy.
# Hypothyroid - elevated TSH, T3 low. Patient without clinical
signs or symptoms of hypothyroidism. Difficult to evaluate
laboratory abnormalities in setting of acute illness and will
defer treatment for now and recommend evaluation by PCP. [**Name10 (NameIs) **]
supplemental medication started.
# Thyroid hypodensity: Noted on imaging as described above.
This should be followed by PCP for further evaluation and
management post-discharge.
#Diabetes mellitus type 2. Managed on sliding scale insulin with
basal glarigne while holding Metformin. Started home medication
metformin the day of discharge as patient was 72 hours after her
contrast load. Additionally, should patient Cr worsen to > 1.5
would stop as will poorly cleared.
# Code: FULL
# Communication: With husband [**Name (NI) 401**] ([**Telephone/Fax (1) 23946**]) and son [**Name (NI) 4648**]
([**Telephone/Fax (1) 23947**])
Medications on Admission:
ASA 81mg daily
Allopurinol 100mg daily
Amiodarone 200mg daily
Amlodipine 10mg daily
Atorvastatin 5mg daily
Darvocet prn pain
Detrol LA 2 mg daily
Digoxin 125 mcg Tablet daily
Diphenoxylate as needed
Fish oil 1g daily
Furosemide 80mg daily
Lisinopril 40mg daily
Metformin 500mg [**Hospital1 **]
Metoprolol 100mg daily
Oxybutynin 5mg [**Hospital1 **]
Zaroulyn 5mg prn 30 min before lasix
Warfarin 2mg qhs
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever/pain: This is a new medication
since admission.
6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO at
bedtime for 1 doses: This medication to be given [**2142-7-27**] PM. On
[**2142-7-28**] AM patient should start Metoprolol Succinate 100mg
daily.
8. Hydrocortisone 1 % Ointment Sig: One (1) Appl Topical TID (3
times a day) as needed for pruritis: This is a new medication
since admission.
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for dermatitis: This is a new
medication since admission.
10. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) as needed for itching: This is a new medication since
admission.
12. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Mid-line, heparin dependent: Flush with 10 mL Normal Saline
followed by Heparin as above, daily and PRN per lumen.
13. Cefepime 2 gram Recon Soln Sig: Two (2) gram Injection Q24H
(every 24 hours) for 4 days.
14. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous
Q 24H (Every 24 Hours) for 4 days.
15. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily):
Start [**2142-7-28**] AM.
16. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
17. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
18. Insulin Sliding Scale
Please see attached insulin sliding scale. Patient was on
insulin sliding scale while inpatient while Metformin was being
held after a CT scan with contrast. If patient does not require
insulin after resumption of her Metformin, this may be
discontinued.
19. Supplemental oxygen
Patient should have supplemental oxygen via nasal cannula at
2-3L/min or at rate as needed to keep O2 saturation > 92%. Wean
as tolerated to room air.
Discharge Disposition:
Extended Care
Facility:
Lifecare Center of Attelboro
Discharge Diagnosis:
Primary: Digoxin toxicity, congestive heart failure (acute on
chronic), Pneumonia likely due to aspiration, Acute renal
failure, Acute gout flare, altered mental status, delirium,
aortic stenosis
Secondary:
Atrial fibrillation
Chronic heart failure (EF 30% to 35%)
Discharge Condition:
Good. Hemodynamically stable and afebrile.
Discharge Instructions:
You were admitted to the hospital with confusion and were found
to have an elevated digoxin level in your blood. You were also
unable to get enough oxygen to your blood and needed to wear a
mask.
The following changes were made to your medications:
1) STOP digoxin
2) HOLD amiodarone, please discuss with your cardiologist
whether to restart this medication
3) START vancomycin and cefepime, to be continued for 4
additional days
4) HOLD lisinopril, this may be restarted while in your nursing
facility depending on whether your kidney function returns to
baseline
5) Hold Darvocet, Detrol LA 2mg, Diphenoxylate, Oxybutynin until
advised to restart them by a physician.
Followup Instructions:
Please contact your primary care physician and your Cardiologist
upon discharge from the skilled nursing facility to schedule
follow-up appointments to discuss your recent hospitalization.
At these appointments please bring your medication list to
discuss any changes.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
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"396.2",
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icd9cm
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[
[
[]
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[
"81.91",
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icd9pcs
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[
[
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17608, 17663
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7857, 9514
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293, 371
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17973, 18018
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3479, 7834
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232, 255
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399, 2391
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2595, 2798
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,320
| 160,757
|
19311
|
Discharge summary
|
report
|
Admission Date: [**2184-7-9**] Discharge Date: [**2184-7-15**]
Date of Birth: [**2132-10-19**] Sex: M
Service: [**Last Name (un) **]
ADMISSION DIAGNOSIS: Hemoptysis and melena.
HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old
male with HCV cirrhosis, a history of IV drug abuse,
esophageal varices, on a liver transplant list, who was in
his usual state of health until [**2184-7-8**] when the patient
awakened with epigastric pain. The patient waited another
day, but his pain persisted. The patient has been having
melena for some time and emesis 16 hours ago. The patient
came to the emergency room for persistent pain.
PAST MEDICAL HISTORY: HCV cirrhosis, hiatal hernia, history
of IV drug abuse, history of esophageal varices, and left
knee injury.
PAST SURGICAL HISTORY: Disc surgery in [**2180**].
ALLERGIES: PENICILLIN.
MEDICATIONS ON ADMISSION: Methadone 35 mg daily, Lasix 20 mg
daily, lactulose p.r.n., Protonix 40 mg daily, Aldactone 50
mg daily, and Metamucil p.r.n.
SOCIAL HISTORY: Lives with 2 children.
PHYSICAL EXAMINATION ON ADMISSION: Heart rate was 83, blood
pressure was 103/52, temperature was 101.4, and 98% on 2
liters. In general, a middle-aged man in no acute distress.
Awake, alert, and oriented x 3. Pleasant and jaundiced. The
lungs were clear to auscultation bilaterally. Cardiovascular
with a regular rate and rhythm. The abdomen was soft,
somewhat tense, epigastric tenderness with rebound. No
hernia. The extremities were warm. Rectal no mass.
LABORATORY DATA ON ADMISSION: WBC of 5.9, hematocrit of
29.8, platelets of 84. PT of 16.4, PTT of 33.6, and INR of
1.8. Sodium of 137, potassium of 4.0, chloride of 108,
bicarbonate of 24, BUN of 18, creatinine of 0.7, glucose of
122. ALT of 22, AST of 33, alkaline phosphatase of 67, total
bilirubin of 2.9. The patient had a lactate level of 2.0.
RADIOLOGIC AND OTHER STUDIES: A CT of the abdomen was
performed, demonstrating a large amount of air in the
retroperitoneum. There is also extravasation of oral contrast
into the retroperitoneum. These findings are suspicious for a
perforation of the duodenum posteriorly especially
considering the patient's history of upper GI bleed. The
patient also has edema of the [**Last Name (LF) 499**], [**First Name3 (LF) **] be related to
hypoalbuminemic state versus colitis. A small amount of free
fluid in the abdomen. The liver lesion in the dome of the
liver is not identified on this study due to difficult
periods of contrast. A small bilateral pleural effusion.
HOSPITAL COURSE: The patient went to the OR on [**2184-7-10**]
in the a.m. Preoperative diagnosis was cirrhosis and
perforated duodenal ulcer. Procedure of exploratory
laparotomy, primary closure of perforated second and third
portion of the duodenum, and a gram patch, and perforated
duodenal ulcer.
Postoperatively, the patient was taken to the ICU. Placed on
Zosyn. The patient was kept n.p.o. Hepatology was following
the patient. The patient had a NG tube in place. On [**2184-7-13**] the patient was passing gas. NG tube was removed. The
patient's diet was advanced slowly. PCA was discontinued, and
the patient was placed on p.o. narcotics. The Foley was
removed. The patient given multiple products of FFP and
packed red blood cells for an elevated INR and decreased
hematocrit. The patient noted to awake, alert, and oriented x
3. No shortness of breath. O2 saturation was excellent. The
abdomen was slightly distended but soft. On [**2184-7-15**] the
patient had a bowel movement. Received 1 mg of vitamin K IV.
Antibiotics were discontinued. The patient was to be
discharged.
Laboratories on [**2184-7-15**] demonstrated a WBC of 4.6, a
hematocrit of 31.8, a PT of 18.3, a PTT of 33.7, and
platelets of 90. The patient had a sodium of 139, K of 3.1,
chloride of 103, bicarbonate of 29, BUN of 18, creatinine of
0.9, and glucose of 125. Because the K was low, the patient
had 40 mEq of K given to him. AST of 25, ALT of 18, alkaline
phosphatase of 71, and total bilirubin of 5.3.
DISCHARGE DISPOSITION: The patient is going to be leaving to
go home on the following medications.
MEDICATIONS ON DISCHARGE: Lasix 20 mg daily, Percocet 1 to 2
tablets q.4-6h. p.r.n., methadone HCl 35 mg p.o. daily,
Protonix 40 mg q.12.
DISCHARGE INSTRUCTIONS: The patient should call transplant
surgery immediately at ([**Telephone/Fax (1) 52586**] for any fevers, chills,
nausea, vomiting, abdominal pain, and significant decrease in
urine output, any melena, shortness of breath, anorexia.
DISCHARGE FOLLOWUP: The patient is to follow up with Dr.
[**Last Name (STitle) 497**] and Dr. [**First Name (STitle) **] next week in the transplant office. The
patient is to be called for an appointment ([**Telephone/Fax (1) 3618**].
FINAL DIAGNOSIS: Perforation of duodenal ulcer.
SECONDARY DIAGNOSIS: Cirrhosis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Last Name (NamePattern1) 4835**]
MEDQUIST36
D: [**2184-7-15**] 14:19:08
T: [**2184-7-15**] 15:51:14
Job#: [**Job Number 52587**]
|
[
"304.01",
"070.70",
"070.30",
"532.50",
"155.0",
"571.5",
"V49.83"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"44.42",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
4058, 4135
|
4162, 4275
|
894, 1021
|
2558, 4034
|
4788, 4820
|
4300, 4533
|
813, 867
|
176, 200
|
4554, 4770
|
229, 656
|
4842, 5121
|
1553, 2540
|
679, 789
|
1038, 1083
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,606
| 134,408
|
37400
|
Discharge summary
|
report
|
Admission Date: [**2158-4-24**] Discharge Date: [**2158-4-30**]
Date of Birth: [**2089-7-24**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Sigmoid colon stricture status post colonic stenting and
diverting loop sigmoid colostomy for diverticular disease.
Major Surgical or Invasive Procedure:
[**2158-4-24**] - Urology
1. Placement of bilateral ureteral stents preoperatively for
open sigmoid colectomy.
[**2158-4-24**] - General Surgery
1. Open laparotomy and extensive lysis of adhesions.
2. Sigmoid colectomy with stapled #31 coloproctostomy.
3. Takedown splenic flexure.
4. Resection of previous colostomy.
5. Repair or stomal hernia.
6. Diverting loop ileostomy
History of Present Illness:
68F w PMHx significant for diverticulitis complicated by
diverticular stricture requiring colonic stent [**2157-12-30**] and
diverting loop colostomy [**2158-1-2**]. On original presentation
[**12-21**] patient demonstrated obstructive symptoms prompting workup
suspicious for an obstructing sigmoid colonic malignancy.
Following endoscopic stent placement and loop colostomy to
address colonic obstruction this was found to be a stricture
related to diverticulitis and no evidence of malignancy was
found. Patient now presents for further management of her
diverticular stricture.
Past Medical History:
PMH: diverticulitis, HTN, polycystic kidney disease
PSH: Loop colostomy [**2158-1-2**] for high grade colonic obstruction
found to be secondary to diverticular stricture; L
hemithyroidectomy for benign goiter, tonsillectomy +
adenoidectomy during childhood
[**Last Name (un) 1724**]: Protonix 40', Atenolol 50', Nifedipine 60', Lasix 20'
All: NKDA
Social History:
quit Tob 1y ago, formerly 1-2ppd x30y. + EtOH, 1-2 drinks
nightly. Lives at home with her eldest son.
Family History:
Not Applicable
Physical Exam:
P/E at Discharge:
VS: AVSS
GEN: NAD
CV: RRR
PULM: No distress
ABD: no rebound/guarding; midline laparotomy wound; ileostomy
pink with output in ostomy bag
NEURO: A&Ox3
Pertinent Results:
Renal U/S ([**2158-4-25**]): Evaluation is limited due to body habitus
and patient's inability to adequately breath hold. No evidence
of hydronephrosis or hydroureter. Normal resistive indices of
the renal arteries bilaterally. Multiple cysts in the kidneys
bilaterally, consistent with patient's known history of
polycystic kidney disease.
[**2158-4-24**] 06:30PM SODIUM-137 POTASSIUM-3.8 CHLORIDE-104
[**2158-4-24**] 06:30PM MAGNESIUM-1.7
[**2158-4-27**] 07:05AM BLOOD WBC-13.3* RBC-3.34* Hgb-11.3* Hct-33.2*
MCV-100* MCH-33.9* MCHC-34.1 RDW-15.2 Plt Ct-245
[**2158-4-29**] 05:40AM BLOOD Glucose-97 UreaN-11 Creat-1.1 Na-135
K-4.2 Cl-102 HCO3-26 AnGap-11
[**2158-4-29**] 05:40AM BLOOD Calcium-7.7* Phos-2.5* Mg-1.8
[**2158-4-25**] 09:08PM BLOOD Glucose-97 UreaN-18 Creat-1.9* Na-133
K-4.6 Cl-102 HCO3-21* AnGap-15
Brief Hospital Course:
The patient was admitted to the Colorectal Surgery service on
[**2158-4-24**] and
had a sigmoid colon resection with takedown of sigmoid colostomy
and creation of diverting loop ileostomy. The patient tolerated
the procedure well.
Neuro: Pre-operatively, an epidural was placed for pain control.
This was removed on POD1 and patient transitioned to Dilaudid
IV/PCA with good effect and adequate pain control. When
tolerating oral intake on POD6, the patient was transitioned to
oral pain medications.
CV: The patient was hypotensive with low urine output on POD1
prompting transfer to [**Hospital Unit Name 153**]. Patient stabilized for transfer to
floor on POD2. vital signs were routinely monitored.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: Post-operatively, the patient was made NPO and given IV
fluids until
tolerating oral intake. Patient advanced to clears in AM on
POD1 but made NPO in PM POD1 when became hypotensive with low
urine output. Patient remained NPO with an NGT being placed on
POD3. NGT was removed POD4 following clamp trial with minimal
residuals and advanced to sips. POD5 she was advanced to
clears. This was tolerated well and she was advanced to regular
diet on POD6. He/She was also started on a bowel regimen to
encourage bowel movement. Foley was maintained until midnight
POD4 for urine output monitoring. Creatinine rose to peak of
1.9 on POD1 and trended to 1.1 by time of discharge. Renal
ultrasound was obtained to assess for hydronephrosis and showed
findings consistent w history polycystic kidney disease. Intake
and output were closely monitored.
ID: Preoperatively, the patient was given appropriate antibiotic
prophylaxis. Intraoperative finding of microabscesses prompted
linezolid to be given postop. Antibiotic coverage was expanded
to linezolid, vancomycin, cipro and flagyl on POD1 for
hypotension and decreased urine output and question of sepsis.
These were discontinued on POD2 upon transfer out of [**Hospital Unit Name 153**].
Patient was not discharged on antibiotics. The patient's
temperature was closely watched for signs of infection.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
At the time of discharge on POD#6, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled.
Medications on Admission:
[**Last Name (un) 1724**]: Protonix 40', Atenolol 50', Nifedipine 60', Lasix 20'
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
2. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever or pain.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Colonic Stricture secondary to Diverticulitis
Discharge Condition:
Alert and Oriented x3, tolerating regular diet, ambulating
Discharge Instructions:
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications. These medications include but are not
limited to: narcotics and benzodiazepines. Do NOT combining
these substances with each other, alcohol, or other central
nervous system depressants. Some medications contain Tylenol
(Percocet), do NOT take more than 4 grams or 4,000 mg of Tylenol
in a given 24 hour period.
Take all medications as directed.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items [**10-27**] pounds for 6 weeks. You may
resume moderate exercise at your discretion, no abdominal
exercises.
Wound Care:
You may shower, no tub baths or swimming. If there is clear
drainage from your incisions, cover with clean, dry gauze. Your
steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery. Please call the doctor
if you have increased pain, swelling, redness, or drainage from
the incision sites.
Ileostomy instructions:
- record all of the output from your ostomy. Please call Dr.
[**Last Name (STitle) 1120**] if your ostomy output is less than 800 or greater than
1200.
-A visiting nurse will be by to check on your ostomy, help you
with cleaning and replacing.
-Gather the following supplies:
Plastic bags
Clean towel
Toilet paper
Extra skin protection
Soft washcloth
Scissors (if needed)
New pouch
Remove the used pouch:
Sit on or next to the toilet.
Empty the used pouch into the toilet if necessary.
Starting at the upper edge of the skin barrier, carefully push
the skin away from the barrier with one hand. Slowly peel back
the skin barrier with the other hand.
Peel all the way around the skin barrier until the pouch comes
off.
Seal the pouch in a plastic bag; then put it in a second plastic
bag. Throw it away in a trash bin.
Clean around the stoma:
Wipe any stool off the skin around the stoma with toilet paper.
Clean the skin with warm water and a soft washcloth. Wash right
up to the edge of the stoma. Pat the skin dry with a clean
towel.
If needed, put on extra skin protection, such as moisture
barrier cream or powder.
Put on the new pouch:
Peel the backing off the skin barrier.
Place the precut skin barrier over the stoma. If you [**Male First Name (un) **]??????t use a
pouch with a precut skin barrier, size and cut the opening ([**1-28**]
inch bigger than the stoma) and peel the backing off the skin
barrier. Carefully place it over the stoma.
The pouch opening should point toward your feet.
If using a pouch with a clamp at the base, it may be easier to
apply the clamp to the pouch first.
Snap the pouch onto the barrier flange (if you use a two-piece
pouch).
Press the barrier against your skin. Hold it in place for 45
seconds.
Clamp the tail of the pouch (if drainable or reusable).
Follow-UpMake a follow-up appointment as directed by our staff.
When to Call Your Doctor
Call your doctor right away if you have any of the following:
Pus, foul-smelling drainage, or excessive bleeding from your
stoma
A stoma that separates from the skin or looks like it??????s getting
longer
A stoma that is recessing (pulling back) into the abdomen
Bulging skin around your stoma
Blood in your stool
Change in the color of your stoma
Fever of 100.4??????F or higher, or chills
Nausea or vomiting
Increased pain
No gas or stool produced after 24 hours
Resume all home medications.
Followup Instructions:
Please call [**Telephone/Fax (1) 160**] to schedule a follow up appointment
with Dr. [**Last Name (STitle) 1120**] in the next week or so.
Please follow up with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] within the next few weeks to
verify dosing of home medications .
Completed by:[**2158-12-9**]
|
[
"584.5",
"753.12",
"599.0",
"458.0",
"276.51",
"562.11",
"569.5",
"997.5",
"568.0",
"569.69",
"338.18",
"560.89",
"V15.82",
"403.90",
"585.9",
"E878.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.52",
"59.8",
"45.94",
"45.23",
"54.59",
"46.01",
"45.76",
"45.75",
"46.42"
] |
icd9pcs
|
[
[
[]
]
] |
6054, 6125
|
2993, 5506
|
431, 807
|
6214, 6275
|
2147, 2970
|
10625, 10946
|
1928, 1944
|
5638, 6031
|
6146, 6193
|
5532, 5615
|
6299, 7846
|
1959, 1963
|
1977, 2128
|
275, 393
|
7858, 10602
|
835, 1420
|
1442, 1792
|
1808, 1912
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,914
| 153,129
|
11800
|
Discharge summary
|
report
|
Admission Date: [**2127-12-4**] Discharge Date: [**2127-12-13**]
Date of Birth: [**2065-10-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Fish Protein / Latex Gloves
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain at rest
Major Surgical or Invasive Procedure:
[**2127-12-5**] Cardiac Catheterization
[**2127-12-9**] Four Vessel Coronary Artery Bypass Grafting utilizing
left internal mammary to left anterior descending, with
saphenous vein grafts to diagonal, obtuse marginal and PLV.
History of Present Illness:
Mr. [**Known lastname **] is a 62 yo male with PMH of hyperlipidemia, history of
elevated mildly blood pressure though no diagnosis of
hypertension, who presented to OSH with chest pressure for one
week found to have ischemic EKG changes, RBBB and trop leak.
Admitted here with NSTEMI for cath.
Per patient he has been in his usual state of health until one
week ago during his morning walk when he felt shortness of
breath when he started walking. When he stopped walking his
dyspnea resolved. He also reported left arm pain at that time.
Four days prior to admission, he was lifting plants and again
has the shortness of breath and left arm pain whic resolved when
he stopped. This morning as he was starting his morning
exercises, patient again felt dyspnic and also felt chest and
throat tightness for 10 minutes. He also had mild nausea and was
diaphoretic. Denies change in vision or headache. He lay down
and his wife did some acupuncture on him, but the symptoms did
not resolved so he called and ambulance.In the ambulance, he
received 4 ASA and his symptoms resolved. At [**Hospital3 **] he
received additional 4 ASA, 300mg po plavix, and intravenous
heparin.
Past Medical History:
- Hyperlipidemia - on no medications
- Hyeprtension
- MGUS followed by Dr. [**Last Name (STitle) **]
- GERD
- Barrett's Esophagus, last EGD in [**7-8**], bx negative
- Contact Dermatitis
- Latex Allergy
Social History:
Originally from [**Country 651**]. Denies tobacco and ETOH. Lives with wife.
Family History:
Father with non-fatal MI in his 60's.
Physical Exam:
Admission VS - t:98 BP: 128/73 HR: 55 RR: 16 O2 sat: 95% on RA
Gen: 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 5 cm.
CV: RR, normal S1, S2. No m/r/g. No S3 or S4.
Chest: CTAB, no crackles, wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
[**2127-12-4**] 02:10PM BLOOD WBC-4.6 RBC-4.41* Hgb-14.1 Hct-40.3
MCV-91 MCH-31.9 MCHC-34.9 RDW-12.6 Plt Ct-168
[**2127-12-5**] 05:35AM BLOOD PT-12.9 PTT-68.4* INR(PT)-1.1
[**2127-12-4**] Glucose-110* UreaN-10 Creat-0.8 Na-141 K-3.5 Cl-106
HCO3-28 [**2127-12-4**] 02:10PM BLOOD CK(CPK)-169
[**2127-12-4**] 02:10PM BLOOD CK-MB-8
[**2127-12-4**] 02:10PM BLOOD cTropnT-0.12*
[**2127-12-8**] 05:45AM BLOOD %HbA1c-6.1*
[**2127-12-5**] 01:45PM BLOOD Triglyc-118 HDL-50 CHOL/HD-3.8
LDLcalc-117
[**2127-12-5**] CARDIAC CATH:
1. Selective coronary angiography of this right dominant system
revealed multivessel coronary artery disease. The LMCA had a
distal 60% stenosis. The LAD had 90% serial disease. The LCx
was 70% stenosed. The RCA had serial 80% lesions. 2. Resting
hemodynamics revealed mild-moderate systemic arterial systolic
hypertension with SBP 155 mmHg. 3. Left ventriculography
revealed a reduced ejection fraction of 50% with mild inferior
and anterolateral hypokinesis.
[**2127-12-5**] CARDIAC ECHO:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is normal (LVEF 70%). Right
ventricular chamber size and free wall motion are normal. The
aortic root is moderately dilated at the sinus level. There are
three aortic valve leaflets. There is no aortic valve stenosis.
No aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. No mitral
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.
[**2127-12-5**] Carotid Ultrasound:
Widely patent common and internal carotid arteries bilaterally.
[**2127-12-12**] 05:35AM BLOOD WBC-7.4 RBC-2.92* Hgb-9.3* Hct-26.0*
MCV-89 MCH-31.7 MCHC-35.6* RDW-12.9 Plt Ct-191
[**2127-12-12**] 05:35AM BLOOD Plt Ct-191
[**2127-12-12**] 05:35AM BLOOD Glucose-153* UreaN-11 Creat-0.8 Na-136
K-3.6 Cl-102 HCO3-29 AnGap-9
[**2127-12-5**] 01:45PM BLOOD ALT-13 AST-16 AlkPhos-55 Amylase-11
TotBili-0.5
[**2127-12-12**] 05:35AM BLOOD Mg-2.2
Brief Hospital Course:
Mr. [**Known lastname **] was admitted under cardiology service with NSTEMI.
Given unstable angina, he was initially maintained on
intravenous Integrilin and Heparin. He was stabilized on medical
therapy and underwent cardiac catheterization the following day.
This was notable for severe three vessel coronary artery disease
including a 60% left main lesion - see result section for more
details. Cardiac surgery was subsequently consulted and further
evaluation was performed. Echocardiogram was notable for an LVEF
of 70% and no mitral regurgitation. Carotid ultrasound showed
normal internal carotid arteries. Surgery was delayed for
several days secondary to recent Plavix load. Workup was
otherwise unremarkable and he was cleared for surgery.
On [**12-9**], Dr. [**Last Name (STitle) **] performed coronary artery bypass
grafting surgery. For surgical details, please see seperate
dictated operative note. Given his inpatient stay was greater
than 24 hours, he received intravenous Vancomycin for
perioperative antibiotic coverage. Following the operation, he
was brought to the CVICU for invasive monitoring. Within 24
hours, he awoke neurologically intact and was extubated without
incident. His CVICU course was uneventful and he transferred to
the SDU on postoperative day one. His chest tubes and
epicardial wires were removed. He was seen in consultation by
physical therapy. By post operative day four he was ready for
discharge to home.
Medications on Admission:
Protonix 40mg qd
Benadryl prn
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) as needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*2*
6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 7
days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary Artery Disease - s/p CABG
Recent Non ST Elevation Myocardial Infarction
Dyslipidemia
Hypertension
GERD, Barretts Esophagus
Contact [**Name (NI) 37291**]
Latex Allergy
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) **] in [**4-5**] weeks, call for appt
Dr. [**Last Name (STitle) 171**] in [**2-2**] weeks, call for appt
Dr. [**Last Name (STitle) 9006**] in [**2-2**] weeks, call for appt
Completed by:[**2127-12-13**]
|
[
"273.1",
"530.81",
"530.85",
"410.71",
"401.9",
"426.4",
"272.4",
"412",
"414.01",
"692.9",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.20",
"88.53",
"39.61",
"37.22",
"36.15",
"36.13",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
7411, 7469
|
4841, 6298
|
315, 543
|
7689, 7696
|
2647, 4818
|
8207, 8438
|
2081, 2120
|
6379, 7388
|
7490, 7668
|
6324, 6356
|
7720, 8184
|
2135, 2628
|
257, 277
|
571, 1744
|
1766, 1970
|
1986, 2065
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,611
| 175,554
|
48239+59072
|
Discharge summary
|
report+addendum
|
Admission Date: [**2188-1-18**] Discharge Date: [**2188-2-5**]
Date of Birth: [**2129-11-4**] Sex: M
Service: HEPATOBILIARY SURGERY SERVICE
ADMISSION DIAGNOSIS: Bile duct stricture.
HISTORY OF PRESENT ILLNESS: Patient is a 58-year-old male
past medical history for Hodgkin lymphoma treated in the late
[**2151**] that is in remission. Status post radiation therapy,
complicated by significant brachial plexus injury rendering
his right upper extremity, which is illicitly nonfunctional.
The patient complained of abdominal discomfort that was
consistent with biliary colic in [**2187-10-2**], underwent
an ultrasound, which demonstrated an intra and extrahepatic
biliary ductal diltation prompting an ERCP. ERCP was
performed in [**2187-12-2**] that demonstrated findings
consistent with a Klatskin type tumor and/or stricture
located at the junction of the right and left hepatic ducts.
CT of the abdomen was performed demonstrating a mass located
in the hilum abutting the cystic and the common and hepatic
duct with intrahepatic ductal diltation. Findings were
consistent with cholangiocarcinoma. Also noted was abdominal
lymphadenopathy with no evidence of hepatic disease, no
intrahepatic metastases. Patient underwent brushings at the
time of the ERCP and there was no evidence of malignancy
observed.
Complains of significant pruritus and back pain. Weight loss
of 16 pounds over several weeks. Complains of dark urine. No
chest pain. No shortness of breath. No nausea, vomiting,
fever, chills.
PAST MEDICAL HISTORY: Significant for hypertension,
hyperthyroidism, Hodgkin lymphoma status post radiation
treatments, history of questionable pancreatitis and duodenal
ulcer.
PAST SURGICAL HISTORY: Splenectomy and appendectomy.
MEDICATIONS: On admission HCTZ and Synthroid 150 every day.
ALLERGIES: Bacitracin and penicillin.
PHYSICAL EXAMINATION: Temperature is 98.4. Blood pressure
178/54. Pulse 84. Respirations 16. Height 5'[**91**]". Weight 142.
HEENT pupils equal, round and react to light. EOMs are full.
Tongue midline. No exudates. Lungs clear to auscultation
bilaterally. Abdomen positive bowel sounds, soft, nontender,
no hepatomegaly. Incisions are well healed. No hernias
appreciated. Extremities no CCE.
HOSPITAL COURSE: The patient was admitted on [**2188-1-18**] and patient was operated by Drs. [**First Name (STitle) **] and [**Name5 (PTitle) **] for a
cholecystectomy, common bile duct excision, septoplasty, Roux-
en-Y hepaticojejunostomy, liver biopsy. Please see operative
note from [**2188-1-18**] for more details of the surgery.
Postoperatively, patient went to PACU and then eventually to
the CICU. Patient was intubated on Propofol. Patient received
fluid boluses for low blood pressure. Patient had 2 JP drains
in place. Patient was placed on meropenem, vancomycin and
fluconazole postoperatively. MRS [**Last Name (STitle) 15570**] was performed with a
rectal swab demonstrating staph aureus coag positive. On
[**2188-1-22**], patient had a bronchioloalveolar lavage.
It was noted on chest x-ray that patient had a right main
stem bronchus with narrowing correlated to secretions that
was demonstrated on recent CAT scan on [**1-16**]. On
[**2188-1-22**], the patient had bronchoalveolar lavage
demonstrating staph aureus coag positive. ID was consulted.
Urine culture, blood cultures were obtained on [**2188-1-22**]. Urine culture demonstrate no growth. Blood cultures
demonstrated no growth. On [**2188-1-24**] the patient had
a post pyloric feeding tube placed for nutrition. Patient
continued being ventilated. Levophed was being weaned off.
Nutritional services were consulted for tube feed
recommendations. Patient continued on Vancomycin and
meropenem. Patient was written for Lasix for diuresis.
Patient was eventually extubated. Physical therapy was
consulted. Patient still had JP drain in place and biliary
tube 1 and biliary tube 2.
The patient was continued on antibiotics for MSSA pneumonia
and polymicrobial cholangitis. On [**2188-1-28**], the
patient had a cholangiogram that demonstrated no evidence of
obstruction, extravasation or anastomotic stricture. Labs on
[**2188-1-29**] were 21.3, hematocrit 29.7, platelets 593,
sodium 138, 4.0, 97, 37, 20, 0.5, glucose 111, ALT is 28, AST
46, alkaline phosphatase 66, total bili is 0.3. [**2188-1-24**] bile fluid was sent for gram stain and culture
demonstrating staph aureus coag positive [**Female First Name (un) **] albicans. JP
drain was removed. Diet was advanced. Calorie counts were
obtained. The patient was transferred to the floor on [**2188-1-30**]. Physical therapy continued working with patient.
Patient received Boost t.i.d. On the floor patient received
aggressive chest PT, pulmonary toilet, calorie counts,
bedside swallow to evaluate if he had any problems
swallowing. His abdomen with 3 cm lateral wall defect,
getting wet to dry dressings. Speech had seen him on [**2188-2-1**] demonstrating that he has significant dysphagia at the
bedside. Speech pathologist suggested him to be NPO pending a
video swallow. Barium swallow was notable for a weak tongue,
dysarthria, right Horner and severe dysphagia. Etiology is
unclear, but is likely multifactorial and felt that he should
be NPO and continue tube feeds. It was strongly suggested by
the speech pathologist that neurology see the patient for
dysphagia and other findings including Horner syndrome. They
felt that patient should be NPO and time course of recovery
of swallow is unclear.
Physical therapy continued to work with patient. Calorie
counts from the [**2188-2-5**] demonstrated 370 calories and 9
grams of protein, but food was supplemented with tube feeds.
All drains have been removed. Continues to be afebrile. Vital
signs stable and the patient has been walking around with
physical therapy, done remarkably well. On [**2188-2-5**]
postop day 18, no significant overnight events. Afebrile.
Vital signs stable. Good Is and Os. Abdomen with bowel sounds
soft, nontender, nondistended. Repeat barium swallow is being
performed today. He is being screened by rehab and hopefully
will have a bed very soon. He will be going home on the
following medications, albuterol inhalers 6 puffs every 4
hours p.r.n., Clobetasol propionate 0.05% cream one
application b.i.d. to effected areas. Heparin subQ 5000
b.i.d., insulin sliding scale, levothyroxine 150 mg every
day, Protonix 40 mg every 24. Patient should call [**Telephone/Fax (1) 30335**] if any fevers, chills, nausea, vomiting, inability to
take medications, any abdominal pain, jaundice, incision
redness/bleeding or purulent discharge, patient to unable eat
or drink or any increased swelling in legs, please call
immediately. Patient is to follow up with Dr. [**Last Name (STitle) **], please
call [**Telephone/Fax (1) 673**] for an appointment.
FINAL DIAGNOSIS: A 58-year-old male status post Roux-en-Y
hepaticojejunostomy for benign stricture on [**2188-1-28**].
SECONDARY DIAGNOSES: Dysphagia.
Path results came back on [**2188-1-18**] from the surgery
demonstrating the lymph node shows no malignancies. The
common bile duct distal margin shows acute and chronic
inflammation and fibrosis. Common bile cyst duct and common
bile duct demonstrate acute and chronic inflammation and
fibrosis. Gallbladder with chronic cholecystitis, 2 lymph
nodes that were not malignant. The septum of bifurcation
demonstrated fibrous and granulation tissue with chronic
inflammation and fibrosis and liver needle core biopsy
demonstrated mild portal inflammation with focal bile duct
proliferation, 2 minimal macrovesicular steatosis without
intracellular hyalin or neutrophils. Also trigone stain
increased portal fibrosis, no bridging and iron stain no
stainable iron.
Patient will go to rehab on tube feeds at this point. He will
be going to rehab on Impact with fiber at 3/4 strength, goal
rate is 110 milliliters per hour. Please check residuals
every 4 hours and hold for residuals of greater than 100
milliliters. Also flush with 30 cc of water ever 4 hours.
Patient should receive physical therapy, occupational therapy
in the rehab setting. Also make sure he has pulmonary toilet.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD,PHD[**Numeric Identifier **]
Dictated By:[**Last Name (NamePattern1) 4835**]
MEDQUIST36
D: [**2188-2-5**] 10:26:22
T: [**2188-2-5**] 11:22:28
Job#: [**Job Number 101653**]
Name: [**Known lastname 2892**], [**Known firstname 499**] Unit No: [**Numeric Identifier 16368**]
Admission Date: [**2188-1-18**] Discharge Date: [**2188-2-8**]
Date of Birth: [**2129-11-4**] Sex: M
Service: Hepatobiliary Surgery Service
ADDENDUM: The patient was evaluated by speech pathology, and
their findings demonstrated that the patient had aspirated
small amounts of all consistencies; which include thin
liquids, nectar, thick liquids and puree. Speech pathology
suggested that the patient would need a PEG tube placement
for primary nutrition, hydration and medications. That,
regardless of the workup the patient should have a video
swallow in 2 weeks and to continue with speech and swallow
therapy. Neurology was consulted for reason of dysarthria,
and a MRA was suggested by neurology to rule out any etiology
for the dysarthria. The MRA demonstrated that there was no
sign of cortical infarction or intracranial mass. There were
no further recommendations or followup needed with neurology.
GI was consulted for possible PEG placement on [**2188-2-7**].
Endoscopy was performed by GI on [**2188-2-7**]; but the PEG
placement was unsuccessful due to the bulk of the stomach
under the ribcage. The scope was changed to a larger single
channel therapeutic scope in order to place an 8 French
nasojejunal feeding tube. The nasojejunal feeding tube was
placed in the usual fashion without difficulty or
complications. Because of the stricture of the second part of
the duodenum, a PEG was not performed; but instead a
nasojejunal feeding tube placed. The patient is going to
continue with tube feeds; Impact with fiber 3/4 strength.
Goal rate is at 110 mL per hour.
DISCHARGE STATUS: On postoperative day #21 - on [**2188-2-8**] - the patient is afebrile, vital signs stable. Tube
feeds 11:45. No IV fluids. Urine output 700+. So, he is doing
very well. He is getting his dressings changed once a day;
wet-to-dry with normal saline.
DISCHARGE DISPOSITION: He will be hopefully going to rehab
today. He will be discharged with the following medications.
DISCHARGE MEDICATIONS: Albuterol inhaler 6 puffs q.4h.
p.r.n.; clobetasol 0.05% cream applied b.i.d. to area; the
patient will be discharged on an insulin sliding scale;
heparin 5000 units subcutaneously b.i.d.; Protonix 40 mg
q.24h.; levothyroxine 150 mcg daily.
DISCHARGE FOLLOWUP: The patient needs to follow up for a
video swallow in [**12-2**]/2 weeks.
NEW DISCHARGE INSTRUCTIONS: The patient will need wet-to-dry
dressings to abdomen once a day. The patient should continue
on current tube feeds that were documented in the previous
discharge summary on this admission, and continue with the
discharge instructions that were also mentioned in the first
discharge summary.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD,PHD[**Numeric Identifier **]
Dictated By:[**Last Name (NamePattern1) 3068**]
MEDQUIST36
D: [**2188-2-8**] 08:30:43
T: [**2188-2-8**] 09:00:02
Job#: [**Job Number 16369**]
|
[
"239.0",
"201.90",
"575.11",
"496",
"518.81",
"511.9",
"787.2",
"576.1",
"576.2",
"780.52",
"515",
"473.9",
"785.0",
"458.29",
"041.11",
"486",
"507.0",
"E878.8",
"518.0",
"E849.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.6",
"51.22",
"33.24",
"96.04",
"51.69",
"38.93",
"51.37",
"45.13",
"50.11",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
10445, 10543
|
10567, 10809
|
2277, 6826
|
6844, 6947
|
10934, 11500
|
1732, 1865
|
6969, 10421
|
1888, 2259
|
183, 205
|
10830, 10909
|
234, 1529
|
1552, 1708
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,308
| 134,813
|
41126
|
Discharge summary
|
report
|
Admission Date: [**2146-3-1**] Discharge Date: [**2146-3-4**]
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **]yo lady transferred from another hospital s/p mechanical fall
at home around 3 this morning with pelvis and bilateral proximal
lower extremity pain immediately after onset of fall. She also
describes a chronic mid and lower back pain that has intensified
in her lower back since time of fall. OSH had been concerned
with possible pelvic hematoma resulting in transfer.
Past Medical History:
Past Medical History: CAD , CHF, Hyperlipidemia
Past Surgical History: CABG; ; Lower midline abdominal incision
Social History:
lives at home alone, ambultates at home without
assistance
Family History:
non contributory
Physical Exam:
Temp HR BP RR Pox
99.7 114 106/52 16 100% 2L
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist; pupils equal
and reactive
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, tender RLQ, no rebound or guarding,
normoactive bowel sounds, no palpable masses. Spine: No step
offs
or deformity. Tenderness to Lower thoracic vertebrae
DRE: normal tone, no gross blood
Ext: No LE edema, LE warm and well perfused; DP and PT
bilaterally were dopplerable
Pertinent Results:
[**2146-3-1**] 05:18PM WBC-15.3* RBC-3.23* HGB-10.6* HCT-31.2*
MCV-97 MCH-32.8* MCHC-34.0 RDW-12.6
[**2146-3-1**] 05:18PM NEUTS-92.1* LYMPHS-4.9* MONOS-2.6 EOS-0.2
BASOS-0.2
[**2146-3-1**] 05:18PM PLT COUNT-211
[**2146-3-1**] 05:18PM PT-12.3 PTT-24.4 INR(PT)-1.0
[**2146-3-1**] 05:18PM GLUCOSE-120* UREA N-22* CREAT-1.2* SODIUM-143
POTASSIUM-4.8 CHLORIDE-111* TOTAL CO2-23 ANION GAP-14
[**2146-3-1**] 11:00PM WBC-10.6 RBC-2.72* HGB-9.0* HCT-26.5* MCV-98
MCH-33.2* MCHC-34.1 RDW-12.6
[**2146-3-1**] 11:00PM NEUTS-88.9* LYMPHS-7.3* MONOS-2.7 EOS-0.8
BASOS-0.3
[**2146-3-1**] B/L Hips:
Bilateral superior and inferior pubic rami fractures, as
demonstrated on prior CT.
[**2146-3-3**] MRI T spine :
1. The T6 and T12 vertebral body fractures appear chronic in
nature. No
acute fractures are identified.
2. Minimal extrinsic indentation on the spinal cord by slightly
retropulsed T12 vertebral body. Subtle increased signal within
the spinal cord at this level could be due to prominent central
canal on an area of myelomalacia only seen on sagittal inversion
recovery images and difficult to evaluate on the axial images
secondary to artifacts.
3. Changes of cervical spondylosis visualized on the sagittal
images in the cervical region from C4-5 to C6-7 level.
Brief Hospital Course:
On [**2146-3-1**], the patient was admitted to the trauma ICU on the
acute care surgery service for a fall with pelvic fractures and
hematoma. Hematocrit was checked regularly, and she was
transfused 1u PRBC for a hematocrit of 23 and subsequently
stabelized in the 27 range. She also had compression fractures
of T6 and T12 that were evaluated as chronic by an MRI. She was
in rapid atrial fibrillation on admission with a Troponin of
0.02-0.06. She was treated with lopressor, her rate was
controlled and she subsequently converted to normal sinus
rhythme with occasional PAC's which she sustained. By
[**2146-3-3**], she was hemodynamically stable and she was
transferred to the floor.
Following transfer to the Trauma floor she continued to make
good progress. She was evaluated by the Physical and
Occupational Therapy services and she was able to bear weight
with some pain but was able to take a few steps. She will need
further rehab with the goal of getting her back home
independently.
She remained in NSR with PAC's and was able to tolerate
lopressor 12.5 mg [**Hospital1 **]. She was taking a regular diet in modest
amounts and voiding sufficiently. Her last hematocrit prior to
discharge was 27.4. She was discharged to rehab on [**2146-3-3**] and
will follow up in the Acute Care Clinic in [**1-6**] weeks as well as
the orthopedic Clinic in 4 weeks.
Medications on Admission:
aspirin 325', lasix 20', lisinopril 10', metoprolol 12.5", MVI',
omeprazole 20', potassium chloride 10 % oral liquid, simvastatin
40'
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q6H (every 6
hours) as needed for severe pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] Health Care Center
Discharge Diagnosis:
S/P Fall
1. Right superior/inferior pubic rami fracture
2. Left superior pubic rami fracture
3. Acute blood loss anemia
4. Pelvic hematoma
5. Atrial fibrillation
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 after falling your xrays
demonstrated pelvic fractures. Your treatment is non operative
and the Orthopedic service recommends that you gat out of bed
and bear weight as tolerated. That means if it's too painful
then stop the activity.
* You will need to take pain medication so that you can stay
mobile. Some of that medicine can cause constipation therefore
take stool softeners or a gentle laxative to stay regular.
* Continue to eat a regular diet and stay well hydrated.
* Due to your injuries and decreased mobility you will spend
some time in rehab prior to returning home to increase your
strength and ability to walk safely.
Followup Instructions:
You need to follow up with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 12207**] (orthopedics) in 1
month. Call [**Telephone/Fax (1) 1228**] for an appointment
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in [**1-6**] weeks.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2146-3-4**]
|
[
"E849.9",
"401.9",
"285.1",
"805.6",
"733.13",
"414.00",
"272.0",
"E884.4",
"868.03",
"808.2",
"V45.81",
"428.0",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4885, 4950
|
2758, 4136
|
252, 258
|
5156, 5156
|
1458, 2735
|
6034, 6456
|
907, 925
|
4320, 4862
|
4971, 5135
|
4162, 4297
|
5339, 6011
|
771, 814
|
940, 1439
|
208, 214
|
286, 677
|
5171, 5315
|
721, 748
|
830, 891
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,900
| 120,644
|
228
|
Discharge summary
|
report
|
Admission Date: [**2194-7-18**] Discharge Date: [**2194-7-25**]
Date of Birth: [**2123-12-24**] Sex: F
Service: MEDICINE
Allergies:
Atorvastatin / Penicillins / Codeine
Attending:[**First Name3 (LF) 2265**]
Chief Complaint:
SOB, decreased urine
Major Surgical or Invasive Procedure:
Hemodialysis
Placement of a R IJ catheter
Placement of a R subclavian tunneled dialysis line
History of Present Illness:
Ms. [**Known lastname 2251**] is a 70yoF with h/o dilated cardiomyopathy [**1-1**]
aortic outflow obstruction, AICD s/p VT, CAD, COPD (on home O2)
who presented with decreased UO and SOB, now transferred from
medicine service to CCU for hypotension. Pt is currently
somnolent and unable to provide a detailed history, so details
are obtained from OMR and Atrius records. Pt saw NP in complex
care clinic on [**7-10**], at that time felt well overall, c/o dry
cough but denied SOB, peripheral edema. At that time her weight
was recorded at 185 lbs (dry weight is estimated at 184 lbs). On
[**7-17**] she called the CCC office c/o minimal urine output ("only
drops") and cough productive of yellow sputum. She reported
compliance with her home diuretic regimen, but [**Name8 (MD) **] NP note she
had not filled her aldactone rx.
.
On DOA, she called EMS due to increasing SOB. When EMS arrived
her SBP was 80. She received 250cc NS and was brought to ED.
In ED she had SBP 90s so received another 500cc NS bolus. CXR
showed no e/o infiltrate but she was treated empirically for CAP
with 1g ceftriaxone given her recent productive cough. Labs were
significant for Na 121 and Cr 5.4 (baseline 3.5-4.0). She was
admitted to medicine service. On the floor, her BP was
initially 98/65 but then decreased to SBP 70s. She was
transferred to CCU for pressor support.
.
On transfer, vitals were T 95.7, HR 60 (v-paced), BP 110/56, RR
18, O2sat 100% on 2LNC. She was drowsy, but denied current SOB,
chest pain, palpitations, LE swelling. She endorsed orthopnea
(c/w baseline) cough productive of yellow sputum, nausea, RUQ
discomfort, and anuria. Denied recent fevers/chills,
diarrhea/constipation, melena/hematochezia, BRBPR.
.
Of note she was admitted 1 month ago (from [**Date range (1) 2266**]) for CHF
exacerbation and hypervolemia. She was started on a lasix drip
with metolazone but was ultimately started on ultrafiltration
with a tunneled HD line which she tolerated well. She has not
required outpatient HD since discharge.
Past Medical History:
1. CARDIAC RISK FACTORS: +Hypertension, +HLD
2. CARDIAC HISTORY:
- CABG:
- PERCUTANEOUS CORONARY INTERVENTIONS:
- PACING/ICD: [**Company 2267**] Cognis 100-D Dual chamber-ICD,
implanted [**2193-4-1**]
-CARDIOMYOPATHY, HYPERTROPHIC OBSTRUCTIVE (EF 35%)
-ATRIAL FIBRILLATION on coumadin
-CORONARY ARTERY DISEASE - NATIVE CORONARY ARTERY
-VENTRICULAR TACHYCARDIA s/p AICD placement
-HEART FAILURE - SYSTOLIC & DIASTOLIC, CHRONIC
3. OTHER PAST MEDICAL HISTORY:
?????? COPD
?????? PSORIASIS
?????? GOUT
?????? RHINITIS - ALLERGIC
?????? HYPOKALEMIA in the past
?????? ANEMIA, normocytic
?????? KIDNEY DISEASE - CHRONIC STAGE III (MODERATE)
?????? OBESITY
?????? Unspecified cataract
?????? Colon polyps
?????? Diverticulosis of colon with hemorrhage
Social History:
Lives alone in [**Location (un) 2268**], but has stayed with her sister recently
[**1-1**] difficulty walking up stairs to her apt. Remote smoking and
EtOH history, pt unable to quantify. Denies IVDU.
Family History:
Non-contributory.
Physical Exam:
ADMISSION EXAM:
GENERAL: Fatigued-appearing elderly female, breathing
comfortably on NC.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM.
NECK: Supple with JVP 12cm (to jaw).
CARDIAC: Distant heart sounds, RRR, II/VI HSM at LLS border.
LUNGS: Resp unlabored, no accessory muscle use. Bibasilar
crackles, R>L.
ABDOMEN: Soft, distended, TTP at RUQ with pulsatile liver. No
abdominial bruits.
EXTREMITIES: No c/c/e. +bulla on anterior LE.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+
.
DISCHARGE EXAM
Pertinent Results:
Admission Labs
[**2194-7-17**] 11:30PM WBC-5.0 RBC-3.46* HGB-10.3* HCT-30.3* MCV-87#
MCH-29.7 MCHC-34.0 RDW-18.5*
[**2194-7-17**] 11:30PM PLT COUNT-100*
[**2194-7-17**] 11:30PM PT-21.6* PTT-34.3 INR(PT)-2.0*
[**2194-7-17**] 11:30PM TSH-14*
[**2194-7-17**] 11:30PM proBNP-8699*
[**2194-7-17**] 11:30PM UREA N-105* CREAT-5.4*# SODIUM-121*
POTASSIUM-3.4 CHLORIDE-77* TOTAL CO2-27 ANION GAP-20
[**2194-7-17**] 11:38PM LACTATE-1.5
[**2194-7-18**] 12:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.0
LEUK-NEG
[**2194-7-18**] 03:03AM URINE OSMOLAL-276
[**2194-7-18**] 03:03AM URINE HOURS-RANDOM UREA N-265 CREAT-152
SODIUM-LESS THAN POTASSIUM-54 CHLORIDE-17
[**2194-7-18**] 04:09PM CK-MB-4 cTropnT-0.17*
[**2194-7-18**] 04:09PM CK(CPK)-66
.
Pertinent Studies
ECHO [**5-/2194**]: The left atrium is moderately dilated. The right
atrium is markedly dilated. There is mild symmetric left
ventricular hypertrophy. Overall left ventricular systolic
function is moderately depressed (LVEF= 35 %) with regional
variation, the apical segments more hypokinetic than the basal
segments. The right ventricular free wall thickness is normal.
The right ventricular cavity is dilated with borderline normal
free wall function. There are focal calcifications in the aortic
arch. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Mild to moderate ([**12-1**]+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is mild pulmonary artery systolic hypertension. The main
pulmonary artery is dilated. The branch pulmonary arteries are
dilated. There is no pericardial effusion.
.
CXR [**2194-7-18**]: There is a left-sided pacemaker/ICD with right
atrial and right ventricular leads, as before. Severe
cardiomegaly is not significantly changed. Pulmonary venous
congestion is seen without definite interstitial pulmonary
edema. No focal consolidations are seen. There are no pleural
effusions. No pneumothorax is seen. There is minimal right
basilar atelectasis.
.
HD Labs:
- Iron studies:
Iron Binding Capacity, Total 433 (nl 260 - 470 ug/dL)
Ferritin 29 (nl 13 - 150 ng/mL)
Transferrin 333 (nl 200 - 360 mg/dL)
- PPD: negative
.
Discharge Labs:
Brief Hospital Course:
Primary Reason for Admission
70yoF with h/o dilated cardiomyopathy (EF 35%), AICD p/w SOB and
poor urine output for several days found to have hyponatremia,
now transferred from medicine to CCU due to hypotension.
.
Active Issues:
.
#Acute on chronic systolic heart failure: The patient was
hypervolemic on exam with elevated JVP and increased abdominal
distension at presentation. Given the patient had been
refractory to diuretic therapy requiring ultrafiltration during
her last hospitalization and was oliguric and hyponatremic on
admission, ultrafiltration was initiated rather than diuretic
therapy. She experienced significant muscle cramping and
hypotension while on CVVHD requiring dopamine. CVVHD was
discontinued on HD#2 and she was diuresed with IV lasix and
metolazone. Pressures improved and she was weaned off of
dopamine. It was noted that urine and blood pressure improved
when the patient was in her native sinus rhythm with
asynchronous ventricular pacing. Therefore the patients
pacemaker escape rate was lowered to allow for increased native
rhythm and the mode was changed to AAIR. Despite this change
urine output remained poor and she was therefore started on a
lasix drip ultimately requiring milrinone to augment diuresis.
On HD#6 patient underwent placement of a tunneled dialysis
catheter, and on HD#7 she continued HD using the tunneled line
(see below). Lasix and metolazone were discontinued as patient
will be HD dependent.
.
#Hypotension: Patient was hypotensive on admission in the
setting of volume overload. Her hypotension was believed to be
due to worsening cardiac output in setting of dilated
cardiomyopathy. She was temporarily on a dopamine gtt, but this
was weaned by HD#2. In addition, she experienced episodes of
hypotension with CVVH with diuresis and antihypertensive
medications, so her antihypertensive medications were held. On
discharge, her BP was stable. She was asked to continue to hold
her carvedilol and to follow up with her PCP about restarting as
tolerated.
.
# Hyponatremia: Pts sodium was 119 on admission and likely cause
of her AMS, thought to be hypervolemic hyponatremia with poor
renal perfusion given e/o volume overload on exam and low urine
Na. Her fluid intake was restricted to 1.5L daily, and she
started CVVH as above with improvement in her hyponatremia as
well as her mental status. At the time of discharge her sodium
was 135.
.
# Acute on chronic renal failure: Patient was noted to have a
creat of 5.4, baseline 3.5-4.0, and oliguria x 2-3 days on
admission. As stated above she had previously required
ultrafiltration during hospitalizations for heart failure
exacerbation. Renal was consulted and felt that the patient
would require chronic HD. Given her hypotension she was
initally started on CVVH with dopamine gtt for pressure support.
However as above she did not tolerate CVVH and it was
discontinued. She was diuresed with lasix gtt and milrinone as
above until she had her tunneled line placed on HD#6. She
tolerated HD well, with stable BP and no muscle cramping.
Outpatient dialysis was arranged with [**Location (un) **] [**Location (un) **] Dialysis
Center for mondays, wednesdays and fridays.
.
# Afib: Pt has a history of atrial fibrillation on coumadin at
home. On admission her coumadin was held in preparation for
placement of a tunneled dialysis catheter. As stated above her
pacemaker settings were changed and she was in sinus rhythm for
most of her CCU course with heart rates in the 50-70s. Her mode
was changed to AAIR to allow for intrinsice AV conduction and
minimize ventricular pacing in an abnormal heart. Her coumadin
was restarted at her home dose on HD#7. Her INR at the time of
discharge was 1.4.
# Stable issues:
.
# COPD: Patient's recent cough and SOB with h/o COPD was
initially c/f COPD exacerbation, and she was initially started
on prednisone and levofloxacin. However there was no wheezing on
exam therefore prednisone and antibiotics were discontinued. She
was continued on her home albuterol/ipratropium nebulizer
treatments, and maintained O2 sats >90% on 2L NC (her baseline
O2 requirement).
.
# CAD: Stable, no c/o chest pain during hospitalization. She
was continued on her home ASA and pravastatin.
.
# HTN: Carvedilol was discontinued due to frequent episodes of
hypotension (with SBP 70s-80s). She can resume as an outpatient
if BP tolerates.
.
# Gout: Patient was continued on her home allopurinol and did
not have any pain concerning for a gout flare.
.
# Transitional issues:
- Patient maintained full code status throughout
hospitalization.
- She will continue outpatient hemodialysis at [**Location (un) **] [**Location (un) **]
Dialysis Center
- She has follow-up scheduled with her PCP and her cardiologist.
She will be contact[**Name (NI) **] regarding a follow-up appointment with
the device clinic in 3 months.
Medications on Admission:
1. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for Insomnia.
2. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day): Start on [**2194-7-2**].
3. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Puff Inhalation Q6H (every 6 hours) as needed for
shortness of breath.
5. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. ferrous gluconate 325 mg (37.5 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*0*
8. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
9. amiodarone 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
10. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain
up to 3x q 5 minutes.
11. Outpatient Lab Work
Please check INR and Chem 10 on [**2194-7-3**] and [**2194-7-7**].
Please fax results to: PCP [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) 2253**] (fax # [**Telephone/Fax (1) 2254**])
12. furosemide 80 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
13. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
14. spironolactone 25 mg Tablet Sig: 0.25 Tablet PO EVERY OTHER
DAY (Every Other Day).
Disp:*4 Tablet(s)* Refills:*0*
15. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
16. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
Disp:*30 Tablet, Chewable(s)* Refills:*2*
17. pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
2. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
3. ferrous gluconate 325 mg (37.5 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
8. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) capsule Inhalation once a day.
9. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) puff Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
10. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
11. amiodarone 100 mg Tablet Sig: One (1) Tablet PO once a day.
12. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual every five minutes up to 3 times as needed as needed
for chest pain.
13. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
14. Senna-Gen 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime.
15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO
BID:prn as needed for constipation.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Chronic Renal Failure
Acute on Chronic systolic CHF
Atrial Fibrillation
Coronary Artery Disease
Chronic Obstructive Pulmonary Disease
Hypertension
Gout
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 while you were in the
hospital.
You were admitted to the hospital for shortness of breath and
not making urine. Your heart was not pumping well which caused
you to have extra fluid. We gave you medication to help you to
urinate out this fluid however your kidneys were not working
properly and you needed dialysis to do the job of your kidneys.
You got a special IV to be used for dialysis. You will need to
continue going to dialysis three times a week. Your blood
pressure was also so low so we did not give you your home blood
pressure medications while you were in the hospital.
You should continue to go to dialysis three times a week. You
were also started on a medication called nephrocaps that you
will need to continue.
You should stop taking your carvedilol, metolazone,
spironolactone and lasix unless your doctor instructs you to
restart these medications.
Continue your coumadin and amiodarone for your abnormal heart
rhythm (atrial fibrillation). Continue your aspirin and
pravastatin for your heart disease, your allopurinol for your
gout, your albuterol and ipratropium for your COPD.
Followup Instructions:
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2269**],MD
Specialty: Internal Medicine
When: Thursday [**7-31**] at 3:30p
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2261**]
Name: [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 2271**], NP
Specialty: Cardiology
When: Tuesday [**8-5**] at 2pm
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2258**]
Please call the Device Clinic in the cardiology department at
[**Hospital1 69**] to schedule an appointment
in 3 months. You can call [**Telephone/Fax (1) 2272**] to schedule.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2273**]
|
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16,994
| 182,616
|
48026
|
Discharge summary
|
report
|
Admission Date: [**2115-12-12**] Discharge Date: [**2115-12-24**]
Date of Birth: [**2046-6-27**] Sex: F
Service: MEDICINE
Allergies:
Motrin / Lipitor
Attending:[**First Name3 (LF) 562**]
Chief Complaint:
Watery diarrhea for two weeks
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 69yo AAF with a PMHx significant for ESRD, COPD,
HIV+, CAD, CHF, PEA arrest, MR, PE, GI bleeds, Anemia, and
Vulvar squamous cell carcinoma that was recently discharged from
[**Hospital1 18**] for pneumonia and treated with a complete dose of
antibiotics, that began to have watery diarrhea for five days,
developed fevers, chills, and abdominal pain. Pain is diffuse,
nonfocal, [**7-28**], and not associated with nausea or vomiting.
.
CC: Transfer from surgery service with diarrhea
.
HPI: 69 female with MMP including ESRD on HD, HIV (cd4 940
[**7-23**], on HAART), CAD s/p MI, CHF, COPD presents to our service
for continued treatment of medical conditions and diarrhea.
Briefly, she was admitted on [**12-12**] with fever chills and
abdominal pain one week after being discharged on
vanco/levo/flagyl for pneumonia. She reports increasing
frequency of BM and worsening abdominal pain. She had F/C at
home, but was free of them since being in hospital. She also
had episodes of chest pain while at rest at hemodialysis.
Cardiology was consulted twice. THe first episode was associated
with a troponin elevation, thought to be due to demand ischemia
in the setting of going into AF. The second episode of
substernal burning was releived with maalox, and felt to be very
atypical for ischemic chest pain. She has also been followed by
infectious disesase for a fairly resistant diarrhea, with the
only positive micro data being positive c.dif. The diarrhea was
watery, and is slowly improving.
.
She currently is feeling well, with much less abdominal pain and
slowing frequency of bowel movements. She had 3 BM two days
ago, 2 BM yesterday, and 1 BM thus far today (more formed). She
has been treated with flagyl, PO vanco, and cholestyramine. She
was admitted with a WBC of 23K, and now is 11K. Her hematocrit
has remained stable in mid 30s. She has been persistently
elevated. Her INR was supratherapeutic on admission (on
warfarin for h/o DVT with PE) at 10. Her warfarin was restarted
now. She currently denies F/C/NS, occasional cough, no
abdominal pain. SHe has occasional nausea that responds to
anzemet.
Past Medical History:
Past Medical History:
1. CAD s/p NSTEMI [**5-19**], s/p PTCA/stent LCX [**2113**]. Latest
catheterization in [**10-21**] with 2-vessel disease. Persantine MIBI
[**4-22**] without symptoms or EKG changes. MIBI images significant
for severe fixed inferior defect, EF 58%.
2. DM type 2, on NPH.
3. HIV, last CD4 count 940 in [**7-/2115**]
4. ESRD on HD since '[**10**] (M, W, F)
5. CHF, with mixed systolic (EF 45-50%) and diastolic
dysfunction.
6. Severe mitral regurgitation [**2115-6-20**]
7. History of RUL segmental PE in [**11/2114**], on coumadin
([**2114-12-5**]) D/C'd in 06/[**2115**].
8. Recently diagnosed right popliteal DVT [**7-/2115**], restarted on
Coumadin
9. H/o multiple AVF clots, s/p thrombectomies, last in [**2115-1-8**]
9. H/o GIB in the setting of coagulopathy and NSAIDs
10. Eosinophilic pneumonia diagnosed [**4-22**], on chronic
prednisone therapy.
11. Anemia [**2-20**] CRF
12. Vulvar intraepithelial neoplasia diagnosed in [**2113-4-18**].
13. COPD with PFTs with FVC 0.69 (27%), FEV1 0.46 (24%),
FEV1/FVC 92%.
14. History of positive Galactomannan antigen
15. RUL nodules on CT, not FDG avid on PET on [**8-20**]. Etiology
unclear.
16. Vulvar squamous cell carcinoma in situ.
Social History:
Recently was at the [**Hospital **] rehab. Lives in [**Location 686**] with her
daughter. [**Name (NI) **] EtOH. Ex-smoker (60 pack-year smoking history)
Family History:
Non-contributory
Physical Exam:
At admission:
VS - T-100.4, HR-80, BP-95/60, RR-16, Sat 99%RA
GEN: A&O x 3, in NAD
ABD: Soft, diffusely tender, minimal guarding without
localization. Patient has guiac positive stools
.
on transfer
.
VS- afebrile 110/80 80s comfortable on room air
GEN- sitting in chair, talking to daughter. NAD.
[**Name2 (NI) 4459**]- no pallor, MMM, OP clear, poor dentition
NECK- supple, no JVP appreciated
CV- RRR, soft II/VI HSM at apex, distant heart sounds.
CHEST- Wheezes bilaterally, otherwise clear
ABD- obese, soft, NT, pos normoactive BS
EXT- dry skin, no edema. Open sore on left shin.
NEURO- AAOx3, MAEW, no focal findings
SKIN- Dry on extremities
Pertinent Results:
[**2115-12-12**] 02:00PM PLT COUNT-220
[**2115-12-12**] 02:00PM NEUTS-81* BANDS-0 LYMPHS-13* MONOS-6 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2115-12-12**] 02:00PM WBC-23.9*# RBC-2.96* HGB-11.3* HCT-36.0
MCV-122* MCH-38.2* MCHC-31.4 RDW-20.1*
[**2115-12-12**] 02:00PM TOT PROT-5.9*
[**2115-12-12**] 02:00PM LIPASE-9
[**2115-12-12**] 02:00PM ALT(SGPT)-11 AST(SGOT)-12 ALK PHOS-92
AMYLASE-47 TOT BILI-0.3
[**2115-12-12**] 02:00PM GLUCOSE-111* UREA N-39* CREAT-7.4*#
SODIUM-144 POTASSIUM-3.3 CHLORIDE-96 TOTAL CO2-29 ANION GAP-22*
[**2115-12-12**] 02:12PM LACTATE-2.2*
[**2115-12-12**] 06:30PM URINE WBCCLUMP-OCC
[**2115-12-12**] 06:30PM URINE RBC-[**6-28**]* WBC-[**12-8**]* BACTERIA-RARE
YEAST-NONE EPI-0-2
[**2115-12-12**] 06:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-MOD
[**2115-12-12**] 06:30PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.013
[**2115-12-12**] 11:15PM PLT COUNT-202
[**2115-12-12**] 11:15PM WBC-24.9* RBC-2.60* HGB-10.1* HCT-30.6*
MCV-117* MCH-38.6* MCHC-32.9 RDW-20.2*
[**2115-12-12**] 11:42PM freeCa-1.03*
[**2115-12-12**] 11:42PM O2 SAT-98
[**2115-12-12**] 11:42PM GLUCOSE-341* K+-3.7
[**2115-12-12**] 11:42PM TYPE-ART PO2-105 PCO2-45 PH-7.40 TOTAL CO2-29
BASE XS-1
CT C/A/P [**12-13**] - 1. Interval development of bowel wall edema
affecting the entire length of the colon with peri-colic
stranding consistent with pan-colitis. In the setting of
prolonged antibiotic use, this is suspicious for Clostridium
difficile / pseudomembranous colitis. No pneumatosis or portal
venous gas is seen. No extraluminal air or free air is seen.
2. Interval improvement with residual opacity in previously
demonstrated multilobar patchy opacities.3. Persistent
spiculated right upper lobe focus that measures smaller in size
compared to the previous exam.
4. Intrahepatic biliary ductal dilatation. 5. Bilateral
low-attenuation renal lesions that are too small to
characterize.6. Possible tiny low-attenuation lesion in the
uncinate process of the pancreas that is probably unchanged
compared to the previous exam
CXR [**12-12**] - Right perihilar ill defined paranchymal opacity; ?
infectious, ? neoplastic
Brief Hospital Course:
Patient admitted to hospital electively on [**12-12**] for watery
diarrhea and possible operative intervention based on patient's
prednisone usage. Patient was started on empiric flagyl and
serial abdominal exams, while obtaining a CT scan whose results
are mentioned above. Patient was admitted to the ICU for her h/o
PEA, and WBC of 24.9 concerning for possible bowel/colitis
rupture. Renal was consulted to manage the patients dialysis
needs, ID was consulted to manage her colitis, and cardiology to
r/o possible MI. Patient felt much improved by HD2, cardiology
supported her beta blockade administration and felt no
antiarrhythmic was warranted. ID recommended vancomycin
empirically while sending three stool studies for c.diff toxin
and stool cultures. By HD4, patient's abdomen was soft and
nontender, but etiology not yet determined, and diarrhea
episodes continued. ID recommended oral vancomycin
administration and no flagyl. Cardiology felt patient's
elevated Troponins were the result of demand ischemia and not an
acute coronary event. Patient was allowed to advance diet as
tolerated but maintained on PO vanco for 14 day total course.
Patient continued to have numerous, nonbloody bowel movements.
On HD 7 while obtaining HD, the patient had episode of CP for
which and EKG was obtained and reviewed by cardiology and did
not reveal st changes, and did not warrant a change in
management. Patient was restarted on her coumadin on HD7, as
well as flagyl to synergistically cure the c.diff colitis.
Patient began to note some interval improvement on the dual
regimen, with more formed stools beginning to pass. On [**12-20**] the
surgical team started cholestyramine as a third [**Doctor Last Name 360**], and
consulted medicine to take over care of the patient, as she was
no longer a surgical candidate and instead needed outpatient
follow-up. She was transferred to the medicine service on [**12-21**]
with their addendum to follow
.
DIARRHEA: On medicine her diarrhea continue to improve. The
flagyl, vancomycin, and cholestyramine were continued. IV
fluids were assessed daily and given to keep up with her stool
output. The BMs began to be more infrequent and more formed.
She had LLQ pain on transfer, but that quickly got better
without any intervention. It was felt much of the pain and
leukocytosis was in part due to the c.dif colitis. She was
discharged to complete two more weeks of flagyla and PO
vancomycin. The cholestyramine was stopped.
.
CAD: Has had sevearl episodes of chest pain during admission,
and given history these are a bit concerning. Will continue to
treat her heartburn with PPI (watch in case this is contributing
to diarrhea). Continued her cardiac regimen of ASA, statin, BB.
Will get another set of enzymes in the morning and ECG to
follow trend. Even though she is ESRD, she still had an
elevation, likely in the stting of a rapid rate while she was on
surgical service. Continued to monitor. She had one episode of
CP while on medical service, which was accompanied with bitter
taste in mouth and felt to be likely [**2-20**] gerd. PPI was
continued, and maalox was given (and then held [**2-20**] ESRD). She
did have one episode of hypotension, which was transient to
78/38, and quickly improved to 92/48 without any intervention.
.
DM2: Continued RSSI, NPH [**Hospital1 **].
.
CHF: Appears euvolemic on exam. Will continue BB and monitor
i/o's very closely with hemodialysis.
.
HIV/AIDS: Will continue current OP regimen of prednisone,
zidovudine, neviarapine, lamivudine, with PCP [**Name Initial (PRE) 1102**].
.
COPD: COntinued nebs. Slight wheezing on exam.
-no wheezing [**12-23**] in AM
.
ESRD: On HD MWF.
.
PPX: Bactrim, PPI, ambulating, eating, neutrophos.
.
DISPO: pending resolution of diarrhea and nausea.
.
CODE: full
Medications on Admission:
Bactrim 80-400, Prednisone 20', B-Complex, Zidovidine 200,
Nevirapine 200, Lamuvidine, colace, protonix, albuterol,
dilaudid, oxycontin, senna, spogen, coumadin, isordil,
metoprolol 25, ASA, lisinopril
Discharge Medications:
1. Prednisone 10 mg Tablet [**Month/Day (1) **]: One (1) Tablet PO DAILY (Daily).
2. Zidovudine 100 mg Capsule [**Month/Day (1) **]: Two (2) Capsule PO BID (2
times a day).
3. Nevirapine 200 mg Tablet [**Month/Day (1) **]: One (1) Tablet PO BID (2 times
a day).
4. Vancomycin 250 mg Capsule [**Month/Day (1) **]: One (1) Capsule PO Q6H (every
6 hours) for 14 days.
Disp:*56 Capsule(s)* Refills:*0*
5. Lamivudine 100 mg Tablet [**Month/Day (1) **]: 0.5 Tablet PO DAILY (Daily).
6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet [**Month/Day (1) **]: One (1)
Tablet PO QHD (each hemodialysis).
7. Aspirin 81 mg Tablet, Chewable [**Month/Day (1) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet [**Month/Day (1) **]: 0.5 Tablet PO TID (3
times a day).
Disp:*15 Tablet(s)* Refills:*2*
9. Simvastatin 40 mg Tablet [**Month/Day (1) **]: One (1) Tablet PO DAILY
(Daily).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Month/Day (1) **]: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Albuterol 90 mcg/Actuation Aerosol [**Month/Day (1) **]: Two (2) Puff
Inhalation Q 12H (Every 12 Hours).
12. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device [**Month/Day (1) **]:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
13. Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
14. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet [**Telephone/Fax (3) **]: One
(1) Packet PO BID (2 times a day).
15. Warfarin 5 mg Tablet [**Telephone/Fax (3) **]: One (1) Tablet PO DAILY (Daily).
16. Flagyl 500 mg Tablet [**Telephone/Fax (3) **]: One (1) Tablet PO three times a
day for 14 days.
Disp:*42 Tablet(s)* Refills:*0*
17. Insulin Regular Human 300 unit/3 mL Insulin Pen [**Telephone/Fax (3) **]: One (1)
Subcutaneous as directed: sliding scale.
Discharge Disposition:
Home With Service
Facility:
Uphams Corner Home Care
Discharge Diagnosis:
Clostridium dificile colitis
End stage renal disease
Coronary artery disease
hypertension
HIV / AIDS
Discharge Condition:
Stable, ambulating, tolerating PO diet, afebrile
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
.
Continue to take all meications as prescribed.
.
If you experience worsening diarrhea, chest pain, difficulty
breathing, passing out, or any other concerning symptom, please
seek immediate medical attention.
.
Continue with your hemodialysis
Followup Instructions:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2116-9-17**] 1:15
Dr. [**Last Name (STitle) **] on Tuesday [**2115-12-31**] at 2:50pm
|
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icd9cm
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239, 270
|
342, 2485
|
2529, 3713
|
3729, 3885
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,203
| 141,997
|
43647
|
Discharge summary
|
report
|
Admission Date: [**2163-5-16**] Discharge Date: [**2163-5-28**]
Service: MEDICINE
Allergies:
Lisinopril / Trileptal
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
CBD stones
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
Pt is a [**Age over 90 **] yo F with h/o CAD, HTN, CHF, hypercholesterolemia,
pernicious anemia, depression/anxiety, dysphagia, presented to
CCH with right-sided abd pain. No n/v. + diarrhea x 1 week.
Pain increases with po intake. Pt found to have dilated
intra/extrahepatic ducts with CBD stones. Pt received 2 units
PRBCs for anemia. Also found to have e.coli UTI, started on
unasyn. ERCP was unsuccessful at OSH and transferred for ERCP.
Past Medical History:
1. CAD, s/p MI [**2155**] adn [**2162**], angioplasty
2. CHF
3. HTN
4. Depression/anxiety
5. Pernicious anemia- receives B12 injection monthly
6. s/p ccy
7. home O2
8. hypercholesterolemia
9. dysphagia
10. post-herpatic neuralgia RUE s/p epidural injection for this
11. GIB
12. UTI
13. Shingles
Social History:
Lives with her son. [**Name (NI) **] tobacco/ETOH/IVDA.
Family History:
NC
Physical Exam:
ADMISSION EXAM
Vitals- 97.7, BP 107/60, HR 73, RR 26, 97% 2L O2
GEN: awake, alert; oriented to place, hospital. does not know
year. preseverating speech 'help me please'
HEENT: EOMI. OP clear
NECK: JVP 10cm
LUNGS: bibasilar rales, velcro crackles
CV: RRR. I/VI apical M
ABD: soft, diffuse epigastric tenderness w/o rebound or
guarding, NABS
EXT: no c/c/e. scd's in place
NEURO: as above. moving all extremities, poor compliance with
exam, but follows simple commands. speech fluent.
Pertinent Results:
[**2163-5-16**] DIFFICULT CROSSMATCH AND/OR EVALUATION OF IRREGULAR
ANTIBODIES: Ms. [**Known lastname **] has a new diagnosis of an anti-E antibody.
E-antigen is a member of the Rhesus blood group system. Anti-E
antibody is clinically significant and is capable of causing
hemolytic transfusion reactions. In the future Ms. [**Known lastname **] should
receive E-antigen negative blood products for all transfusions.
Approximately 70% of otherwise ABO compatible units will be
E-antigen negative. A wallet card and a letter stating the above
information will be sent to the patient.
.
[**2163-5-17**] CXR: 1. Diffuse interstitial abnormality, whose
chronicity is unclear without comparison to old films.
2. Diffuse bony demineralization with possible compression
deformities of several thoracic vertebral bodies, chronicity
indeterminate.
3. Elevation of the right hemidiaphragm.
.
[**2163-5-17**] ECG: Sinus rhythm @ 81
Nonspecific precorial/anterior T wave abnormalities - cannot
exclude in part ischemia - clinical correlation is suggested
No previous tracing available for comparison
.
[**2163-5-17**] ERCP: Findings: Esophagus: Limited exam of the esophagus
was normal
Stomach: Limited exam of the stomach was normal
Duodenum: Limited exam of the duodenum was normal
Major Papilla: Normal major papilla
Cannulation: Cannulation of the pancreatic duct was successful
and superficial with a sphincterotome. Contrast medium was
injected resulting in partial opacification. The partial
pancreatogram was normal in appearance. Cannulation of the
biliary duct was successful and deep with a sphincterotome.
Contrast medium was injected resulting in complete
opacification.
Biliary Tree: Many irregular stones ranging in size from 2mm to
6mm that were causing partial obstruction were seen at the
common bile duct.
Procedures: A sphincterotomy was performed in the 12 o'clock
position using a sphincterotome over an existing guidewire.
Many, many pigmented gallstones were extracted successfully from
the CBD using a balloon catheter. The duct was clear at the end
of the procedure on occlusion cholangiogram.
Radiologic interpretation: Fluoro time: 8.1 min. The CBD
measured approx. 8 - 16mm. Filling defects in CBD were noted.
The intrahepatic ducts were normal.
Impression: Cannulation of the pancreatic duct was successful
and superficial with a sphincterotome. Contrast medium was
injected resulting in partial opacification. The partial
pancreatogram was normal in appearance. Cannulation of the
biliary duct was successful and deep with a sphincterotome.
Contrast medium was injected resulting in complete
opacification.
The CBD measured approx. 8 - 16mm. Filling defects in CBD were
noted. The intrahepatic ducts were normal.
Many irregular stones ranging in size from 2mm to 6mm that were
causing partial obstruction were seen at the common bile duct.
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
Many, many pigmented gallstones were extracted successfully from
the CBD using a balloon catheter. The duct was clear at the end
of the procedure on occlusion cholangiogram.
.
[**2163-5-16**] 08:30PM PT-12.1 PTT-26.5 INR(PT)-1.0
[**2163-5-16**] 08:30PM PLT COUNT-162
[**2163-5-16**] 08:30PM MACROCYT-1+
[**2163-5-16**] 08:30PM NEUTS-83.6* LYMPHS-10.4* MONOS-4.6 EOS-1.0
BASOS-0.3
[**2163-5-16**] 08:30PM WBC-9.3 RBC-3.42* HGB-11.5* HCT-33.5* MCV-98
MCH-33.7* MCHC-34.4 RDW-14.3
[**2163-5-16**] 08:30PM ALBUMIN-3.5 CALCIUM-9.3 PHOSPHATE-2.4*
MAGNESIUM-2.4
[**2163-5-16**] 08:30PM LIPASE-15
[**2163-5-16**] 08:30PM ALT(SGPT)-135* AST(SGOT)-41* ALK PHOS-118*
AMYLASE-26 TOT BILI-1.1
[**2163-5-16**] 08:30PM estGFR-Using this
[**2163-5-16**] 08:30PM GLUCOSE-122* UREA N-23* CREAT-0.8 SODIUM-145
POTASSIUM-4.0 CHLORIDE-110* TOTAL CO2-28 ANION GAP-11
Brief Hospital Course:
Brief summary:
Pt is a [**Age over 90 **] yo F with h/o CAD, HTN, CHF, hypercholesterolemia,
pernicious anemia, depression/anxiety, and dysphagia. She
initially presented with r-sided abd pain and diarrhea, and
underwent ERCP/sphincterotomy on [**5-17**] for CBD stone. She was
then transferred to the MICU for chest pain and afib with RVR.
Pt noted to be in clinical heart failure with BNP noted >70,000.
Seen by cardiology who recomended med mgt. Diuresed and
converted to NSR with dilt, beta blocker. She was transferred
back to the floor for further diuresis on [**2163-5-20**], and completed
a 7-day course of levo/flagyl post-ERCP. She remained stable in
NSR until [**5-24**], when she again went into Afib with RVR with
hypotension to the 80s, and was transferred back to the ICU.
She spontaneously converted into Sinus w/i 8 hours and BP
stabilized.
.
Problem list:
.
# Afib: Recurrent episodes, s/p two ICU admissions. Pt need
atrial kick to maintain BP. She was started on digoxin 0.125
every other day, as well Metoprolol for rate control. Metoprolol
was titrated up to 25mg TID. Of note, she was on Correg as an
outpatient (3.125 [**Hospital1 **]), and can discuss changes in her b-blocker
with her outpatient physicians. She should discuss long-term
anti-coaggulation with her physician.
.
# CHF - EF 35% and Echo was suggestive of diastolic dysfunction
as well. BNP was >70,000 and exam revealed volume overload. She
was diuresed with IV lasix. Her final lasix dose is 20mg [**Hospital1 **].
She was placed on metoprolol as above. ACE-I causes fatigue per
family report, but she should discuss starting an angiotensive
receptor blocker with her outpatient physician.
.
# Ischemia/Chest Pain - Medical management recommended by
Cardiology. She was continued on aspirin, b-blocker, and
statin. She should consider [**Last Name (un) **] as an outpatient.
.
# Biliary obstruction/CBD stones: ERCP performed on [**2163-5-17**] (Dr.
[**Last Name (STitle) **] w/ sphincterotomy and removal of multiple pigmented
stones. Completed 7 days of levo/flagyl.
.
# Chronic lung disease: nature unclear, but on 2L O2 at baseline
at home. CXR here with diffuse interstitial process. After
diuresis, she was satting well (>98%) on rooom air. She may
require home O2 in the future.
.
# Post-herpetic neuralgia (chronic right arm pain): On fentanyl
TP (changed every FIVE days), dilaudid prn, and Cymbalta.
.
# PPx: hep sq
.
# Code: DNR/DNI
Medications on Admission:
MEDICATIONS AT HOME:
1. Fentanyl patch 25 mcg changed subcutaneously q 72 hr.
According to the dtr, she has been changing it q 5 days because
it was making her sedated and confused.
2. Cymbalta 30 mg [**Hospital1 **]
3. Coreg 3.125 mg [**Hospital1 **]
4. Lasix 40 mg po qam
5. Lasix 20 mg po q noon
6. Zocor 20 mg daily
7. Nexium 40 mg daily
8. Magnesium 400 mg daily
9. Ambien 5 mg po qhs
10. Ferrous sulfate 325 mg po daily
11. Potassium 99 meq po daily OTC
12. ASA 81 mg daily
13. Vit. B12 injection once monthly
14. Glycol powder in [**Location (un) 2452**] juice every morning
15. Albuterol neb q2-4h prn SOB/wheezing
16. pt taking advil daily for the last few days
17. dilaud 2 mg po q6h prn pain for her postherpetic neuralgia
.
MEDICATIONS AT OSH:
1. Albuterol neb q2h prn
2. Ambien 5 mg qhs prn
3. ASA 81 mg daily - on hold
4. Coreg 3.125 mg [**Hospital1 **]
5. Cymbalta 30 mg [**Hospital1 **]
6. Dilauidid 2 mg IV q2h prn
7. Fentanyl patch 25 mcg transdermal, change q 5 days
8. Protonix 40 mg daily
9. Tylenol 650 mg q4-6 h prn
10. Unasyn 3g q12h
11. Zocor 20 mg po qpm
Discharge Medications:
1. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q 5 DAYS ().
Disp:*30 days supply* Refills:*0*
2. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO BID (2 times a day).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) syringe
Injection TID (3 times a day).
8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day): Next dose [**2163-5-29**].
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Hydromorphone 2 mg Tablet Sig: 0.5-1 Tablet PO every [**6-17**]
hours as needed.
Disp:*60 Tablet(s)* Refills:*0*
12. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed for constipation. ML(s)
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
14. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day.
15. Albuterol 90 mcg/Actuation Aerosol Sig: [**1-11**] Inhalation
every four (4) hours as needed.
16. Potassium 99 mg Tablet Sig: One (1) Tablet PO once a day.
17. Magnesium 300 mg Capsule Sig: One (1) Capsule PO once a day.
18. Vitamin B12-Vitamin B1 100-1 mg/mL Solution Sig: One (1)
syringe Intramuscular once a month.
19. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
once a day.
Discharge Disposition:
Extended Care
Facility:
Cape [**Hospital **] Rehabilitation & Nursing Center - [**Location (un) **]
Discharge Diagnosis:
Primary:
1. Cholangitis
2. Atrial fibrillation with RVR
3. Congestive heart failure (EF =25%)
Discharge Condition:
stable
Discharge Instructions:
During this admission you were treated for bilary obstruction
with an ERCP which removed the gallstone and antibiotics, as
well as for atrial fibillation which caused your blood pressure
to be low.
We have changed some of your medications (see below). Please
continue to take all medications as prescribed.
Seek immediate medical care if you develop chest pain, shortness
of breath, palpatations, dizzyness/fainting or any other
concerning symptoms.
Followup Instructions:
Follow up with your PCP with in 1 week of leaving rehab. Call
for an appointment. [**Telephone/Fax (1) 69695**]
|
[
"427.32",
"574.51",
"272.0",
"458.29",
"496",
"281.0",
"300.00",
"412",
"428.30",
"053.19",
"E944.4",
"414.01",
"428.0",
"576.1",
"311",
"427.31",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.88",
"51.85"
] |
icd9pcs
|
[
[
[]
]
] |
10860, 10962
|
5515, 6380
|
241, 247
|
11099, 11107
|
1654, 5492
|
11608, 11723
|
1131, 1135
|
9100, 10837
|
10983, 11078
|
7995, 7995
|
11131, 11585
|
8016, 9077
|
1150, 1635
|
191, 203
|
275, 723
|
6394, 7969
|
745, 1041
|
1057, 1115
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,090
| 138,877
|
53417
|
Discharge summary
|
report
|
Admission Date: [**2137-11-15**] Discharge Date: [**2137-11-25**]
Date of Birth: [**2061-4-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Amiodarone / Monosodium Glutamate
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Readmitted with fevers and seizures
Major Surgical or Invasive Procedure:
[**2137-11-16**] Ultrasound-guided percutaneous cholecystostomy tube
placement
History of Present Illness:
This is a 76 year old male who [**Month/Day/Year 1834**] replacement of the
entire ascending aorta and total arch with multibranched Dacron
graft in [**2137-10-3**]. His post-operative course was complicated
by seizures, initially with no clear etiology. He concomitantly
spiked fevers, and was found to have bacteremia with E. faecalis
(pan-sensitive) and treated appropriately with intravenous
antibiotics. Brain imaging revealed no acute process, and
seizures improved on antiepileptics and antibiotics, with mental
status gradually improving towards the end of his admission. He
was eventually discharged to ECF on [**2137-11-11**] on trach collar on
CPAP, off antibiotics. While at rehab, his ventilatory
requirements increased while he spiked a fever up to 103.4F,
with witnessed seizures, and acute renal insufficiency. Blood
cultures grew out CONS while urine culture grew out Proteus and
E. coli. He was subsequently started on Vancomycin and Zosyn,
and transferred back to the [**Hospital1 18**] for further care.
Past Medical History:
Seizure disorder after cardiac surgery
paroxysmal Atrial Fibrillation
s/p replacement aortic arch, resuspension of aortic valve,
coronary artery bypass graft x1- [**2-6**]
s/p replacement of ascending aorta and coronary artery bypass
graft x 1 - [**2137**]
diverticulosis
hyperlipidemia
benign prostatic hypertrophy
s/p permanent pacemaker implantation
hypertension
Social History:
He is married with three grown children. He does not smoke and
drinks occasionally. He is an art representative for the [**Hospital1 **]
Market.
Family History:
Noncontributory
Physical Exam:
ADMISSION:
Pulse:68 Resp:19 O2 sat: 96
B/P L:91/41
Height: 5'[**39**]" Weight: 203 lbs
General: Elderly male, lying in bed, non-responsive to voice
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X] trach collar, site clean,dry,
intact
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X] ventral hernia [X]G to J tube, insertion site clean dry and
intact
Extremities: Warm [X], well-perfused [X] Edema U and Lower
extremities bilaterally 2+, PICC right arm
None [X] left thigh saph. vein harvest site incision well-healed
Neuro: Blinks spontaneously but not to command, attempts to
speak
when asked questions, not moving extremities, winces to painful
stimuli
Pulses:
Femoral Right/Left: 2+
DP Right/Left: 2+
PT [**Name (NI) 167**]/Left: 2+
Radial Right/Left: 2+
Skin: mediastinal incision clean/dry/intact. sternum stable.
left upper medial arm with ulcer
Pertinent Results:
[**2137-11-15**] WBC-20.2*# RBC-1.95*# Hgb-5.9*# Hct-18.1*# MCV-93
MCH-30.0 MCHC-32.5 RDW-16.5* Plt Ct-245
[**2137-11-15**] PT-20.0* PTT-48.8* INR(PT)-1.8*
[**2137-11-15**] Glucose-107* UreaN-58* Creat-2.5*# Na-138 K-5.3* Cl-103
HCO3-25 AnGap-15
[**2137-11-15**] ALT -51* AST-60* LD(LDH)-314* AlkPhos-83 Amylase-115*
TotBili-1.5
[**2137-11-15**] Albumin -2.9* Calcium-7.7* Phos-4.7* Mg-2.3
[**2137-11-15**] Vanco -23.7*
[**2137-11-15**] Phenobarb -8.6*
[**2137-11-25**] 04:45AM BLOOD WBC-5.8 RBC-3.13* Hgb-9.2* Hct-28.4*
MCV-91 MCH-29.6 MCHC-32.6 RDW-16.6* Plt Ct-360
[**2137-11-25**] 04:45AM BLOOD Plt Ct-360
[**2137-11-25**] 04:45AM BLOOD PT-24.5* PTT-81.4* INR(PT)-2.3*
[**2137-11-25**] 04:45AM BLOOD Glucose-111* UreaN-25* Creat-1.0 Na-139
K-4.6 Cl-101 HCO3-29 AnGap-14
[**2137-11-25**] 04:45AM BLOOD TotBili-0.4
[**2137-11-20**] 02:17AM BLOOD ALT-70* AST-76* LD(LDH)-243 AlkPhos-268*
Amylase-82 TotBili-0.9
[**2137-11-20**] 02:17AM BLOOD Lipase-113*
[**2137-11-21**] 06:20AM BLOOD Vanco-17.0
[**2137-11-23**] 03:21AM BLOOD Phenoba-10.5 Phenyto-6.7*
[**2137-11-15**] Portable Chest X-ray:
In comparison to the previous chest radiograph of [**2137-11-11**], the small-to-moderate layering left pleural effusion with
left lower lobe atelectasis is unchanged. No newly developed
areas of consolidation or right pleural effusion. Tracheostomy
tube and cardiac pacing wires are unchanged in position. Slight
widening of the superior mediastinum is stable.
[**2137-11-16**] RUQ Ultrasound:
Gallbladder wall thickening and pericholecystic fluid. While
these findings can be seen in liver disease, in the appropriate
clinical setting, this may represent acute cholecystitis.
[**2137-11-16**] Chest/Abd CT Scan:
1. Markedly distended gallbladder containing stones, with wall
thickening and pericholecystic fluid, concerning for acute
cholecystitis. 2. Stable appearance of the chest with
post-surgical changes from ascending aortic repair and small
bilateral pleural effusions and consolidation. 3. Left inguinal
hernia containing a small amount of sigmoid colon, without
evidence of bowel obstruction.
[**2137-11-19**] Transesophogeal Echocardiogram:
The left atrial appendage emptying velocity is depressed
(<0.2m/s). No atrial septal defect is seen by 2D or color
Doppler. Overall left and right ventricular systolic function
cannot be reliably assessed due to limited views (no gastric
views obtained due to known hernia). A mobile linear flat is
seen in the descending aorta, consistent with an intimal
flap/aortic dissection, which was visualized at 40cm from the
incisors up to to the aortic arch. The laortic arch to the
ascending aorta was not well visualized. The aortic valve
leaflets (3) are mildly thickened with no masses or vegetations
seen. There are filamentous strands on the aortic leaflets
consistent with Lambl's excresences (normal variant). Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened with no mass or vegetation seen. Mild (1+)
mitral regurgitation is seen. No masses or vegetations are seen
on the tricuspid valve. No masses or vegetations are seen on the
pulmonic valve. A wire is seen in the right atrium entering the
right ventricle without any evident masses or vegetations.
CHEST (PORTABLE AP) Study Date of [**2137-11-22**] 7:24 AM
Final Report
INDICATION: Status post aortic valve replacement.
COMPARISON: Recent chest radiograph from [**2137-11-20**].
In comparison to the recent chest radiograph, there has been no
significant change in the retrocardiac left lung base opacity
and the associated small left pleural effusion. The right
pleural surfaces are smooth without evidence of pleural
effusions or pneumothorax. There is stable postoperative
widening of the superior mediastinum unchanged since the prior
study. The cardiac size is mildly enlarged and stable since the
prior study. There is interval improvement in the pulmonary
vascular congestion.
Mildly twisted configuration of the tracheostomy tube is noted,
assessment of the tracheostomy tube position may be helpful. The
tube tip is positioned appropriately at a distance of about 7 cm
from the carina.
IMPRESSION:
1) No significant interval change in the left retrocardiac lobe
opacity, most likely representing atelectasis and unchanged
small left pleural effusion.
2) Mildly twisted position of the tracheostomy tube,
re-assessing the
tracheostomy tube position may be helpful.
The study and the report were reviewed by the staff
radiologist.
DR. [**First Name (STitle) 17414**] [**Name (STitle) 17415**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: FRI [**2137-11-22**] 8:47 PM
Brief Hospital Course:
Mr. [**Known lastname 656**] was admitted to the CVICU, and pan-cultures were
obtained. Due to hypotension, he was initially maintained on
Phenylephrine and Vasopressin. He was also started on Esmolol
gtt for rapid atrial fibrillation. The ID service was consulted
and initially recommended broadening antibiotic therapy. Work-up
was notable for rapidly rising bilirubin. Imaging studies were
consistent with acute cholecystitis for which an
ultrasound-guided percutaneous cholecystostomy tube was placed
without complication.
A sample of the bile was sent for culture and which eventually
grew coagulase negative staph.. Sputum culture eventually grew
out Serratia (chronic)for which 8 day course of Cefepime was
completed. The ID service recommended a 6 week course of
Vancomycin for bacteremia in the setting of a new aortic root
graft.
His anticonvulsants were titrated by the neurology service and
his cardiac medications also adjusted to optimize his clinical
status. He will be readmitted in [**4-10**] weeks for cholecystectomy.
He was discharged back to rehabilitation for further recovery.
Medications on Admission:
Vancomycin 1000 mg IV Q 24H
CefePIME 1 g IV Q12H
Nystatin Oral Suspension 5 mL PO QID
Acetaminophen 325-650 mg PO/NG Q4H:PRN pain
PHENObarbital 30 mg PO/NG TID
Albuterol-Ipratropium [**1-4**] PUFF IH Q6H
Tears Preserv. Free 1-2 DROP BOTH EYES Q6H
Phenylephrine 0.5-5 mcg/kg/min IV DRIP INFUSION
Aspirin 81 mg PO/NG DAILY
Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
Propofol 5-20 mcg/kg/min IV DRIP INFUSION
Ranitidine (Liquid) 150 mg PO/NG DAILY
Senna 1 TAB PO/NG [**Hospital1 **]
Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL [**Hospital1 **]
Simvastatin 10 mg PO/NG DAILY
Docusate Sodium (Liquid) 100 mg PO/NG [**Hospital1 **]
Terazosin 1 mg PO HS
Dronedarone 400 mg PO/NG [**Hospital1 **]
Vasopressin 2.4 UNIT/HR IV DRIP TITRATE TO sbp>90
LeVETiracetam 1000 mg PO/NG [**Hospital1 **]
Lorazepam 1-2 mg IV Q4H:PRN seizure activity
Warfarin MD to order daily dose PO/NG DAILY16
Metoprolol Tartrate 150 mg PO/NG [**Hospital1 **]
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Acetaminophen 325 mg Tablet Sig: 650 mg Tablets PO Q4H (every
4 hours) as needed for pain.
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Dronedarone 400 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-4**]
Drops Ophthalmic Q6H (every 6 hours).
6. Phenobarbital 20 mg/5 mL Elixir Sig: Thirty (30) mg PO TID (3
times a day).
7. Ranitidine HCl 15 mg/mL Syrup Sig: One [**Age over 90 1230**]y (150) mg
PO DAILY (Daily).
8. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
10. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day).
11. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**6-10**]
Puffs Inhalation Q4H (every 4 hours) as needed for for wheezing.
14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. Warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY
(Daily): Target INR 2.5-3.0
7.5 mg for [**11-25**].
16. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: as directed
below ML Intravenous PRN (as needed) as needed for line flush:
Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
17. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gm Intravenous Q 24H (Every 24 Hours): to continue thru [**12-16**].
18. Dilantin-125 125 mg/5 mL Suspension Sig: One Hundred (100)
mg PO three times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Sepsis/Bacteremia
Acute Cholecystitis
Seizure disorder after cardiac surgery
paroxysmal Atrial Fibrillation
s/p replacement aortic arch, resuspension of aortic valve,
coronary artery bypass graft x1- [**2-6**]
s/p replacement of ascending aorta and coronary artery bypass
graft x 1 - [**2137**]
diverticulosis
hyperlipidemia
benign prostatic hypertrophy
s/p permanent pacemaker implantation
hypertension
Discharge Condition:
Stable
Discharge Instructions:
Keep wounds clean and dry, OK to shower no bathing.
Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
Report any temperature greater then 100.5.
Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1
week.
Shower daily. Wash incisions with soap and water.no swimming or
baths.
No lotions, creams or powders to incisions for 6 weeks.
No driving for 1 month andtaking narcotics.
No lifting greater then 10 pounds for 10 weeks from date of
surgery.
Take all medications as directed.
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1728**] in [**2-5**] weeks ([**Telephone/Fax (1) 14148**])
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in 6 weeks (Gen [**Doctor First Name **] for chole tube)
Dr [**Last Name (STitle) **],[**Name8 (MD) **] MD in 2 weeeks (Infectious disease)
Dr [**First Name8 (NamePattern2) 10733**] [**Last Name (NamePattern1) 12536**]/Dr [**Last Name (STitle) **] [**Name (STitle) 851**](Neurology)in 1 month
call [**Telephone/Fax (1) 26609**] to schedule
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2137-12-3**]
10:00
Provider: [**First Name8 (NamePattern2) 6118**] [**Last Name (NamePattern1) 6119**], RN,MS,[**MD Number(3) 1240**]:[**Telephone/Fax (1) 1971**]
Date/Time:[**2138-3-7**] 10:00
Weekly Dilantin/Keppra level results to [**Hospital 878**] clinic (Keppra
goal [**10-13**]/Dilantin goal [**6-9**])
Weekly vanco levels, CBC,LFT's-results to [**Hospital **] clinic
Completed by:[**2137-11-25**]
|
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"550.90",
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"428.0",
"345.90",
"272.4",
"359.81",
"041.6",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"88.72",
"96.72",
"51.02",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
11840, 11906
|
7829, 8933
|
336, 416
|
12354, 12363
|
3113, 7806
|
12941, 14047
|
2041, 2058
|
9920, 11817
|
11927, 12333
|
8959, 9897
|
12387, 12918
|
2073, 3094
|
261, 298
|
444, 1470
|
1492, 1860
|
1876, 2025
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,069
| 165,068
|
13353
|
Discharge summary
|
report
|
Admission Date: [**2139-3-3**] Discharge Date: [**2139-3-7**]
Date of Birth: [**2075-5-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Found unresponsive
Hematemesis
Odynophagia
Major Surgical or Invasive Procedure:
EGD - esophagogastroduodenoscopy
History of Present Illness:
63 year-old man with a history of alcohol abuse, emphysema,
presenting from home with a few days of hemoptysis vs.
hematemesis brought in after syncopal episode at home. He states
he was in his usual state of health until two days prior to
presentation, when he developed malaise and cough. Cough was
initially productive of white sputum, which turned dark
yesterday. This morning he produced bright red blood - it is
unclear if this was hemoptysis or hematemesis. He states he
attributes it to sputum because it was small in quality, but
does endorse wretching with vomiting (patient somewhat unclear
historian regarding this). His wife states more clearly that he
had several wretching and vomiting episodes.
He recalls getting up to cough vs. vomit blood, and then passed
out. Remembers then being in ambulance on way to OSH. Wife
apparently found him in bathroom, unclear how long he was down.
Per patient's wife, patient's best friend died on Saturday and
he had a large drinking binge on Saturday. He normally drinks 2
liters of liquor a week at least, plus extra vodka in between.
He then stopped drinking completely since Saturday ([**2139-2-28**]).
She noticed he had been vomitting profusely with large amounts
of frequent wretching. On [**2139-3-2**], the pt developed a cough.
Then on [**2139-3-3**] the patient began to vomit blood and later cough
up blood. The same day the wife heard a loud thump and scream
from his husband while in the bathroom. She went upstairs to
find him "shaking all over". She thinks he was having a seizure.
He was unresponsive, moving all four extremities in a rhythmic
shaking pattern. No bowel/bladder incontinence. This episode
lasted 1-2 minutes. After he stopped shaking he was still
unresponsive for 10-20 minutes. He finally started coming to in
the ED, about 1.5 hours later.
He was brought to an outside hospital. Nasogastric lavage was
attempted but nasogastric tube was not successfully placed. Hct
was 42. Reportedly guaiac positive. Received antiemetics and
potassium. He was transferred to [**Hospital1 18**] for further care.
In the [**Hospital1 18**] ED, initial vs were: T 98.2, HR 133, BP 138/76, RR
22 98% 2L. Continued to have sinus tach throughout stay. ECG
unremarkable otherwise. Patient was given vancomycin 1g, zosyn,
pantoprazole 80 mg, lorazepam 4 mg, banana bag. CTA negative for
PE. Was guaiac negative here. Admitted to MICU given unclear how
stable patient was from bleeding/respiratory standpoint.
Past Medical History:
- Pleural asbestos related disease - pleural calcifications and
scarring seen on radiology. Also reports having had asbestos
related pleural effusion in past.
- COPD/emphysema. Significant disease by imaging, unknown PFTs.
- Skin cancers of face and chest (presumed nonmelanoma but not
entirely clear)
- EtOH abuse
- s/p umbilical hernia repair.
Social History:
Alcohol abuse as above; reports drinking [**3-19**] very large rum and
cokes daily, none since Saturday/Sunday binge. Smokes 1 PPD x
many years, more at times and has quit at other times. Previous
asbestos exposure working in a shipyard. Lives with wife.
Family History:
Brother died of cirrhosis, other brother with lung cancer.
Mother had question of colon cancer.
Physical Exam:
Tmax: 37.7 ??????C Tcurrent: 37.3 ??????C HR: 110 BP: 113/46 RR: 21
SpO2: 100%
General: Alert, oriented, appropriate, no distress.
HEENT: Sclera anicteric, PERRL, MM slightly dry, oropharynx
clear
Neck: in hard collar, JVP not obviously elevated but difficult
to appreciate under collar, no LAD
Lungs: Diminished throughout with prolonged expiratory phase, no
wheezing or crackles.
CV: tachy, regular, no murmurs, rubs, gallops appreciated.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, no clear
ascites.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: alert, oriented x 3, CN II-XII intact, strength 5/5 in
UEs and LEs.
Pertinent Results:
Admission Labs:
[**2139-3-3**] 09:25AM WBC-5.1 RBC-4.22* HGB-14.0 HCT-40.9 MCV-97
MCH-33.1* MCHC-34.2 RDW-16.0*
[**2139-3-3**] 09:25AM NEUTS-92.0* LYMPHS-5.8* MONOS-1.7* EOS-0.2
BASOS-0.4
[**2139-3-3**] 09:25AM PLT SMR-VERY LOW PLT COUNT-59*
[**2139-3-3**] 09:25AM PT-12.0 PTT-24.1 INR(PT)-1.0
[**2139-3-3**] 09:25AM GLUCOSE-117* UREA N-25* CREAT-1.1 SODIUM-137
POTASSIUM-2.9* CHLORIDE-96 TOTAL CO2-21* ANION GAP-23*
[**2139-3-3**] 09:25AM ALT(SGPT)-18 AST(SGOT)-72* CK(CPK)-1407* ALK
PHOS-112 TOT BILI-1.1
LIPASE-590 --> 178
ALBUMIN-4.7 CALCIUM-9.1 PHOSPHATE-1.1* MAGNESIUM-1.7
THEOPHYL-25.2*
cTropnT-0.09* --> .07 --> .07
CK-MB-21* MB INDX-1.5
Serial Hct: 40 (believed hemoconcentrated) -> 29-31 range,
stable
[**2139-3-3**] CT CHEST/AB/PELVIS
CHEST: There is no evidence of pulmonary embolism or acute
aortic process. The heart is normal in size and shape. No
lymphadenopathy is seen. The airway is centrally patent. There
is diffuse thickening of the esophagus, which is more pronounced
distally. An underlying malignancy cannot be excluded. No
cardiophrenic lymphadenopathy is seen. There are small bilateral
pleural effusions. Pleural calcifications are also noted, which
is likely related to prior asbestos exposure.
Lung windows are notable for significant paraseptal and
centrilobular
emphysema. No definite nodule, mass, or consolidation is seen.
Prominent
diaphragmatic calcification along the pleural surfaces with
associated
scarring is noted.
ABDOMEN: Within segment IV of the liver, there are three
discrete liver
lesions, the largest of which measures approximately 3.1 x 3.2
cm with
peripheral enhancement and central low density concerning for
necrosis.
Overall, this appearance is concerning for metastatic lesion. A
second lesion abutting the left portal vein, best seen on series
2C, image 123 measuring approximately 2.4 x 1.3 cm. A third
lesion is seen abutting the liver capsule in segment IVB on
series 2B, image 136. There is no intrahepatic or extrahepatic
biliary ductal dilation. The gallbladder is normal. There is
trace free fluid inferior to the liver edge. The spleen appears
normal. A small hiatal hernia is noted. The stomach is mostly
collapsed. The pancreas appears atrophic without focal lesion or
ductal dilation. Adrenal glands appear grossly unremarkable
bilaterally. Kidneys enhance symmetrically. There is a tiny
hypodensity within the right kidney mid-upper pole of series 2B,
image 135, too small to accurately characterize. Bilateral
perinephric stranding is nonspecific. The abdominal aorta and
major branch vessels are widely patent with scattered
atherosclerotic calcifications noted. There is artial
duplication of the IVC merging at the level of the left renal
vein.
There is evidence of prior abdominal surgery with multiple clips
noted along the abdominal wall.
PELVIS: Small bowel demonstrates no evidence of ileus or
obstruction.
Colonic diverticulosis is noted without evidence of
diverticulitis.
Evaluation for colonic neoplasm is limited given the lack of
bowel distention.
There is no free fluid in the deep pelvis. The urinary bladder
is moderately
distended and appears unremarkable. The prostate gland measures
approximately
4.1 cm in transverse dimension and contains coarse
calcifications. There is
no pelvic or inguinal lymphadenopathy.
BONES: No worrisome lytic or sclerotic osseous lesion is seen.
IMPRESSION:
1. Three discrete liver lesions, with appearance concerning for
metastatic
disease. Given the peripheral location, the lesions would be
amenable to
percutaneous biopsy.
2. Diffuse thickening along the distal esophagus which in the
setting of
hematemesis require further evaluation by endoscopy.
3. Extensive paraseptal and centrilobular emphysema with
evidence of
asbestos-related disease of the pleura.
4. Colonic diverticulosis without evidence of diverticulitis.
5. No pulmonary embolism.
[**2139-3-3**] CT C-spine w/out contrast
FINDINGS: There is diffuse mild degenerative disease of the
cervical spine
with preservation of normal cervical lordosis. No fracture or
malalignment is
noted. There is no sugnificant neural foraminal narrowing or
evidence of
central canal encroachment. The visualized lung apices show
severe
paraseptal/centrilobular emphysema. Calcifications of the
carotid arteries
noted.
IMPRESSION:
1. No fracture or malalignment.
2. Severe paraseptal/centrilobular emphysema, better evaluated
on the
concurrent CT torso.
EGD [**2139-3-5**]
Esophagus:
Mucosa: Severe esophagitis with overlying white exudate
extending from approximately 23cm to the GE junction. Cold
forceps biopsies were performed for histology at the esophagus.
Stomach:
Mucosa: Patchy erythema and edema noted in the body and antrum
of the stomach. Cold forceps biopsies were performed for
histology at the stomach antrum. Cold forceps biopsies were
performed for histology at the stomach body.
Duodenum: Normal duodenum.
Impression: Esophagitis (biopsy)
Abnormal mucosa in the stomach (biopsy, biopsy)
Otherwise normal EGD to second part of the duodenum
Recommendations: PPI [**Hospital1 **]. Carafate slurry. Follow-up biopsies.
Brief Hospital Course:
63M with history of COPD/emphysema on theophylline, asbestos
exposure, EtOH abuse, presenting with hematemesis (and not
hemoptysis), syncopal episode.
# Hematemesis: By patient and wife's history consistent with
hematemesis (not hemoptysis). History of wretching, alcohol
abuse, and thickening of esophagus. Initial concern for
gastritis, esophagitis, [**Doctor First Name 329**] [**Doctor Last Name **] tear, or UGI malignancy.
No evidence of portal hypertension to suggest varices. He
appeared quite hemoconcentrated on admission with Hct 40,
dropped to 30 after hydration but hematocrit remained stable
thereafter. Endoscopy performed on [**2139-3-5**] demonstrating severe
esophagitis and abnormal mucosa in the stomach that were
biopsied. Placed on PPI [**Hospital1 **] and Carafate QID for symptom relief
of severe dysphagia. They will followup with him in clinic and
call beforehand if any concerning findings on biopsy results. Pt
advised to not drink alcohol because it will exacerbate his
esophagitis.
# Pancytopenia: Most likely secondary to alcohol abuse and
malnutrition, though upon speaking with PCP does not appear to
have pancytopenia chronically. HIV negative here, SPEP
negative, UPEP pending. CMV viral load pending, CMV IgG
positive but IgM negative. Patient w/ evidence of B12
deficiency, he was started on B12, folate, MVI, and thiamine.
No heparin given. Anemia labs consistent with anemia of chronic
disease, reticulocyte count very low at 0.1% He will need close
follow-up with PCP and if no improvement in pancytopenia may
need referral to hematology.
# Syncope vs. seizure. Main differential includes EtOH
withdrawal (appropriate timing - 48 hours following last drink)
and theophylline toxicity (or perhaps combination of 2) and
vagal episode. No underlying seizure disorder. No abnormalities
on OSH head CT to explain. No evidence of CNS infection.
Theophylline was held. Patient had no evidence of alcohol
withdrawal on CIWA scale and had no seizure like activity during
his stay. EEG was negative by preliminary verbal report from
neuro lab. No events on telemetry
# Tachycardia on presentation 140s, corrected to 100 with
fluids. Differential included hypovolemia, bleeding (stable Hct
though), alcohol withdrawal, theophylline toxicity, low
suspicion PE on presentation with no symptoms. TSH normal. Held
theophylline, not to be restarted.
# Theophylline toxicity. Elevated level to 25, unclear trigger
(no known new meds to interact with). Tachycardia, hypokalemia
and other metabolic abnormalities can be consistent with
theophylline toxicity. His theophylline levels reduced and this
medication was not restarted given concern for toxicity.
# Emphysema. Extensive disease on imaging with reported history
of asbestos injury to lungs. Mild O2 requirement here, though
unclear if with normal baseline sats given destructive disease.
Patient sats remained stable. Theophyline was discontinued and
patient was started on advair and albuterol/atrovent.
Discussed with PCP who agreed stopping theophylline.
# Alcohol abuse. Social work consulted. Pt did not exhibit
withdrawal symptoms during the hospital admission. Advised that
alcohol can exacerbate or cause esophagitis.
# Liver lesions - three discrete lesions, concerning for
malignancy/metastatic disease. Will need liver biopsy but could
not be done this admission (IR was not comfortable due to low
platelets). PCP has been alerted and he will arrange for biopsy
as an outpatient. Interventional Radiology will contact patient
and arrange with PCP an elective liver lesion biopsy.
Medications on Admission:
Theophylline - dosing unknown
Discharge Medications:
1. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day): Make into a slurry to take.
Disp:*120 Tablet(s)* Refills:*0*
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 doses* Refills:*0*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing: Use only if needed for shortness of breath
or wheezing.
Disp:*1 inhaler* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Severe esophagitis
Syncope
Liver lesions of unclear etiology, will need follow-up and
biopsy
Pancytopenia
Vitamin B12 deficiency
Alcohol abuse
Chronic obstructive pulmonary disease / emphysema / asbestos
lung injury
Discharge Condition:
Mental Status: Alert and oriented x3
Ambulatory Status: Ambulatory
Able to tolerate liquid and solid oral intake.
Discharge Instructions:
You were admitted for evaluation of vomiting blood and severe
pain with swallowing and also being found unresponsive at home.
Endoscopy was performed which revealed severe Esophagitis, which
is irritation of the esophagus. You have been started on two
medications (Pantoprazole and Carafate) to treat Esophagitis and
to ameliorate the pain associated with it. Please avoid alcohol
as this may exacerbate your condition.
CT scan of your abdomen revealed 3 lesions in the liver that we
recommend to have biopsied. Biopsy will be able to evaluate if
these lesions are related to benign process or from cancer.
For the unresponsiveness, an EEG was performed to assess for
seizures. The EEG was normal.
You have a Vitamin B12 deficiency that may be contributing to
anemia. We have started you on Vitamin B12 supplement.
You have been taking Theophylline for COPD / emphysema. We
found it to be above the therapeutic level in your blood which
can cause toxicity. We recommend discontinuing this medication.
We will change you to Advair and Albuterol instead and you may
follow up with your primary care physician regarding these
medication changes.
We recommend that you work with your primary care physician to
arrange for a screen colonoscopy for colon cancer screening.
MEDICATION CHANGES:
DISCONTINUE Theophylline
Start Pantoprazole (for esophagitis)
Start Carafate (for esophagitis)
Start Cyanocobalamin (vitamin B12)
Start Advair (for COPD/emphysema)
Use Albuterol only if needed for shortness of breath
Followup Instructions:
MD: Dr. [**First Name (STitle) 4370**] [**Name (STitle) **]
Specialty: Gastroenterology
Date/ Time: Wednesday, [**4-8**] @ 4pm
Location: [**Hospital1 69**], [**Hospital Ward Name 516**],
[**Hospital Ward Name 452**] 1
Phone number: [**Telephone/Fax (1) 463**]
Special instructions for patient: Pt can try calling [**Telephone/Fax (1) **]
for a earlier appt to see if they can get an earlier
cancellation appt. The GI physicians will call you before your
appointment if there are any worrisome findings on the biopsy
from your esophagus.
Appointment #2
MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 18694**]
Specialty: PCP
[**Name Initial (PRE) 2897**]/ Time: Wednesday, [**3-25**] @ 1:30pm
Location: [**Street Address(2) 40604**]., [**Location (un) 3320**] [**Numeric Identifier **]
Phone number: ([**Telephone/Fax (1) 40605**]
Special instructions for patient: This was the earliest
appointment available for now, but call the office again this
week and ask to speak to Dr. [**Last Name (STitle) 18694**]. He knows that you will
need a liver biopsy soon and may arrange for some labs (such as
blood and platelet count) to see if your platelets have
recovered enough for a liver biopsy
Appointment #3
Specialty: Interventional Radiology
Date/Time: Expect a call within one week to have an appointment
set up.
Location: [**Hospital1 69**] in [**Location (un) 86**]
Phone number: [**Telephone/Fax (1) 25094**]
Reason: For Liver lesion biopsy
Special instructions: If for some reason you do not get a call
this week, give the General Radiology department at a call at
the number listed above and get connected with the
Interventional [**Hospital **] clinic. You may ask for Dr. [**First Name (STitle) **]
[**Name (STitle) 40606**] or Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
|
[
"305.01",
"275.3",
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"199.1",
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icd9cm
|
[
[
[]
]
] |
[
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] |
icd9pcs
|
[
[
[]
]
] |
14059, 14065
|
9558, 13156
|
356, 391
|
14324, 14324
|
4407, 4407
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16005, 17841
|
3555, 3652
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13236, 14036
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14086, 14303
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13182, 13213
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14463, 15744
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3667, 4388
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15764, 15982
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419, 2897
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4423, 9535
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14339, 14439
|
2919, 3267
|
3283, 3539
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,166
| 113,311
|
10729
|
Discharge summary
|
report
|
Admission Date: [**2194-11-17**] Discharge Date: [**2194-12-25**]
Date of Birth: [**2145-9-22**] Sex: M
Service: CARDIOTHOR
HISTORY OF PRESENT ILLNESS: This is a 48 year old male with
adenocarcinoma of the distal esophagus. He underwent
neoadjuvant therapy with chemotherapy and radiation. He
completed chemotherapy four weeks prior to admission and
radiation therapy two weeks prior to admission. The patient
had a significant weight loss of approximately 30 pounds.
CT scan per Oncology demonstrated partial resolution of the
tumor.
PAST MEDICAL HISTORY:
1. Nephrolithiasis in [**2172**].
2. Chronic low back pain.
PAST SURGICAL HISTORY:
1. J-tube placement.
2. Porta-Cath placement.
ALLERGIES: Erythromycin.
PHYSICAL EXAMINATION: Afebrile, vital signs stable. HEENT:
No lymphadenopathy. Lungs are clear to auscultation.
Cardiac: Regular rate and rhythm. Abdomen soft, nontender,
nondistended.
HOSPITAL COURSE: The patient was admitted on [**2194-11-17**], where he went to the Operating Room and had an
esophagogastrectomy with mediastinal lymph node dissection.
Postoperatively, the patient had a mild episode of
hypotension which was attributed to the epidural catheter.
The patient was doing well until he became febrile on
[**2194-11-20**]. On [**11-21**], some wound drainage was
seen from the abdominal incision. A CT scan was obtained
after several days of monitoring the drainage and the scan
revealed a wound dehiscence.
The patient went to the Operating Room on [**11-25**], for
debridement of fascia and a buttress repair of the wound
dehiscence. Postoperatively, the patient had hypotension and
was transferred to the Intensive Care Unit. The patient was
started on Vancomycin, Levofloxacin and Flagyl.
On [**11-29**], the patient had an episode of tachycardias in
to the 160s. Copious amounts of green drainage was seen from
the right chest tube. Another chest tube was placed which
revealed also copious amounts of drainage. The patient was
placed on multiple pressors and was intubated.
On [**11-30**], the patient was brought to the Operating Room
again for esophageal diversion of his split fistula.
Infectious Disease consultation was obtained and he was
placed on Imipenem, Vancomycin, Fluconazole, Levofloxacin,
for multiple organisms. He was started on total parenteral
nutrition.
On [**12-2**], the patient grew out Methicillin resistant
Staphylococcus aureus from his sputum. Gradually, in the
Intensive Care Unit his pressors were weaned. Tube feeds
were started on [**12-5**]. A follow-up chest CT scan was
obtained which revealed a small right fluid collection which
was significantly improved from the prior.
Tube feeds were advanced to goal and the TPN was discontinued
[**12-8**]. On [**12-8**] also, all antibiotics were
discontinued except for Vancomycin which was kept for MRSA.
The patient had a CT scan guided procedure of a fluid
collection by Interventional Radiology on [**12-13**].
After multiple attempts of extubation and weaning, the
patient was finally extubated on [**12-18**]. On [**12-19**],
all of the chest tubes were removed due to minimal amounts of
drainage. On [**12-21**], the patient was transferred to the
Floor.
On the Floor, the patient did well, had no complaints. Tube
feeds were at goal. The patient was afebrile.
LABORATORY: Laboratory values upon discharge are as follows:
Sodium 141, potassium 3.5, chloride 101, bicarbonate 29, BUN
14, creatinine 0.3, glucose 137, white blood cell count 18,
hematocrit 30.6, platelets 446. The patient's white blood
cell count significantly decreased from higher values
obtained during the admission.
CONDITION AT DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
1. Epogen 40,000 units subcutaneously q. week.
2. Heparin 5000 units subcutaneously twice a day.
3. Zinc Sulfate 220 mg per J-tube q. day.
4. Clonidine patch 0.2 mg q. week.
5. Vitamin C 500 mg twice a day via NG tube.
6. Vancomycin 2 grams intravenously q. 12 hours.
7. Lopressor 25 mg per J-tube twice a day.
8. Celexa 20 mg per J-tube q. day.
9. Oxy-Codon Elixir 5 to 10 cc q. six hours p.r.n. via
J-tube.
10. Haldol Elixir 1 mg per J-tube q. eight hours p.r.n.
11. The patient was also on Impact with fiber tube feeds at
75 cc per hour which was his goal.
DISCHARGE STATUS: Rehabilitation facility.
DISCHARGE INSTRUCTIONS: The patient will follow-up with the
following people:
1. Dr. [**Last Name (STitle) 175**] in two weeks.
2. Dr. [**Last Name (STitle) 1305**] in two weeks.
3. His primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
4. Infectious Disease Clinic in two weeks.
DISCHARGE DIAGNOSES:
1. Status post esophagogastrectomy complicated by wound
dehiscence and anastomotic leak.
[**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 178**], M.D. [**MD Number(1) 179**]
Dictated By:[**Name8 (MD) 1308**]
MEDQUIST36
D: [**2194-12-25**] 10:40
T: [**2194-12-25**] 10:56
JOB#: [**Job Number 35105**]
|
[
"998.3",
"150.5",
"511.9",
"997.4",
"707.0",
"512.1",
"482.41",
"567.2",
"998.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"43.5",
"43.89",
"40.3",
"50.12",
"86.22",
"42.41",
"42.10",
"44.5"
] |
icd9pcs
|
[
[
[]
]
] |
4731, 5092
|
3728, 4351
|
955, 3680
|
4376, 4710
|
670, 746
|
769, 937
|
3696, 3705
|
174, 562
|
584, 647
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,490
| 128,498
|
44560
|
Discharge summary
|
report
|
Admission Date: [**2105-6-1**] Discharge Date: [**2105-6-8**]
Date of Birth: [**2028-3-5**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 77 year old white male
who has no known coronary artery disease history but had a
vascular history positive for transient ischemic attacks and
is status post right carotid endarterectomy in [**3-11**]. He
states that his blood pressure has been difficult to control
for many years but more recently since his right carotid. He
started having substernal chest pressure one week prior to
admission with work out on a Nordic track, and on [**2105-5-31**],
he noted some more discomfort with minimal activity. He
presented to the [**Hospital3 **] for evaluation and ruled
out for a myocardial infarction. He was started on
intravenous Nitroglycerin and given Lopressor for blood
pressure control. He was transferred to the [**Hospital1 346**] for question of a PCI.
PAST MEDICAL HISTORY:
1. History of hypertension.
2. History of peripheral vascular disease, status post right
carotid endarterectomy in [**3-11**].
3. History of transient ischemic attack.
4. History of bipolar disorder.
5. History of gastroesophageal reflux disease.
6. History of hypothyroidism, status post thyroid cancer in
[**2091**], with a thyroidectomy.
7. History of dyslipidemia.
8. History of paroxysmal atrial tachycardia.
MEDICATIONS ON ADMISSION:
1. Lopressor 25 mg p.o. twice a day.
2. Synthroid 125 mcg p.o. once daily.
3. Lipitor 40 mg p.o. q.h.s.
4. Plavix 75 mg p.o. once daily.
5. Aciphex 20 mg p.o. once daily.
6. Verapamil 120 mg p.o. twice a day.
7. Monopril.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Unremarkable.
SOCIAL HISTORY: He quit smoking fourteen years ago and has
not had alcohol for 23 years.
REVIEW OF SYSTEMS: Unremarkable.
PHYSICAL EXAMINATION: He is well developed, well nourished
white male in no apparent distress. Vital signs are stable,
afebrile. Head, eyes, ears, nose and throat examination is
normocephalic and atraumatic. Extraocular movements are
intact. The oropharynx is benign. Neck was supple with full
range of motion, no lymphadenopathy or thyromegaly. Carotids
had bilateral bruits, left greater than right.
Cardiovascular examination is regular rate and rhythm, normal
S1 and S2, no murmurs, rubs or gallops. The lungs were clear
to auscultation and percussion. The abdomen was soft,
nontender, with positive bowel sounds, no masses or
hepatosplenomegaly. Neurologic examination was nonfocal.
His pulses were 1+ and equal bilaterally throughout with
bilateral femoral bruits.
HOSPITAL COURSE: He underwent cardiac catheterization on
admission which revealed a 60% ostial left main lesion. The
left anterior descending had an 80% proximal lesion. The
left circumflex had a 60% midlesion, 80% OM1 lesion and the
right coronary artery was nondominant and had a 90% mid
lesion. Cardiac surgery was consulted and on [**2105-6-3**], the
patient underwent a coronary artery bypass graft times three
with left internal mammary artery to the left anterior
descending, reversed saphenous vein graft to the posterior
descending artery and OM with an end to side anastomosis of
the OM graft to the posterior descending artery. Cross plant
time was 51 minutes, total bypass time 83 minutes. He was
transferred to the CSRU on Neo-Synephrine and Propofol in
stable condition. He was extubated his postoperative night.
Postoperative day one, he required aggressive respiratory
therapy. Postoperative day two, his chest tubes were
discontinued. Postoperative day three, his epicardial pacing
wires were discontinued. He was transferred to the floor in
stable condition. He continued to have a stable
postoperative course and, on postoperative day five, he was
discharged to home in stable condition.
His laboratories on discharge showed a hematocrit of 28.2,
white blood cell count 7.2, platelet count 219,000. Sodium
143, potassium 4.5, chloride 106, bicarbonate 28, blood urea
nitrogen 25, creatinine 0.9, blood sugar 118.
MEDICATIONS ON DISCHARGE:
1. Lasix 20 mg p.o. twice a day for seven days.
2. Potassium 20 mEq p.o. once daily for seven days.
3. Colace 100 mg p.o. twice a day.
4. Aciphex 20 mg p.o. once daily.
5. Ecotrin 325 mg p.o. once daily.
6. Percocet one to two p.o. q4-6hours p.r.n. pain.
7. Plavix 75 mg p.o. once daily.
8. Levoxyl 125 mcg p.o. once daily.
9. Lopressor 25 mg p.o. twice a day.
10. Lipitor 40 mg p.o. once daily.
DISCHARGE DIAGNOSES:
1. Peripheral vascular disease.
2. Hypertension.
3. Coronary artery disease.
4. Hypercholesterolemia.
5. Gastroesophageal reflux disease.
6. Bipolar disorder.
FOLLOW-UP: He will be followed by Dr. [**Last Name (STitle) 70**] in six weeks
and Dr. [**Last Name (STitle) 11493**] in two to three weeks and by Dr. [**First Name8 (NamePattern2) 487**]
[**Last Name (NamePattern1) **] in three weeks for evaluation of renal artery
stenosis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 95442**]
MEDQUIST36
D: [**2105-6-8**] 18:19
T: [**2105-6-8**] 18:40
JOB#: [**Job Number 95443**]
|
[
"401.9",
"440.1",
"414.01",
"272.0",
"443.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.22",
"36.12",
"88.53",
"39.61",
"88.42",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
1691, 1706
|
4511, 5228
|
4084, 4490
|
1406, 1674
|
2632, 4058
|
1855, 2614
|
1817, 1832
|
157, 935
|
957, 1380
|
1723, 1797
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,272
| 156,961
|
25550
|
Discharge summary
|
report
|
Admission Date: [**2173-7-27**] Discharge Date: [**2173-8-5**]
Date of Birth: [**2102-9-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
Febrile and Neutropenia
Major Surgical or Invasive Procedure:
RIJ central line placement
PICC line placement
Portocath placement
History of Present Illness:
HPI: 70 yo gentleman with Multiple Myeloma, on chemotherapy, who
noted an axillary temperature of 101.7 in the evening of [**7-26**]
after receving chemotherapy with Velcade as an outpatient the
same day. He called the hospital and was told to come to the ED
for evaluation and treatment of febrile neutropenia. He denies
any cough, SOB, headache, nausea/vomiting/diarrhea, no dysuria.
His WBC was 26.0 with 1% Neutrophils (ANC = 260) on [**7-26**]. In the
ED on [**7-27**]: VS Tm=102.9 116/63 110 18 99% RA WBC 30.7 Lactate
3.8. He was started on vancomycin 1 g IV, Levaquin 500 mg IV ,
Cefepime x1, Tylenol 1 g po . He also received IVF NS 3L total -
bolus to maintain BP. His CXR (portable): no edema, no
infiltrate. Blood cultuures, UA/Urine culture were sent.
Past Medical History:
PMHx:
1. Diabetes mellitus type 2 - had been on glyburide, currently
not on any meds
2. Multiple Myeloma: dx [**5-23**], treated w/ velcade; c/b
pancytopenia - baseline creatinine since diagnosis 2.0-3.0.
2. Hypertension
3. Hyperlipidemia
4. s/p MVA
5. s/p tonsillectomy at age 19
.
Onc Hx:
In [**2173-5-19**] Mr. [**Known lastname 6164**] presented for evaluation of diffuse
bone pain. At that time, he was noted to have an increased BUN,
creatinine, was hypercalcemic. He was initially seen in [**Hospital **]Emergency Room. He had abnormal cells circulating his
peripheral smear. He is referred to the [**Hospital1 63808**]. On admission, he was noted to be in acute renal
failure with plasma blast on his peripheral smear. He had
diffuse bony tenderness.
.
He was treated with intravenous hydration, steroids, and
Velcade. His renal function improved. He received single
injection of pamidronate. His renal function stabilizes in the
1.8 range. He was initially discharged. One week after
discharge, he presented with disseminated zoster. He was
admitted for intravenous acyclovir followed by oral acyclovir.
His disseminated zoster responded to treatment. He has been
afebrile and stable at home but has had an approximately 55
pounds weight loss over a several month period.
.
Social History:
Retired, previously worked as a florist. He lives with his
daughter [**Name (NI) 3968**] who is involved in his care. He has a history of
15 years of cigarette smoking, stopped 20 years ago. No
recreational drug use. Social alcohol.
Family History:
Sister with DM.
No family history of cancer or heart disease.
Physical Exam:
T 103 SBP 140 RR 30s O2 99 on 1L
GENERAL: elderly gentleman, lying in bed comfortably
Skin: multiple healing scars over body s/p disseminated zoster,
all over body
HEENT: OP clear, dry, multipl healing scars over forehead
LUNGS: Decreased breath sound over L lower lung base, CTA over
rest of lung fields
HEART: S1, S2 +, rrr, II/VI ESM over LSB
ABDOMEN: soft, nt, nd, BS+
EXTREMITIES: multiple healing lesions, warm, no c/c/e
Neuro: AAO, moves all extremities, CN II-XII grossly intact
Pertinent Results:
On Admission:
[**2173-7-26**] 10:55AM PLT SMR-VERY LOW PLT COUNT-37*
[**2173-7-26**] 10:55AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2173-7-26**] 10:55AM NEUTS-1* BANDS-0 LYMPHS-69* MONOS-0 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 PLASMA-29*
[**2173-7-26**] 10:55AM WBC-26.0* RBC-3.11* HGB-9.3* HCT-27.2* MCV-87
MCH-29.7 MCHC-34.0 RDW-15.7*
[**2173-7-26**] 10:55AM ALBUMIN-3.2* CALCIUM-8.8 PHOSPHATE-3.5
MAGNESIUM-2.1
[**2173-7-26**] 10:55AM ALT(SGPT)-39 AST(SGOT)-24 LD(LDH)-185 ALK
PHOS-117 TOT BILI-0.3
[**2173-7-26**] 10:55AM GLUCOSE-195* UREA N-27* CREAT-1.8* SODIUM-134
POTASSIUM-4.8 CHLORIDE-107 TOTAL CO2-20* ANION GAP-12
[**2173-7-27**] 03:40AM PT-14.6* PTT-31.2 INR(PT)-1.4
[**2173-7-27**] 03:54AM LACTATE-3.8*
[**2173-7-27**] 04:10AM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2173-7-27**] 04:10AM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2173-7-27**] 04:10AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.005
[**2173-7-27**] 06:54AM LACTATE-2.6*
.
Pertinent Interval Labs:
[**2173-7-28**] 06:56PM BLOOD FDP-40-80
[**2173-7-28**] 06:56PM BLOOD Fibrino-493*# D-Dimer-1236*
[**2173-7-28**] 06:56PM BLOOD Fibrino-493*# D-Dimer-1236*
[**2173-7-29**] 04:36PM BLOOD Fibrino-546*
[**2173-7-29**] 04:16AM BLOOD Fibrino-424*
[**2173-7-28**] 01:59PM BLOOD CK-MB-2 cTropnT-0.03*
[**2173-7-29**] 04:36PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-0.12
.
Blood Gases:
[**2173-7-28**] 06:06PM BLOOD Type-ART Rates-/34 pO2-111* pCO2-17*
pH-7.49* calHCO3-13* Base XS--6 Intubat-NOT INTUBA
[**2173-8-2**] 11:40AM BLOOD Type-ART pO2-101 pCO2-24* pH-7.39
calHCO3-15* Base XS--8 Intubat-NOT INTUBA Vent-SPONTANEOU
[**2173-8-4**] 03:42PM BLOOD Type-MIX pO2-42* pCO2-29* pH-7.42
calHCO3-19* Base XS--3
.
On Discharge:
[**2173-8-5**] 12:00AM BLOOD WBC-3.1* RBC-3.07* Hgb-8.9* Hct-26.4*
MCV-86 MCH-29.1 MCHC-33.9 RDW-16.3* Plt Ct-81*
[**2173-8-1**] 12:35AM BLOOD Neuts-5* Bands-0 Lymphs-66* Monos-0 Eos-2
Baso-0 Atyps-0 Metas-0 Myelos-0 Plasma-27*
[**2173-8-5**] 12:00AM BLOOD Plt Ct-81*
[**2173-8-5**] 12:00AM BLOOD Gran Ct-180*
[**2173-8-5**] 12:00AM BLOOD Glucose-65* UreaN-15 Creat-1.1 Na-138
K-4.0 Cl-112* HCO3-17* AnGap-13
[**2173-8-5**] 12:00AM BLOOD Calcium-9.1 Phos-4.3 Mg-1.7
[**2173-7-29**] 04:36PM BLOOD Hapto-222*
[**2173-8-4**] 03:42PM BLOOD Lactate-2.1*
[**2173-8-3**] 12:00AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-0.007
.
Microbiology:
Blood culture [**2173-7-27**] - no growth
Urine culture [**2173-7-27**] - no growth
Blood fungal cultures [**2173-7-28**] - no growth
Sputum culture [**2173-7-30**] - GRAM STAIN <10 PMNs and >10 epithelial
cells/100X field. Gram stain indicates extensive contamination
with upper respiratory
secretions. Bacterial culture results are invalid. PNEUMOCYSTIS
CARINII NOT SEEN. POOR QUALITY SPECIMEN.
Blood cultures 8/11, [**8-1**] - no growth to date
Catheter tip cultures 8/17 - pending
.
Imaging:
EKG: Sinus tachycardia, Nonspecific ST-T abnormalities
Since previous tracing of [**2173-7-14**], rate is increased
.
CXR [**2173-7-27**]: Slight increase in pulmonary vascularity without
frank pulmonary edema.
.
CXR [**2173-7-29**]: INDICATION: Line placement. A right internal
jugular vascular catheter has been placed, terminating in the
lower superior vena cava at the junction with the right atrium.
No pneumothorax is evident. The heart size is normal. There is
vascular engorgement and perihilar haziness, likely due to mild
fluid overload. Attention to this region on followup films would
be helpful to exclude atypical pneumonia.
.
CXR [**2173-7-30**]: Improving congestive heart failure. Right lower
lobe pneumonia.
.
Chest CT w/out Contrast [**2173-7-30**]: Two focal areas of
consolidation, one in the left upper lobe and the other in the
right lower lobe, which demonstrate a surrounding ground-glass
halo. The imaging characteristics are most consistent with
invasive aspergillosis. Other forms of infection are also
possible. Small bilateral pleural effusions and diffuse
mediastinal adenopathy. Multiple non-obstructing renal stones
bilaterally.
Widespread osseous involvement from the patient's known plasma
cell
leukemia. Diffuse anasarca.
.
CXR [**2173-8-4**]: successful placement of right subclavian venous
access device. No pneumothorax is identified.
Brief Hospital Course:
Mr. [**Known firstname 4884**] [**Known lastname 6164**] is a 70-year-old man with Multiple Myeloma and
plasma cell leukemia, hypertension, hypercholesterolemia, DM
type 2, who presents with fever and neutropenia. He had recently
received outpatient chemotherapy with Velcade on [**2173-7-26**].
.
# Fever with Neutropenia: In the ED, the patient had a
temperature of 102.9 with a WBC count of 21.1 with 1%
Neutrophils (ANC ~210). There were no localizing signs of
infection on examination. CXR was negative in the ED. He was
treated empirically with 1x Vancomycin, 1x Levaquin and 1x
Cefepime. On the floor, antibiotic coverage was changed to IV
Cefepime to cover GI organisms and pseudomonas. The patient
remained febrile and therefore Acyclovir was added since the
patient was recently admitted with disseminated zoster. The
lesions on his body, however, appeared to be healing. The
patient still remained febrile and Vancomycin and Azithromycin
were added as per ID consultation. On [**2173-7-28**] the patient became
progressively tachypneic to the 30s, SBP 140-150s, increasingly
tachycardic to the 140s, diaphoretic with O2 saturation of 99%
on 1L. EKG showed sinus tachycardia with no evidence of
ischemia, cardiac enzymes were negative x 1. He continued to
have high grade temperatures as high as 103 F. Blood cultures
just grew gram positive cocci in clusters. He is transferred to
[**Hospital Unit Name 153**] for closer monitoring for sepsis/SIRS. In the ICU,
antifungal therapy was started with Caspofungin. A RIJ central
line was placed for better access. Initial CXR was negative for
any infiltrate. Repeat CXR the next day revealed a right lower
lobe pneumonia. CT scan was then obtained which showed two focal
areas of consolidation, one in the left upper lobe and the other
in the right lower lobe, which demonstrate a surrounding
ground-glass appearance, most consistent with invasive
aspergillosis. Treatment was then initiated with IV Voriconazole
and Caspofungin was discontinued. The patient then stabilized in
the ICU and was transferred back to the floor on [**2173-7-30**]. The
patient continued to have low grade fevers and baseline
tachycardia. His WBC count remained low with ANC between
300-400. Pulmonary evaluation was obtained to evaluate the
possibility of doing a bronchoscopy for the purpose of getting a
tissue diagnosis according to the recommendations of Infectious
Diseases. Pulmonary felt that treatment would be continued
despite a negative biopsy and therefore the risk of undergoing
such a procedure was considered too risky given his degree of
neutropenia. Blood cultures were subsequently all negative.
Since the patient was responding to treatment, Voriconazole was
continued PO, Acyclovir was continued at prophylactic doses PO,
Vancomycin was discontinued and Levaquin PO was added for a two
week time course. The patient was discharged on this regimen.
Follow up CT scan in two weeks was ordered and the patient was
scheduled to follow up with Dr. [**Last Name (STitle) **] in the Pulmonary clinic.
Upon discharge the patient was persistently neutropenic. This
was considered his baseline due to severe and progressive
involvement of his bone marrow. G-CSF was not thought to be of
any use given the degree of bone marrow invasion. On discharge
he had been afebrile for more than 3 days and was markedly
improved clinically with stable vital signs.
.
# Respiratory Alkalosis/Metabolic Acidosis: On admission the
patient was noted to have a low bicarbonate level of 16 that
later dropped further to 12 on [**7-28**] when the patient was
evaluated by the ICU team. ABG at the time revealed a
respiratory alkalosis with a pH of 7.49, pCO2 17 with a
concomitant non gap metabolic acidosis. This was thought to be
secondary to tachypneic secondary to sepsis and his underlying
pulmonary infection. In addition, the patient was thought to
have renal tubular acidosis either secondary to his multiple
myeloma (proximal RTA) or due to chronic renal failure with a
persistently low bicarbonate on previous admissions. With
improvement in his respiratory status, repeat blood gases showed
a neutral pH and his bicarbonate began to rise steadily up to 17
on discharge, likely due to his resolving pulmonary infection.
Once back on the floor, formal renal consultation was obtained
for further evaluation and guidance in treatment. No treatment
was necessary since the patient's acid-base status improved on
its own with treatment of his underlying disease.
.
# MM/plasma cell leukemia: The patient had been receiving
chemotherapy up until this admission with the last dose given on
[**2173-7-26**]. During his hospital stay no chemotherapy was given due
to his complicated hospital course with persistent neutropenia.
A portocath was placed the day prior to discharge and the
patient was advised to follow up in clinic for possible future
treatments. It is unlikely that he will be able to tolerate
Velcade again and other treatments will have to be explored. His
last dose of chemotherapy was on [**7-26**].
.
# Thrombocytopenia/Anemia - Thought to be secondary to bone
marrow invasion of plasma cells with concomitant
chemotherapeutic effects. Mr. [**Known lastname 6164**] received multiple
transfusions of both platelets and pRBCs in order to maintain
his counts. No ASA or heparin was given while in hospital except
for minimal amounts of heparin to flush central lines. Upon
discharge his Hct was 26.4 and his plts were 81K.
.
# Chronic Renal Insufficiency: The patient has a baseline Cr of
[**1-21**]. Medications were dosed according to his renal function.
Upon discharge his Cr. was 1.1.
.
# HTN - Patient was hypotensive in the ED requiring fluid
boluses, on the floor he remained borderline hypotensive
requiring IVF. After stabilization the patient had a stable
blood pressure and did not require any antihypertensive
medications.
.
# DM - The patient was monitored throughout his stay with QID
finger sticks with sliding scale insulin. The patient did not
require insulin and his glucose values where consistently within
normal limits. On the last two days of admission, finger sticks
and insulin were discontinued. He was discharged without any
oral hypoglycemics.
.
# Hyperlipidemia - Lipitor was held during this admission.
.
# PPx - Neutropenic precautions, bowel regimen, no heparin due
to low plts
# FEN - Neutropenic diet, IVF to maintain BP, electrolytes
sliding scale
.
# Code - Full
Medications on Admission:
-Allopurinol 100 mg daily
-Norvasc 5 mg [**Hospital1 **]
-ASA
-Zofran
-Lipitor
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*1*
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
4. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO every [**5-26**]
hours.
Disp:*1 ML(s)* Refills:*2*
5. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
Disp:*120 Capsule(s)* Refills:*1*
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*12 Tablet(s)* Refills:*0*
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
8. Phytonadione 5 mg Tablet Sig: Two (2) Tablet PO once a day
for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Diversified VNA
Discharge Diagnosis:
Primary:
Multiple Myeloma/Plasma cell leukemia
Pulmonary Aspergillosis
.
Secondary:
Hypertension
Diabetes Mellitus
Hyperlipidemia
Discharge Condition:
Good
Discharge Instructions:
Please take all of your medications as directed
Please follow up as described below
Please come back to the hospital if you have fevers, chills,
shortness of breath, nausea/vomiting/diarrhea or any other
complaints.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 6175**], MD Where: [**Hospital6 29**]
HEMATOLOGY/BMT Phone:[**Telephone/Fax (1) 3237**] Date/Time:[**2173-8-9**] 12:00
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Where: [**Hospital6 29**]
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2173-8-20**]
10:55
Provider: [**Name10 (NameIs) 1571**] EXAM ROOM IS (NO CHARGE) Where: IS (NO
CHARGE) Date/Time:[**2173-8-20**] 11:15
CHEST CT SCAN on Thursday [**8-12**] at 11:45 AM [**Location (un) **]
[**Hospital Ward Name 23**] prior - please do not eat or drink anything prior to
this test
Completed by:[**2173-8-6**]
|
[
"276.3",
"276.5",
"995.91",
"284.8",
"401.9",
"484.6",
"272.4",
"038.9",
"117.3",
"276.2",
"203.00",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.05",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
15236, 15282
|
7773, 14221
|
338, 407
|
15456, 15463
|
3362, 3362
|
15729, 16403
|
2776, 2839
|
14350, 15213
|
15303, 15435
|
14247, 14327
|
15487, 15706
|
2854, 3343
|
5242, 7750
|
275, 300
|
435, 1203
|
3376, 5228
|
1225, 2510
|
2526, 2760
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,009
| 155,505
|
623
|
Discharge summary
|
report
|
Admission Date: [**2194-6-18**] Discharge Date: [**2194-6-29**]
Date of Birth: [**2126-4-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine / Tylenol
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
dyspnea on exertion and chest tightness
Major Surgical or Invasive Procedure:
[**2194-6-23**]
redo sternotomy/Aortic Valve Replacement with #23 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] tissue
valve
History of Present Illness:
68 year old male with PMH significant for type 2 DM, HTN, High
cholesterol, CAD and BPH who presented to an outside hospital
c/o SOb, DOE and chest tightness. Pt also had leg edema-. Work
up showed that pt had severe aortic valve stenosis.
Past Medical History:
Past Medical History
Aortic Stenosis
type 2 Diabetes Mellitus
Hypertension
High cholesterol
Coronary Artery Disease
Benign Prostatic Hypertrophy-retention after surgery
Past Surgical History
Coronary Bypass Grafting 15 yrs ago at BIs
cholesystectomy
Rt shoulder rotator cuff
tonsillectomy
left index finger surgery
left ring finger trigger surgery
eye surgery
Social History:
Occupation:retired bus driver
Cigarettes: Smoked no [] yes [x] last cigarette 20 years ago
Other Tobacco use:none
ETOH: < 1 drink/week [] [**3-18**] drinks/week [x] >8 drinks/week []
Illicit drug use, none
Last Dental Exam:>1 year
Lives with:Alone
Contact: [**Name (NI) **] (son) Phone ([**Telephone/Fax (1) 4779**]
[**Doctor Last Name **] (son) Phone ([**Telephone/Fax (1) 4780**]
Family History:
Family History:Premature coronary artery disease
Father MI < 55 [] Mother < 65 []
Race:White
Physical Exam:
Pulse: 66 Resp: 18 O2 sat: 95% RA
B/P 129/61
Height:5'8" Weight:86.8 kgs
General: NAD
Skin: Dry [x] intact [x]Well healed sternal scar right calf vein
harvest
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2 Left:2
DP Right: 1 Left:0
PT [**Name (NI) 167**]: 1 Left:1
Radial Right: 2 Left:2
Carotid Bruit Right: none Left:none
Pertinent Results:
[**2194-6-26**] 04:11AM BLOOD WBC-10.4 RBC-3.46* Hgb-8.1* Hct-25.9*
MCV-75* MCH-23.4* MCHC-31.2 RDW-20.2* Plt Ct-120*
[**2194-6-23**] 03:36PM BLOOD PT-16.2* PTT-30.5 INR(PT)-1.5*
[**2194-6-26**] 04:11AM BLOOD Glucose-110* UreaN-27* Creat-1.1 Na-136
K-4.4 Cl-102 HCO3-29 AnGap-9
[**2194-6-19**] 09:35AM BLOOD ALT-18 AST-17 AlkPhos-58 Amylase-44
TotBili-1.0
[**2194-6-26**] 04:11AM BLOOD Calcium-7.7* Phos-2.8# Mg-2.3
[**2194-6-23**]
PRE-CPB:
The left atrium is markedly dilated. No thrombus is seen in the
left atrial appendage. No atrial septal defect is seen by 2D or
color Doppler.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is mildly dilated. Overall left ventricular
systolic function is low normal (estimated LVEF 50%). The right
ventricular cavity is mildly dilated with normal free wall
contractility.
The descending thoracic aorta is mildly dilated. There are
simple atheroma in the descending thoracic aorta. No thoracic
aortic dissection is seen. There are three aortic valve
leaflets. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (valve
area 0.8-1.0cm2). No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**2-10**]+) mitral regurgitation is seen.
Dr.[**Last Name (STitle) **] was notified in person of the results at time of
study.
POST-CPB:
A bioprosthetic valve is seen in the aortic position. The valve
appears well-seated with normal leaflet motion. There are no
paravalvular leaks. There is no apparent AI. The peak gradient
across the aortic valve is 38mmHg, the mean gradient is 22mmHg
with CO of 5L/min.
The patient is on low dose epi and norepi infusions. The LV
systolic function remains low normal, estimated EF=50%. The RV
systolic function remains normal.
The MR remains mild-to-moderate. Other valvular function is also
unchanged.
There is no evidence of aortic dissection.
Brief Hospital Course:
Pre-operatively, Mr. [**Known lastname 4781**] had a low grade temp without
source. He was afebrile with a normal white count and was
brought to the Operating Room on [**2194-6-23**] where he underwent Redo
Sternotomy, AVR (23mm St.[**Male First Name (un) 923**] tissue)-see operative note for
details. Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. Intraop noted to
have pulmonary hypertension and postoperatively he had a
persistent metabolic acidosis. His pressure was labile and was
on levo and Epi. He was also mildly hypoxic and eventually
extubated without difficulty the following morning and was
alert, oriented and breathing comfortably. He weaned from all
pressors and inortopic support. Beta blocker was initiated and
the patient was gently diuresed toward the preoperative weight.
The patient was transferred to the telemetry floor on POD #1 for
further recovery. he contiued to have low [**Last Name (un) 4782**] temps from
99.5-100.8 with a normal white count and all culture data
negative. While on the floor he remained hemodynamically stable.
Chest tubes and pacing wires were discontinued without
complication. He failed his first voiding trial and foley was
replaced for urine retention. Patient has a history of BPH. He
underwent a second voiding trial and was unsuccessful - a foley
was replaced and he was discharged to home with a foley. He will
follow up with his primary urologist as an outpatient for repeat
voiding trial. mr. [**Known lastname **] did experience acute aggitation
and paranoia on POD#[**5-15**]. he was given low dose haldol x 2 doses
and was finally able to sleep for the first time since hs
surgery. On POD#6 he was calm and cooperative without aggitation
or paranoia and his haldol was d/c'd. The patient was evaluated
by the physical therapy service for assistance with strength and
mobility. By the time of discharge on POD #6 the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged to home in
good condition with appropriate follow up instructions.
Medications on Admission:
Medications from OSH
toprol XL 20mg daily
metformin 1000mg [**Hospital1 **]
zocor 20mg daily
iron 325mg dialy
ASA 325mg daily
alfuzosin 10mg daily
finasteride 5mg daily
uroxatral 10mg daily
citalopram 20mg daily
alprazolam 1mg HS
ascorbic acid 1000mg
irbesartan 150mg daily
lisinopril 40mg [**Hospital1 **]
atorvastatin 20mg daily
aspart insulin SS
lantus insulin 37 units at bedtime
celebrex 200mg PRN
Discharge Medications:
1. Uroxatral 10 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO daily ().
2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
6. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day for 10
days.
Disp:*20 Tablet(s)* Refills:*0*
10. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 10 days.
Disp:*20 Tablet Extended Release(s)* Refills:*0*
11. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for t>101.
Disp:*90 Tablet(s)* Refills:*0*
12. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
13. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Lantus insulin
20 units SQ at bedtime
15. Aspart insulin
Aspart insulin - dose as prior to admission per sliding scale
based on finger stick
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
s/p redo sternotomy/Aortic Valve Replacement with #23 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**]
tissue valve
Past Medical History
Aortic Stenosis
type 2 Diabetes Mellitus
Hypertension
High cholesterol
Coronary Artery Disease
Benign Prostatic Hypertrophy-retention after surgery
Past Surgical History:
Coronary artery bypass grafting 15 yrs ago at [**Hospital1 **],
cholesystectomy,
Rt shoulder rotator cuff,
tonsillectomy,
left index finger surgery,
left ring finger trigger surgery,
eye surgery
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with tylenol and ultram
Incisions:
Sternal - healing well, no erythema or drainage
Edema +1
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 one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Keep your urine catheter in until you are seen bu your
urologist. If you do not see urine in the bag every hour or if
the urine becomes more bloody and you cannot see through it,
Call us at [**Telephone/Fax (1) 170**] and go to the emergency room.
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Wound check: NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2194-7-3**] 10:30
in the [**Hospital **] Medical office building, [**Doctor First Name **] , [**Hospital Unit Name **]
Surgeon: Dr [**First Name (STitle) **] [**Name (STitle) **] Date/Time:[**2194-7-30**] 1:30 in the [**Hospital **]
Medical office building, [**Doctor First Name **] , [**Hospital Unit Name **]
Cardiologist: Dr. [**Last Name (STitle) 4783**]. The office will call with a
follow-up appointment
Please call to schedule appointments with your:
Urologist: to be seen this week. Keep your urine catheter until
you see your urologist
Primary Care Dr. [**Last Name (STitle) 4784**],[**First Name3 (LF) **] G. [**Telephone/Fax (1) 4785**] in [**5-15**] 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:[**2194-6-29**]
|
[
"V15.82",
"276.2",
"428.0",
"297.1",
"788.20",
"V69.4",
"424.1",
"V17.3",
"416.8",
"V45.81",
"250.00",
"414.01",
"272.0",
"600.01",
"518.51",
"401.9",
"428.22",
"780.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.11",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
8528, 8603
|
4347, 6537
|
324, 470
|
9165, 9343
|
2372, 4324
|
10395, 11379
|
1582, 1671
|
6991, 8505
|
8624, 8925
|
6563, 6968
|
9367, 10372
|
8948, 9144
|
1686, 2353
|
245, 286
|
498, 740
|
762, 1124
|
1140, 1551
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,392
| 141,098
|
1266
|
Discharge summary
|
report
|
Admission Date: [**2157-3-21**] Discharge Date: [**2157-3-25**]
Date of Birth: [**2075-12-6**] Sex: F
Service: MEDICINE
Allergies:
Oxybutynin
Attending:[**First Name3 (LF) 663**]
Chief Complaint:
Tremors, confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
81 yo F with CAD s/p past PCI, CKD, hypertension, recent
diagnosis of heart failure, was discharged from the hospital on
[**2157-3-11**] after a presentation for chest pain. She reports that
she had 7 good days following discharge and then started feeling
poorly on Thursday [**2157-3-17**]. Symptoms began with unsteadiness
and tremulouness. She reports some mild confusion in last week.
Patient also began to notice worsening LE edema as well as
weight gain from 148 pounds at discharge on [**2157-3-11**] to 153
pounds on morning of presentation here. In the two days prior to
admission, the patient developed a right-sided CP,
non-radiating, which she reports was similar to the CP she had
at last presentation. Of note, patient reports a week of
constipation prior to having formed bowel movement two days
prior to presentation as well as loose stool on morning prior to
admission. She notes abdominal distension, some abdominal pain,
loss of appetite, and early satiety. She has had poor PO intake
in the last two weeks, but reports that she has been strictly
adhering to a low sodium diet and has been drinking lots of
water daily.
In the ED, initial vital signs were T 97.5, HR 62, BP 168/60, RR
18, 95% RA. For her CP received nitro SL and morphine and became
chest pain free. First set of cardiac enzymes was negative. CXR
was taken with note of small bilateral pleural effusion, not
significantly changed from CXR at prior admission on [**2157-3-9**].
Was identified as having hyponatremia with serum sodium of 112.
For her hyponatremia, received a 250 mL NS bolus.
Upon transfer to the floor, the patient was comfortable and
chest pain free. Denied confusion, though reported some
increased tremulousness.
ROS:
(+)ve: chest pain, lower extremity edema, weight gain, dyspnea
on exertion, tremulousness, unsteady gait, abdominal pain,
abdominal distension, constipation, loss of appetite, early
satiety
(-)ve: orthopnea, paroxysmal nocturnal dyspnea, cough fever,
sweats, nausea, vomiting, hematemesis, hematuria, hematochezia,
melena, visual changes
Past Medical History:
1. CAD s/p PCI to mid LAD, LCx, mid RCA c/b in stent restenosis
of mid LAD rx'ed with POBA and brachytherapy.
2. Chronic diastolic heart failure
3. CRI - baseline Cr 1.8-2.3
4. Hypercholesterolemia.
5. Hypertension.
6. ? h/o Gallstones.
8. Basal cell CA to R eye
9. Osteoporosis
10. Spinal Stenosis
ALLERGIES:
Oxybutynin (dry mouth)
Social History:
The patient is a retired dental hygienist.
Tobacco: Denies present or former use
EtOH: One per day
Illicits: Denies
Family History:
The patient's parents both died of a myocardial infarctions in
their 60s. The patient's only sibling, a sister, died of breast
cancer.
Physical Exam:
VS: T: 95.9 BP: 154/56 HR: 69 RR: 16 O2sats: 94% 2L NC
GEN: NAD
HEENT: PERRL, EOMI, oral mucosa moist, oral pharynx without
erythema
NECK: Supple, unable to appreciate JVP elevation in short neck
PULM: Rare bibasilar crackles, dullness to percussion at both
lung bases
CARD: Bradycardic, nl S1, nl S2, II/VI holosystolic murmur, no
chest pain ellicited with palpation of chest wall
ABD: BS+, soft, distended, tympanitic, diffusely tender, no
rebound or guarding
EXT: 3+ pitting edema of LE bilaterally with venous stasis
changes and broken skin
NEURO: Oriented to "[**Hospital3 **] Intensive Care", date, year,
current president. Able to recite days of week backward with
fluidity.
Pertinent Results:
CHEST (PORTABLE AP) [**2157-3-20**]:
IMPRESSION: Small bilateral pleural effusions, left greater than
right, with slight increase in size of left pleural effusion.
There is associated bibasilar atelectasis.
PORTABLE ABDOMEN [**2157-3-21**]:
IMPRESSION:
1. Nonspecific bowel gas pattern.
2. Incompletely evaluated retrocardiac opacity which may
represent atelectasis or consolidation. Clinical correlation
recommended.
RENAL U.S. [**2157-3-22**]:
FINDINGS: Comparison is made with prior study from [**2155-8-18**]. The
right kidney measures 9.5 cm, the left 10.5 cm. There are simple
cysts on the left, the largest in the interpolar region on the
left measuring 1.8 cm. There is no hydronephrosis, stone, or
mass. Doppler evaluation could not be performed, as the patient
was unable to breath-hold.
IMPRESSION: No hydronephrosis or renal stones. Unable to
evaluate renal arteries.
HEMATOLOGY:
[**2157-3-20**] 10:00PM BLOOD WBC-12.7* RBC-3.52* Hgb-10.4* Hct-30.8*
MCV-88 MCH-29.6 MCHC-33.8 RDW-16.3* Plt Ct-322
[**2157-3-20**] 10:00PM BLOOD Neuts-87.3* Lymphs-8.5* Monos-3.9 Eos-0.2
Baso-0
[**2157-3-23**] 04:12AM BLOOD WBC-8.0 RBC-3.17* Hgb-9.1* Hct-27.5*
MCV-87 MCH-28.8 MCHC-33.2 RDW-16.7* Plt Ct-258
CHEMISTRIES:
[**2157-3-20**] 10:00PM BLOOD Glucose-106* UreaN-25* Creat-1.6* Na-112*
K-5.8* Cl-89* HCO3-15* AnGap-14
[**2157-3-22**] 03:45AM BLOOD Glucose-72 UreaN-23* Creat-1.7* Na-119*
K-4.4 Cl-94* HCO3-18* AnGap-11
[**2157-3-23**] 04:12AM BLOOD Glucose-80 UreaN-21* Creat-1.5* Na-127*
K-4.3 Cl-103 HCO3-18* AnGap-10
CARDIAC ENZYMES:
[**2157-3-20**] 10:00PM BLOOD CK(CPK)-77
[**2157-3-20**] 10:00PM BLOOD cTropnT-<0.01
[**2157-3-20**] 10:00PM BLOOD proBNP-5679*
[**2157-3-21**] 05:28AM BLOOD CK(CPK)-65
[**2157-3-21**] 05:28AM BLOOD cTropnT-<0.01
[**2157-3-21**] 02:15PM BLOOD CK(CPK)-70
[**2157-3-21**] 02:15PM BLOOD cTropnT-<0.01
ENDOCRINE:
[**2157-3-20**] 10:00PM BLOOD TSH-1.2
[**2157-3-21**] 05:28AM BLOOD Cortsol-19.6
URINE STUDIES:
[**2157-3-21**] 01:06AM URINE Hours-RANDOM Creat-75 Na-16
[**2157-3-21**] 01:06AM URINE Osmolal-330
[**2157-3-22**] 10:09AM URINE Hours-RANDOM Creat-77 Na-16
[**2157-3-22**] 10:09AM URINE Osmolal-292
[**2157-3-23**] 04:12AM URINE Hours-RANDOM Creat-30 Na-14
[**2157-3-23**] 04:12AM URINE Osmolal-127
[**2157-3-25**] 05:50AM BLOOD WBC-7.5 RBC-3.24* Hgb-9.4* Hct-29.4*
MCV-91 MCH-29.1 MCHC-32.1 RDW-17.1* Plt Ct-327
[**2157-3-25**] 05:50AM BLOOD Glucose-95 UreaN-19 Creat-1.1 Na-136
K-4.8 Cl-110* HCO3-20* AnGap-11
[**2157-3-21**] 12:30AM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2157-3-23**] 09:59PM URINE Hours-RANDOM Creat-26 Na-12 K-8 Cl-13
TotProt-82 Prot/Cr-3.2*
[**3-22**], [**3-23**] C diff negative
Brief Hospital Course:
81 yo F with CAD s/p previous PCI, CKD, hypertension, recent
diagnosis of heart failure, admitted with chest pain, LE edema,
and severe hyponatremia.
1. Hyponatremia:
Sodium at presentation was 112. Likely due to diastolic heart
failure causing inappropriate activation of
renin/angiotensin/aldosterone system complicated by excessive
free water intake by patient at home. As patient was reporting
symtpoms of gait instability, tremor, and confusion at
presentation, she was fluid restricted to 1 liter daily and put
on hypertonic saline at low rate (per nephrology consult recs)
the night following admission. Serum sodium rose to 124 on
morning following hypertonic saline administration and
hypertonic saline was stopped. Tremors and confusion resolved on
morning of [**2157-3-22**]. From this point patient began diuresing
without needing furosemide, so this was held while patient's
sodium began to stabilize. At time of transfer out of the
intensive care unit, the patient was feeling well with serum
sodium up to 130. Renal ultrasound on [**2157-3-22**] revealed no
obvious hydronephrosis or other abnormality; however, RAS could
not be ruled out due to patient inability to hold breath during
testing. Home dose of lasix was restarted 24 hours prior to
discharge, and fluid restriction was changed to 2.5L. Na on
discharge was 136.
2. Oxygen desaturations overnight:
Witnessed in MICU overnight on night of [**2157-3-22**]. Likely sleep
apnea given son[**Name (NI) 7884**] respirations and observed apneic episodes
by nursing.
-Recommend outpatient pulmonary sleep study
2. Constipation / abdominal pain:
Patient presented to ICU with abdominal pain and bloating in
setting of history of greater than one week of constipation
prior to presentation with only two liquid bowel movements.
Liver enzymes were normal. Lipase was slightly elevated at 66.
Patient was put on bowel regimen upon presentation to the ICU
and had several liquid bowel movements prior to normalizing and
having formed bowel movements. Two were sent for c. diff and
both were returned as negative. Patient was without fever or
leukocytosis.
3. Diastolic heart failure:
By recent ECHO on [**2157-3-10**] has moderate LV diastolic
dysfunction. Additionally had BNP of [**Numeric Identifier 7883**] on [**2157-3-9**] which has
improved to BNP of 5679 upon admission here. We continued home
metoprolol. Furosemide was restarted 24 hours prior to
discharge.
4. Chronic renal failure:
Patient with baseline Cr of 1.8 - 2.3 per review of records.
5. Coronary artery disease / Hypertension / Hyperlipidemia:
Patient with a past history of anginal chest pain; however, she
reports that chest pain at presentation to hospital this time
was different. Recent presentation for chest pain (discharged
[**2157-3-11**]), for which she ruled-out for MI with three sets of
negative cardiac enzymes. Also had a low probability V/Q scan on
[**2157-3-10**]. Following admission to ICU she had no chest pain and
has had three sets of negative cardiac enzymes (trop <0.01). No
chest pain during hospital stay. She was continued on aspirin,
clopidogrel, amlodipine, metoprolol, atorvastatin.
Medications on Admission:
MEDICATIONS AT HOME: (per recent discharge on [**2157-3-11**])
1. Atorvastatin 80 mg PO daily
2. Clopidogrel 75 mg PO daily
3. Aspirin 325 mg daily
4. Tramadol 50 mg PO BID PRN pain
5. Omeprazole 20 mg PO daily
6. Calcium Citrate-Vitamin D3 315-200 mg-unit [**Unit Number **] tabs PO BID
7. Acetaminophen 325 mg 1-2 Tablets PO Q6H as needed
8. Amlodipine 10 mg PO daily (patient was not taking 15 mg as
instructed in recent cardiology notes)
9. Metoprolol Tartrate 50 mg PO BID
10. Lasix 20 mg PO daily
11. NitroQuick 0.3 mg Tablet PRN
12. Trimethoprim-Sulfamethoxazole 800 mg-160 mg Tablet [**Hospital1 **]
starting on [**2157-3-3**] for chronic sinusitis
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Tramadol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for pain.
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
8. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
Discharge Disposition:
Home With Service
Facility:
[**Location 7885**]
Discharge Diagnosis:
Primary diagnosis:
1. Hyponatremia secondary to SIADH and diastolic heart failure
Secondary diagnosis:
Chronic renal failure
Diastolic heart failure
Hypertension
Coronary artery disease
Discharge Condition:
Stable. Na 136.
Discharge Instructions:
You were admitted because your sodium was dangerously low. We
closely monitored you in the intensive care unit. We limited
your fluid intake, and increased your salt intake. The
nephrology team was consulted, and helped to manage this
condition. By discharge, your sodium was within normal limits
for over 48 hours. You were evaluated by physical therapy, who
recommended PT at home.
Please keep a weight log at home. Weigh yourself every morning,
[**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
You have no fluid restrictions. Drink to thirst.
No changes were made to your medications.
If you develop chest pain, shortness of breath, abdominal pain,
weakness, lightheadedness, or any other symptoms that concern
you please call your primary doctor or go to the emergency room.
Followup Instructions:
You have the following appointments:
Appointment #1
MD: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Specialty: pcp
Date and time: [**2157-4-1**] at 11:20am
Location: [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Bldg, First Fl, [**Company 191**]
Phone number: [**Telephone/Fax (1) 250**]
Special instructions if applicable:
Appointment #2
MD: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Specialty: Cardiology
Date and time: [**4-4**] at 1:20pm
Location: [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Bldg, [**Location (un) **], Cardiology
Phone number: [**Telephone/Fax (1) 62**]
*****
MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Specialty: Nephrology
Date and time: Friday [**2157-4-8**] at 9 AM
Location: [**Hospital1 18**] [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Building [**Location (un) **]
Phone number: ([**Telephone/Fax (1) 773**]
Completed by:[**2157-3-27**]
|
[
"428.33",
"327.23",
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"414.01",
"733.00",
"403.90",
"564.09",
"272.0",
"428.0",
"585.9",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11328, 11378
|
6498, 9655
|
289, 296
|
11609, 11627
|
3751, 5277
|
12479, 13493
|
2896, 3033
|
10362, 11305
|
11399, 11399
|
9681, 9681
|
11651, 12456
|
9702, 10339
|
3048, 3732
|
5294, 6475
|
231, 251
|
324, 2389
|
11503, 11588
|
11418, 11482
|
2411, 2746
|
2762, 2880
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,514
| 170,308
|
37532
|
Discharge summary
|
report
|
Admission Date: [**2192-12-28**] Discharge Date: [**2193-1-11**]
Date of Birth: [**2137-12-1**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
Groin and thigh pain/cellulitis
Major Surgical or Invasive Procedure:
Debridement of Bilateral Thigh and Abdomen (Fournier's Gangrene)
[**2192-12-28**]
Incision and Drainage Peripenile Abscess
Washout of Thigh Wounds [**2192-12-30**]
Debridement during vac change [**2193-1-10**]
History of Present Illness:
55 y/o morbidly obese male transfered to [**Hospital1 18**] from
[**Hospital6 19155**] with lower extremity and scrotal
cellulitic infection suspicious for Fournier's gangreen.
Patient
intermittently coherent and therefore interview difficult.
Review of OSH medical records show patient sustained a fall
while
walking dog in the first week of [**Month (only) **], he was hospitalized
with complaint of upper left leg pain on [**2192-12-11**], evaluated for
musculoskeletal injury and released on [**2192-12-14**]. Admitted to
MVH
last evening with increasing left leg pain and inability to
walk.
Evaluated at OSH for cellulitic infection of left upper thigh
and
scrotum with suspicion for Fournier's gangrene. CT of abdomen
and
pelvis unattainable at OSH due to patient's size and body
habitus. He was Started on IV abx at OSH, Zosyn and Vancomycin.
WBC 18.8, Cr 0.8 at OSH.
Past Medical History:
PMH/PSH: obesity, prostate CA s/p XRT, scrotal surgery ?, IDDM,
HTN, anxiety, asthma
Social History:
ex-smoker 15 yrs ago, no illicit drugs/IVDA
Family History:
noncontributory
Physical Exam:
Initial PE:
Physical exam:
Vitals: 99 108 155/106 20 93 RA
Gen:intermittently alert, not oriented to time or place, asking
to eat, asking to leave hospital
Cards: mildly tachycardic
Pulm: w/o distress
Neuro: CN II-XII grossly intact
Abd: large protuberant, mildy typmpanic
GU: significant scrotal edema down to perineum and dependent
erythema, no sinus tract noted, no crepitis noted on palpation,
non tender to palpation (pt has been medicated), penis
uncircumcised with polyp noted at 6:00 just below meatus, foley
in place with clear urine. Inguinal folds inspected, with foul
odor but no crepitus or evidence of skin breakdown.
Ext: Bilat thighs with tense, leathery cellulitic feel,
nontender
on palpation. Significant edema. No skin breakdown noted
externally. Lower ext with 1+ pitting edema noted, right lower
leg with ? of diabetic skin infection.
DISCHARGE PE:
97.3 82 118/72 20 97% RA
Gen: NAD, morbidly obese
CV: RRR
PULM: CTAB, no wheezes/crackles, decreased at bases
GI/GU: protuberant, soft, NT. Peripenile wound with penrose in
place and wet to dry dressing without evidence of infection.
EXT: Wound vac in place to bilateral leg wounds, suction
initially not working, fixed and now suctioning at 125mmHg
Pertinent Results:
Admission Labs:
[**2192-12-28**] 08:30AM BLOOD WBC-16.7* RBC-4.04* Hgb-10.8* Hct-34.5*
MCV-86 MCH-26.7* MCHC-31.3 RDW-14.5 Plt Ct-426
[**2192-12-28**] 08:30AM BLOOD Neuts-88.6* Lymphs-6.7* Monos-4.2 Eos-0.3
Baso-0.1
[**2192-12-28**] 08:30AM BLOOD Glucose-81 UreaN-22* Creat-0.8 Na-140
K-4.1 Cl-99 HCO3-28 AnGap-17
[**2192-12-28**] 10:10AM BLOOD ALT-15 AST-16 AlkPhos-103 TotBili-0.4
[**2192-12-28**] 05:02PM BLOOD Calcium-9.2 Phos-4.9* Mg-1.7
[**2192-12-28**] 08:38AM BLOOD Comment-GREEN TOP
Discharge Labs:
[**2193-1-7**] 05:50AM BLOOD WBC-8.9 RBC-3.57* Hgb-9.3* Hct-30.3*
MCV-85 MCH-26.1* MCHC-30.8* RDW-16.2* Plt Ct-606*
[**2192-12-31**] 01:22AM BLOOD Neuts-83.2* Lymphs-9.4* Monos-6.1 Eos-1.0
Baso-0.2
[**2193-1-7**] 05:50AM BLOOD Glucose-117* UreaN-12 Creat-0.5 Na-138
K-3.9 Cl-96 HCO3-32 AnGap-14
[**2193-1-8**] 11:51AM BLOOD Phos-4.2 Mg-1.9
Wound Culture:
[**2192-12-28**] 3:30 pm ABSCESS
RIGHT MEDIAL THIGH EVALUATE FOR CLOSTRIDIAL SPORES.
**FINAL REPORT [**2193-1-1**]**
GRAM STAIN (Final [**2192-12-28**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAIN
WOUND CULTURE (Final [**2192-12-31**]):
BETA STREPTOCOCCUS GROUP B. MODERATE GROWTH.
ANAEROBIC CULTURE (Final [**2193-1-1**]): NO ANAEROBES ISOLATED.
Scrotal Ultrasound [**2192-12-28**]
IMPRESSION: Normal testes. Diffuse scrotal edema. No gas seen in
the imaged
soft tissues about the scrotum. CT of the pelvis is more
sensitive for the
detection of subcutaneous gas in this patient with an extremely
large body
habitus.
CT Abdomen/Pelvis [**2192-12-28**]
IMPRESSION:
1. Findings compatible with necrotizing fasciitis and Fournier's
gangrene
with multifocal abscesses and locules of gas with phlegmonous
changes
involving the medial compartments of both thighs, left inguinal
hernia, and
the left penis.
2. Nonspecific enlarged portacaval lymph node. Clinical
correlation with any underlying liver disease is recommended.
Brief Hospital Course:
The patient was admitted to the general surgery service on
[**2192-12-28**] and had a an extensive debridement of his Fournier's
Gangrene. His peripenile abscess was also incised and drained
and a penrose placed by urology.
Neuro: Post-operatively, the patient remained intubated and in
the ICU due to his extensive wounds. He was initially delirious
thought to be secondary to sepsis on presentation. Once
extubated, his mental status steadily improved and he became
clear and coherent. He self extubated on [**2193-1-15**].
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Pulmonary: The patient was intubated and taken to the OR for
extensive debridement on [**2192-12-28**]. He remained intubated until
[**2193-1-4**] when he self extubated. He was placed on oxygen which
was weaned over the duration of his admission and was saturating
well on room air. He was kept intubated due to his extensive
dressing changes during which he required a great deal of
sedation and pain control.
GI/GU: Post-operatively, the patient was given IV fluids and
tube feeds while intubated in order to maintain nutrition. His
tube feeds reached an adequate goal. Once extubated and his
mental status cleared his diet was advanced. He was tolerating
a regular diet without nausea or vomiting.
Endocrine: While in the ICU, the patient required an insulin
infusion in addition to standing doses and sliding scales.
[**Last Name (un) **] was consulted for the management of his diabetes. He was
started on an agressive humalog sliding scale (please see
orders). His glargine was increased to 90 units nightly. At
the time of discharge his blood sugars were ranging from
80s-100s.
ID: ID was consulted on the management of his necrotizing
fasciitis/[**Last Name (un) 26581**];s Gangrene. He was initially placed on IV
Vanco/zosyn/clinda. As cultures resulted, the regimen was
changed to zosyn/clinda. Cultures showed GBS and the ID
recommendation was to give PCNG 4 million units 24h for 14 days
after the last debridement. He was last debrided during his vac
change on [**2193-1-10**] and should remain on IV antibiotics until
[**2193-1-24**].
Prophylaxis: The patient received subcutaneous heparin during
this stay, pneumoboots, and was put on famotidine while NPO. PT
worked with him, but he remained fairly immobile. He was able
to stand with minimal assist using a rollwing walker, but had
difficulty ambulating. He was discharged to a facility in order
to continue his rehabilitation.
At the time of discharge on HD 15, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
voiding without assitance and still requiring physical therapy
for mobility issues as well as continued IV antibiotics.
Medications on Admission:
tricor 145', lisinopril 10', aldactone 25', omeprazole 40',
voltran 50'', wellbutrin 100''', metformin 500 [**Hospital1 **], zetia 10',
insulin 70/30 100 tid, ativan prn, lasix 40', advair 250/50 '',
mvi, chlorthalidone 50'
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for BM.
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever.
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. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Four (4) Puff Inhalation Q6H (every 6 hours) as needed for
shortness of breath or wheezing.
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
8. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
9. Clonidine 0.1 mg Tablet Sig: 1-2 Tablets PO TID (3 times a
day) as needed for anxiety.
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
14. Diclofenac Sodium 25 mg Tablet, Delayed Release (E.C.) Sig:
Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
15. Bupropion HCl 100 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
16. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
17. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
18. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) inhalation - Disk with Device Inhalation [**Hospital1 **] (2 times a
day).
19. Chlorthalidone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
20. Insulin Glargine 100 unit/mL Solution Sig: Ninety (90) units
Subcutaneous at bedtime.
21. Insulin Sliding Scale
Please see Page 1 for insullin sliding scale orders.
22. Penicillin G Potassium 20,000,000 unit Recon Soln Sig: Four
(4) million units Injection Q4H (every 4 hours) for 14 days:
Should continue antibiotics for 14 days after his last
debridement (last debrided [**2193-1-10**]) - please continue as
advised if further debridement takes place.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
Fournier's Gangrene
Necrotizing Fasciitis
Diabetes Mellitus Type 2
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please continue medications as prescribed.
Please get plenty of rest, increase ambulation, and drink
adequate amounts of fluids.
Avoid driving or operating heavy machinery while taking pain
medications.
Wound Care:
1. VAC applied to bilateral leg wounds and abdominal wound.
The vac should be changed every 3 days.
2. Peri-penile abscess wound: This was incised and drained by
urology. There is a penrose drain in place which should not be
removed or manipulated. Please change wet to dry dressing over
this area twice daily.
Followup Instructions:
Please follow up in the [**Hospital 159**] Clinic [**1-23**] at 10:00 am -
[**Hospital Ward Name 23**] Building [**Location (un) 470**]. [**Telephone/Fax (1) 164**]
Please follow up in the surgery clinic with Dr. [**Last Name (STitle) **] on
[**2193-1-16**] at 2:30 pm. Call [**Telephone/Fax (1) 600**] with any questions. The
clinic is on the [**Location (un) 470**] of the [**Hospital Unit Name **].
Once discharged from rehab please follow up with your
endocrinologist within 2 weeks.
Additionally it is also important that you follow up with your
primary care physician. [**Name10 (NameIs) **] had a large lymph node near your
liver on the CT scan that was done and while there is currently
nothing urgent to be done, your liver function should be
followed up by your primary care doctor within 1 month of being
discharged.
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
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10366, 10436
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346, 558
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|
2933, 2933
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586, 1464
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1486, 1574
|
1590, 1636
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,714
| 115,276
|
17532
|
Discharge summary
|
report
|
Admission Date: [**2151-1-12**] Discharge Date: [**2151-1-19**]
Date of Birth: [**2123-10-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
fever, hypotension
Major Surgical or Invasive Procedure:
1. Withdrawal Right tunneled line.
2. Placement and withdrawal of right subclavian line.
3. Placement and withdrawal of right femoral line.
4. Placement of left subclavian tunneled line.
History of Present Illness:
27 yo M w/ESRD on HD presented to the ED [**1-12**] with fever and
hypotension. He was feeling well after HD day pta, when he
developed fever and rigors. These were associated with nausea,
leading to vomiting every 20-30 minutes overnight.
.
Day of admission Mr. [**Known lastname 34030**] felt so weak that he fell to the
floor multiple times on his way to the bathroom, though he never
lost consciousness. His profound weakness and persistent nausea
prompted his call to EMS, and he was brought by ambulance to the
[**Hospital1 18**] ED. He admits to diarrhea since day pta. Per his wife, he
has had no chest pain, dyspnea, abd pain, melena, or
hematochezia.
.
In the ED, he had a temp of 103.6, BP 70/30, HR 140. He was
treated with 6.5 liters NS, and SBP transiently improved to
100s, then drifted down to 80's-90's. he was treated empirically
with IV vanco, ceftazidime, doxycycline, and dexamethasone.
Phenylephrine gtt and norepi gtt were started for BP support. He
was transfused 2 units FFP for unclear reasons. UA, CXR, and abd
CT were completed and showed no localizing signs of infection.
He was admitted to the MICU.
.
MICU course - found to have bacteremia, MSSA, treated now with
nafcillin. TEE neg. for endocarditis, but needs TLC pulled and
cultured once piv access established.
Past Medical History:
ESRD [**1-1**] reflux nephropathy
s/p failed kidney transplant in [**2-2**] and again in [**8-5**]
HTN
UTIs
s/p Tenckhoff placement
s/p tunnelled line placement
Social History:
Pt denies any tobacco, alcohol, or IVDU. Pt currently on
disability.
Family History:
Mother's side of the family with kidney disease (uncertain
etiology). Father with DM.
Physical Exam:
PLEASE NOTE THAT WHAT FOLLOWS IS THE PHYSICAL EXAM AFTER THE
PATIENT WAS TRANSFERRED OUT OF THE MICU ON [**2151-1-17**]. THERE ARE
NO PHYSICAL EXAMS IN THE SYSTEM FOR THE ADMISSION DATE. VITALS
IN THE EMERGENCY ROOM WERE 103.6, BP 70/30, HR 140.
NAD
98.3 120/70 80 16 98 2L
NAD
RRR, [**1-5**] hsm at apex
CTA, min expiratory wheeze
NT, ND, BS+, no HSM, soft
No edema
Pertinent Results:
[**2151-1-12**] 08:29PM TYPE-MIX TEMP-39.1 PO2-42* PCO2-38 PH-7.29*
TOTAL CO2-19* BASE XS--7
[**2151-1-12**] 08:29PM O2 SAT-63
[**2151-1-12**] 08:21PM GLUCOSE-126* UREA N-33* CREAT-13.0*#
SODIUM-137 POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-18* ANION GAP-20
[**2151-1-12**] 08:21PM CK(CPK)-413*
[**2151-1-12**] 08:21PM CK-MB-7 cTropnT-0.07*
[**2151-1-12**] 08:21PM CALCIUM-8.2* PHOSPHATE-2.2*# MAGNESIUM-0.9*
[**2151-1-12**] 08:14PM WBC-23.2*# RBC-2.92* HGB-10.2* HCT-29.8*
MCV-102* MCH-34.9* MCHC-34.3 RDW-16.3*
[**2151-1-12**] 08:14PM PLT COUNT-153
[**2151-1-12**] 07:08PM LACTATE-2.4*
[**2151-1-12**] 05:45PM LACTATE-2.0
[**2151-1-12**] 04:51PM LACTATE-2.1*
[**2151-1-12**] 03:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-250 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2151-1-12**] 03:30PM URINE RBC->50 WBC-[**2-1**] BACTERIA-RARE YEAST-NONE
EPI-0
[**2151-1-12**] 01:07PM LACTATE-4.6*
[**2151-1-12**] 01:05PM GLUCOSE-107* UREA N-37* CREAT-14.6*#
SODIUM-135 POTASSIUM-3.8 CHLORIDE-93* TOTAL CO2-24 ANION GAP-22*
[**2151-1-12**] 01:05PM CK(CPK)-149
[**2151-1-12**] 01:05PM cTropnT-0.09*
[**2151-1-12**] 01:05PM CK-MB-1
[**2151-1-12**] 01:05PM CALCIUM-10.6* PHOSPHATE-0.6*# MAGNESIUM-1.2*
[**2151-1-12**] 01:05PM CORTISOL-28.7*
[**2151-1-12**] 01:05PM CRP-69.6*
[**2151-1-12**] 01:05PM WBC-11.6*# RBC-3.75* HGB-13.2* HCT-38.3*
MCV-102* MCH-35.2* MCHC-34.5 RDW-15.6*
[**2151-1-12**] 01:05PM NEUTS-73* BANDS-19* LYMPHS-6* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2151-1-12**] 01:05PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+
[**2151-1-12**] 01:05PM PLT COUNT-196
[**2151-1-12**] 01:05PM PT-15.6* PTT-29.1 INR(PT)-1.4*
.
[**2151-1-12**] 1:05 pm BLOOD CULTURE
AEROBIC BOTTLE (Final [**2151-1-15**]):
[**2151-1-13**] REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 29926**] AT 7:30 AM.
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
PENICILLIN------------ 0.25 R
ANAEROBIC BOTTLE (Final [**2151-1-15**]):
STAPH AUREUS COAG +. SENSITIVITIES PERFORMED FROM
AEROBIC BOTTLE.
.
[**2151-1-12**] CT-TORSO WITH CONTRAST IMPRESSION:
1. No pulmonary embolism or aortic pathology noted.
2. Minimal bibasilar atelectasis left worse than right with
small bilateral pleural effusions.
3. CT findings consistent with aggressive fluid resuscitation.
4. Questionable bowel wall thickening involving the cecum,
ascending colon, and proximal transverse colon. Diagnostic
considerations include pseudomembranous colitis, typhlitis (if
immunocompromised), further sequela of fluid resuscitation, and
much less likely ischemia.
5. Internal fluid within the colon highly suggestive of
diarrhea.
6. No intra-abdominal abscess. Explanted kidney transplant site
unremarkable.
.
[**2151-1-15**] CXR AP PORTABLE.
Worsening of alveolar consolidative process within right upper,
right lower, and retrocardiac regions probably pneumonia or
multifocal alveolar hemmorhage, edema less likely.
.
[**2151-1-18**] CXR PA/LAT
IMPRESSION: Marked interval improvement in the diffuse
opacities. In retrospect this behavior is most concordant with
alveolar edema. Minimal left base atelectasis and left
costophrenic angle blunting.
.
[**2151-1-19**] tunneled line placement.
IMPRESSION: Successful placement of a 14.5 French double lumen
hemodialysis catheter via the left subclavian vein, with 19 cm
tip to cuff in length and tip in the right atrium. The line is
ready for use.
Brief Hospital Course:
By Problem:
1. Sepsis: The patient was admitted to the MICU on phenylephrine
and norepinephrine drips. The patient did not require
intubation. Blood cultures grew MSSA. It was felt that the
patient's sepsis originated from the tunneled hemodialysis
catheter. Another possible source was the finding on the
abdominal CT of bowel wall thickening. The dialysis catheter
was removed and the tip failed to grow any bacteria. Access was
obtained by the angiography service who placed a right
subclavian central venous catheter. The patient was treated
with naficillin, levofloxacin and vancomycin. The patient's WBC
dropped, the fever resolved, the blood pressure stablized. An
ECHO on [**1-16**] showed that there was a possible vegatation at the
tip of the new catheter. A right femoral central venous
catheter was placed and the right subclavian catheter was
removed. A tip culture from the right subclavian line failed to
grow bacteria. On [**1-18**] the patient went for dialysis and after
3 hours the line clotted off. It could not be cleared. On [**1-19**]
the femoral line was removed and the angiography service placed
a left subclavian tunneled catheter. All surveillance cultures
of the blood, urine and stool, including three serial C.diffs
were negative. Despite the growth of MSSA the renal service
asked that the patient be kept on Vancomycin for ease of dosing
at dialysis. The Nafcillin and levofloxacin were discontinued.
The patient will complete 2 weeks on vancomycin.
.
2. ESRD: Secondary to reflux nephropathy. The renal service
helped ensure that the patient recieved hemodialysis and guided
the management of the patient's electrolytes.
.
3. Hypoxia: The patient had an oxygen requirement of uncertain
etiology. Possible etiologies considered were DAH, PNA, and
ARDS. The patient was put on levofloxacin until the CXR on the
19th showed that the parenchymal opacities had resolved. In
retrospect this was likely just pulmonary edema from aggressive
fluid resucitation.
Medications on Admission:
1. Cinacalcet 30 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. Doxercalciferol 2.5 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
3. Renagel 800 mg Tablet Sig: Four (4) Tablet PO three times a
day: Please take with meals. .
4. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
Discharge Medications:
1. Cinacalcet 30 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. Doxercalciferol 2.5 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
3. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram
Intravenous QHD (each hemodialysis) for 7 days: This will be
managed at dialysis.
4. Renagel 800 mg Tablet Sig: Four (4) Tablet PO three times a
day: Please take with meals. .
5. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Sepsis likely originating in right tunnled line.
Discharge Condition:
Afebrile, blood pressure stable, patient ambulating.
Discharge Instructions:
Please return to the hospital if you have fevers, chills,
nightsweats, if you notice blood around the catheter site, or if
you are just not feeling well.
.
Please follow up with plans for dialysis tomorrow, Wednesday
[**2151-1-20**].
.
Please note that you will need to recieve antibiotics at
dialysis at least until [**2151-1-26**].
.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2151-1-21**]
8:20
You should present for dialysis on [**2151-1-20**].
Per our discussion your wife has your primary care [**Name (NI) 48924**]
contact information and you will make a follow up appointment in
the next week. Of note the number listed above for Dr. [**First Name (STitle) **]
is not active.
Completed by:[**2151-1-20**]
|
[
"038.11",
"285.21",
"403.91",
"995.92",
"996.62",
"996.73",
"486",
"585.6",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
9724, 9730
|
6855, 8863
|
334, 527
|
9823, 9878
|
2632, 6832
|
10263, 10735
|
2140, 2227
|
9233, 9701
|
9751, 9802
|
8889, 9210
|
9902, 10240
|
2242, 2613
|
276, 296
|
555, 1853
|
1875, 2037
|
2053, 2124
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,186
| 196,517
|
47872
|
Discharge summary
|
report
|
Admission Date: [**2156-12-10**] Discharge Date: [**2157-2-25**]
Date of Birth: [**2097-8-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3283**]
Chief Complaint:
Wrist pain.
Major Surgical or Invasive Procedure:
[**2156-12-10**]: Left wrist incision and drainage.
- Upper GI endoscopy.
Trans-esophageal echocardiogram.
[**2157-1-11**]: Right hip hemiarthroplasty.
[**2157-1-13**]: Exploratory laparotomy, Subtotal colectomy, Resection
of terminal ileum, Temporary abdominal closure
[**2157-1-14**]: Exploratory laparoscopy, subtotal colectomy.
[**2157-1-15**]: Exploratory laparotomy, gastrostomy tube, ileocolonic
anastomosis and diverting loop ileostomy
[**2157-1-26**]: Right hip revision of hemi arthroplasty due to
dislocation
[**2157-2-18**]: Right hip girdlestone procedure, removal of Right hip
hardward, placement of spacer.
History of Present Illness:
HPI: Mr. [**Known lastname **] is a 59 year old man w/ a hx of ESRD on HD, s/p
failed transplant, and HTN who presented with sudden onset left
wrist pain. He noted that his wrist (distal to his native vessel
fistula site) was swollen and had reduced range of motion. Pain
present at rest and with motion. Pt also noted fevers and chills
the night before, but no nausea or vomiting. He did not recall
any trauma to the area or skin lesion. He is on a M/W/F dialysis
schedule, but because of increased pain and swelling, presented
to ED instead of usual HD.
Upon arrival at the [**Hospital1 18**] ED, his vitals were T 100.5, HR 97, BP
173/71, RR 14, O2sat 100% on RA. New-onset afib was noted. His
left wrist was aspirated and returned frank pus, consistent with
septic arthritis. Pt started empirically on vancomycin and
gentamycin while awaiting wound and blood cultures, then taken
to the OR by plastic surgery for wash-out of pus in the joint
and placement of Penrose drain. Following PACU recovery, the
patient was transferred to the Medicine service.
Past Medical History:
1. ESRD, secondary to post-streptococcal glomerulonephritis.
Renal transplant in [**2137**] failed after several years. Transplant
nephrectomy in [**2143**]. Currently on hemodialysis. Remains on the
transplant list.
2. Hyperparathyroidism due to ESRD
3. Hypertension
4. Coronary artery disease
5. Diastolic CHF with remote history of systolic CHF (resolved);
normal LVEF in [**2152**]
6. Repeated episodes of pneumonia
7. Pulmonary nodules
8. Carpal tunnel release
9. Left hand flexor tenosynovitis status post flexor
tenosynovectomy, trigger release, and right ring finger mallet
finger.
10. Amyloid lesions in the wrist and metacarpals.
Social History:
Owner of a very successful vintage clothing store in downtown
[**Location (un) 86**] and travels extensively. Currently lives with mother and
brother in [**Name (NI) **]. Divorced with 1 daughter. Denies current
tobacco and alcohol use but notes intermittent tobacco use in
the past (~3 pack-years). Denies illicit drug use. Current
orientation is homosexual; HIV test negative in [**2156-9-10**], not in
a relationship recently but notes that he always uses
protection.
Family History:
Positive for cancer (father-prostate), [**Name (NI) 2481**] (mother).
Father deceased. Brother has fibromyalgia. Daughter in good
health.
Physical Exam:
On admission:
VS: Tm 101.6, T 99.6, BP 137/72, HR 78, RR 20, O2sat 98% on RA
Gen: Well-nourished African American man sitting up in bed,
trying to rip of EKG leads, clearly disoriented and ill, but not
septic appearing.
HEENT: NCAT. Eyes PERRLA 2->1mm. Notable for injected sclera.
No abnormalities of nose or ears. Throat w/o exudate or
erythema.
Neck: Supple. No thyromegaly, no LAD.
CV: Irregularly, irregular heart rate and rhythm. S1, S2, and
S4 audible w/ 3/6 systolic murmer heard best at apex.
Pulm: CTAB with exception of crackles in the bases bilaterally
which largely resolve on deep cough. Able to speak in full
sentences w/o SOB.
Abd: Voluntary guarding w/ some tenderness diffusely. Tense abd
musculature on palpation. Very active bowel sounds.
Extrem: WWP. No edema. L Wrist wound w/ erythema and swelling,
but no pus. Exquisitely tender. Margin of 1.5in btwn fistula
and wound. Bruit over fistula.
Neuro: Awake. Oriented only to person and year. Believes he is
going to [**Location (un) 101015**]. No recollection of reason for being in
hospital. Very inattentive. Unable to complete [**Doctor Last Name 1841**] backwards.
0/3 recall. Comprehension intact to 2 step commands. Strength
full in lower extremities w/ exception of R IP [**3-17**]. Unclear if
pain complicating strength exam. Sensory intact to gross touch.
Proprioception intact. Reflexes [**3-14**] patellar, biceps, triceps.
No asterixis. Unable to cooperate w/ finger to nose testing.
Unable to ambulate 2* to fever and disorientation.
On discharge:
VS: T 97.1, BP 105/60, HR 90, RR 20, 99% on room air
Tm 97.4, 98-126/40-61, 76-90, 16-20, 97-100% RA
Gen: NAD
HEENT: OP dry, but clear, no scleral icterus
Neck: JVP to mid-neck
Chest: CTA anteriorly, no crackles, wheezes, or rhonchi
CV: regular, normal S1 and S2, 4/6 systolic murmur loudest at
LLSB
Abd: abd wound vac in place w/minimal drainage, G-tube site
c/d/i, ostomy bag on, no soilage around ostomy site; NABS, soft,
NT, ND
R hip: no erythema or exudate, warm to touch, pain with minimal
movement, with ~100cc bloody drainage in hemovac from r-hip
Ext: warm, no edema.
Pertinent Results:
Admission labs:
[**2156-12-10**] 02:19PM BLOOD WBC-5.7 RBC-3.94* Hgb-13.6* Hct-38.5*
MCV-98 MCH-34.4* MCHC-35.2* RDW-15.5 Plt Ct-78*
[**2156-12-10**] 02:19PM BLOOD Neuts-80.5* Lymphs-8.4* Monos-4.0
Eos-6.9* Baso-0.2
[**2156-12-10**] 02:19PM BLOOD PT-14.7* PTT-28.9 INR(PT)-1.3*
[**2156-12-10**] 02:19PM BLOOD Glucose-82 UreaN-40* Creat-10.6*# Na-137
K-4.6 Cl-90* HCO3-29 AnGap-23*
[**2156-12-10**] 02:19PM BLOOD Calcium-9.6 Phos-6.3* Mg-2.0 UricAcd-4.6
On discharge:
[**2157-2-25**] BLOOD WBC-7.8 RBC-3.15* Hgb-9.9* Hct-28.7* MCV-91
MCH-31.5* MCHC-34.5* RDW-18.8 Plt Ct-137*
[**2157-2-25**] BLOOD PT-19.4* PTT-34.5 INR(PT)-1.8*
[**2157-2-25**] BLOOD Glucose-111 UreaN-40* Creat-5.3*# Na-135 K-4.8
Cl-101* HCO3-26 AnGap-13*
[**2157-2-25**] BLOOD Calcium-8.5 Phos-4.2* Mg-1.7
ROMI:
[**2156-12-10**] 02:19PM BLOOD CK(CPK)-122
[**2156-12-11**] 07:15AM BLOOD CK(CPK)-206
[**2156-12-10**] 02:19PM BLOOD CK-MB-4
[**2156-12-11**] 07:15AM BLOOD CK-MB-6
[**2156-12-10**] 02:19PM BLOOD cTropnT-0.17
[**2156-12-11**] 07:15AM BLOOD cTropnT-0.18
Delirium workup:
[**2156-12-10**] 02:19PM BLOOD Digoxin-1.9
[**2156-12-13**] 07:05AM BLOOD Digoxin-2.5
[**2156-12-13**] 07:05AM BLOOD TSH-0.16
[**2156-12-13**] 07:05AM BLOOD VitB12-1857
Infectious work-up:
[**2156-12-10**] 02:42PM BLOOD Lactate-2.1
[**2156-12-10**]: L Wrist Cell Count: 100000WBC 150000RBC 64Poly 6Lymp
12Mono 1Eo 17Macro
[**2156-12-10**] 10:49 pm L Wrist SWAB
GRAM STAIN (Final [**2156-12-11**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
WOUND CULTURE (Final [**2156-12-13**]):
STAPH AUREUS COAG +. HEAVY GROWTH. OXACILLIN <=0.25 S
[**2156-12-10**] 1:54 pm BLOOD CULTURE STAPH AUREUS COAG +, OXACILLIN
<=0.25 S
[**2156-12-12**] 9:15 am BLOOD CULTURE STAPH AUREUS COAG +.
[**2156-12-12**] 7:27 pm BLOOD CULTURE NO GROWTH.
[**2156-12-13**] 7:00 am RAPID PLASMA REAGIN TEST NONREACTIVE.
[**2156-12-18**] 11:00 am JOINT FLUID RIGHT HIP ASPIRATION.
GRAM STAIN (Final [**2156-12-18**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2156-12-21**]): NO GROWTH.
[**2156-12-19**] 6:09 am SWAB LEFT WRIST
GRAM STAIN (Final [**2156-12-19**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2156-12-22**]):
STAPH AUREUS COAG +. RARE GROWTH. OXACILLIN 0.5 S
ANAEROBIC CULTURE (Final [**2156-12-23**]): NO ANAEROBES ISOLATED.
[**2156-12-17**] 5:23 pm STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST
negative
[**2156-12-20**] 5:23 pm STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST
negative
[**2156-12-22**] 5:23 pm STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST
negative
[**2157-1-6**] 5:23 pm STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST
negative
[**2156-12-27**] CMV Viral Load: CMV DNA not detected.
[**2156-12-27**] HIV SEROLOGY HIV Ab: NEGATIVE
[**2156-2-18**]:
WOUND CULTURE (Final [**2157-2-23**]):
ENTEROCOCCUS SP.. SPARSE GROWTH.
Daptomycin Sensitivity testing per DR [**First Name (STitle) **] ([**Numeric Identifier 95354**]).
DAPTOMYCIN 1 UG/ML = SENSITIVE BY E-TEST.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ =>32 R
ANAEROBIC CULTURE (Final [**2157-2-21**]): NO ANAEROBES ISOLATED.
[**2156-12-10**] CXR: In comparison with study of [**9-23**], there is
continued enlargement of the cardiac silhouette with evidence of
elevated pulmonary venous pressure. No acute focal pneumonia. On
the lateral view, there appears to be some opacification in the
retrocardiac area. However, some of this may be merely due to
overlying soft tissues. In view of the clinical history, the
possibility of a region of pneumonia cannot be excluded.
[**2156-12-10**] Left wrist x-ray: Soft tissue calcifications and
swelling overlying the radial aspect of the distal radius are
grossly stable since [**2156-3-3**]. The scapholunate interval again
measures 3 mm. Diffuse osteopenia is unchanged. Lucencies are
noted within the capitate and scaphoid which are grossly stable.
There is no evidence of acute fracture or malalignment.
IMPRESSION: Stable exam without evidence of acute process
[**2156-12-11**] Right shoulder x-ray: No previous images. Three views
show loss of the cortical margin involving the distal clavicle
with widening of the acromioclavicular joint. Suggestion of an
associated soft tissue prominence. In view of the clinical
history, the possibility of a septic arthritis with
osteomyelitis must be seriously considered.
[**2156-12-12**] CT head (prelim report): No evidence of acute
intracranial abnormality seen on non-contrast head CT, although
for more sensitive evaluation for subtle intracranial infection
or small acute infarct, MRI would be recommended for more
sensitive evaluation. Diffuse small lucencies in the calvarium,
particularly along the vertex, without cortical breakthrough or
cortical thickening likely relates to chronic renal
failure/renal osteodystrophy, less likely Paget's disease or
diffuse metastatic disease.
[**2156-12-13**] TTE: The left atrium is moderately dilated. There is
mild symmetric left ventricular hypertrophy with normal cavity
size and regional/global systolic function (LVEF>55%). The
estimated cardiac index is normal (>=2.5L/min/m2). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg).The estimated cardiac index is normal
(>=2.5L/min/m2). The right ventricular cavity is markedly
dilated with moderate global free wall hypokinesis. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened with trivial mitral regurgitation. There is
moderate to severe pulmonary artery systolic hypertension. There
is a small to moderate sized pericardial effusion. Compared with
the report of the prior study (images unavailable for review) of
[**2148-9-20**], the right ventricular cavity dilation and
moderate/severe PA systolic hypertension are new. The
pericardial effusion is likely similar.
[**2156-12-13**] Portable abdomen:Non-specific bowel gas pattern without
evidence for obstruction or ileus. No intraperitoneal free air.
[**2156-12-13**] MRI head: There is no evidence of hemorrhage, edema, or
infarction. There is no evidence of mass effect. There are no
diffusion abnormalities detected, that would be suggestive of
septic emboli. The ventricles and sulci are normal in caliber
and configuration. There is noted to be fluid in the left
petrous apex. There are a few small hyperintense foci seen in
the white matter on FLAIR images that are non specific in nature
and demonstrate no restricted diffusion. The patient is noted to
be status post lens replacement on the right eyeglobe. In
comparison to the CT scan from [**2156-12-12**] the diffuse patchy and
small rounded lucencies in the calvarium are not well
demonstrated on this current MR study. The basilar artery is
noted to be small in diameter. There is noted to be opacity
within the mastoid air cells suggestive of fluid in the
mastoids. This could be suggestive of mastoiditis. IMPRESSION:
1. No evidence for septic emboli or abscess. No acute infarction
or hemorrhage. 2. Areas of rounded lucencies within the
calvarium are not well demonstrated on this current MR study.
Please refer to CT report from [**2156-12-12**] for full
characterization. 3. There is noted to be fluid in the left
petrous apex.
[**2156-12-14**] Upper GI Endoscopy: Findings: Esophagus: Normal
esophagus. Stomach: Mucosa: Erythema and congestion of the
mucosa were noted in the whole stomach. Cold forceps biopsies
were performed for histology at the stomach antrum. Duodenum:
Mucosa: Erythema, congestion and friability of the mucosa with
no bleeding were noted in the duodenal bulb compatible with
duodenitis. Excavated Lesions Multiple non-bleeding, clean
based, small ulcers were found in the duodenal bulb.
Impression: Ulcers in the duodenal bulb. Erythema, congestion
and friability in the duodenal bulb compatible with duodenitis.
Erythema and congestion in the whole stomach (biopsy) Otherwise
normal EGD to third part of the duodenum.
[**2156-12-14**] Pathology: Gastric Tissue Sample: Regeneration of
gastric pits suggestive of chemical gastropathy.
[**2156-12-14**] EKG: Primarily atrial fibrillation although there appear
to be some flutter waves in leads V1-V2. Non-specific
intraventricular conduction delay. Left anterior fascicular
block. Consider left ventricular hypertrophy. Consider prior
lateral myocardial infarction. Non specific ST-T wave changes.
Compared to the previous tracing of [**2156-12-14**] the rhythm is more
irregular consistent with atrial fibrillation.
[**2156-12-14**] U/S of L AV fistula: Widely patent left brachial and
left radial arteries with suggestion of some degree of
atherosclerotic disease. Widely patent radiocephalic fistula
without visualized stenosis of the outflow vein which appears to
be the cephalic vein.
[**2156-12-16**]: MRI of the R hip: There is small amount of joint fluid
in the right hip, which is in the range for physiological
quantity. There are degenerative changes in the right hip which
include subchondral cystic changes in the femoral head. A
subchondral cystic change is also noted in the femoral head-neck
junction. Given the superior joint space narrowing, the
appearance favors degenerative changes. However, less likely
infection may also produce this appearance. Infection is
considered less likely due to lack of joint fluid.
There is a lobulated bright T2 signal intensity lesion adjacent
to the superior labrum measuring 2.8 x 2.0 cm, which is most
consistent with a paralabral cyst. The labrum is not well
assessed on this non-dedicated examination.
There is fluid signal intensity which spans 10 cm along the
greater trochanteric bursa, and measures 5.8 x 1.6 cm in axial
dimensions, with appearance consistent with right greater
trochanteric bursitis. Degenerative changes are also noted in
the left hip. There is physiological joint fluid in the left
hip. A tiny amount of fluid is also noted in the left greater
trochanteric bursa, consistent with mild bursitis.
There is diffuse soft tissue edema. There is edema in the right
hemipelvis greater than left hemipelvis musculature,
particularly in the iliacus and gluteus minimus.
IMPRESSION:
Physiological quantity of right hip joint fluid. Insufficient
fluid for aspiration. Greater trochanteric bursitis, right
side significantly greater than left. Presence of a paralabral
cyst suggests a superior labral tear, but the exact tear this is
not optimally seen due to lack of dedicated technique. Muscular
edema as detailed.
[**2156-12-18**]: CT Guided Biopsy: 25 cc of red serosanguineous colored
fluid was aspirated with no complication fluid was sent for
microbiologic examination. Culture: GRAM STAIN 4+(>10 per 1000X
FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2156-12-21**]): NO GROWTH.
[**2156-12-21**] EKG: Atrial fibrillation with controlled ventricular
response. Occasional ventricular premature beats. Compared to
the previous tracing of [**2156-12-16**] ectopy is new.
[**2156-12-21**]: CT of the torso, abdomen and pelvis to r/o occult
abscess: 1. Mild pulmonary edema and background nodular and
cystic changes, again concerning for LIP (lymphocytic
interstitial pneumonitis). 2. Unchanged marked cardiomegaly
and small-to-moderate-sized pericardial effusion. 3. Small
splenic infarct, age indeterminate due to lack of prior
examinations. 4. No evidence of intrathoracic or intra-abdominal
abscess.
[**2156-12-22**] TEE: Conclusions The left atrium is dilated. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium or left atrial appendage. No atrial septal defect is
seen by 2D or color Doppler. Overall left ventricular systolic
function is normal (LVEF>55%). There are simple atheroma in the
aortic arch. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened. No masses or vegetations are seen on the aortic
valve. There is no valvular aortic stenosis. The increased
transaortic velocity is likely related to high cardiac output.
Mild to moderate ([**2-11**]+) aortic regurgitation is seen. The aortic
regurgitation jet is eccentric. The mitral valve leaflets are
moderately thickened.There are torn, calcified mitral chordae
seen. No masses or vegetations are seen on the mitral valve, but
cannot be fully excluded due to suboptimal image quality. There
is severe mitral annular calcification. Two eccentric (anterior
and posterior directed) jets of mitral regurgitation are seen
with moderate to severe mitral regurgitation (3+) . A small
perforation of the posterior leaflet cannot be excluded on the
basis of this study. No masses or vegetations are seen on the
tricuspid valve. No vegetation/mass is seen on the pulmonic
valve. There is a small pericardial effusion.
Impression: No valvular vegetations seen. Moderate to severe,
eccentric mitral regurgitation.
[**2156-12-23**]: CT of the L wrist: Innumerable lucencies are seen
throughout the carpus. This includes large ill-defined lucencies
in the scaphoid, lunate, capitate, hamate, trapezium,
triquetrum, and the bases of the metacarpals particularly the
second through fourth metacarpals. Numerous irregular lucencies
and areas of cortical destruction are also seen in the distal
ulna. There is extensive atherosclerotic vascular calcification.
Gas is seen within the dorsal soft tissues at the level of the
wrist likely related to previous incision and drainage. The
absence of intravenous contrast severely limits evaluation for
an underlying fluid collection, although no discrete soft tissue
density is identified. Circumferential soft tissue edema is seen
throughout the subcutaneous and deep fat as well as associated
skin thickening. Tendons are suboptimally assessed.
IMPRESSION:
1. Innumerable lucencies throughout the carpus, distal ulna, and
the bases of the metacarpals as described could reflect an
erosive process such as amyloidosis. However, given the history
and the destructive and ill-defined appearance of these
lucencies, the possibility of superimposed osteomyelitis is
difficult to exclude.
2. No discrete soft tissue collection, although evaluation is
suboptimal due to the absence of intravenous contrast.
3. Post-surgical changes including gas in the dorsal soft
tissues of the wrist.
[**2156-12-29**] EKG: Sinus rhythm and occasional ventricular ectopy.
A-V conduction delay. Left atrial abnormality. Right
bundle-branch block. Compared to the previous tracing of
[**2156-12-20**] sinus rhythm has appeared.
[**2156-12-31**] CXR: Comparison is made to the prior chest x-ray of
[**12-13**]. The heart remains enlarged. Some pulmonary
plethora is present suggesting incipient failure. No areas of
pneumonia are seen. IMPRESSION: Cardiomegaly, mild failure
[**2157-1-2**] MRI right hip:
1. Interval increase in the amount of right hip joint fluid, now
large in quantity.
2. More conspicuous signal changes in the right femoral head and
neck and diaphysis, likely representing components of mild
marrow edema and hematopoietic marrow.
3. Persistent, but slightly decreased, right greater
trochanteric bursitis.
4. Persistent, and slightly increased, diffuse muscle edema as
detailed.
[**2157-1-6**] CXR
1) Marked cardiomegaly consistent with polychamber enlargement
and/or an element of pericardial fluid.
2) Diffusely increased interstitial markings consistent with
interstitial edema or another interstial process, (Please note
that the report from the [**2156-12-21**] CT scan also raised concern
for a lymphocytic interstitial pneumonitis.)
2) Compared with [**2156-12-31**] and allowing for technical
differences, the interstitial markings are without significant
interval change. No pleural effusion.
Left-Wrist x-ray [**2157-2-11**]:
Diffuse osteoporosis is again seen, worse than on the prior
occasion. Soft tissue vascular calcification is again seen, and
also is present on the thenar aspect of the forearm. No definite
areas of bony destruction are seen; though, there is some
irregularity at the distal aspect of the scaphoid on the thenar
aspect. These films should be compared with the MR films by
musculoskeletal radiologist.
CT abd/pelvis [**2157-2-13**]:
1. Small pelvic fluid collections noted on prior studies are
less conspicuous on current study. No drainable fluid
collections are identified within the pelvis, although
evaluation limited given streak artifact from right hip
arthroplasty.
2. Little change to stranding and fluid within the region of the
right gluteal musculature after hip arthroplasty.
3. Bibasilar atelectasis and small right pleural effusion.
Smooth septal
thickening within the bases again may represent pulmonary edema
superimposed on previously described lymphocytic interstitial
pneumonitis (LIP).
4. Cardiomegaly with mitral annular calcifications. Significant
calcifications within the SMA as detailed above.
5. Splenomegaly.
Brief Hospital Course:
"Brief"
This is a 59 year old male with ESRD on HD with persistent
fevers despite appropriate IV abx for MSSA+ bacteremia and
likely endocarditis following septic arthritis of left wrist s/p
wash-out.
# Fever: Vancomycin and gentamycin started empirically for joint
aspirate consistent with septic arthritis. Patient taken to OR
by plastic reconstructive surgery for wash-out of left wrist.
Blood cultures and fluid cultures subsequently grew out S.
aureus, and gentamycin discontinued. MSSA by [**Last Name (LF) 101016**], [**First Name3 (LF) **]
vancomycin switched to nafcillin for better coverage, then to
cefazolin with hemodialysis. Drainage from left wrist noted to
be less purulent and less erythematous per PRS evaluation.
However, as Mr. [**Known lastname **] continued to spike fevers with
persistently positive cultures, ID consulted and recommended
restarting on nafcillin. Pt continued spiking fevers although
cultures cleared [**12-12**]. Gentamicin with HD started for synergy.
Concern for endocarditis as pt with murmur at baseline and new
afib but no vegetations seen. No evidence of septic emboli on CT
and MRI head. X-ray to evaluate for right shoulder infection
with absent cortex likely [**3-14**] old trauma - pt later noted pain
old. Ultrasound of fistula with no evidence of infection.
Pt with pain on mobilization of R hip, concern for septic joint.
MRI with no evidence of hip joint involvement but showed fluid
collection at tronchanteric bursa (culture negative), labral
tear, muscle tear, improved with steroid injection. Left wrist
re-aspirated and showed rare S. aureus. Wrist re-imaged with CT
without significant fluid collection. TEE to re-evaluate for
vegetations showed increased mitral regurgitation with 2 jets
concerning for valve perforation as well as new aortic
regurgurgitation, both consistent with likely endocarditis. CT
surgery consulted and recommended surgery. Fevers continued
intermittently (at least 1 every 24hrs) along w/ development of
night sweats until [**12-27**]. Concern for nafcillin-related drug
fever, and patient switched to vancomycin with HD. Afebrile from
late [**12-27**] to [**12-30**], and Gentamicin discontinued. However,
continued to spike fevers on vancomycin and switched back to
beta-lactam for better coverage of MSSA but still continued to
spike fevers.
Treated for 8 wks w/ cefazolin for IE and wrist osteomyelitis.
Was temporarily afebrile, then broke R hip had hemiarthroplasty,
got ischemic colitis and hemicolectomy w/ ostomy. Ostomy leaked
into hip wound which became infected w/ enterobacter and
Klebsiella sensitive to cipro. Initially afebrile after starting
cipro and washing out hip. ID recommended continuing cipro for 6
months because of concern for infected prosthesis though ortho
said it was an infected hematoma. Recommended switching to
cefepime if he spiked a fever through the cipro. Over the
weekend of [**2-12**] and [**2-13**], the patient continued to spike low grade
fevers. Out of concern for continuuing infection, the patient
received a CT of the abd/pelvis on [**2157-2-13**]. This showed several
fluid collections and possibly a larger hematoma at the right
hip joint. The patient then had an IR guided drainage of fluid.
The hematoma near the joint did not aspirate and 100cc of fluid
collection near the staples was sampled. This fluid subsequently
grew VRE. It was determined the patient would need a Girdlestone
procedure in which the hardware of the right hip is removed and
replaced with a spacer so the area could be sterilized before
reinserting hardware. The patient went for this procedure on
[**2157-2-19**]. Post-op, the patient had a large amount of bloody
drainage from the wound vac and did requires an additional 10
units of pRBC's. After a brief stay in the MICU, the patient was
called out to the floor where he remained stable.
# Confusion: Pt initially delirious in setting of persistently
positive blood cultures and continuing fevers, improved back to
baseline 5-6d later when no longer bacteremic and fevers running
lower and more infrequent. Likely also to be more sensitive to
narcotics base on past response, per daughter. Of note, no acute
intracranial process on CT or MRI head. RPR neg. B12 wnl. TSH
elevated but T3 low, T4 wnl, likely euthyroid sick. Uremia
unlikely as lytes at baseline on HD. Now resolved and remains
AAO x 3 on discharge.
# Cardiac dysarrhythmia: On admission, EKG regular with
prolonged PR, unchanged from baseline. However, pt developed
Afib and occasional aflutter during hospital course. Initially
with RVR then associated with bradycardia into HR 30s-40s.
Evaluated by cardiology, who recommended anticoagulation with
coumadin and cardioversion. However, pt was not candidate at
that time as with new GI bleed, in which setting ASA also
discontinued. Pt remained hemodynamically stable. Now in Afib.
Would consider anticoagulation in the future if bleed is no
longer a concern.
# Cardiac/valvular disease: TTE on [**2156-12-13**] without vegetations,
trivial MR, no AI, normal EF. TEE on [**2156-12-12**] to re-evaluate for
vegetations showed increased mitral regurgitation w/ 2 jets
concerning for valve perforation as well as new aortic
regurgurgitation, both consistent with endocarditis. Restarted
on ACE I to decrease afterload. Evaluated by CT surgery who
recommended mitral and aortic replacement. Decision made by pt
and medical teams to defer in setting of acute infection while
aware that delay would increase risk of complications from
ongoing medical issues. Prior to surgery, pt will require cath
and dental clearance. At the time of surgery, a bypass will
likely be needed with renal transplant should follow. CT surgery
will remain in contact with the patient, scheduled to follow up
with Dr. [**Last Name (STitle) 914**] on [**2157-1-18**]. Pt. remained in house [**3-14**]
complicated complications and Dr. [**Last Name (STitle) 914**] saw him again in house
and recomended no valve surgery unless would go for renal
transplant, also too debilitated w/ infectious processes going
on [**2158-2-9**]. He was also given multiple blood transfusions out
of concern for demand ischemia.
# Elevated troponin: Likely baseline in setting of renal failure
although with transient worsening probably [**3-14**] to high output in
setting of infection. Sharp chest pain noted on several
occassions throughout stay, thought to be related to anxiety and
demand ischemia from MR, AI, and anemia. No EKG changes
appreciated with any episode; trop at baseline. Pain resolved
each time within several minutes and responded well to
nitroglycerin SL.
# CHF: Pt with chronic diastolic CHF and history of systolic CHF
(thought to be hypertensive cardiomyopathy) resolved on TTE in
[**2152**] but continued on digoxin and euvolemic on admission. As TTE
on this admission also showed normal EF and as digoxin levels
toxic in setting of delirium, digoxin discontinued; continued on
beta blocker. As pt complaining of increased angina, restarted
on ACE-I for afterload reduction. Repeat TTE after the diagnosis
of endocarditis with new finding of focal inferior wall motion
abnormality with EF of 45%, likely in setting of increased
valvular disease v. ischemic change. The patient was restarted
on digoxin. His Ace-I has since been discontinued and he is
being discharged on 12.5mg PO BID of Metoprolol.
# HTN: Continued on metoprolol. Initially held moexipril,
clonidine, and minoxidil as blood pressures lower running. As
these normalized, pt restarted on ACE-I (lisinopril) for
afterload reduction in setting of increased angina, though this
is now discontinued again. He is on Metoprolol for improved rate
control of afib as we are currently unable to anticoagulate him.
# Anemia: Patient was admitted w/ Hct of 38.5 which slowly
trended down over admission to a low of 19.4. Anemia thought to
be of combined etiology including GI bleed, frequent blood
draws, anemia of chronic disease (as supported by Fe studies),
and ESRD (on Epogen w/ HD). Patient transfused with HD as Hct
dropped into low 20s as developed more frequent episodes CP and
SOB, likely exacerbated by valvular damage [**3-14**] endocarditis. The
patient is currently guaiac negative but if Hct continues to
trend down, may need outpt colonoscopy. Hct should be monitored
on discharge, even after his hip wound ceases to drain.
# Guaiac positive stools: Patient complained of abdominal
tenderness on [**12-12**] exam with voluntary guarding. LFTs wnl and
KUB unremarkable, date of last bowel movement unclear. Pt with
one large episode melanic stool on [**12-14**], EGD showed nonbleeding
duodenol ulcers, duodenitis. Pt started on PPI [**Hospital1 **] and home ASA
held. Stools no longer guaiac positive except in setting of
nosebleed, now again resolving.
# Ischemic colitis: Pt complained of increasing abdominal pain
during his HD session on [**1-13**]. Abdominal exam without guarding
or rebound but concern as pt appeared unwell, worsened from
baseline. Found to have ischemic colitis on stat CT. Surgery
consulted and pt taken to OR for left hemicolectomy and
transferred to the SICU afterwards. Post-op course notable for
some hypotension requiring blood transfusion and pressors.
However, remaining bowel appeared pink and no further bowel
resection required, and pt underwent abdominal closure,
ileostomy, Gtube placement on [**1-16**]. Extubated without difficulty
on [**1-17**]. Of note, wound vac placed on abdominal wound for caudal
aspect opening on [**1-25**]. The abdominal wound vac should be
replaced every 3 days until it can be discontinued.
# ESRD on HD: Patient s/p failed transplant, on transplant list
again. Between HD sessions, pt developed increased JVD and
bibasilar rales but breathing comfortably and satting well. Does
not produce urine at baseline. Continued on HD MWF, home meds,
medications renally dosed.
# Right shoulder pain: Pt complaining of right shoulder pain on
movement, concern for septic involvement initially. Xray showed
cortical absence at distal cortex, c/w old trauma v. infection.
However, as patient without point tenderness and no signs of
inflammation, low suspicion for infection. On further
questioning, pt reports having had pain on and off for few weeks
prior to presentation; per pt, it is possible he has sustained
trauma to that shoulder.
# Right hip fracture happened after bumping right knee on bed
rail on [**2157-1-10**]. Taken to the operating room on [**2157-1-11**] and
underwent an right hip hemiarthroplasty. Unfortunately found to
have same hip dislocated on [**2157-1-25**]. Returned to the operating
room on [**2157-1-26**] and underwent a revision of his right
hemiarthroplasty. He was found to have Enterococcus growing
from his wound on [**2157-2-17**]. He was taken back to the OR for
removal of the hardware on [**2157-2-18**]. At that time he was
coagulopathic with an INR of 1.8 He was transfered to the MICU
following the procedure as he became hypotensive. He was found
to have profound blood loss into his hip joint. He was
transfused a total of 10 units of PRBCs and 10 units of FFP at
taht time and 2 additional units of PRBCs the following day. He
was stablized and monitored in the ICU until [**2157-2-22**] when he was
taken back to the OR for washout. He was found to have VRE in
the wound and treated with daptomycin and ciprofloxacin. He was
then transfered to the floor on the night of [**2157-2-22**].
Medications on Admission:
Nephrocaps daily
Clonidine 0.1 mg daily
Digoxin 125 mcg every other day and 250mcg every other day
Moexipril 15 mg in the morning and 30mg in the evening
Metoprolol 50 mg [**Hospital1 **]
Minoxidil 5 mg daily
Lorazepam or valium at night
Discharge Medications:
1. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime)
as needed for insomnia.
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
4. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H ()
as needed for pain, fever.
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q4-6H () as
needed for pain: Please use for pain prior to using opiates.
10. Outpatient Lab Work
Please check Hct daily until stable and transfuse with blood in
hemodialysis as needed.
11. Outpatient Lab Work
Please guaiac all stools.
12. Insulin Regular Human 100 unit/mL Solution Sig: SSI per
sliding scale Injection ASDIR (AS DIRECTED).
13. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
14. Lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane
[**Hospital1 **] (2 times a day) as needed.
15. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
16. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: Ten
(10) ML Intravenous Q8H (every 8 hours) as needed for line
flush.
17. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 4 weeks.
18. Daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q48H (every 48 hours) for 4 weeks.
19. Mirtazapine 7.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
20. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
21. Tramadol 50 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
22. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed: Please hold for sedation or RR<12.
23. Outpatient Lab Work
Please have weekly CBC, chemistries and liver function tests
faxed to the Infectious Disease Clinic at [**Telephone/Fax (1) 432**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
1. Methicillin-sensitive staph aureus septicemia with confirmed
L septic wrist and highly probable bacterial endocarditis.
2. New mod/severe mitral regurgitation w/ perforation of the
posterior leaflet and mild/moderate aortic insuffiency.
3. New onset atrial fibrillation.
4. Duodenal ulcers.
5. ESRD, hemodialysis dependent.
6. L hip bursitis.
7. Febrile-associated delirium.
8. Possible nafcillin related drug fever.
9. Right femoral neck fracture, status-post girdlestone
procedure
10. Adrenal Nodule, likely adenoma
11. Non-ST Segment Myocardial Infarction
12. Vancomycin Resistent Enterococcus infection.
Discharge Condition:
Stable. afebrile.
Discharge Instructions:
You were admitted with an infected left wrist, which was
surgically cleaned. The wrist and your blood cultures contained
bacteria, and therefore you were started on IV antibiotics.
These were changed several times during your stay here to
specifically target the bacteria. Despite these antibiotics,
you remained febrile for several weeks and we were concerned for
infection in other parts of your body. Imaging of your heart
showed evidence of infection, including new valve damage to your
mitral and aortic valves. This makes it harder for your heart
to pump blood forwards and may require replacement of your heart
valves at a future date. In addition, during your stay, you
were noted to have blood in your stool, found to be the result
of ulcers in your duodenum. You received several blood
transfusions during your hospital course.
While you were here, you broke your right hip and received a hip
replacement. Following this, you had ischemic colitis requiring
a hemicolectomy with ostomy placement. Subsequently, it was
found that your hip wound grew Klebsiella and Enterobacter. You
were treated for these but continued to have low grade fevers. A
CT scan showed continuing fluid collection near your hip. A
Girdlestone procedure was performed in which your hip hardware
was removed and a spacer placed. You will receive IV antibiotics
for the next several weeks for this. The bacteria which grew
from this wound is called VRE, which is a resistent bacteria
requiring special antiobiotics. You were also noted to have had
an small heart attack sometime during [**Month (only) **]. You do have a
history of atrial fibrillation for which you were previously
taking Coumadin, but this is currently being held.
1. You will be discharged to [**Hospital **] Rehabilitation facility
where you will have hemodialysis (HD) on your regular schedule.
Your antibiotics will also be continued. At a follow-up
appointment with infectious disease, it will be determined the
exact length of antibiotic treatment.
2. If you become very short of breath or experience a
significant increase in the swelling in your legs, please let
the staff at the rehab facility know. This can be a result of
your heart's pumping function.
3. Please follow up with Dr. [**Last Name (STitle) 2450**], Dr. [**Last Name (STitle) 438**], and Dr. [**Last Name (STitle) 914**]
as below.
4. Do not take aspirin unless instructed to by a physician as
this can worsen your small intestinal bleed.
5. At rehab, the following labs should be checked:
- Hct once every day until stable, with transfusions at HD if
clinically appropriate.
- Guaiac stools
Followup Instructions:
Please follow up with the physicians below. You will note that
appointments have already been scheduled. [**Hospital **] Rehab will
arrange transportation.
-Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2450**], PCP: [**2157-3-10**] at 8:20 am. [**Telephone/Fax (1) 250**]. Dr.
[**Last Name (STitle) 2450**] will contact you if he would like to see you in clinic
sooner.
-Infectious disease: You have an appointment scheduled with Dr.
[**Last Name (STitle) 438**]:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 456**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2157-3-21**] 9:00am. [**Last Name (NamePattern1) **].
-Dr. [**Known firstname **] [**Last Name (NamePattern1) 914**], CT surgery: [**2157-2-15**] at 2:15pm. [**Telephone/Fax (1) 170**].
[**Hospital Unit Name 4081**]
-Please see Dr. [**Last Name (STitle) 1005**], Dr. [**Last Name (STitle) **], in orthopedic clinic.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in orthopedics in 2 weeks, please call
[**Telephone/Fax (1) 1228**] to schedule that appointment
Completed by:[**2157-3-9**]
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"80.05",
"81.52",
"46.01",
"38.93",
"45.16",
"83.95",
"39.95",
"77.19",
"84.56",
"83.94",
"45.79",
"00.72",
"45.62",
"96.6",
"45.93"
] |
icd9pcs
|
[
[
[]
]
] |
37214, 37293
|
23147, 34598
|
328, 961
|
37948, 37968
|
5517, 5517
|
40644, 41781
|
3216, 3355
|
34887, 37191
|
37314, 37927
|
34624, 34864
|
37992, 40621
|
3370, 3370
|
5985, 23124
|
277, 290
|
989, 2047
|
5533, 5971
|
3384, 4905
|
2069, 2712
|
2728, 3200
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,110
| 137,284
|
32629
|
Discharge summary
|
report
|
Admission Date: [**2152-10-30**] Discharge Date: [**2152-11-8**]
Date of Birth: [**2101-3-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2108**]
Chief Complaint:
Fevers and flank pain
Major Surgical or Invasive Procedure:
Right IJ CVL placed [**2152-10-30**]
Left PICC line placed [**2152-11-1**]
Cystoscopy / uretoscopy with lithotripsy and double J stent
replacement on [**2152-11-7**].
History of Present Illness:
Ms. [**Known firstname 76054**] [**Known lastname 76050**] is a 51 year old woman with history of IVDU,
HCV, DM2, and xanthogranulomatous pyelonephritis with recent
hospitalization for renal abscess in the setting of
nephrolithiais s/p percutaneous abscess drain placement and left
UPJ stent placement on [**2152-9-5**]. She was discharged on [**2152-9-11**]
with plan for 21 day course of ceftriaxone. Her course of
ceftriaxone was reportedly completed on [**2152-10-19**] though
compromised by patient's noncompliance with follow up
appointments at the [**Hospital 4898**] clinic, IR and with [**Hospital **]. Per
medical record she received a total of 23 doses of ceftriaxone
over 44 days (course intended to be completed in 21 days).
Patient presents today with reports of fever to 104 F at home
and persistent left flank pain.
.
In the ED initial vital signs were: T 97 HR 106 BP 119/79 RR 18
SpO2 100% RA. Her PICC line and percutaneous abscess drain are
still in place. CTU was performed and preliminarily reported
unchanged imaging showing pernephric stranding and mild
hydronephrosis. She initially was normotensive but became
hypotensive to SBP in 70s. Central access was attempted
multiple times at the R IJ and R femoral before obtaining access
in the R IJ. CVL placement was challenged by body habitus and
extreme anxiety requiring haldol 10 mg and ativan 4 mg. Levophed
was started and blood pressure responded appropriately. Patient
developed fevers to 101.7 in the Emergency Department and was
treated empirically with vancomycin 1 g IV, ceftriaxone 1 g IV,
and zosyn 3.25 mg IV. She received 5 L IV NS, acetaminophen 1
gram po, morphine 4 mg x 2, toradol 30 mg IV prior to transfer
to the ICU for further medical management.
.
ROS: Patient is too sedated to give any history. She is only
responsive to sternal rub.
Past Medical History:
Diabetes Mellitus
Hypertension
IVDU
Hepatitis C
HPV- high risk type, normal PAP
History of MSSA endocarditis and spinal osteomyelitis [**2146**]
Left renal staghorn calculi
.
Past Surgical History:
[**8-23**] Left ureteral stent placement
[**4-23**] ESWL, Removal of stone encrusted stent, Left stent
replacement
[**8-24**] Left PCNL, inability to pass wire down from her UPJ given
she had significant bleeding at the time of the operation
[**2152-9-5**] CT guided drainage by IR
[**2152-9-5**] UPJ stone s/p cystoscopy and stenting by [**Month/Day/Year **]
C-section
[**2133**] Open cholecystectomy
[**11-22**] Right groin lymph node biopsy
Social History:
From [**Country 13622**] Republic, English is second language.
Family History:
(Per OMR) Son and daughter both have renal stones. Many
relatives with [**Name (NI) 2320**].
No known heart problems or cancer.
Physical Exam:
VS: Temp: 99 BP: 85/46 HR: 106 RR: 17 O2sat 100% 2 L
GEN: Patient is lethargic, arousable to sternal rub, oriented
to place.
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, unable to assess
JVD given habitus
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, L sided flank drain
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: compromised by patients sedation; patient moving all four
extremities in response to pain, no facial droop, follows
commands when awoken with painful stimuli
Pertinent Results:
ADMISSION LABS:
[**2152-10-30**] 01:45AM NEUTS-92.2* LYMPHS-5.1* MONOS-1.4* EOS-1.0
BASOS-0.3
[**2152-10-30**] 01:45AM WBC-7.2 RBC-3.98* HGB-11.9* HCT-35.3* MCV-89
MCH-30.0 MCHC-33.9 RDW-16.5*
[**2152-10-30**] 01:45AM ALBUMIN-3.0*
[**2152-10-30**] 01:45AM LIPASE-25
[**2152-10-30**] 01:45AM ALT(SGPT)-125* AST(SGOT)-182* ALK PHOS-122*
TOT BILI-1.8*
[**2152-10-30**] 01:45AM GLUCOSE-152* UREA N-17 CREAT-0.9 SODIUM-131*
POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-25 ANION GAP-9
[**2152-10-30**] 01:50AM LACTATE-1.8
[**2152-10-30**] 04:24AM URINE RBC->50 WBC-[**5-25**]* BACTERIA-FEW
YEAST-NONE EPI-[**5-25**]
[**2152-10-30**] 04:24AM URINE BLOOD-LG NITRITE-NEG PROTEIN-150
GLUCOSE-NEG KETONE-TR BILIRUBIN-MOD UROBILNGN-4* PH-6.5 LEUK-MOD
[**2152-10-30**] 04:24AM URINE COLOR-Amber APPEAR-Cloudy SP [**Last Name (un) 155**]-1.024
[**2152-10-30**] 09:51AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-POS amphetmn-NEG mthdone-POS
[**2152-10-30**] 09:51AM URINE UCG-NEGATIVE OSMOLAL-600
[**2152-10-30**] 09:51AM URINE HOURS-RANDOM UREA N-694 CREAT-143
SODIUM-37 CHLORIDE-21
[**2152-10-30**] 09:52AM PLT COUNT-81*
[**2152-10-30**] 09:52AM WBC-14.6*# RBC-3.77* HGB-10.8* HCT-34.4*
MCV-91 MCH-28.8 MCHC-31.5 RDW-16.3*
[**2152-10-30**] 09:52AM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2152-10-30**] 09:52AM calTIBC-261 HAPTOGLOB-93 FERRITIN-213*
TRF-201
[**2152-10-30**] 09:52AM CALCIUM-7.2* PHOSPHATE-2.0* MAGNESIUM-1.1*
IRON-13*
[**2152-10-30**] 09:52AM ALT(SGPT)-133* AST(SGOT)-286* LD(LDH)-243 ALK
PHOS-88 TOT BILI-2.2*
[**2152-10-30**] 10:17AM LACTATE-3.0*
[**2152-10-30**] 11:50AM LACTATE-3.1*
[**2152-10-30**] 04:20PM WBC-13.7* RBC-3.96* HGB-11.3* HCT-36.1 MCV-91
MCH-28.5 MCHC-31.3 RDW-16.2*
DISCHARGE LABS: WBC 7.6 HCT 29.7 PLT 135, NEUT 86, LYMPH 12
GLUCOSE 115, BUN 9, CR 0.6, NA 133, K 4.6 CL 104, BICARB 25
ALT 75, AST 103, AP 82 T BILI 2.0
LIPASE 25
MG 1.8
MICRO:
[**2152-10-30**] URINE CULTURE: no growth
[**2152-10-30**] 1:45 am BLOOD CULTURE
Blood Culture, Routine (Preliminary):
GRAM NEGATIVE ROD #1.
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
GRAM NEGATIVE ROD #3.
ENTEROBACTER CLOACAE. FINAL SENSITIVITIES.
ENTEROCOCCUS SP..
VIRIDANS STREPTOCOCCI. STRAIN 1. FINAL SENSITIVITIES.
Sensitivity testing performed by Sensititre.
CLINDAMYCIN = <=0.12 MCG/ML.
VIRIDANS STREPTOCOCCI. STRAIN 2. FINAL SENSITIVITIES.
Sensitivity testing performed by Sensititre.
CLINDAMYCIN = <=0.12 MCG/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| ENTEROBACTER CLOACAE
| | VIRIDANS
STREPTOCOCCI
| | |
VIRIDANS STREPTO
| | | |
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
CLINDAMYCIN----------- S S
ERYTHROMYCIN---------- 2 R 4 R
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PENICILLIN G---------- 0.25 I 4 R
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
VANCOMYCIN------------ <=1 S <=1 S
Aerobic Bottle Gram Stain (Final [**2152-10-30**]):
GRAM NEGATIVE ROD(S).
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] #[**Numeric Identifier 76055**] [**2152-10-30**] 1030.
Anaerobic Bottle Gram Stain (Final [**2152-10-30**]):
GRAM NEGATIVE ROD(S).
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
[**2152-10-30**] PICC line catheter tip: No growth.
IMAGING:
[**2152-10-30**] CTU:
1. Stable mild left hydronephrosis and perinephric stranding
with a double-J stent and left percutaneous catheter in place.
2. Ten millimeter stone in the left kidney. Multiple left renal
calculi
unchanged from [**2151-11-9**].
3. Mesenteric and retroperitoneal lymphadenopathy similar to
prior.
4. Splenomegaly. Does the patient have stable
lymphoproliferative disease?
[**2152-10-31**] ECHO:
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. Left ventricular systolic
function is hyperdynamic (EF>75%). Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (?#) appear
structurally normal with good leaflet excursion. 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. No mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
No vegetation seen (cannot definitively exclude).
Compared with the prior study (images reviewed) of [**2152-9-8**],
findings are similar. The heart rate is now higher.
[**2152-10-31**] RUQ ultrasound:
1. Limited Doppler evaluation demonstrating patency of the main
portal vein along with the middle and left hepatic veins.
2. No evidence of intra- or extra-hepatic biliary duct dilation.
[**2152-11-2**]:
Portable AP chest radiograph was compared to [**2152-11-1**].
The left PICC line was inserted with its tip at the level of low
SVC. The
right internal jugular line has been re-positioned, pulled back
with its tip currently at the level of low SVC/cavoatrial
junction.
Mild interstitial pulmonary edema grossly unchanged.
Cardiomediastinal
silhouette is unchanged. No appreciable pleural effusion or
appreciable
pneumothorax is demonstrated on the current study.
Brief Hospital Course:
Septic shock/Bacteremia and acute pyelonephritis: Patient with
multiple sources of infection given chronic PICC and
percutaneous renal abscess drain without appropriate care,
chronic nephrolithiasis, and her recent pyelonephritis with
concern for incomplete antibiotic course (recent diagnosis of
perinephric abscess s/p percutaneous drain placement. Between
[**2152-9-12**] and [**2152-10-19**] she received 23 doses of ceftriaxone
(suboptimal treatment course) but represented with septic shock
in the setting of at least medication non compliance). She
required pressors in the ICU, fluid resuscitation, empiric
coverage with vanco and zosyn. Her hemodynamic status became
stable and she was transferred to the general medical floor.
She was treated with IV vancomycin and cefepime given
polymicrobial bacteremia. Medicationn compliance and PICC line
tampering were both possible issues as to why her initial
infection was not treated adequately. She will continue this
course until [**11-22**]. She had a vanc level of 14 on a dose
of 1250mg IV q12 hours. She had a ureteral stent exchange and
lithotripsy on [**2152-11-7**], following this she had severe abdominal
pain not relieved by narcotics initially but then completely
resolved with toradol 30mg x 1. She at the time of her pain
underwent repeat blood cultures on [**11-8**] as she had a low grade
temperature of 100.4 (likely from acute inflammation from stent
change, she had same symptoms upon initial stent placement) and
a KUB was obtained which revealed no specific pathology. She
should follow up with [**Month/Year (2) **] Dr. [**Last Name (STitle) 770**] in 2 weeks for
re-evaluation and likely stent removal.
HCV: Patient with known HCV cirrhosis. Transaminases elevated
above baseline on presentation. Most recent INR elevated at 1.5.
Patient does have a history of taking excessive amounts of
percocet in recent weeks.
Thrombocytopenia: Platelets 93 on presentation below baseline.
[**Month (only) 116**] be due to sepsis vs HCV cirrhosis. Several days into her
hospitalization her platelets dropped further (as did other cell
lines), possibly secondary to zosyn so abx were switched to
cefepime. Her platelets recovered rapidly, discharge plts were
> 100. (platelet nadir was 37 on [**2152-11-3**])
Anemia: Onset of anemia related to onset of urologic
complications in 9/[**2151**]. [**Month (only) 116**] be due to chronic illness or most
likely chronic hematuria.
DM2: Unclear home regimen. She was well controlled on a simple
sliding scale insulin (2 units at meal times for BG 150-200,
increase by 2 units per 50 increase in BG).
Medications on Admission:
Unknown
Discharge Medications:
1. insulin lispro 100 unit/mL Solution Sig: sliding scale units
Subcutaneous ASDIR (AS DIRECTED): insulin sliding scale, before
meals and at bedtime.
2. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO four times a day
as needed for pain.
3. ibuprofen 200 mg Tablet Sig: Two (2) Tablet PO three times a
day as needed for pain.
4. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constip.
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constip.
8. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO three
times a day as needed for nausea.
9. vancomycin 500 mg Recon Soln Sig: 1250 (1250) mg Intravenous
Q 12H (Every 12 Hours) for 2 weeks: last dose on [**2152-11-22**].
10. cefepime 2 gram Recon Soln Sig: Two (2) grams Intravenous
twice a day for 2 weeks: last dose [**2152-11-22**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Bacteremia
Acute Pyleonephritis
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 with a kidney infection which
led to a blood stream infection. You were treated with IV
antibiotics.
Followup Instructions:
Please follow up with your PCP [**Name Initial (PRE) 176**] 2 weeks of your discharge
from the hospital. If you do not have a PCP please call
[**Telephone/Fax (1) 250**] to set up a new PCP at the [**Hospital3 **].
Please call the [**Hospital3 **] department to set up an appointment with
Dr. [**Last Name (STitle) 770**] within 2 weeks of your discharge from the [**Hospital 61**]: ([**Telephone/Fax (1) 7707**].
|
[
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icd9cm
|
[
[
[]
]
] |
[
"56.0",
"59.8",
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] |
icd9pcs
|
[
[
[]
]
] |
13934, 14007
|
10208, 12836
|
338, 507
|
14083, 14083
|
3914, 3914
|
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|
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|
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|
14028, 14062
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|
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|
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|
3283, 3895
|
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|
277, 300
|
535, 2375
|
3930, 5670
|
14098, 14210
|
2397, 2572
|
3057, 3122
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,776
| 117,902
|
14585
|
Discharge summary
|
report
|
Admission Date: [**2129-4-3**] Discharge Date: [**2129-4-19**]
Date of Birth: [**2057-10-1**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Tegretol / Spironolactone
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
heart failure
Major Surgical or Invasive Procedure:
Attempted right heart catheterization
History of Present Illness:
71 yo M h/o severe dCHF (EF>55%), AS s/p mechanical AVR, AFib on
coumadin, pulmonary HTN, CAD s/p CABG, 3rd-degree heart block
s/p ppm, and [**Hospital 2182**] transferred from OSH for further management of
chronic diastolic congestion heart failure.
.
The patient was recently admitted to [**Hospital1 18**] from [**2129-3-7**] to
[**2129-3-17**] for altered mental status and failure to thrive. The
[**Hospital 228**] hospital course was complicated by
healthcare-associated pneumonia, which was treated with
ceftriaxone and vancomycin. The patient was discharged to Life
Care Center of [**Location (un) 2199**]. At the time, his weight was documented
as 161 lb.
.
At rehab, the patient was initially doing well. He was even able
to walk with a walker. Beginning around [**3-26**], however, the
patient's family began to notice increasing fatigue along with
intermittent confusion, agitation, poor sleep and poor appetite.
The family also described [**10-18**] second periods of tachypnea
occurring at 5-minute intervals. The family also describes
increased swelling in the patient's face and belly. In the early
morning of [**3-29**], the patient was noted to be more confused,
leading him to present to [**Hospital 43018**] Hospital.
.
At Wincester, his initial weight was 165 pounds. The patient was
started on cefepime and linezolid for HCAP, although there was
no evidence of pneumonia. There was no documented fever or
leukocytosis. CT chest showed mediastinal adenopathy and
bilateral pleural effusions but no infiltrate. The patient was
diuresed with Lasix 80 mg IV for presumed CHF in the ambulance
on the way to the hospital but did not receive further diuresis
in house due to concern for renal failure. There was an episode
of desaturation to 80% with confusion. Bronchodilators and IV
steroids were given for COPD. The patient was noted to have
mildly elevated bilirubin and alk phos. RUQ U/S was negative
Coumadin was held and a heparin gtt was started for
consideration of thoracentesis, which was not done prior to
transfer.
.
The patient was transferred directly to the CCU at [**Hospital1 18**]. On
arrival, initial vital signs were T 98.6 BP 112/68 HR 65 RR 23
Sat 98% 2L weight 174 pounds. Review of systems was not reliable
due to altered mental status. However, patient denied pain,
dyspnea, or other symptoms.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, ?Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: 2 vessel CABG
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD: PPM placed for 3rd degree AV block
3. OTHER PAST MEDICAL HISTORY:
-AS s/p AVR with [**First Name8 (NamePattern2) **] [**Male First Name (un) 1525**] Mechanical Valve s/p AVR in [**2116**]
-Atrial fibrillation, on coumadin
-COPD - on spiriva and flovent
-HTN
-CAD s/p CABG (2 vessel)
-s/p CVA with seizure d/o - on lamictal; last sz >1 year ago
-Diastolic CHF, EF >70%
-Pulmonary HTN
-DM: diet controlled
-Chronic lethargy and confusion with concern for Dementia
-Focal disection of abd aorta - noted CT abdomen [**2126-10-16**]-
unchanged from [**2124**]
-BPH - no difficulty voiding
-s/p L ORIF and THR [**9-/2128**]
-S/P pacemaker for 3rd degree AV block
-Has had seasonal and H1N1 vaccinations
Social History:
Lives with wife; son/family lives in same town house; 6 children
total. Retired newpaper journalist; He moved to the U.S.A. in
[**2098**], but returned to [**Country 11150**] to work. He returned here for good
in [**2120**].
-Tobacco history: quit 10 years ago; 80 pack years; chewed
tobacco until approximately 5mo ago
-ETOH: quit long time ago; unclear how much pt drank in past
-Illicit drugs: never
Family History:
CAD in family with hx of CABG - everyone including all sisters
and brothers, who have all died before him, as well as his
mother and father.
Physical Exam:
VS: T 98.6 BP 112/68 HR 65 RR 23 Sat 98% 2L Weight 174# (79.2kg)
GENERAL: Frail elderly gentleman in no acute distress, though he
does appear uncomfortable when he moves.
HEENT: NCAT. Sclera anicteric.
NECK: Supple with JVP elevated to ear with patient upright.
CARDIAC: RRR, normal S1, mechanical S2. s3 present. No m/r/g. No
thrills, lifts.
LUNGS: Speaking in [**1-8**] work sentences but denies dyspnea.
Diffusely wheezy and rhonchorous.
ABDOMEN: Distended. Non-tender. Exam limited by distention.
EXTREMITIES: Poor capillary refill.
SKIN: Skin breakdown on lower extremities.
NEURO: Sleepy but arousable, oriented to "hospital", "[**2128**]". Can
state his occupation. CN II-XII intact. Asterixis present. No
pronator drift. Strength 5/5 throughout.
PULSES:
Right: Radial 2+ DP doppler PT doppler
Left: Radial 2+ DP doppler PT doppler
Pertinent Results:
Admissions labs:
[**2129-4-3**] 03:07PM BLOOD WBC-6.9 RBC-4.25* Hgb-10.9* Hct-35.8*
MCV-84 MCH-25.6* MCHC-30.4* RDW-16.9* Plt Ct-194
[**2129-4-3**] 06:00PM BLOOD PTT-67.1*
[**2129-4-3**] 03:07PM BLOOD Glucose-105* UreaN-74* Creat-1.8* Na-129*
K-4.3 Cl-94* HCO3-26 AnGap-13
[**2129-4-3**] 03:07PM BLOOD ALT-13 AST-33 LD(LDH)-274* AlkPhos-157*
TotBili-1.4
[**2129-4-3**] 03:07PM BLOOD proBNP-2790*
[**2129-4-3**] 03:07PM BLOOD Albumin-3.5 Calcium-9.6 Phos-3.1 Mg-3.1*
[**2129-4-3**] 06:00PM BLOOD Type-ART pO2-87 pCO2-39 pH-7.43
calTCO2-27 Base XS-1
[**2129-4-3**] 06:00PM BLOOD Lactate-1.4
.
CXR (portable AP) [**2129-4-4**]: Cardiac silhouette has slightly
increased in size, and is accompanied by worsening pulmonary
vascular engorgement and increasing predominantly interstitial
edema. Additional areas of coalescing opacities in the
infrahilar region could reflect progression to alveolar edema.
Bilateral pleural effusions have increased in size, right
greater than left.
Brief Hospital Course:
Mr [**Known lastname 43019**] is a 71-year-old man with a history of dCHF (EF>55%),
AS s/p AVR, AF, pulmonary HTN, CAD s/p CABG, 3rd-degree heart
block s/p ppm, transferred from [**Hospital 43018**] Hospital for
consideration of vasodilator therapy for pulmonary hypertension
in the setting of severe diastolic biventricular heart failure.
Acute on chronic diastolic heart failure
The patient presented with predominantly right-sided heart
failure with peripheral edema, hepatic congestion, poor
appetite, weight gain, and elevated JVP. He was diuresed with PO
torsemide without effect. The patient was then successfully
diuresed with Lasix 100mg IV BID. Metolazone was added however
the family warned that this can cause bumps in the creatinine,
which we have not noted, however today's creatinine was 1.7. The
patient's heart failure was thought to be end-stage, class 4
diastolic and pt has a poor prognosis. Palliative medicine
consult was considered however, the family was not interested in
this route and was more interested in aggressive medical
treatment more than symptom control. Metolazone (2.5 - 5 mg) 30
minuntes prior to Lasix affords improved diuresis, but has in
the past resulted in renal failure. This should be done
cautiously. When he approaches dry weight of just over 150 lbs,
he can be converted to an oral regimen of torsamide.
Altered mental status
This was thought to be related to CHF encephalopathy or poor
forward flow in setting of heart failure. However, asterixis
also suggested a toxic-metabolic cause. Hypercarbia was ruled
out by ABG. Neurology was consulted and ruled out seizures by
negative EEG. Observation has revealed that mental status is
improved when pt is not fluid overloaded. It is very helpful his
family to be present to assist with orientation, particularly at
night.
Lateral abdominal hematoma
The patient developed a lateral wall abdominal hematoma most
likely from trauma by leaning or hitting his flank on the bed
rail in the setting of agitation/delerium and supratherapeutic
INR. The patient's HCT dropped nearly 10 points from 34 to 24
and CT confirmed an extraperitoneal musculoskeletal hematoma. IR
was notified but favored conservative management by correcting
coaggulopathy and transfusing. The patient received a total of 4
units of PRBCs and his HCT stabilized once the underlying
coaggulopathy corrected. The patient's HCT remained stable for
the remainder of the admission in the low 30s.
Chronic kidney disease
The patient's creatinine remained at his recent baseline of
1.5 to 1.8 even with diuresis.
COPD
The patient was noted to be rhonchorous and wheezy on exam. He
was treated with inhaled fluticasone and nebulized albuterol and
ipratropium.
Status-post mechanical aortic valve
The patient's Coumadin was initially held. The patient was
kept on a heparin drip. This was discontinued during the acute
bleed, then restarted once patient's HCT stabilized and bridged
pt to coumadin.
DM
The patient was started on an insulin sliding scale.
BPH
Continued Flomax at home dose.
Medications on Admission:
Meds on Transfer:
Cefepime 1g IV Q24H
Linezolid 600mg IV Q12H
Methylprednisolone 40mg IV Q8H -- received [**4-1**] and [**4-2**]
Heparin gtt at 850
Lasix 40mg IV prn -- unclear how many doses he received
Lopressor 25mg daily
Enalapril 5mg daily -- on hold
Flomax 0.4mg QHS
Zocor 20mg QHS
Lamictal 150mg [**Hospital1 **]
Calcium carbonate 1000mg [**Hospital1 **]
MVI daily
Coumadin -- on hold
Vitamin D 800 IU daily
Spiriva inh daily
Duoneb QID
Fluticasone inhaler 2 puffs [**Hospital1 **]
Colace 100mg [**Hospital1 **]
Trusopt 2% [**Hospital1 **]
Xalatan eye drops 0.005% 1 drop at night both eyes
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for wheeze.
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
3. Lamotrigine 100 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
7. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
10. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
11. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED): Sliding scale insulin.
12. Dextromethorphan Poly Complex 30 mg/5 mL Suspension,
Sust.Release 12 hr Sig: One (1) PO Q12H (every 12 hours) as
needed for cough.
13. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
15. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscellaneous Q6H (every 6 hours) as needed for cough, wheeze.
16. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
18. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
19. Sildenafil 20 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day) as needed for diastolic dysfunction.
20. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
21. Furosemide 10 mg/mL Solution Sig: One Hundred (100) MG
Injection [**Hospital1 **] (2 times a day).
22. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
23. Sodium Chloride 0.9% Flush 10 mL IV Q8H:PRN line flush
Midline: Flush with 10 mL Normal Saline every 24 hours and PRN
before and after use
24. Heparin Flush (10 units/ml) 2 mL IV PRN use of Midline
Daily and after each use
25. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: per sliding scale units Intravenous continuous.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
NYHA Class [**3-10**], acute on chronic diastolic congestive Heart
Failure
Secondary:
Mechanical AVR
Pulmonary Hypertension
Chronic Obstructive Pulmonary Disease
Diabetes Mellitus, diet controlled.
Atrial Fibrillation
S/P Pacemaker
Seizure Disorder
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
It was a pleasure to take care of you here at [**Hospital1 18**]. You were
admitted for acute on chronic heart failure. We used a water
medicine called Lasix to remove the fluid from your lungs and
your body. Your heart failure is end-stage and for this reason
it is critically important that you follow a low sodium diet,
take all your medications as prescribed, and contact your doctor
if your weight increases > 3lbs in 1 day or 6 pounds in 3 days.
.
Medication changes:
1. STOP taking Linezolid, cefepime, methylprednisolone and
fluticasone inhaler.
2. START taking Acetylcysteine, Benzonatate, and
Dextromethoraphan for your cough
3. Restart coumadin to prevent blood clots
4. Start tylenol for pain as needed
5. STart Aspirin for heart protection
6. Increase lasix to 100mg twice daily
7. Decrease Metoprolol to 12.5 mg twice daily
8. Start Sildenafil to treat your heart failure
9. Start insulin sliding scale to keep your blood sugars under
control
10. Start Heparin IV to prevent blood clots until the coumadin
level is therapeutic.
11. Start senna to prevent constipation
12. Stop Methylprednisolone and Fluticasone inhaler
13. Start calcium to prevent bone loss.
Followup Instructions:
Cardiology:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 62**] Date/time: [**2129-5-24**] 10:40
.
Primary Care;
[**Last Name (LF) **],[**First Name3 (LF) **] B. Phone: [**Telephone/Fax (1) 17826**] Date/time: please
make an appt to be seen after you get out of rehabilitation.
Completed by:[**2129-4-20**]
|
[
"V45.01",
"V64.2",
"428.33",
"V58.61",
"428.0",
"496",
"285.1",
"437.0",
"V43.3",
"290.40",
"999.9",
"349.82",
"427.31",
"286.9",
"E879.8",
"V45.81",
"416.8",
"E928.8",
"922.2",
"486",
"585.9",
"E849.7",
"600.00",
"785.6",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12210, 12281
|
6048, 9117
|
313, 353
|
12574, 12574
|
5047, 6025
|
13912, 14273
|
4031, 4173
|
9765, 12187
|
12302, 12553
|
9143, 9143
|
12713, 13167
|
4188, 5028
|
2825, 2932
|
13187, 13889
|
260, 275
|
381, 2717
|
12589, 12689
|
2963, 3595
|
2739, 2805
|
3611, 4015
|
9161, 9742
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,710
| 105,972
|
3382
|
Discharge summary
|
report
|
Admission Date: [**2153-3-17**] Discharge Date: [**2153-3-19**]
Date of Birth: [**2105-12-25**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8684**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is 47 yo f with h/o anemia (unclear etiology), s/p
polypectomy on [**2153-3-5**], who awoke at 3 am with crampy abdominal
pain and BRBPR. Pt felt like she was about to have diarrhea,
then went to the toilet and passed large amount of BRBPR. She
felt lightheaded and passed out 2-3 times (no head trauma). She
denies recent black or tarry stools. No N/V, SOB, CP, or F/C. Pt
went to an OSH ED, found to have hct 26.6, and was transfused 2
U PRBC's. She was then transferred to [**Hospital1 18**].
Past Medical History:
- anemia: unclear etiology, but present since childhood
(baseline approx low 30's, dropped to 19 in setting of prior
C-section)
- h/o C-section
- h/o fibroid removal
Social History:
Currently a student (studying education). Married with 1 child.
No smoking. Occasional EtOH.
Family History:
Mother with DM.
Physical Exam:
Vitals: T 97.6 BP 115/72 HR 61 RR 18 O2sat 98% RA
Gen: pleasant, NAD
HEENT: PERRL. Slight R eye ptosis.
Neck: Supple. No JVD.
Cardio: RRR, nl S1S2, [**2-6**] sys murmur @ apex
Resp: CTAB
Abd: soft, nt (mild sensitivity diffusely), nd, +BS
Ext: no c/c/e
Neuro: A&Ox3
Pertinent Results:
Hct:
28.8->31->31->29.4->30.5
Brief Hospital Course:
47 yo f with h/o anemia, s/p recent [**Last Name (un) **]/EGD now with episodes
of BRBPR and anemia.
.
#) GI Bleed: Most likely lower GI bleed, due to BRBPR and modest
fall in hematocrit. Most likely secondary to recent
polypectomies, as post-polypectomy hemorrhage can occur up to 29
days post procedure and patient had multiple polyps, close to
1cm in size, and 1 that was sessile, all of which can predispose
to bleeding. There were no other abnormalities seen on
colonoscopy to account for her BRBPR. She remained
hemodynamically stable with stable hematocrits during her MICU
course. Recent upper endoscopy demonstrated normal oesophagus,
stomach, and duodenum. 2 Peripheral IVs were placed, patient
was typed and screen, and started on intravenous pantoprazole.
After multiple stable hematocrits, her diet was advanced and she
was transferred to regular medicine floor. She was observed one
more night and her hct remained stable. She did not have any
further bleeding and was tolerating a regular diet at the time
of discharge.
.
#) Anemia: Patient appears to have chronic iron deficiency
anemia, with more acute blood loss anemia from GI bleed. This
was the reason for her initial colonscopy, for colon CA workup.
Patient was restarted on supplemental iron per outpatient
regimen with no further events. Her hct was stable at her
baseline at the time of discharge.
.
#) Syncope: most likely [**2-2**] vasovagal events in setting of acute
blood loss. Pt appears to be bradycardic at baseline. No
further events were noted on telemetry.
.
#) FEN: Patient's diet was advanced once bleeding resolved and
her hct was stable. She tolerated a regular diet without
difficulty.
.
#) Code: Full
.
#) Comm: with pt and husband
Medications on Admission:
Ferrous Sulfate
Multivitamin.
Discharge Medications:
1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 disks* Refills:*1*
4. Advair Diskus 100-50 mcg/Dose Disk with Device Sig: One (1)
Puff Inhalation twice a day.
Disp:*1 INH* Refills:*2*
5. Saline Mist 0.65 % Aerosol, Spray Sig: 1-2 Puffs Nasal twice
a day as needed.
Disp:*1 INH* Refills:*0*
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Post-polypectomy bleeding-resolved
Discharge Condition:
Afebrile. Tolerating PO. Hematocrit stable.
Discharge Instructions:
Please continue to take your medications as directed.
.
If you experience bleeding from your rectum, high fevers,
abdominal pain, difficulty breathing or other concerning
symptoms, please call your doctor or return to the emergency
room.
.
We have started you on an inhaler called advair which you can
take twice daily for your wheezing.
Followup Instructions:
.
Dr.[**Name (NI) 8687**] office will call to schedule a follow up
appointment with you. If you don't hear from them by the end of
the week, call [**Telephone/Fax (1) 608**] to schedule follow up.
.
Provider: [**Name10 (NameIs) **],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 2788**] INTERNAL MEDICINE
Date/Time:[**2153-4-23**] 9:15
|
[
"780.2",
"285.1",
"282.49",
"E878.8",
"427.89",
"998.11",
"E849.9",
"V12.72"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
3991, 3997
|
1546, 3281
|
322, 329
|
4076, 4123
|
1492, 1523
|
4509, 4896
|
1173, 1190
|
3361, 3968
|
4018, 4055
|
3307, 3338
|
4147, 4486
|
1205, 1473
|
277, 284
|
358, 858
|
880, 1047
|
1063, 1157
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,965
| 105,308
|
46162
|
Discharge summary
|
report
|
Admission Date: [**2109-8-24**] Discharge Date: [**2109-8-30**]
Service: MED
Allergies:
Aspirin / Codeine
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
Central Line Placement
History of Present Illness:
82 year old woman with metastatic cancer, presumed pancreatic
but w/o tissue diagnosis, who presents with two week history of
weakness. Pt has been has had decreased food intake and is
never hungry and has been losing weight. Recently she has
become more short of breath and is on oxygen at home. She said
she has not been able to move around either. At night she gets
short of breath. She has had no nausea, vomiting, or diarrhea.
No cough, or chest pain. She had a similar presentation at her
[**Hospital **] clinic on [**2109-8-16**]. At that time she also complained of having
increased anxiety attacks as well as palpitations. In the ED
the CXR was read as new pleural effusion, but CXR on [**7-24**] was
read as suggestive of bilateral pleural effusion. It is,
however, more apparent than in prior and pt. has a newly
elevated wbc.
Past Medical History:
Probable metastatic pancreatic cancer to the lungs, LN,
and left adrenal. No tissue diagnosis CA19.9 NL, ECRP NL
anxiety attacks
Diabetes for 15 years although this has been more difficult
to control over the past two months.
Hypertension, ??GAP-7??
Endometrial cancer in [**2097**] status post TAH-BSO for grade 1
adenocarcinoma.
Angina by report although the patient just states that she
has weakness.
Palpitations.
Cholecystectomy in [**2095**].
Diverticulitis status post colon resection (partial) in [**2095**].
Left knee meniscal tear that the daughter says needs
replacement.
Social History:
She lives at home with her son. She was born in [**Country 3399**] and then
lived in [**Country **] until she immigrated to the US in [**2071**]. She has
never smoked. She has never drunk significant amount of alcohol.
She lives in [**Location 11270**]. She is Sephardic Jew. She has a
significant secondhand [**Location **] from family members who [**Name2 (NI) **].
Family History:
Significant for a large number of cousins with a
variety of cancer. Paternal cousin: Ovarian, paternal cousin:
[**Name (NI) **], paternal cousin: Stomach, paternal cousin: Breast,
maternal uncle: Prostate. No history of pancreatic cancer in
the family.
Physical Exam:
A large woman who appears tired but is in NAD
98.2 166/68 73 18 99% 4l
HEENT: No icterus, EOMI.
CARD: RRR, Nl S1 S2 no M/G/R
Pulm: Decreased breath sounds, increased exp. phase, slight
wheezing
Abd: Obese, +BS, soft, NT
EXT: Trace edema, 2+ post tibial
Pertinent Results:
[**2109-8-24**] 02:00PM
WBC-12.9*# HCT-43.3 PLT COUNT-408
MCV-93 MCH-29.7 MCHC-31.9 RDW-13.5
NEUTS-86.4* LYMPHS-9.2* MONOS-3.9 EOS-0.3 BASOS-0.2
URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.025 BLOOD-NEG
NITRITE-NEG PROTEIN-TR GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG
UROBILNGN-NEG PH-5.0 LEUK-NEG
Brief Hospital Course:
82 year old woman with metastatic cancer, presumed pancreatic
but w/o tissue diagnosis, who presents with symptoms of
weakness, O2 dependence and anorexia that are consistent with
advanced pancreatic cancer with lung metastases. She had a
similar presentation at her [**Hospital **] clinic on [**2109-8-16**]. Of concern is
her elevated wbc and increased new pleural effusions on CXR vs
prior from [**2109-7-24**], though pt is afebrile. It is difficult to
evaluate her lungs due to the extensive metastatic infiltration.
Patient was noted to have an asytolic arrest on the floor with
elevated K in the 6 [**Hospital 98175**] transfered to the MICU service
after CODE BLUE was called. After the arrest, pt remained
non-reponsive and CT scan demonstrated diffuse brain edema c/w
anoxic brain injury. Pt requiring increasing pressor suppot,
spiked high fevers, and had an elevated wbc which was concerning
for sepsis.
Pt's clinical course deteriored at the patient expired on
[**2109-8-30**].
Medications on Admission:
Darvocet-N 650-100 Q6H Prn
oxybutynin 5mg qd
captopril 12.5 [**Hospital1 **]
Colace 100mg [**Hospital1 **]
Celebrex 200mg QD
senna [**Hospital1 **]
Compazine 10mg Q8h PRN Nausea
Protonix 40mg QD
meclizine 12.5mg TID
metoprolol 50mg [**Hospital1 **]
Zyprexa 2.5mg QD
Ranitidine 150mg QD
Ativan 1-1.5mg [**Hospital1 **]
Megace 800 mg QD on [**8-16**] not taken due to N & diarrhea
Insulin 75/25
Discharge Medications:
N/A
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic Pancreatic Cancer
Asystolic Arrest
Septic Shock
Probable metastatic pancreatic cancer to the lungs, LN,
and left adrenal. No tissue diagnosis CA19.9 NL, ECRP NL
Hypertension
Endometrial cancer in [**2097**] status post TAH-BSO for grade 1
adenocarcinoma.
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"518.81",
"998.12",
"157.9",
"198.7",
"196.2",
"197.0",
"427.31",
"038.10",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
4492, 4498
|
3021, 4021
|
228, 252
|
4808, 4817
|
2683, 2998
|
4869, 4875
|
2139, 2394
|
4464, 4469
|
4519, 4787
|
4047, 4441
|
4841, 4846
|
2409, 2664
|
180, 190
|
280, 1129
|
1151, 1737
|
1753, 2123
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,492
| 133,491
|
48514
|
Discharge summary
|
report
|
Admission Date: [**2117-4-1**] Discharge Date: [**2117-4-6**]
Date of Birth: [**2038-9-24**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
IR mesenteric angiography [**4-2**]
Colonoscopy [**4-2**]
EGD [**4-2**]
History of Present Illness:
78F with Aflutter on coumadin, diverticulosis, s/p trach with
episodes of hypercarbic respiratory failure; DM, breast Ca, OSA,
pulmonary hypertension; sent from [**Hospital 100**] Rehab with BRBPR.
Episode of BRBPR with clots with stable vital signs at 7pm
evening of admission. Also noted to have some increase in O2
requirement from 35% to 50% TM.
.
In the ED, initial vitals 97.8, 110/66, HR 48, R18, 98% 8L TM.
SBPs then dropped to 70s, came up with minimal (unclear how
much) fluids. Hct 24 (from 30 on [**2117-3-31**]). Started on 2 PRBCs,
2 units FFP, 10 mg IV vit K. Also complaining of abdominal
pain. GI consulted. NGL negative. Seeming fairly stable until
opened up again with passage of large amount of BRBPR; getting 2
more units PRBCs and got profilnine. SBPs tolerating blood loss
(in 100s-110s); HR around 100. Has gotten a lot of volume (4
PRBCs, 2 FFP, 4L NS), has not needed vent thus far but may need
this evening. Considered CT for eval of ischemic colitis, but
not done [**1-25**] anticipation of contrast for angio procedure. Also
noted to have troponin bump to 0.13; cardiology contact[**Name (NI) **] and
will consult on patient when/if needed. Surgery and IR also
consulted for management of large LGIB, presumably
diverticulosis related. [**Month (only) 116**] go to IR tonight. Also recieved
zosyn for +UA.
Past Medical History:
Past Medical History:
- HYPERTENSION
- DIABETES MELLITUS
- BREAST CANCER ddx: Infiltrating ductal carcinoma
- SLEEP APNEA [**2087**]
- S/P tracheostomy [**2089**]. hx acute and chronic resp failure in
[**2077**]'s.
- OSTEOARTHRITIS right knee
- MULTIPLE FALLS
- SYSTOLIC DYSFUNCTION global LV hypokinesis [**2110**] echo: LVEF
50-55%
- ATRIAL FLUTTER [**2102**]
- ATRIAL SEPTAL DEFECT [**2102**]
- MITRAL REGURGITATION [**2102**]
- COR PULMONALE [**2087**]'S
- S/P STROKE
- OBESITY [Notes]
- SPINAL STENOSIS
- LOWER GASTROINTESTINAL BLEED
- [**2111**]: neg colonoscopy
- ACUTE RESPIRATORY FAILURE [**2106**]
Social History:
Normally lives at home, but has been at rehab since last
hospitalization. Denies alcohol, drug or current tobacco use.
Per her sister, she is a former smoker, but unclear what her
pack year smoking history is.
Family History:
DM
Physical Exam:
Physical Examination
General Appearance: Well nourished, No acute distress,
Overweight
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, Trach
Cardiovascular: Normal S1/S2
Respiratory / Chest: Clear anteriorly
Abdominal: Soft, Bowel sounds present, Non-distended, diffuse
mild TTP, Obese
Extremities: 1+ pitting bilat edema
Neurologic: Somewhat responsive, follows simple commands.
Pertinent Results:
Labs:
[**2117-4-5**] 04:28AM BLOOD WBC-8.6 RBC-2.82* Hgb-8.6* Hct-25.8*
MCV-92 MCH-30.4 MCHC-33.3 RDW-17.5* Plt Ct-153
[**2117-4-4**] 09:36PM BLOOD Hct-26.1*
[**2117-4-4**] 02:14PM BLOOD Hct-25.5*
[**2117-4-4**] 04:02AM BLOOD WBC-10.0 RBC-3.05* Hgb-9.3* Hct-26.8*
MCV-88 MCH-30.4 MCHC-34.6 RDW-18.6* Plt Ct-180
[**2117-4-3**] 09:02PM BLOOD Hct-27.5*
[**2117-4-3**] 03:26PM BLOOD Hct-27.9*
[**2117-4-3**] 08:51AM BLOOD Hct-28.1*
[**2117-4-3**] 03:10AM BLOOD WBC-10.8 RBC-2.94* Hgb-8.9* Hct-26.4*
MCV-90 MCH-30.3 MCHC-33.7 RDW-17.9* Plt Ct-166
[**2117-4-2**] 10:00PM BLOOD Hct-27.4*
[**2117-4-2**] 05:13PM BLOOD Hct-28.2*
[**2117-4-1**] 08:20PM BLOOD WBC-6.9 RBC-2.51* Hgb-7.7* Hct-24.3*
MCV-97 MCH-30.5 MCHC-31.5 RDW-17.2* Plt Ct-295#
[**2117-4-2**] 07:03AM BLOOD WBC-13.7*# RBC-3.48*# Hgb-10.6*#
Hct-30.6*# MCV-88# MCH-30.4 MCHC-34.5 RDW-18.2* Plt Ct-200
[**2117-4-5**] 04:28AM BLOOD PT-13.3 PTT-30.5 INR(PT)-1.1
[**2117-4-3**] 03:10AM BLOOD PT-13.7* PTT-32.5 INR(PT)-1.2*
[**2117-4-2**] 10:00PM BLOOD PT-14.0* PTT-33.6 INR(PT)-1.2*
[**2117-4-2**] 05:13PM BLOOD PT-13.8* PTT-33.3 INR(PT)-1.2*
[**2117-4-5**] 04:28AM BLOOD Glucose-82 UreaN-25* Creat-1.3* Na-144
K-3.7 Cl-110* HCO3-26 AnGap-12
[**2117-4-4**] 04:02AM BLOOD Glucose-106* UreaN-30* Creat-1.5* Na-145
K-4.0 Cl-109* HCO3-26 AnGap-14
[**2117-4-3**] 03:10AM BLOOD Glucose-127* UreaN-30* Creat-1.2* Na-146*
K-3.2* Cl-113* HCO3-26 AnGap-10
[**2117-4-2**] 10:00PM BLOOD Glucose-118* UreaN-31* Creat-1.2* Na-146*
K-3.0* Cl-111* HCO3-27 AnGap-11
[**2117-4-2**] 07:03AM BLOOD Glucose-142* UreaN-30* Creat-1.1 Na-144
K-3.6 Cl-112* HCO3-25 AnGap-11
[**2117-4-2**] 07:03AM BLOOD CK(CPK)-106
[**2117-4-1**] 08:20PM BLOOD ALT-22 AST-26 CK(CPK)-85 AlkPhos-64
TotBili-0.4
[**2117-4-2**] 07:03AM BLOOD CK-MB-5 cTropnT-0.08*
[**2117-4-1**] 08:20PM BLOOD CK-MB-NotDone cTropnT-0.13*
[**2117-4-4**] 04:02AM BLOOD Cortsol-14.0
[**2117-4-4**] 04:02AM BLOOD TSH-0.30
Imaging:
[**4-1**] CXR:
IMPRESSION: Worsening pulmonary edema with left pleural effusion
and
retrocardiac opacity. Superimposed infection cannot be excluded.
Repeat
radiograph after appropriate diuresis to further evaluate the
retrocardiac
region is recommended.
[**4-2**] IR Mesenteric Angio:
No sign of active bleeding, pseudoaneurysm, or angiodysplasia in
the SMA or [**Female First Name (un) 899**] territories.
[**4-2**] EGD:
Impression:
Small hiatal hernia
Schatzki's ring
Erosions in the stomach body and antrum
There were no peptic or duodenal ulcers and there was no blood
seen in the stomach or duodenum. There was bile in the duodenum.
Otherwise normal EGD to second part of the duodenum
[**4-2**] Colonoscopy:
Diverticulosis of the sigmoid colon, descending colon,
transverse colon and ascending colon
Blood in the colon
No large mass of AVMs were noted.
Otherwise normal colonoscopy to cecum
[**4-3**] CT Chest:
IMPRESSION:
1. No evidence of pneumomediastinum to suggest esophageal
perforation.
Esophagus appears normal.
2. Trace bilateral pleural effusions. Atelectasis is seen in the
left upper lobe along the major fissure and in the left lower
lobe dependently.
3. Massive cardiomegaly with right greater than left chamber
enlargement.
4. CT findings suggestive of pulmonary arterial hypertension.
5. Right adrenal nodule measuring 1.7 cm, which is not fully
characterized on this study.
6. Persistent bilateral nephrograms on this noncontrast CT scan.
This contrast is likely related to the prior mesenteric
angiogram performed on [**2117-4-2**] (over 24 hours ago). These
findings are concerning for ATN.
Brief Hospital Course:
Assessment and Plan
78 F with MMP including dHF, OSA, s/p trach, HTN, DM, atrial
fibrillation on warfarin, history of LGIB [**1-25**] diverticulosis in
[**2111**] presents with rectal bleeding.
.
# BRBPR ?????? Admission for BRBPR with hypotension and respiratory
failure, likely diverticular bleed, s/p reversal with FFP,
vitamin K, profilnine. Patient given 6units PRBC total for GI
bleed, 3units on admission and 3units the following day with
stable HCT during hospital course. Likely etiology determined
to be diverticulosis given similar presentation in [**2111**] where
colonoscopy showed diverticulosis. No evidence of UGI source
given overall stability and negative NGL. Patient was
hypotensive intitially, responded well to IVF, but then was
placed on dopamine overnight of admission for BP support.
Patient initially went emergently to angio but no bleed was
identified. A colonoscopy was done which showed old blood,
multiple diverticuli but no clear source of bleed. Surgery
recommended that patient is not a good surgical candidate if
rebleeds. Patient remained with stable HCT x24hrs post-bleed
and serial HCT values were stable. IR was following patient and
felt that no further intervention was needed given stable HCT
since angio. Warfarin was held during hospital course.
.
# Hypotension: Patient with hypotension upon admission in
conjunction with GI bleed that persisted despite adequate fluid
recuscitation. Patient was on dopamine for three days after
bleed but was weaned off of dopamine on HD3 without
complications or need for reinitiation of dopamine. Echo done
on [**4-5**] with markedly dilated, hypokinetic right ventricle with
severe tricuspid regurgitation that is directed towards the
inter-atrial septum. Severe pulmonary artery systolic
hypertension with pressure/volume overload of the left
ventricle. Left ventricular function with EF>55%. Echo
determined to be related to overall fluid positive status for
LOS due to pressors/fluid recuscitation/blood products given for
GI bleed. Random cortisol level 14, TSH 0.3. Once dopamine
waened off, no further blood pressure issues. Pt is currently
only on Lasix 20 mg IV bid. As tolerated, her home
antihypertensives may be reinitiated. She was on lisinopril 20
mg daily and diltizaem SR 120 mg daily prior to admission.
.
# Respiratory failure. Multifactorial respiratory failure with
OSA, CHF exacerbation related to fluid recuscitation for GI
bleed. Patient on admission requiring placement on ventilator
for respiratory support. CXR done on HD 1 AM with left-sided
chest white-out, possibly collapse. A CT chest was done for
futher evaluation which was without e/o esophageal perforation,
LLL atelectasis/collapse but with L lung expanded, a small
plueral. The patients AM CXR continued to improve daily as she
was weaned off pressors, continued on albuterol/ipratropium and
decreased on her overall fluid intake. On HD 3 she was weaned
off vent to trach collar successfully without further ventilator
support requirements. She is currently volume overloaded and
being diuresed wtih Lasix 20 mg IV BID. Once euvolemic, Lasix
dose may be titrated down to maintenance dose.
.
# Bradycardia/NSTEMI. Troponin bump to 0.13 with normal CK.
Likely demand in setting of large GI losses. Cardiac enzymes
trended down during hospital course and there was no further
conern for cardiac ischemia. Echo performed on HD4 as discussed
above. Bradycardia resolved during hospital course without
further issues.
.
# Chronic dHF- Last TTE shows grade I diastolic dysfxn and EF
50-55%. Due to hypotension requiring dopamine during hospital
course, patient was held on her home lasix and lisinopril. Echo
done on [**4-5**] with markedly dilated, hypokinetic right ventricle
with severe tricuspid regurgitation that is directed towards the
inter-atrial septum. Severe pulmonary artery systolic
hypertension with pressure/volume overload of the left
ventricle. Left ventricular function with EF>55%. New echo
findings felt to be due to elements of volume overload from
fluids given during inpatient stay. She is currently volume
overloaded and being diuresed wtih Lasix 20 mg IV BID. Once
euvolemic, Lasix dose may be titrated down to maintenance dose.
.
# Atrial fibrillation. Given high risk of bleeding, decision
made not to restart warfarin anticoagulation while in the
hospital. Please discuss with her cardiologist, Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] on when to restart her anticoagulation.
.
# UTI. Continuous hospital exposures with risk for resistant
organisms. U/A on admission concerning for UTI. She was
started empirically on zosyn on admission given exposures.
Subsequent Ucx from ED on [**4-1**] with E.coli sensitive to zosyn,
cipro, CTX, [**Last Name (un) 2830**]. She was switched from zosyn to cipro on [**4-4**]
after sensitivities back. She will complete a full 7 day course
which should end on [**4-8**].
.
# Diabetes- Seems like this is diet controlled, no diabetes
medications on past d/c summaries, [**11-30**] HgbA1c 6.1%. Her blood
glucose was well controlled on sliding scale insulin.
.
# CKD- stage III - Baseline 1.2-1.5. During admission, Cr from
1.1 on admission with rise to 1.5 and then trended down to
baseline range. Patient started back on lasix on HD 4.
Medications on Admission:
Calcitriol 0.25 mcg daily
Anastrozole 1 mg daily
Lisinopril 20 mg daily
Simvastatin 10 mg daily
Ferrous Gluconate 325 mg daily
Albuterol nebs Q6H
Ipratropium nebs Q6H
Warfarin 2mg PO daily ?? dosing - not on [**Hospital1 1501**] med list currently
but with therapeutic INR.
Lasix 20mg PO daily
Diltiazem PO 120 mg SR once a day
prilosec 20 mg daily
APAP prn
AlOH prn heartburn
mucomyst inhaled 200 mg [**Hospital1 **]
Insulin sliding scale
Discharge Medications:
1. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily ().
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q4H (every 4 hours) as needed.
5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q6H (every 6 hours).
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours: Stop date [**4-8**].
7. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
8. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed.
9. Furosemide 10 mg/mL Solution Sig: Twenty (20) mg Injection
[**Hospital1 **] (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Diverticular bleed
Discharge Condition:
Stable, good
Discharge Instructions:
You were admitted with a gastrointestinal bleed likely due to
your diverticulosis in combination with your anticoagulation
from your coumadin. During your hospital course, you needed a
ventilator connected to your tracheostomy for respiratory
support and required medications for blood pressure support.
You were able to be weaned to your baseline respiratory status
and baseline blood pressures. You will need to discuss with
your primary doctors when and if [**Name5 (PTitle) **] should ever be restarted on
your coumadin because you have a very high risk of bleeding
again and another bleed could be life threatening.
Your care will be continued at the Acute Rehab facility.
Followup Instructions:
Your care will continue at the rehabilitation facility through
which you should arrange follow-up.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2117-4-23**] 3:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5447**], M.D. Date/Time:[**2117-5-14**] 8:10
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2117-6-10**] 10:00
|
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icd9cm
|
[
[
[]
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[
"45.23",
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icd9pcs
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[
[
[]
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13269, 13335
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6642, 11975
|
317, 390
|
13398, 13413
|
3082, 6619
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,967
| 119,182
|
6307
|
Discharge summary
|
report
|
Admission Date: [**2161-6-18**] Discharge Date: [**2161-6-22**]
Service: NEUROSURGERY
Allergies:
Ceclor
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Fall with loss of consciousness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Asked to evaluate this 87 year old white female s/p
mechanical fall for SDH and SAH. Pt unaware of this am's events
but RN reports that pt was a witnessed fall down [**2-8**] flight of
granite steps with LOC x 1 min. Pt currently admits to headache
and nausea. She is a poor historian and slightly perseverative.
Hard of hearing as well.
Past Medical History:
hysterectomy
left eye surgery / recently
DM
Social History:
lives with her husband
Family History:
unknown
Physical Exam:
On Admission:
O: T: Afebrile BP:163 /123 HR:61 R18 O2Sats98
Gen: WD/WN, comfortable, slight distress [**3-11**] being on back board
and wanting to sit up.
HEENT: Multiple lacerations to forehaed. No hemotympanum, no
csf
rhinorrhea or otorrhea/ no battle or raccoons sign. Pupils: R
is
[**4-8**] left is 2.5 mm non reactive EOMs intact
Neck: Supple. in cervical collar
Extrem: Warm and well-perfused.
Neuro:
Mental status: opens eyes to voice, slightly lethargic,
cooperative with exam, normal affect.
Orientation: Oriented to person, place, and date (month and yr
only).
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors. +
preseveration.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light as above in
HEENT.
Visual fields are grossly intact.
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 [**6-11**] throughout. No pronator drift
Sensation: Intact to light touch
On Discharge: stable and nonfocal
Pertinent Results:
[**2161-6-18**] 11:20AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2161-6-18**] 11:20AM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2161-6-18**] 11:20AM URINE RBC-7* WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2161-6-18**] 11:17AM GLUCOSE-133* LACTATE-1.9 NA+-140 K+-4.1
CL--101 TCO2-27
[**2161-6-18**] 11:00AM UREA N-27* CREAT-0.7
[**2161-6-18**] 11:00AM WBC-5.9 RBC-4.14* HGB-13.1 HCT-37.7 MCV-91
MCH-31.8 MCHC-34.9 RDW-13.3
[**2161-6-18**] 11:00AM PT-12.2 PTT-23.4 INR(PT)-1.0
[**2161-6-18**] 11:00AM PLT COUNT-207
[**2161-6-18**] 11:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2161-6-18**] 11:20AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
CT Head [**6-18**]:IMPRESSION:
1. Left frontoparietal subdural hematoma with minimal local mass
effect.
Bilateral mild subarachnoid hemorrhage in the temporalparietal
regions.
2. No shift of the usually midline structures or evidence of
herniation.
3. Opacification of the sphenoid sinuses and ethmoid air cells.
Possible
underlying sinus disease. No adjacent fracture noted.
CT Cervical spine [**6-18**]: No acute fracture, malalignment, or
prevertebral soft tissue swelling. Multilevel degenerative
changes with fragmented anterior osteophytes are noted.
CT Chest/Abd/Pelv [**6-18**]: No Trauma.
IMPRESSION:
1. No acute traumatic pathology within the chest, abdomen or
pelvis.
2. 9 x 8 mm nodule in the posterior inferior segment of the left
upper lobe. Recommend followup CT at three months for further
evaluation. PET/CT could also be considered if there is clinical
concern for malignancy.
3. Scattered mediastinal lymphadenopathy, non-specific. Evaluate
for
resolution/change at follow-up CT.
4. 6 mm soft tissue density nodule in the left paracolic gutter
of uncertain significance. Recommend close attention to the this
region on follow-up imaging.
CT head [**6-19**]: Overall stable appearance to bilateral subdural
and subarachnoid hemorrhage. Small focus of blood layering
dependently in the right lateral ventricle. No midline shift. No
new hemorrhage.
Left wrist Xrays [**6-19**]: no signs of acute bony injury
Hip Xray [**6-20**]: No fracture or dislocation is detected involving
the right hip. There are mild degenerative changes about the
right hip with subchondral sclerosis and small marginal spurs.
Pelvic girdle is congruent, without displaced fracture or SI
joint or pubic symphysis diastasis. The sacrum is obscured by
overlying bowel gas, but visualized portion is grossly
unremarkable. Degenerative changes are noted in the lower lumbar
spine and left hip.
Brief Hospital Course:
Pt was admitted to the ICU on the Neurosurgery service for Q1
hour neurochecks and systolic blood pressure control less than
140. Her mental status improved throughout her hospital stay.
Cervical spine was cleared with negatvie CT and negative neck
tenderness. Repeat Head CT on [**6-19**] demonstrated stable
appearance of SDH and traumatic SAH. She was transfered to the
regular floor and her diet was advanced.
From a trauma perspective, CT chest/Abd/Pelvis were done and
were negative for trauma. Xrays of her right wrist and hip were
done as she complained of pain in both areas and both were
negative for trauma and dislocation. She did have findings on
her CT Chest/Abdomen/Pelvis (see Pertinent Results section) that
will need close followup by her PCP, [**Name10 (NameIs) **] an email was sent to
Dr. [**Last Name (STitle) 3273**]. The patient is aware of this.
She was seen by Physical therapy and Occupational therapy who
felt that she would benefit from acute rehab. She remained
neurologically intact throughout her hospital stay. She
continued to complain of mild headache that was treated with
Tylenol. She complained of intermittent dizziness, mostly with
movement that did improve somewhat while she was in hospital.
At the time of discharge she is tolerating a regular diet,
ambulating with a cane/walker at times, afebrile with stable
vital signs.
Dilantin level was 11.8 on [**6-21**] and should be checked weekly
while on Dilantin. Pt should continue on dilantin for seizure
prophylaxis until she is seen in followup by Dr. [**Last Name (STitle) **] in
clinic.
Medications on Admission:
metformin
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for pain.
2. senna 8.6 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed for constipation.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
7. metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. oxycodone 5 mg Capsule Sig: [**2-8**] Capsules PO every 4-6 hours
as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Location 24442**]
Discharge Diagnosis:
Left frontoparietal- temporal Subdural hematoma
Traumatic Subarachnoid hemorrhage
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:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week. This can be drawn at your PCP??????s
office, but please have the results faxed to [**Telephone/Fax (1) 87**].
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
- Suture removal for your eyebrow laceration can be done by your
PCP. [**Name10 (NameIs) **] should be removed on [**6-25**].
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
PLEASE FOLLOW UP WITH YOUR PRIMARY CARE PHYSICIAN [**Name Initial (PRE) **] 2 WEEKS
AN EMAIL WAS SENT TO YOUR PRIMARY CARE PHYSICIAN REGARDING YOUR
Chest and Abdominal CT SCAN FINDINGS / YOU [**Month (only) **] REQUIRE REPEAT
IMAGING.
Completed by:[**2161-6-22**]
|
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icd9cm
|
[
[
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[
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icd9pcs
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|
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|
7511, 7511
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|
712, 737
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,490
| 153,656
|
38806
|
Discharge summary
|
report
|
Admission Date: [**2175-7-6**] Discharge Date: [**2175-7-11**]
Date of Birth: [**2100-6-28**] Sex: F
Service: SURGERY
Allergies:
Aspirin / Fosamax / Avelox / Shellfish Derived
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Splenic laceration s/p colonscopy
Major Surgical or Invasive Procedure:
[**7-6**] - Interventional Radiology Selective Embolization of spleen
History of Present Illness:
75 year old female transferred from an OSH after splenic
rupture. Patient underwent colonscopy on [**6-30**] where a colon
polyp was discovered. She then presented on [**7-5**] to OSH with
sudden onset on LUQ pain around 10pm. Patient underwent CT scan
revealing splenic laceration. Patient transferred to [**Hospital1 18**] for
further management. Repeat read of CT scan evaluated by
radiology shows splenic laceration with questionable blush.
Labs at time of presentation to [**Hospital1 18**] showed HCT at OSH 37.7
with repeat HCT 35.7. Patient with pain in LUQ with radiation
to her left shoulder blade. She
denies any SOB, CP or difficulty breathing. Patient with no
dizziness, lightheadedness or confusion.
Past Medical History:
COPD
spinal stenosis
Emphysema
Herniated disk
Hiatal hernia
PSHx:
Knee replacementx2
Bladder suspensionx2
Hysterectomy
Cholecystectomy
Hernia repair x4
Right lower lobe lobectomy
Colonoscopy x2
Social History:
Lives at home
Family History:
Non-contributory
Physical Exam:
Physical Exam:
GEN: A&O, NAD
HEENT: No scleral icterus
CV: RRR, No M/G/R
PULM: CTAB
ABD: Soft, nondistended, nontender, no rebound or guarding
Ext: No LE edema, LE warm and well perfused
Pertinent Results:
[**7-6**] - CT Abd - Splenic laceration with hemoperitoneum and focus
of active extravasation. Multiple bilateral pulmonary nodules,
increased in size and number from prior examination of [**2174**].
Nonemergent dedicated chest CT recommended
[**7-7**] - CT Abd/Pelvis - 1. New extraperitoneal hematoma intimately
associated with the right external
iliac and femoral arteries, spanning approximately 13 cm CC.
Cannot assess
for active extravasation in the absence of IV contrast.
2. Persistent hemoperitoneum from prior splenic laceration, now
collecting
more in the dependent pelvis, but overall, not increased.
Stable Hct:
[**2175-7-11**] 09:20AM BLOOD Hct-25.8*
[**2175-7-10**] 06:25PM BLOOD Hct-26.7*
[**2175-7-10**] 05:55AM BLOOD Hct-25.5*
[**2175-7-9**] 12:50PM BLOOD Hct-28.2*
[**2175-7-9**] 08:00AM BLOOD Hct-23.9*
[**2175-7-9**] 02:46AM BLOOD Hct-24.9*
[**2175-7-8**] 04:20PM BLOOD Hct-25.9*
Brief Hospital Course:
The patient was admitted to the Acute Care Service on [**7-6**] for
evaluation and treatment of splenic lacerations s/p colonoscopy
on [**7-1**]. Abdominal CT scans showed active bleeding from splenic
lacerations and patient was for splenic arteriogram and
selective embolization on [**7-6**] by Interventional Radiology.
Follow-up angiogram showed minimal devascularization of the
spleen. After the procedure patient was brought to the floor to
monitor hemodynamincally and to monitor serial hematocrits. Pain
was well controlled. Patient's condition improved, diet was
advanced as tolerated, and patient produced adequate urine
output. Serial HCTs stablized over 96 hours before discharge to
home.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored..
ID: The patient was found to have UTI and started on a 3-day
course of Bactrim on [**7-10**] and sent home on [**7-11**] with remaining
doses of medication.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Prophylaxis: The patient received subcutaneous heparin after
hematocrit stabilization; 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
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:
Medications:
--------------- --------------- --------------- ---------------
Active Medication list as of [**2175-7-6**]:
Medications - Prescription
ALBUTEROL SULFATE [PROAIR HFA] - (Prescribed by Other Provider)
- 90 mcg HFA Aerosol Inhaler - 1 twice a day
ALPRAZOLAM - (Prescribed by Other Provider) - 0.25 mg Tablet -
Tablet(s) by mouth as needed
AMLODIPINE - (Prescribed by Other Provider) - 10 mg Tablet -
Tablet(s) by mouth once a day
AMOXICILLIN-POT CLAVULANATE - (Prescribed by Other Provider) -
875 mg-125 mg Tablet - Tablet(s) by mouth before surgery or
dentist
FLUTICASONE-SALMETEROL [ADVAIR HFA] - (Prescribed by Other
Provider) - Dosage uncertain
FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet -
Tablet(s) by mouth once a day
LEVOTHYROXINE - (Prescribed by Other Provider) - 75 mcg Tablet
-
Tablet(s) by mouth once a day
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - Capsule(s) by mouth once a day
SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet -
Tablet(s) by mouth at bedtime
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - (Prescribed by
Other Provider) - 18 mcg Capsule, w/Inhalation Device - 2 once a
day
Medications - OTC
ACETAMINOPHEN [TYLENOL ARTHRITIS] - (Prescribed by Other
Provider) - 650 mg Tablet Sustained Release - 2 Tablet(s) by
mouth as needed
CALCIUM CARBONATE [CALTRATE 600] - (Prescribed by Other
Provider) - 600 mg (1,500 mg) Tablet - 2 Tablet(s) by mouth at
bedtime
CETIRIZINE [ZYRTEC] - (Prescribed by Other Provider) - 10 mg
Capsule - Capsule(s) by mouth as needed for allergy symptoms
DOCUSATE SODIUM [[**Doctor Last Name **] LIQUI-GELS] - (Prescribed by Other
Provider) - 100 mg Capsule - Capsule(s) by mouth at bedtime
ECHINACEA - (Prescribed by Other Provider) - Dosage uncertain
MULTIVITAMINS-MINERALS-LUTEIN [CENTRUM SILVER] - (Prescribed by
Other Provider) - Tablet - Tablet(s) by mouth at bedtime
--------------- --------------- --------------- ---------------
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
2. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**4-11**]
hours as needed for pain for 1 weeks.
Disp:*30 Tablet(s)* Refills:*0*
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for
1 weeks.
Disp:*14 Capsule(s)* Refills:*0*
4. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
Patient will resume Home Medications.
Discharge Disposition:
Home
Discharge Diagnosis:
Splenic laceration
Discharge Condition:
Stable. Alert and Oriented. Ambulating.
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
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 [**5-15**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
Please follow-up with [**Hospital 2536**] Clinic in one week, call [**Telephone/Fax (1) 600**].
Will discuss possible colonic polyp resection.
Completed by:[**2175-7-11**]
|
[
"492.8",
"300.00",
"998.2",
"599.0",
"E870.4",
"244.9",
"568.81",
"865.02",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"39.79"
] |
icd9pcs
|
[
[
[]
]
] |
6861, 6867
|
2592, 4260
|
338, 410
|
6930, 6972
|
1666, 2569
|
8465, 8639
|
1426, 1444
|
6304, 6838
|
6888, 6909
|
4286, 6281
|
6996, 8442
|
1474, 1647
|
265, 300
|
438, 1160
|
1182, 1379
|
1395, 1410
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,998
| 146,481
|
47708
|
Discharge summary
|
report
|
Admission Date: [**2132-8-15**] Discharge Date: [**2132-8-23**]
Date of Birth: [**2057-1-13**] Sex: F
Service: MEDICINE
Allergies:
Haldol / Mellaril / Ibuprofen / Lithium / Depakote
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
Hypertensive urgency, respiratory distress
Major Surgical or Invasive Procedure:
Intubation
Arterial line placement
Hemodialysis
Left IJ CVL placement
History of Present Illness:
Mrs. [**Known lastname **] is a 75yo female with ESRD on HD, HTN, bipolar Bipolar
disorder, cognitive impairment secondary to chronic medical
comorbidities, and Parkinsinism who was presents from home,
after her family became concerned that she has refused HD x2
this wk. The pt missed multiple HD sesssions this wk reportedly
b/c she was upset about her care--per OMR notes. Her family
contact[**Name (NI) **] her PCP, [**Name10 (NameIs) 1023**] made decision w/ family to have the pt
brought to [**Hospital1 18**] ED for eval of lytes & volume status. Pt
brought to ED by ambulance.
.
In ED, VS were notable for BP 200-220/70-80s, HR 70s, RR 16,
100% on RA. Labs notable for K 6.1 & ekg w/ some peaked TWaves.
Pt was given calcium chloride & kayexylate. She was not
documented as receiving anti-HTN in the ED. She was seen be
psychiatry who felt that she was not manic and did not need a
sister. Decision made to admit patient for dialysis in AM.
.
On arrival to wards, the patient triggered for hypertension to
220-250s systolic. She was also tachypneic and diaphoretic, c/o
SOB. She was given 10mg IV hydral w/ minimal response. She was
transferred to the ICU for tx of HTN urgency/emergency and
respiratory distress.
.
On arrival to the MICU, the patient's BP was 183/130, RR 40s,
and she was using her accessory muscles to breath. She appeared
uncomfortable, and again reported SOB, though denied CP. Her
lungs revealed b/l crackles, though R>L. She was given labetolol
20mg IV x2 and started on nitro gtt. Her BP responded
well-->160-170s systolic. The nitro gtt was stopped b/c of
concern for dropping BP too rapidly. She was put on Bipap
10/5/100%. Her ABG after approx 1hr was 7.29/45/479 (on 100%
Fi02). Despite being on Bipap she remained tachypneic & appeared
to be working hard to breath. Renal was contact[**Name (NI) **] & came into
see the patient. It was felt that pt would needed HD soon, but
that realistically it would be a few hrs before it could
actually get started. Given this and pt's increased work of
breathing, the decision was made to electively intubate the
patient. The patient was awake & responsive and asked if
intubation was ok with her. She said it would be ok. Attempts to
reach her daughter by telephone were unsuccessful. Anesthesia
was called and the patient was intubated w/o complication using
etomidate & succ. She required fentanyl gtt w/ versed bolus to
get comfortable w/ vent.
Past Medical History:
1)Hypertension
2)Parkinsonism
3)ESRD on HD
4)Bipolar disorder
5)Vitamin B12 deficiency
6)Nephrogenic DI - lithium induced
7)Hyperlipidemia
8)Psoriasis
9)Hypothyroidism
10)Osteoarthritis (s/p bilat knee replacements)
11)Asthma
12)Urinary retention
13)Impaired glucose tolerance
14)h/o frequent UTIs
15)h/o frequent falls - fracture of her L middle phalanx at PIP
joint
16)multiple knee surgeries, failed right total knee replacement
17)s/p R knee patellectomy in [**6-23**]
18)depression
Social History:
?lives at home. Has dtrs. [**Name (NI) **] known active ETOH/tobacco
Family History:
Noncontributory
Physical Exam:
vitals: 183/130, 70, 45, 100% on NRB
Gen: Patient sleeping but easily aroused, speaking shortened
sentences
HEENT: MMM, PERRL, JVP up to ~jaw
Heart: RRR, ? murmur
Lungs: b/l crackles R>L, w/ scattered wheezes
Abdomen: soft, NT/ND, +BS
Extremities: 1+ bilateral edema, pulses difficult to palpate
Pertinent Results:
[**2132-8-15**] 07:10PM BLOOD WBC-9.9 RBC-3.57* Hgb-9.9* Hct-32.6*#
MCV-91 MCH-27.7 MCHC-30.4* RDW-15.8* Plt Ct-286
[**2132-8-16**] 11:41PM BLOOD WBC-27.0*# RBC-3.22* Hgb-9.0* Hct-28.7*
MCV-89 MCH-27.8 MCHC-31.2 RDW-14.8 Plt Ct-221
[**2132-8-19**] 03:42AM BLOOD WBC-12.7* RBC-2.58* Hgb-7.2* Hct-22.8*
MCV-88 MCH-27.7 MCHC-31.4 RDW-14.7 Plt Ct-205
[**2132-8-23**] 05:06AM BLOOD WBC-6.1 RBC-2.99* Hgb-8.3* Hct-26.8*
MCV-90 MCH-27.9 MCHC-31.1 RDW-15.2 Plt Ct-291
[**2132-8-15**] 07:10PM BLOOD Neuts-74.9* Lymphs-16.0* Monos-6.2
Eos-2.7 Baso-0.2
[**2132-8-15**] 08:30PM BLOOD PT-13.0 PTT-24.3 INR(PT)-1.1
[**2132-8-17**] 08:16AM BLOOD PT-14.6* PTT-36.9* INR(PT)-1.3*
[**2132-8-15**] 07:10PM BLOOD Plt Ct-286
[**2132-8-15**] 08:30PM BLOOD Glucose-89 UreaN-63* Creat-11.0*# Na-144
K-6.2* Cl-104 HCO3-25 AnGap-21*
[**2132-8-16**] 02:36AM BLOOD Glucose-140* UreaN-67* Creat-11.2* Na-141
K-6.5* Cl-105 HCO3-20* AnGap-23*
[**2132-8-23**] 05:06AM BLOOD Glucose-78 UreaN-28* Creat-6.1*# Na-138
K-4.2 Cl-100 HCO3-27 AnGap-15
[**2132-8-16**] 02:10PM BLOOD CK(CPK)-105
[**2132-8-18**] 03:41AM BLOOD LD(LDH)-184 TotBili-0.2
[**2132-8-17**] 08:16AM BLOOD ALT-16 AST-29 LD(LDH)-171 CK(CPK)-359*
AlkPhos-70 Amylase-518* TotBili-0.3
[**2132-8-16**] 02:10PM BLOOD CK-MB-3 cTropnT-0.06*
[**2132-8-16**] 11:41PM BLOOD CK-MB-3 cTropnT-0.06*
[**2132-8-17**] 08:16AM BLOOD CK-MB-4 cTropnT-0.10*
[**2132-8-17**] 08:16AM BLOOD Lipase-27
[**2132-8-23**] 05:06AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.0
[**2132-8-20**] 10:50AM BLOOD calTIBC-133* Ferritn-1287* TRF-102*
[**2132-8-16**] 03:32AM BLOOD Type-ART Temp-36.1 pO2-497* pCO2-45
pH-7.29* calTCO2-23 Base XS--4
[**2132-8-16**] 12:24PM BLOOD Na-142 K-6.3* Cl-104
Final Report
HISTORY: 35-year-old female missing hemodialysis for two days.
COMPARISON: Chest radiograph, [**2132-1-18**].
TWO VIEWS OF THE CHEST: There is moderate cardiomegaly with
pulmonary
vascular congestion and a small amount of basilar atelectasis.
There is no
focal consolidation. The aorta is unfolded and calcified.
Osseous structures
demonstrate moderate degenerative change as in the prior study.
IMPRESSION: Moderate cardiomegaly with pulmonary vascular
congestion and
bibasilar minimal atelectasis.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
Mrs. [**Known lastname **] is a 75yo female with ESRD on HD, bipolar disease,
hypothyroidism, who presented following multiple missed dialysis
sessions, with hypertensive urgency and resultant respiratory
failure.
.
# Respiratory failure:
The patient presented with respiratory failure and was initially
intubated due to increased work of breathing (RR>40) for
prolonged period. Initially she was to be extubated after
dialysis as it was initially thought that respiratory distress
was primarily due to excess volume. However, this failed as she
was apneic even while off sedation. CXR, leukocytosis & fever
all suggested superimposed PNA in addition to fluid overload. As
sputum from admission grew strep pneumo and the patient's family
reported that she had had a cough prior to admission, the
patient was treated for a hospital-acquired pneumonia (given
frequent presence in dialysis centers). The patient's symptoms
and chest xray improved with dialysis and antibiotic treatment.
.
# Anemia:
During the hospitalization the patient had an acute hematocrit
drop from 32 to 22. There was no evidence of gross bleeding and
the patient remained stable without transfusions. Hemolysis labs
were negative, and iron studies were consistent with anemia of
chronic disease. As stool guaiac studies were also positive, the
patient was encouraged to have an outpatient colonoscopy. The
nephrology consultant recommended that the patient begin IV iron
weekly at hemodialysis sessions.
.
# Shock:
The patient's sepsis was likely due to pneumonia. The patient's
hypotension improved with appropriate antibiotic coverage.
.
# HTN:
The pt initially presented with hypertensive emergency after
missing dialysis, and was treated effectively with nitro gtt to
temporize her for dialysis. In setting of probably evolving
sepsis, pt unable to tolerate planned fluid removal of 4L with
resultant hypotension. Following transfer from MICU to floor the
patient was slowly restarted on her home anytihypertensive
regimen with no additional episodes of hypotension.
.
#Hyperlipidemia: The patient was continued on home Lipitor.
.
#Hypothyroidism: The patient was continued on home Levoxyl.
.
#Asthma: Continued outpatient regimen
.
#Psych: Psychiatry was consulted in light of pt entering
hospital on a section 12 (made by mutual agreement between pt's
family and PCP). Psychiatry recommended that pt continue home
BPD meds. Social work determined that pt has supportive
environment at home and the medical team as well as psychiatry
emphasized to pt's family the significance of pt's regular
attendance of dialysis sessions. No changes were made to pt's
home psych med regimen and pt was discharged with psych and PCP
follow up.
.
# Full code: The patient was full code.
.
# Communication was with pt, daughters [**Name (NI) **], [**First Name3 (LF) **] and
[**Name (NI) 2411**] --> [**Telephone/Fax (1) 100753**]
Medications on Admission:
Pantoprazole 40mg PO daily
Cinacalcet 30mg PO daily
Docusate Sodium 100mg PO BID
Fluticasone 2 puffs [**Hospital1 **]
Lamotrigine 50mg PO daily
Levothyroxine 200mcg PO daily
Atorvastatin 10mg PO daily
Lisinopril 20mg PO BID
Metoprolol Tartrate 50mg PO BID
Perphenazine 8mg PO QHS
Quetiapine 100mg PO QHS
Sevelamer 1600mg PO TID
Calcium Carbonate 500mg PO TID
Vitamin D 800 unit PO daily
Oxycodone 5mg PO Q6H PRN
Albuterol MDI
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Lamotrigine 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Perphenazine 8 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
6. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
7. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO QHD (each
hemodialysis): Please take after each session of dialysis until
[**2132-8-28**]. .
Disp:*2 Tablet(s)* Refills:*0*
13. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
15. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnosis:
1. Pulmonary edema
2. Hypertensive urgency
3. Bipolar disorder
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted after you missed dialysis due to a manic
episode from your bipolar disorder and developed fluid in your
lungs and high blood pressure. You had to be intubated to
support your breathing. Please continue to go to dialysis
Tuesday, Thursday, Saturday.
Please take your medications as prescribed. The following
changes were made:
1. Please take perphenazine 16 mg at bedtime
2. Please take Seroquel (quetiapine) 25 mg in the morning
3. Please take Seroquel (quetiapine) 125 mg at bedtime
4. Please stop taking your calcium carbonate.
5. Please stop taking your Vitamin D.
6. Please take Sevelamer 800 mg three times daily.
Please make all your follow up appointments.
If you develop shortness of breath, crushing chest pain, blurry
vision or leg pain please contact your primary care doctor or go
to the emergency room.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5447**], M.D. Date/Time:[**2132-8-26**] 8:50
Provider [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) 9141**] Phone:[**Telephone/Fax (1) 1387**] Date/Time:[**2132-8-28**]
2:20
Provider [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 100754**]
Date/Time:[**2132-10-7**] 11:00
[**2133-1-7**] 10:00a [**Last Name (LF) **],[**First Name3 (LF) 177**] A.
[**Hospital6 29**], [**Location (un) **]
RENAL DIV-CC7 (SB)
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
|
[
"584.9",
"403.01",
"332.0",
"585.6",
"518.4",
"785.50",
"276.7",
"285.9",
"518.81",
"481"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.93",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
10891, 10948
|
6134, 9028
|
354, 425
|
11074, 11084
|
3844, 6111
|
11971, 12707
|
3495, 3512
|
9505, 10868
|
10969, 10969
|
9054, 9482
|
11108, 11948
|
3527, 3825
|
272, 316
|
453, 2880
|
10988, 11053
|
2902, 3392
|
3409, 3479
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,536
| 107,800
|
11218+56218
|
Discharge summary
|
report+addendum
|
Admission Date: [**2125-6-29**] Discharge Date: [**2125-7-13**]
Date of Birth: [**2067-10-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5037**]
Chief Complaint:
Diarrhea, fever
Major Surgical or Invasive Procedure:
Right subclavian CVL [**2125-6-29**] -> removed during course of stay
History of Present Illness:
57 yo F with history of CKD s/p kidney transplant in [**2122**], on
immunosupressants, lymphangioleimeiomatosis, diabetes, who was
admitted with one week of diarrhea, fever to 102.7 and shortness
of breath. She started having watery diarrhea about one week
ago. She denies abd pain, nausea, vomiting, BRBPR, dark stools.
She does have decrased appetite and poor PO intake. She also
complains of SOB, DOE and orthopnea since about the same time.
She has a nonproductive cough and chills adn increased lower
extremity edema. She denies dysuria, hematuria, chest pain,
rash. In the ED, Temp 102.7, HR 113, 183/67, 18, 84%2L - >
100%NRB, lactate 2.3, elevated WBC to 14 with left shift,
elevated creatinine to 4.1 from baseline of 3.2, + anion gap of
17. She was given 2 L of IVF and had abdominal CT that was
unrevealing. She was started on Levofloxacin and flagyl for
presumed gastroenteritis. She was admitted to the ICU becuase of
her oxygen requirement. In ICU ABG showed profound metabolic
acidosis (anion gap and non anion gap) 7.17/45/268 on NRB.
Past Medical History:
Hepatocellular carcinoma, dx [**5-/2125**], grade 2 (focal clear cell
differentiation, immunohistochemical stains highlight
canalicular patterns by CEA, the tumor cells are focally
positive for CAM 5.2 and negative for cytokeratin A1/A3, the
tumor cells are positive for Hep PAR1 and TTF-1). [**Last Name (un) 36065**] scan in
[**4-/2125**] negative for mets.
s/p Splenectomy
Diabetes
ESRD (secondary to DM and HTN), s/p renal transplant [**2122**] on
immunosuppressants, episode of allograft nephropathy documented
by biopsy, basleine creatinine 3
Hypertension
b/l thoracotomy for spontaneous PTX, [**2110**]
Hyperlipidemia
Lymphangioleimyomatosis (cystic dz) of lung, on home oxygen 2L
NC all the time
Pulmonary Artery Hypertension
Cardiac stress test (P MIBI) in [**4-/2125**] with no perfusion defects
Seizures in setting of hypertensive emergency
Social History:
Pt was raised in the Phillipines, immigrated to the US in
[**2096**]. Married lives with husband. 2 kids. No tob/etoh/drugs.
Family History:
FH - Mother died from pancreatic ca
Physical Exam:
99, 82, 154/68, 20, 97%NRB
GENL: mild distress
HEENT: no elevated JVP, OP clear with slightly dry membranes
CV: RRR +systolic murmur best heard at apex.
Lungs: crackles at R base, otherwise clear without rhonchi
Abd: tender over transplanted kidney and in R LQ, but soft, no
hepatomegaly, +BS
Ext: 2+ edema to kness bl, 1+ DP pulses
Pertinent Results:
[**2125-6-29**] 05:55AM BLOOD WBC-14.3*# RBC-3.05* Hgb-8.5* Hct-27.7*
MCV-91 MCH-27.7 MCHC-30.5* RDW-18.6* Plt Ct-312
[**2125-6-29**] 07:59PM BLOOD WBC-10.7 RBC-2.83* Hgb-7.9* Hct-25.8*
MCV-91 MCH-28.1 MCHC-30.8* RDW-18.0* Plt Ct-242
[**2125-6-29**] 11:52PM BLOOD Hct-28.2*
[**2125-6-30**] 02:21AM BLOOD WBC-13.2* RBC-2.97* Hgb-8.4* Hct-26.9*
MCV-91 MCH-28.3 MCHC-31.2 RDW-18.4* Plt Ct-263
[**2125-7-1**] 03:50AM BLOOD WBC-10.1 RBC-2.84* Hgb-8.0* Hct-25.4*
MCV-89 MCH-28.2 MCHC-31.6 RDW-18.5* Plt Ct-226
[**2125-7-3**] 03:13AM BLOOD WBC-7.8 RBC-2.82* Hgb-7.8* Hct-25.1*
MCV-89 MCH-27.7 MCHC-31.2 RDW-18.0* Plt Ct-221
[**2125-7-5**] 03:34AM BLOOD WBC-8.8 RBC-3.02* Hgb-8.3* Hct-26.5*
MCV-88 MCH-27.4 MCHC-31.2 RDW-17.8* Plt Ct-257
[**2125-7-6**] 05:15AM BLOOD WBC-9.8 RBC-3.09* Hgb-8.5* Hct-27.2*
MCV-88 MCH-27.7 MCHC-31.4 RDW-18.0* Plt Ct-265
[**2125-7-7**] 05:20AM BLOOD WBC-9.1 RBC-3.07* Hgb-8.7* Hct-27.1*
MCV-88 MCH-28.2 MCHC-32.0 RDW-18.1* Plt Ct-301
[**2125-7-8**] 05:45AM BLOOD WBC-8.6 RBC-3.11* Hgb-8.8* Hct-27.6*
MCV-89 MCH-28.1 MCHC-31.7 RDW-17.8* Plt Ct-334
[**2125-7-9**] 06:15AM BLOOD WBC-7.1 RBC-3.22* Hgb-9.0* Hct-28.6*
MCV-89 MCH-27.8 MCHC-31.3 RDW-18.3* Plt Ct-375
[**2125-7-11**] 05:30AM BLOOD WBC-8.3 RBC-3.40* Hgb-9.2* Hct-30.5*
MCV-90 MCH-27.1 MCHC-30.3* RDW-18.1* Plt Ct-456*
[**2125-7-2**] 04:14AM BLOOD Glucose-130* UreaN-42* Creat-4.5* Na-141
K-4.0 Cl-108 HCO3-20* AnGap-17
[**2125-7-3**] 03:13AM BLOOD Glucose-128* UreaN-44* Creat-4.7* Na-137
K-3.7 Cl-105 HCO3-20* AnGap-16
[**2125-7-3**] 03:50PM BLOOD Creat-4.7* Na-135 K-3.8
[**2125-7-3**] 09:45PM BLOOD Na-134 K-3.9
[**2125-7-4**] 02:48AM BLOOD Glucose-112* UreaN-46* Creat-4.8* Na-134
K-3.6 Cl-101 HCO3-20* AnGap-17
[**2125-7-7**] 05:20AM BLOOD Glucose-213* UreaN-57* Creat-4.9* Na-137
K-3.2* Cl-103 HCO3-26 AnGap-11
[**2125-7-8**] 05:45AM BLOOD Glucose-206* UreaN-60* Creat-4.4* Na-139
K-3.4 Cl-103 HCO3-24 AnGap-15
Brief Hospital Course:
This is a 57 yo F with ESRD s/p renal transplant,
lymphangioleimeiomatosis, admitted with fever, diarrhea, acute
renal failure and metabolic acidosis. The patient was sent to
the Medical Intensive Care Unit from the emergency department
because of increased oxygen requirement.
.
Her MICU course was notable for an ongoing AG and non-AG
acidosis attributed to the combination of renal failure/ketosis
and diarrhea, which has since improved with HD x 1, lessening
diarrhea, bicarb, and lasix. She also had an ongoing respiratory
acidosis from hypercarbia, likely [**2-22**] underlying poor lung
reserve and fatigue. She required BiPAP several times during her
course for ventilation assistance. Intubation was considered at
several points, but was not required. ID and renal were involved
in the care of this patient. CT studies of the abdomen were
unremarkable for an infectious source. Blood, urine cultures
were negative while patient was in the MICU. Stool cultures were
also negative. The patient was continued empirically on
levo/flagyl for a presumed GI source, given diarrhea. Urine
legionella was negative. CMV and EBV were checked given
immunosuppression, but were negative. Her course was also
notable for a fluid overload state given evidence of pulmonary
edema on CXR and exam, requiring agressive diuresis with lasix
gtt and IV chlorothiazide.
After her diarrhea, fever, ARF and metabolic acidosis improved,
she was transferred to medicine floor for further care with a
5.5 L oxygen requirement.
1. Fever - resolved after transfer to the medical service. Blood
cultures from [**2125-7-6**] subsequently grew [**1-24**] Coag negative staph
(sensitivities pending) from the central line site. The central
line was d/c'd and the patient was started on vancomycin
empirically (1 gram dosed for daily levels<15). Surveillance
cultures remained negative, patient remained stable without a
fever or white count. The positive cultures may be [**2-22**]
contamination, but it is unclear. She was treated with 5 days
of IV vancomycin and transitioned to oral therapy with
Doxycycline for a further 8 days on discharge. Her urine on
[**2125-7-6**] also grew out <10,000 Enterococcus senstive to IV vanc
and IV ampicillin. Although this is not a true UTI as it is less
than <10,000 and her u/a was sterile, it was decided to treat
with vanc as she is a renal transplant patient. Given her CRI,
she should be dosed 750 mg/qd and have levels checked in [**1-22**]
days to ensure therapeutic levels - done for 5 days as above,
and no evidence UTI on d/c. Her initial fever on presentation
was attributed to a GI source, give negative blood, urine, and
stools cx. She was treated with levofloxacin and flagyl
empirically for 14 days. CMV negative.
.
2. Hypoxia - required 6 L -> NRB on admission from her baseline
of 2 L NC. This was all most likely [**2-22**] lymphangioleimeimatosis
combined with fluid overload; no sign of pneumonia on CXR. With
diuresis, her pulmonary edema removed and her oxygenation status
returned to baseline of 2 L NC. She shoudl continue aggressive
pulmonary toilet to improve her lung function as much as
possible. On d/c to rehab she was subjectively near her
baseline, but allowed to remain on 3L since she is not at risk
for oxygen toxicity at that level
.
3. ESRD s/p transplant with ARF - likely intrinsic process as
FENa of 1.21% and FeUrea = 47.8; no evidence of obstruction on
U/S; creatinine stable at 4.0
- cont immunosuppressants for now
- restrict phosphate and potassium intake
- may require HD in the future, patient refusing currently;
transplant renal followed during course
- need to follow renal function carefully as pt may require HD
in the near future
.
4. NIDDM - initially on a HISS during her course, added NPH due
to elevated BS on a HISS. Currently suguars controlled with 12 U
NPH in AM, 6 U NPH at dinner, and HISS. Continued diabetic diet
with FS QACHS.
.
5. HTN - continued norvasc and metoprolol, BP well controlled
.
6. F/E/N - The patient was placed on a diabetic, low sodium
diet. She was restricted to < 1.5L/day fluid intake, 1 gram
phosphate as patient was hyperphosphatemic on admission, and
2grams of potassium daily. Nutritional status should be
carefully monitored.
Medications on Admission:
MEDS (at home) -
Crestor 5 mg qd
Alendronate QW
Bactrim 3 x per wk
Prednisone 5 mg QD
Metoprolol 100 [**Hospital1 **]
Regular Insulin sliding scale plus 70/30,
Iron
Norvasc 10 mg qd
CellCept 1 g [**Hospital1 **]
Calcitriol 0.5 mcg qd
Procrit
Was on prgraf previously but pt says not anymore.
.
MEDS (on transfer) -
Tylenol prn
Albuterol prn
Amlodipine 10 mg qd
Calcitriol 0.25 mcg qd
Chlorothiazide 500 mg IV bid
Levoflox 250 mg IV q48
Ativan prn
Metoprolol 100 mg tid
Flagyl 500 mg tid
CellCept [**Pager number **] mg IV bid
Protonix 40 mg IV qd
Lasix gtt
Hep SC
RISS
Labetolol gtt
Prednisone 5 mg qd
Bactrim SS 3x/week
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
4. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
5. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
7. Ferrous Sulfate 325 (65) mg Tablet Sig: 325mg Tablets PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Epoetin Alfa 10,000 unit/mL Solution Sig: 10,000 units
Injection QMOWEFR (Monday -Wednesday-Friday).
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3)
Tablet, Chewable PO once a day.
Disp:*90 Tablet, Chewable(s)* Refills:*2*
10. Calcitriol 0.25 mcg Capsule Sig: 0.25 microgram Capsule PO
DAILY (Daily).
11. Insulin
Please see attached sliding scale sheet
12. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 8 days: Do not take within two hours
of taking Iron or calcium.
Disp:*16 Capsule(s)* Refills:*0*
13. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 23973**] [**Location (un) 1110**]
Discharge Diagnosis:
Primary: Fever, acute renal failure, diarrhea, pulmonary edema
.
Secondary: LAM, hypertension, NIDDM, HCC
.
Discharge Condition:
afebrile, oxygen saturation 94-100% on 2L Nasal cannula, other
vital signs stable
Discharge Instructions:
-Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in 2 weeks; your
appointment has already been set
-Take all medications as prescribed
-Please call your doctor or return to the ER if you experience
fever, increased shortness of breath, or if you have any other
symptoms that concern you.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2125-7-30**] 2:40
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]
Name: [**Known lastname 6432**],[**Known firstname 6433**] Unit No: [**Numeric Identifier 6434**]
Admission Date: [**2125-6-29**] Discharge Date: [**2125-7-13**]
Date of Birth: [**2067-10-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3541**]
Addendum:
We added Nitrofurantoin 50mg PO QD to cover tetracycline
resistant enterococcus that grew from urine specimen, for a 14
day course to start on day of discharge.
Chief Complaint:
Diarrhea, fever
Major Surgical or Invasive Procedure:
Right subclavian CVL [**2125-6-29**] -> removed during course of stay
History of Present Illness:
57 yo F with history of CKD s/p kidney transplant in [**2122**], on
immunosupressants, lymphangioleimeiomatosis, diabetes, who was
admitted with one week of diarrhea, fever to 102.7 and shortness
of breath. She started having watery diarrhea about one week
ago. She denies abd pain, nausea, vomiting, BRBPR, dark stools.
She does have decrased appetite and poor PO intake. She also
complains of SOB, DOE and orthopnea since about the same time.
She has a nonproductive cough and chills adn increased lower
extremity edema. She denies dysuria, hematuria, chest pain,
rash. In the ED, Temp 102.7, HR 113, 183/67, 18, 84%2L - >
100%NRB, lactate 2.3, elevated WBC to 14 with left shift,
elevated creatinine to 4.1 from baseline of 3.2, + anion gap of
17. She was given 2 L of IVF and had abdominal CT that was
unrevealing. She was started on Levofloxacin and flagyl for
presumed gastroenteritis. She was admitted to the ICU becuase of
her oxygen requirement. In ICU ABG showed profound metabolic
acidosis (anion gap and non anion gap) 7.17/45/268 on NRB.
Past Medical History:
Hepatocellular carcinoma, dx [**5-/2125**], grade 2 (focal clear cell
differentiation, immunohistochemical stains highlight
canalicular patterns by CEA, the tumor cells are focally
positive for CAM 5.2 and negative for cytokeratin A1/A3, the
tumor cells are positive for Hep PAR1 and TTF-1). [**Last Name (un) 6435**] scan in
[**4-/2125**] negative for mets.
s/p Splenectomy
Diabetes
ESRD (secondary to DM and HTN), s/p renal transplant [**2122**] on
immunosuppressants, episode of allograft nephropathy documented
by biopsy, basleine creatinine 3
Hypertension
b/l thoracotomy for spontaneous PTX, [**2110**]
Hyperlipidemia
Lymphangioleimyomatosis (cystic dz) of lung, on home oxygen 2L
NC all the time
Pulmonary Artery Hypertension
Cardiac stress test (P MIBI) in [**4-/2125**] with no perfusion defects
Seizures in setting of hypertensive emergency
Social History:
Pt was raised in the Phillipines, immigrated to the US in
[**2096**]. Married lives with husband. 2 kids. No tob/etoh/drugs.
Family History:
FH - Mother died from pancreatic ca
Physical Exam:
99, 82, 154/68, 20, 97%NRB
GENL: mild distress
HEENT: no elevated JVP, OP clear with slightly dry membranes
CV: RRR +systolic murmur best heard at apex.
Lungs: crackles at R base, otherwise clear without rhonchi
Abd: tender over transplanted kidney and in R LQ, but soft, no
hepatomegaly, +BS
Ext: 2+ edema to kness bl, 1+ DP pulses
Pertinent Results:
[**2125-6-29**] 05:55AM BLOOD WBC-14.3*# RBC-3.05* Hgb-8.5* Hct-27.7*
MCV-91 MCH-27.7 MCHC-30.5* RDW-18.6* Plt Ct-312
[**2125-6-29**] 07:59PM BLOOD WBC-10.7 RBC-2.83* Hgb-7.9* Hct-25.8*
MCV-91 MCH-28.1 MCHC-30.8* RDW-18.0* Plt Ct-242
[**2125-6-29**] 11:52PM BLOOD Hct-28.2*
[**2125-6-30**] 02:21AM BLOOD WBC-13.2* RBC-2.97* Hgb-8.4* Hct-26.9*
MCV-91 MCH-28.3 MCHC-31.2 RDW-18.4* Plt Ct-263
[**2125-7-1**] 03:50AM BLOOD WBC-10.1 RBC-2.84* Hgb-8.0* Hct-25.4*
MCV-89 MCH-28.2 MCHC-31.6 RDW-18.5* Plt Ct-226
[**2125-7-3**] 03:13AM BLOOD WBC-7.8 RBC-2.82* Hgb-7.8* Hct-25.1*
MCV-89 MCH-27.7 MCHC-31.2 RDW-18.0* Plt Ct-221
[**2125-7-5**] 03:34AM BLOOD WBC-8.8 RBC-3.02* Hgb-8.3* Hct-26.5*
MCV-88 MCH-27.4 MCHC-31.2 RDW-17.8* Plt Ct-257
[**2125-7-6**] 05:15AM BLOOD WBC-9.8 RBC-3.09* Hgb-8.5* Hct-27.2*
MCV-88 MCH-27.7 MCHC-31.4 RDW-18.0* Plt Ct-265
[**2125-7-7**] 05:20AM BLOOD WBC-9.1 RBC-3.07* Hgb-8.7* Hct-27.1*
MCV-88 MCH-28.2 MCHC-32.0 RDW-18.1* Plt Ct-301
[**2125-7-8**] 05:45AM BLOOD WBC-8.6 RBC-3.11* Hgb-8.8* Hct-27.6*
MCV-89 MCH-28.1 MCHC-31.7 RDW-17.8* Plt Ct-334
[**2125-7-9**] 06:15AM BLOOD WBC-7.1 RBC-3.22* Hgb-9.0* Hct-28.6*
MCV-89 MCH-27.8 MCHC-31.3 RDW-18.3* Plt Ct-375
[**2125-7-11**] 05:30AM BLOOD WBC-8.3 RBC-3.40* Hgb-9.2* Hct-30.5*
MCV-90 MCH-27.1 MCHC-30.3* RDW-18.1* Plt Ct-456*
[**2125-7-2**] 04:14AM BLOOD Glucose-130* UreaN-42* Creat-4.5* Na-141
K-4.0 Cl-108 HCO3-20* AnGap-17
[**2125-7-3**] 03:13AM BLOOD Glucose-128* UreaN-44* Creat-4.7* Na-137
K-3.7 Cl-105 HCO3-20* AnGap-16
[**2125-7-3**] 03:50PM BLOOD Creat-4.7* Na-135 K-3.8
[**2125-7-3**] 09:45PM BLOOD Na-134 K-3.9
[**2125-7-4**] 02:48AM BLOOD Glucose-112* UreaN-46* Creat-4.8* Na-134
K-3.6 Cl-101 HCO3-20* AnGap-17
[**2125-7-7**] 05:20AM BLOOD Glucose-213* UreaN-57* Creat-4.9* Na-137
K-3.2* Cl-103 HCO3-26 AnGap-11
[**2125-7-8**] 05:45AM BLOOD Glucose-206* UreaN-60* Creat-4.4* Na-139
K-3.4 Cl-103 HCO3-24 AnGap-15
Brief Hospital Course:
This is a 57 yo F with ESRD s/p renal transplant,
lymphangioleimeiomatosis, admitted with fever, diarrhea, acute
renal failure and metabolic acidosis. The patient was sent to
the Medical Intensive Care Unit from the emergency department
because of increased oxygen requirement.
.
Her MICU course was notable for an ongoing AG and non-AG
acidosis attributed to the combination of renal failure/ketosis
and diarrhea, which has since improved with HD x 1, lessening
diarrhea, bicarb, and lasix. She also had an ongoing respiratory
acidosis from hypercarbia, likely [**2-22**] underlying poor lung
reserve and fatigue. She required BiPAP several times during her
course for ventilation assistance. Intubation was considered at
several points, but was not required. ID and renal were involved
in the care of this patient. CT studies of the abdomen were
unremarkable for an infectious source. Blood, urine cultures
were negative while patient was in the MICU. Stool cultures were
also negative. The patient was continued empirically on
levo/flagyl for a presumed GI source, given diarrhea. Urine
legionella was negative. CMV and EBV were checked given
immunosuppression, but were negative. Her course was also
notable for a fluid overload state given evidence of pulmonary
edema on CXR and exam, requiring agressive diuresis with lasix
gtt and IV chlorothiazide.
After her diarrhea, fever, ARF and metabolic acidosis improved,
she was transferred to medicine floor for further care with a
5.5 L oxygen requirement.
1. Fever - resolved after transfer to the medical service. Blood
cultures from [**2125-7-6**] subsequently grew [**1-24**] Coag negative staph
(sensitivities pending) from the central line site. The central
line was d/c'd and the patient was started on vancomycin
empirically (1 gram dosed for daily levels<15). Surveillance
cultures remained negative, patient remained stable without a
fever or white count. The positive cultures may be [**2-22**]
contamination, but it is unclear. She was treated with 5 days
of IV vancomycin and transitioned to oral therapy with
Doxycycline for a further 8 days on discharge. Her urine on
[**2125-7-6**] also grew out <10,000 Enterococcus senstive to IV vanc
but resistant to tetracycline. Although this is not a true UTI
as it is less than <10,000 and her u/a was sterile, it was
decided to treat
with vanc as she is a renal transplant patient. Given her CRI,
she was dosed 750 mg/qd and have levels checked in [**1-22**]
days to ensure therapeutic levels - done for 5 days as above,
and no evidence UTI on d/c. She was switched to Nitrofurantion
50mg PO QD for 14 days on the day of discharge for enterococcus.
Her initial fever on presentation
was attributed to a GI source, give negative blood, urine, and
stools cx. She was treated with levofloxacin and flagyl
empirically for 14 days. CMV negative.
.
2. Hypoxia - required 6 L -> NRB on admission from her baseline
of 2 L NC. This was all most likely [**2-22**] lymphangioleimeimatosis
combined with fluid overload; no sign of pneumonia on CXR. With
diuresis, her pulmonary edema removed and her oxygenation status
returned to baseline of 2 L NC. She shoudl continue aggressive
pulmonary toilet to improve her lung function as much as
possible. On d/c to rehab she was subjectively near her
baseline, but allowed to remain on 3L since she is not at risk
for oxygen toxicity at that level
.
3. ESRD s/p transplant with ARF - likely intrinsic process as
FENa of 1.21% and FeUrea = 47.8; no evidence of obstruction on
U/S; creatinine stable at 4.0
- cont immunosuppressants for now
- restrict phosphate and potassium intake
- may require HD in the future, patient refusing currently;
transplant renal followed during course
- need to follow renal function carefully as pt may require HD
in the near future
.
4. NIDDM - initially on a HISS during her course, added NPH due
to elevated BS on a HISS. Currently suguars controlled with 12 U
NPH in AM, 6 U NPH at dinner, and HISS. Continued diabetic diet
with FS QACHS.
.
5. HTN - continued norvasc and metoprolol, BP well controlled
.
6. F/E/N - The patient was placed on a diabetic, low sodium
diet. She was restricted to < 1.5L/day fluid intake, 1 gram
phosphate as patient was hyperphosphatemic on admission, and
2grams of potassium daily. Nutritional status should be
carefully monitored.
Medications on Admission:
MEDS (at home) -
Crestor 5 mg qd
Alendronate QW
Bactrim 3 x per wk
Prednisone 5 mg QD
Metoprolol 100 [**Hospital1 **]
Regular Insulin sliding scale plus 70/30,
Iron
Norvasc 10 mg qd
CellCept 1 g [**Hospital1 **]
Calcitriol 0.5 mcg qd
Procrit
Was on prgraf previously but pt says not anymore.
.
MEDS (on transfer) -
Tylenol prn
Albuterol prn
Amlodipine 10 mg qd
Calcitriol 0.25 mcg qd
Chlorothiazide 500 mg IV bid
Levoflox 250 mg IV q48
Ativan prn
Metoprolol 100 mg tid
Flagyl 500 mg tid
CellCept [**Pager number **] mg IV bid
Protonix 40 mg IV qd
Lasix gtt
Hep SC
RISS
Labetolol gtt
Prednisone 5 mg qd
Bactrim SS 3x/week
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
4. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
5. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
7. Ferrous Sulfate 325 (65) mg Tablet Sig: 325mg Tablets PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Epoetin Alfa 10,000 unit/mL Solution Sig: 10,000 units
Injection QMOWEFR (Monday -Wednesday-Friday).
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3)
Tablet, Chewable PO once a day.
Disp:*90 Tablet, Chewable(s)* Refills:*2*
10. Calcitriol 0.25 mcg Capsule Sig: 0.25 microgram Capsule PO
DAILY (Daily).
11. Insulin
Please see attached sliding scale sheet
12. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 8 days: Do not take within two hours
of taking Iron or calcium.
Disp:*16 Capsule(s)* Refills:*0*
13. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*2*
14. Nitrofurantoin (Macrocryst25%) 100 mg Capsule Sig: 0.5
Capsule PO once a day for 14 days: Please give 50mg by mouth
once daily for 14 days.
Disp:*7 Capsule(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 6436**] [**Location (un) 437**]
Discharge Diagnosis:
Primary: Fever, acute renal failure, diarrhea, pulmonary edema
.
Secondary: LAM, hypertension, NIDDM, HCC
.
Discharge Condition:
afebrile, oxygen saturation 94-100% on [**2-23**] L Nasal cannula,
other vital signs stable
Discharge Instructions:
-Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in 2 weeks; your
appointment has already been set
-Take all medications as prescribed
-Please call your doctor or return to the ER if you experience
fever, increased shortness of breath, or if you have any other
symptoms that concern you.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) 460**] [**Last Name (NamePattern1) 461**], MD Phone:[**Telephone/Fax (1) 242**]
Date/Time:[**2125-7-30**] 2:40
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3543**]
Completed by:[**2125-7-13**]
|
[
"996.81",
"250.00",
"780.6",
"558.9",
"276.2",
"401.9",
"584.9",
"235.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
23525, 23596
|
17089, 21444
|
12566, 12638
|
23748, 23842
|
15167, 17066
|
24223, 24497
|
14759, 14797
|
22117, 23502
|
23617, 23727
|
21470, 22094
|
23866, 24200
|
14812, 15148
|
12511, 12528
|
12667, 13721
|
13743, 14600
|
14616, 14743
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,420
| 187,356
|
30413
|
Discharge summary
|
report
|
Admission Date: [**2144-4-8**] Discharge Date: [**2144-4-11**]
Date of Birth: [**2093-7-22**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
retroperitoneal bleed.
Major Surgical or Invasive Procedure:
atrial ablation
History of Present Illness:
50 yo F w/ long hx of a.fib previously controlled with
Propafenone. In the past 8 mo. pt. has noted incr. freq. of AF.
She also reports associated weakness, lightheadedness,
palpitations. She underwent pulmonary vein isolation today.
After the procedure it was noted that she had a hct drop from 47
to 27. a CT abd/pelvis showed a 13x2.9cm extraperitoneal bleed
with extension into the retroperitoneum limited to the pelvis
and extending to the right upper to mid thigh. Her subsequent
HCTs have remained stable. She is admitted to the CCU for
observation.
.
REVIEW OF SYSTEMS:
Denies any prior history of stroke, TIA, deep venous thrombosis,
pulmonary embolism, myalgias, joint pains, cough, hemoptysis,
black stools or red stools. Denies recent fevers, chills or
rigors. Denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, syncope or presyncope. As above she does admit to
lightheadedness and palpitations with a.fib.
Past Medical History:
A.fib
Borderline hypertension
Genital herpes
Raynaud??????s disease
[**12-15**]: benign cyst removed from base of spine.
Social History:
Patient is single and lives alone. Her friend [**Name (NI) 51796**]
[**Name (NI) **] will bring her to and from the procedure. She can be
reached at [**Telephone/Fax (1) 72302**].
-Health Care Proxy: [**Name (NI) **] [**Name (NI) 4643**] (friend): [**Telephone/Fax (1) 72303**]
Family History:
NC
Physical Exam:
VS: T 98.5 BP 92/54 HR 75 RR 15 O2 98RA
Gen: NAD, laying flat in bed, AAOx3
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. dry MM
Neck: no JVD noted
CV: rrr
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits. Right groin site pressure
dressing applied.
.
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:
TELEMETRY demonstrated:NSR s/p pulmonary vein isolation
.
??????[**2144-2-22**] CT of chest: No acute disease. Two right pulmonary
venous ostia identified. Single common left atrial pulmonary
ostia, bifurcating after a short distance to upper lobe and
lower
lobe ostia.
.
??????Echo and ETT approximately 2-3 years ago at [**Hospital **] Medical
unremarkable.
.
-CT abd/pelvis [**2144-4-8**]:
1. Extraperitoneal bleed 13 x 2.9 cm in greatest dimension that
has a small extension into the retroperitoneum that is limited
to the pelvis. There is also extension of the hematoma to the
right upper to mid thigh.
2. Small amount of prehepatic fluid is seen.
3. Small area of pleural thickening at the left lower lobe.
.
LABORATORY DATA:
HCT- 47 to 27 to 30 to 28.
INR 1.5
[**2144-4-8**] 07:40AM WBC-3.9* RBC-4.39 HGB-15.7 HCT-47.4 MCV-108*
MCH-35.7* MCHC-33.1 RDW-13.4
[**2144-4-8**] 07:40AM PLT COUNT-225
[**2144-4-8**] 06:20PM PLT COUNT-152
Brief Hospital Course:
This is a 50 yo F with a long h/o A.fib. on propafenone, who
recently became symptomatic and was admitted for pulmonary vein
isolation. The patient developed an RP bleed s/p AF ablation for
which she was monitored in the CCU for one night.
.
1. RP bleed: developed s/p pulmonary vein isolation. Extra- and
retroperitoneal spread on CT abd/pelvis. Hct dropped from 47 to
27 but remained stable overnight in the CCU after the initial
drop. However, it further trended down to 23 after that and the
patient received 2U pRBC with an appropriate bump. Hematocrits
were checked frequently. Her Hct was stable upon discharge.
.
2. CAD: continued atenolol and ASA
.
3. Rhythm: s/p pulmonary vein isolation, continued propafenone.
Coumadin was restarted after the RP bleed had stabilized. Has
outpatient f/u appointment in [**Hospital **] clinic.
.
4. HTN: continued home dose of atenolol.
.
5. Thrombocytopenia: Plt slowly trended down from 225 at
admission to low 100s. Avoided heparin products but it was felt
that the drop was rather due to the bleed and blood transfusion
than HIT. Plt levels should be followed after discharge.
.
6. Depression: continued zoloft
.
7. Pleuritic chest pain: The patient possibly had mild
pericarditis. She was asked to take NSAIDS for relief of
pleuritic chest pain. She will follow up with her primary care
physician [**Name Initial (PRE) 72304**] 1 week.
.
8. FEN: diet as tolerated
.
9. PPX: Anticoagulation with coumadin was restarted once the RP
bleed had stabilized.
.
10. Code: full.
Medications on Admission:
Zoloft 50mg daily every morning, Valtrex 500mg daily every
morning, Propafenone 150mg, one tablet every morning, 1.5
tablets
every evening, Atenolol 50mg daily every evening, Coumadin
2.5mg
on Monday??????s and Wednesday??????s, 5mg all other days (last dose
[**2144-4-4**]), MVI.
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**3-13**]
hours as needed for pain for 7 days.
Disp:*36 Tablet(s)* Refills:*0*
3. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Valacyclovir 500 mg Tablet Sig: One (1) Tablet PO qd ().
Disp:*30 Tablet(s)* Refills:*2*
5. Propafenone 150 mg Tablet Sig: One (1) Tablet PO BREAKFAST
(Breakfast).
Disp:*30 Tablet(s)* Refills:*2*
6. Propafenone 225 mg Tablet Sig: One (1) Tablet PO DINNER
(Dinner).
Disp:*30 Tablet(s)* Refills:*2*
7. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO 2X/WEEK
(MO,WE).
Disp:*60 Tablet(s)* Refills:*2*
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO 4X/WEEK
([**Doctor First Name **],TU,TH,FR,SA).
Disp:*120 Tablet(s)* Refills:*2*
10. Motrin 400 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for chest pain for 5 days.
Disp:*20 Tablet(s)* Refills:*0*
11. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Atrial fibrillation, s/p pulmonary vein isolation
2. Hypertension
3. CAD
4. Retroperitoneal bleed requiring 2U pRBC transfusion
.
Secondary Diagnosis:
1. Depression
Discharge Condition:
Afebrile. Hemodynamically stable. Ambulating. Tolerating PO.
Discharge Instructions:
You have been treated for your atrial fibrillation with a
procedure called pulmonary vein isolation. You have developed
internal bleeding after the procedure and received blood
products. You also have developed so called pleuritic chest pain
and have been prescribed an antiinflammatory [**Doctor Last Name 360**] to be taken
as needed. Please discontinue it if you develop any signs of
bleeding or stomach or belly discomfort.
please try motrin 400-600 tid with food, if this irritates your
stomach, you can try aspirin 600 tid.
.
Please call your primary doctor or return to the ED with fever,
chills, chest pain, shortness of breath, nausea/vomiting,
spontaneous bleeding, near fainting, dizziness, palpitations or
any other concerning symptoms.
.
Please take all your medications as directed.
.
Please keep you follow up appointments as below.
Followup Instructions:
Please follow up with your primary care [**First Name8 (NamePattern2) **] [**Last Name (Titles) **],[**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 20**] [**Telephone/Fax (1) 64161**] or your [**Hospital3 **] within the
next 2-3 days in order to have your INR checked.
You will also need a follow up with Dr. [**Last Name (STitle) **] in the next 1
week for a chest x-ray, your chest x-ray at [**Hospital1 18**] showed small
bilateral pleural effusions. Please arrange this with your
primary care physician
.
Please also follow up with your Electrophysiologist at [**Location (un) 12914**] as scheduled.
Completed by:[**2144-4-11**]
|
[
"287.5",
"E879.0",
"V58.61",
"285.1",
"443.0",
"998.11",
"786.52",
"414.01",
"427.31",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"37.28",
"37.27",
"37.34",
"37.26"
] |
icd9pcs
|
[
[
[]
]
] |
6438, 6444
|
3411, 4932
|
336, 353
|
6675, 6738
|
2439, 3388
|
7639, 8288
|
1937, 1941
|
5265, 6415
|
6465, 6465
|
4958, 5242
|
6762, 7616
|
1956, 2420
|
959, 1480
|
274, 298
|
381, 940
|
6638, 6654
|
6484, 6617
|
1502, 1625
|
1641, 1921
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,765
| 166,384
|
46852
|
Discharge summary
|
report
|
Admission Date: [**2120-4-24**] Discharge Date: [**2120-5-2**]
Service: SURGERY
Allergies:
Enalapril / Lovastatin / Simvastatin / Dilantin / Tagamet /
Percocet / Vicodin / Hydrochlorothiazide / Vasotec / Mevacor
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
ERCP
Open Cholecystectomy
History of Present Illness:
Ms [**Known lastname **] presented to the emergency room on [**2120-4-24**] with
complaints of abdominal pain. ERCP revealed dilated common bile
duct and fragmented stones. T. bili was also elevated. She was
admitted to medical service for management of
choleducolithiasis.
Past Medical History:
CHF - diastolic dysfunction on cath in [**2115**]
DM 2
HTN
sleep apnea
depression
Pulmonary hypertension
Left TKR.
Social History:
Pt lives alone in a senior citizen home. One daughter who lives
in [**Location (un) **]. Quit smoking 20 years ago, no ETOH, no illicits.
Retired teacher aide, has a cat.
Family History:
none significant
Physical Exam:
T: 96.7 HR: 60 BP: 140/75 RR: 18 SPO2: 96% RA
Constitutional: No acute distress
Head/Eyes: Pupils equal round reactive to light
Chest/Respiratory: Clear to auscultation bilaterally
Cardiovascular: Regular rate & rhythm S1/S2. No murmur
regurgitation or gallop
GI/Abdominal: soft nontender nondistended
Musculoskeletal: No edema, mild erythema R great toe
Skin: No rash
Neuro: Alert & oriented x 3.
Pertinent Results:
[**2120-4-25**] 05:40AM BLOOD Albumin-4.0 Calcium-9.4 Phos-3.4 Mg-1.9
UricAcd-3.7
[**2120-4-24**] 12:00PM BLOOD ALT-331* AST-229* AlkPhos-896* Amylase-68
TotBili-4.6* DirBili-3.8* IndBili-0.8
[**2120-4-28**] 02:59AM BLOOD ALT-138* AST-94* AlkPhos-547* Amylase-15
TotBili-1.7*
[**2120-4-24**] 12:00PM BLOOD Glucose-147* UreaN-12 Creat-0.8 Na-141
K-4.1 Cl-104 HCO3-24 AnGap-17
[**2120-5-1**] 07:15AM BLOOD Glucose-99 UreaN-18 Creat-0.9 Na-146*
K-4.1 Cl-108 HCO3-26 AnGap-16
[**2120-4-27**] 05:31PM BLOOD Neuts-88.8* Bands-0 Lymphs-7.4* Monos-3.2
Eos-0.4 Baso-0.1
[**2120-5-1**] 07:15AM BLOOD WBC-10.0 RBC-3.48* Hgb-9.9* Hct-29.9*
MCV-86 MCH-28.5 MCHC-33.1 RDW-16.0* Plt Ct-423
[**2120-4-24**] 12:00PM BLOOD WBC-8.9 RBC-4.08* Hgb-11.5* Hct-36.5
MCV-89 MCH-28.2 MCHC-31.5 RDW-16.1* Plt Ct-210
.
ERCP BILIARY&PANCREAS BY GI UNIT [**2120-4-25**] 1:46 PM
FINDINGS: Six spot fluoroscopic images were obtained without a
radiologist present. The ampulla was cannulated and retrograde
injection of contrast into the biliary tree performed. Only the
common duct is included in the field of view which is noted to
be mildly dilated. The common duct is not fully distended with
contrast on these images. There is no filling of the cystic duct
remnant. The distal common duct demonstrates smooth tapering. A
plastic biliary stent was then placed. For further detail,
reference to the ERCP report of the same date is suggested.
.
CXR [**2120-4-29**]
Cardiomegaly and pulmonary arterial hypertension, without acute
cardiopulmonary process.
Brief Hospital Course:
82 yo female with post prandial LUQ pain post ERCP with
sphincterotomy x 1 week ago for cholelithiasis.
.
# LUQ pain:
This can be mesenteric ischemia related given relationship to
food. But given elevated LFTS and bili, more likely from biliary
obstruction (though pain pattern is odd). US also argues for
this with finding of nonshadowing stone or dependent sludge; ?
of thrombus given sphincterotomy as well. Pancreatitis also on
diff given elevated lipase - but relapsing/remitting pain is not
consistent. Noted that extraheptic duct is now 8mm versus 1.2cm
from ERCP last week. ERCP [**4-25**] with cannulation of bile duct,
CBD dilatation 15mm, no filling defects, 7 cm x 10F biliary
stent placed.
- pending pre-op risk assessment with pMIBI
- possible lap cholecystectomy tonight/saturday based on pMIBI
results
- ERCP, cytology from narrowing and stent pull in 6 weeks
- keep NPO, cont IVFs
- continue abx for 10 days
- trend LFTs, especially t bili
- holding ASA, naproxen, tylenol #3, fioricet, [**Month/Year (2) **], lasix,
calcium citrate
- GI and surgery following
.
# Pre-op risk assessment:
Pt with hx of CHF, HTN, lung disease, and DM. She has
compensated heart failure placing her at intermediate risk. The
surgery, lap vs open, has intermediate to high risk as its
peritoneal. She had cath in [**2115**] that revealed diastolic
dysfunction, nuclear stress test in [**2118**] was normal, echo last
year with mild LVH, EF >75%, nl LV function/size. EKG with 1st
degree AV block. Issue is her exercise capacity as she is now
limited by pain in her feet and cannot determine current risk
stratification due to lack of recent testing. She sometimes gets
SOB with exertion and climbing flight of stairs, however, this
may not be reliable.
- pMIBI today, if normal then to OR
- may need further cardiac eval based on MIBI results
.
# Gout:
Per outpatient rheumatologist, avoid colchicine at this time.
She got one dose on evening of admission. Uric acid 3.7, within
normal range.
- holding naproxen and ASA
- to followup with outpatient rhematologist
.
# CHF:
Not vol overloaded at this time.
- holding lasix
- monitor hemodynamics
.
# FEN:
- NPO for procedure and abdominal pain
- cont IVF
.
# PPX
- SC heparin (hold in AM)
- PPI
.
# Code: FULL
.
Ms [**Known lastname **] was taken to the OR on HD#2, [**2120-4-25**] for open
cholecystectomy. Post-operatively she was taken to the PACU and
extubated. POD#[**2-13**] she remained in TSICU due to low urine output
and acute renal failure. She was transfused 1 unit of prbcs and
given lasix IV. Her pain was well controlled by PCA and tylenol.
She remained NPO with IV fluids and IV antibiotics. Her urine
output increased and her creatinine continued to approach her
baseline. POD#3 she was transferred to [**Hospital Ward Name 121**] 9 for further
recovery. She tolerated clear liquids without difficulty. Her
abdomen remained soft and nontender, incision intact with
staples. She remained on nasal cannula oxygen during the day and
BIPAP at night. Her diet was advanced to regular. IV fluids were
discontinued and her pain well controlled with Tylenol #3. She
experienced worsening shortness of breath at rest. She was
aggressively diuresed with IV lasix with fair effect. She was
stabilized on a regimen of Lasix 40 mg po BID. POD#4 she was
seen by physical therapy, but she was unable to ambulate due to
pain in her feet related to gout. Rheumatology was consulted and
she was initiated on Naproxyn. She continued to improve and was
able to ambulate without difficulty POD#5. She will be
discharged with one day of Levofloxacin. She was discharged in
stable condition to [**Hospital 100**] rehab for physical therapy.
Medications on Admission:
Albuterol 1-2 puffs 4x/day.
Aspirin 325 mg po qd.
Atorvastatin 20 mg po qdBaclofen 10 mg po qd
Coreg 12.5 mg po bid
Cozaar 50 mg po bid
Caltrate 600 mg po qd
Fiorcet [**2-13**] tab qd for migraine
Latanoprost 0.005% to each eye at bedtime
Multivitamin daily
[**Month/Day (2) 9889**] 2mg po qd
furosemide 80 mg po bid
protonix 40 mg po qd
Vitamin D 50,000 units, 1 capsule weekly
Procardia XL 90 mg po qd
Discharge Medications:
1. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO qd ().
2. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) as needed for HTN.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Naproxen 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12
hours).
6. Albuterol Sulfate 0.083 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours).
7. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 1 days.
Disp:*1 Tablet(s)* Refills:*0*
9. Caltrate-600 Plus Vitamin D3 600-400 mg-unit Tablet Sig: One
(1) Tablet PO once a day.
10. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
11. medications
Please do not take your cozaar, colchicine, or [**Month/Day (2) **] at this
time.
12. insulin sliding scale
Fingerstick 6Insulin SC Sliding Scale
Q6H
Regular
Glucose Insulin Dose
0-50 mg/dL [**2-13**] amp D50
51-150 mg/dL 0 Units
151-200 mg/dL 4 Units
201-250 mg/dL 8 Units
251-300 mg/dL 12 Units
301-350 mg/dL 16 Units
> 351 mg/dL Notify M.D.
13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
CHF
Acute Cholecystitis
S/P Open Cholecystectomy
Discharge Condition:
good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Please call Dr. [**Last Name (STitle) **] for an appointment next week to
change your medications for gout and see if you can restart your
colchicine. [**Telephone/Fax (1) 2226**]
Please call your surgeon if you develop chest pain, shortness of
breath, fever greater than 101.5, foul smelling or colorful
drainage from your incisions, redness or swelling, severe
abdominal pain or distention, persistent nausea or vomiting,
inability to eat or drink, or any other symptoms which are
concerning to you.
No tub baths or swimming. You may shower. If there is clear
drainage from your incisions, cover with a dry dressing. Leave
white strips above your incisions in place, allow them to fall
off on their own.
Activity: No heavy lifting of items [**11-25**] pounds until the
follow up
appointment with your doctor.
Medications: Resume your home medications, except cozaar,
[**Month/Year (2) **] and colchicine. You should take a stool softener, Colace
100 mg twice daily as needed for constipation. You will be given
pain medication which may make you drowsy. No driving while
taking pain medicine.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 13229**], [**First Name3 (LF) **] Phone:[**Telephone/Fax (1) 2226**] for an
appointment in the next week to change your medications for
gout.
Dr. [**Last Name (STitle) 99413**]: Monday [**5-6**] 1:30, on [**Location (un) 448**] [**Hospital Ward Name **]
atrium suite.
Please call [**Telephone/Fax (1) 3201**] to schedule an appointment to be seen
by Dr. [**Last Name (STitle) **] in 2 weeks.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5447**], M.D. Date/Time: [**2120-6-21**] 9:30
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2120-5-21**] 9:45
Completed by:[**2120-5-2**]
|
[
"574.61",
"428.0",
"584.9",
"401.9",
"278.00",
"346.90",
"327.23",
"V64.41",
"274.9",
"416.8",
"250.02",
"V43.65"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.22",
"51.87",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8551, 8617
|
3019, 6703
|
342, 370
|
8710, 8717
|
1470, 2996
|
9965, 10707
|
1017, 1035
|
7158, 8528
|
8638, 8689
|
6729, 7135
|
8741, 9942
|
1050, 1451
|
287, 304
|
398, 674
|
696, 812
|
828, 1001
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,516
| 166,107
|
21488
|
Discharge summary
|
report
|
Admission Date: [**2103-10-5**] Discharge Date: [**2103-11-9**]
Date of Birth: [**2053-10-29**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
black stools
Major Surgical or Invasive Procedure:
1. EGD.
2. Repeated Paracentesis.
3. ERCP
History of Present Illness:
49 yo F with a h/o cirrhosis [**2-22**] to hep C on the transplant list
p/w with a 2 day h/o black stools. Pt first noticed change in
her BMs [**2103-10-5**] AM. The stools were loose and dark, though not
"tarry." She had multple of these BMs [**10-5**] and [**10-6**] though she
cannot quantify. She has had a few episodes of non-bloody,
non-bilious emesis, not asssociated with eating. She feels her
retching is associated with being increasingly "dry" after her
home lasix and aldactone doses were increased 2-3 days ago. She
denies any associated abd pain. Her appetite has been lower over
the past 2 days.
Past Medical History:
cirrhosis [**2-22**] to hep C (on tx list)
osteopenia
reflex sympathetic dystrophy
pulmonary artery hypertension
MVA in '[**83**] with head injury
Social History:
TOB: [**2-23**] ppd sincew teenage years now down to 1/2 ppd. Denies
etoh/illicits.
Family History:
father with MI at 40
Physical Exam:
Temp 97.9
BP 121/54
Pulse 76
Resp 22
O2 sat 93% ra
Gen - Alert, no acute distress
HEENT - PERRL, extraocular motions intact, icteric pupils,
mucous membranes dry
Neck - no JVD, no cervical lymphadenopathy
Chest - crackles at bases b/l
CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops
Abd - Soft, nontender, +distension with central tympany, with
normoactive bowel sounds
Extr - 2+edema to knees b/l, 2+ DP pulses bilaterally
Neuro - Alert and oriented x 3, +asterixis
Skin - mild jaundice
Pertinent Results:
EGD [**2103-10-8**]
Varices at the lower third of the esophagus
Blood in the first part of the duodenum, likely from scope
trauma
Otherwise normal EGD to second part of the duodenum.
.
CXR [**2103-10-19**]: Probable CHF with bilateral pleural effusions and
left lower lobe atelectasis. Prominent azygos vein. Pleural
appearances are worse than on the prior study of [**2103-10-6**].
.
ERCP 9/27/06:1. A single stricture, 10mm in length, was noted at
the hilum. The proximal IHDs appeared dilated.
2. Cytology samples were obtained using a brush in the hilar
stricture.
3. A 11cm by 10Fr Cotton [**Doctor Last Name **] biliary stent was placed
successfully across the hilar stricture. Excellent bile drainage
was subsequently noted
Cultures:
=========
Peritoneal fluid [**2103-10-12**] GRAM STAIN (Final [**2103-10-12**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2103-10-15**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2103-10-18**]): NO GROWTH.
Urine [**2103-10-5**] - negative Final.
.
.
Chemistries:
============
On admission
============
[**2103-10-5**] 12:30PM WBC-6.3 RBC-3.70* Hgb-13.0 Hct-35.9* MCV-97
MCH-35.2*# MCHC-36.3*# RDW-16.4* Plt Ct-114*
[**2103-10-5**] 12:30PM PT-26.4* PTT-150* INR(PT)-2.7*
[**2103-10-5**] 12:30PM Glucose-119* UreaN-13 Creat-0.4 Na-118* K-5.5*
Cl-86* HCO3-26 AnGap-12
[**2103-10-5**] 12:30PM ALT-72* AST-147* AlkPhos-167* Amylase-23
TotBili-13.5* DirBili-3.8* IndBili-9.7
[**2103-10-5**] 12:30PM Lipase-29
[**2103-10-5**] 12:30PM Albumin-2.3* Calcium-8.6 Phos-3.6 Mg-1.9
.
Incidental Chemsitries:
=======================
[**2103-10-13**] 09:15AM AFP-2.3
[**2103-10-12**] 10:45AM CA [**16**]-9 -PND.
.
.
Radiology:
==========
Abdominal ultrasound [**2103-10-5**]
IMPRESSION:
1) Nodular, cirrhotic liver with a large amount of ascites.
2) Patent hepatic vasculature; hepatofugal flow in the main
portal vein.
3) Markedly distended gallbladder with mild wall thickening,
which likely relates to coexisting liver disease. Negative
son[**Name (NI) 493**] [**Name (NI) **] sign.
.
Adominal MRI [**2103-10-10**]
IMPRESSION:
1. Cirrhotic liver, apparantly with moderate biliary dilatation
involving the left-sided intrahepatic bile ducts, but without
dilatation of the right bile ducts or the extrahepatic bile
ducts. This is presumably secondary to hilar stricture, although
further detail could not be obtained despite attempt to re-image
the patient.
2. No discrete mass lesions are identified, although this is a
technically and habitus-limited examination.
3. There is a large amount of ascites, with moderate left
pleural effusion and small right pleural effusion.
[**2103-10-12**] 03:19PM ASCITES WBC-100* RBC-7800* Polys-42* Lymphs-15*
Monos-29* Mesothe-12* Macroph-2*
[**2103-10-21**] 10:15AM BLOOD WBC-4.7 RBC-2.65* Hgb-9.3* Hct-27.2*
MCV-103* MCH-35.3* MCHC-34.4 RDW-19.3* Plt Ct-94*
[**2103-10-22**] 05:00AM BLOOD WBC-3.9* RBC-2.63* Hgb-9.3* Hct-26.9*
MCV-103* MCH-35.5* MCHC-34.7 RDW-19.5* Plt Ct-83*
[**2103-10-22**] 05:00AM BLOOD Glucose-131* UreaN-7 Creat-0.4 Na-128*
K-3.3 Cl-85* HCO3-39* AnGap-7*
[**2103-10-21**] 10:15AM BLOOD Glucose-211* UreaN-7 Creat-0.4 Na-129*
K-3.7 Cl-87* HCO3-38* AnGap-8
[**2103-10-20**] 06:00AM BLOOD Glucose-104 UreaN-6 Creat-0.4 Na-133
K-3.3 Cl-89* HCO3-39* AnGap-8
[**2103-10-22**] 05:00AM BLOOD ALT-26 AST-37 AlkPhos-136* TotBili-8.4*
Brief Hospital Course:
49 yo F with a h/o cirrhosis [**2-22**] to hep C on the transplant list
p/w with a 2 day h/o black stools c/w UGIB. The patient's
multiple medical problems will be described here individually
for the sake of clarity.
.
On the 2nd and 3rd days of admission the patient was noted to
have deteriorating mental status and severe asterixis consistent
with hepatic encephlopathy. These symptoms resolved with
titration of lactulose and several bowel movements.
.
The patient w/ baseline pulmonary hypertension, noted on [**2103-10-12**]
to be hypoxic and tachycardic while in bed w/worsening while
working with physical therapy. Pt continued to require
supplemental oxygen throughout hospital stay [**2-22**] pleural
effusion; mild improvement w/diuresis and therapeutic
paracentesis, however she will require home oxygen. Plan for
outpt cardiac cath to assess PA htn.
.
The patient's intial complaint of melena was never verified by
witnessing a dark tarry stool in the hospital. Though her HCT
was low relative to her baseline of ~35, her HCT stayed stable
while in the hospital around 28-30. There was no obvious source
of potential recent bleeding on the EGD performed on [**2103-10-8**];
continued PPI throughout hospital course.
.
The patient was noted to be hyponatremia on admission at 118.
This corrected during her stay with discontinuation of
furosemide and volume resucitation to a baseline of 128. Based
on BUN/CR there has been no renal failure during this admission.
Lasix was been restarted without a decline in the patient's Na.
.
The patient is not clear how she contracted hep C cirrhosis.
She is on the transplant list with a MELD score on [**2103-10-14**] of
28. An ECHO was obtained to assess the pulmonary hypertension
which would affect the suitability for surgery. The ECHO was
unable to comment on PA pressures. An MRI/MRA/MRCP was obtained
to assess the gallbladder which was thought to be thickened
based on an admission ultrasound. The MR read did not comment
on the gall bladder but rather reported on dilation of the left
intrahepatic bile ducts. This is concerning for CA in the bile
ducts at the hilum. An ERCP to obtain a tissue diagnosis
[**2103-10-17**]. Continued nadolol/lasix/lactulose throughout hospital
course. HepC+ cirrhosis- encephalopathic sx have resolved;pt on
transplant list; transplant team aware of pt. Workup for
transplant ongoing. Therapeutic/diagnostic paracentesis Cx ngtd,
cytology pending.
.
# biliary stricture- MRI/MRA/MRCP suggesting hepatic hilar left
bile duct stricture; ERCP [**2103-10-17**] showed single stricture at
the hilum which they were able to stent. Stent to be changed in
3 months to metallic stent, CA19-9 levels from [**2103-10-12**] 193
concerning for malignancy (cholangio ca). CEA 12.
.
.
Pt was transferred to the MICU on [**2103-11-7**] for worsening
hypoxemia and mental status changes due to decompensated CHF
with pleural effusions and GI bleed. Pt was treated for
hypoxemia and covered with broad antibiotics for fever of
unknown etiolgy; a DNR/DNI order was obtained at 12:00 on
[**2103-11-7**] following detailed discussion with pt's HCP regarding
end of life management. Aggressive management was later
deferred per HCP's wishes following further discussion with
family, and subsequent efforts focused on providing full comfort
measures, including morphine for pain and social work
consultation for family coping. Pt ultimately died and was
pronounced by MD examination at 14:00 on [**2103-11-9**]; cause of
death was cardio-pulmonary failure due to fulminant hepatic
failure extending from decompensated Hep C Cirrhosis. Pt's
family was present for pt's death.
Medications on Admission:
lactulose 2 tablespoons (30cc) three times a day
clonazepam 1 mg q h.s. prn
spironolactone new dose unknown
lasix, dose unknown
calcium with D one tablet per day
levothyroxine 50 mcg once a week
nadolol 40 mg
sildenafil 60 mg daily
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnoses.
1. Heptic encephalopathy.
2. Anemia
3. Melena
4. Varices of the esophagus.
.
Secondary Diagnoses:
1. cirrhosis [**2-22**] to hep C (on tx list)
2. osteopenia
3. reflex sympathetic dystrophy
4. pulmonary artery hypertension - not confirmed on most recent
ECHO.
5. MVA in '[**83**] with head injury
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2104-2-13**]
|
[
"995.92",
"244.9",
"998.11",
"576.8",
"570",
"305.1",
"276.1",
"518.84",
"785.52",
"286.7",
"745.5",
"428.0",
"576.1",
"456.8",
"996.59",
"038.42",
"416.8",
"578.1",
"070.41",
"572.3",
"574.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"96.6",
"96.72",
"97.05",
"88.47",
"96.08",
"96.04",
"51.14",
"51.10",
"51.87",
"45.13",
"99.05",
"51.88",
"99.06",
"88.64",
"99.07",
"99.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9194, 9203
|
5218, 8883
|
284, 328
|
9563, 9574
|
1807, 5195
|
9626, 9661
|
1256, 1278
|
9165, 9171
|
9224, 9320
|
8909, 9142
|
9598, 9603
|
1293, 1788
|
9341, 9542
|
232, 246
|
356, 968
|
990, 1139
|
1155, 1240
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,216
| 143,292
|
28331
|
Discharge summary
|
report
|
Admission Date: [**2141-4-14**] Discharge Date: [**2141-4-17**]
Service: MEDICINE
Allergies:
Boniva
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with angioplasty
History of Present Illness:
[**Age over 90 **]F history of hypertension, hyperlipidemia, recent
hospitalization for NSTEMI with acute systolic CHF that is
transferred to [**Hospital1 18**] for c. cath.
Patient was recently admitted from [**2141-4-7**] to [**2141-4-11**] at
[**Hospital1 **] for acute on chronic systolic congestive heart
failure, acute coronary syndrome s/p NSTEMI with intermittent
short runs of atrial fibrillation.
[**First Name8 (NamePattern2) **] [**Location (un) 620**] discharge summaries, the patient was complaining of
mid-upper back pain for 6 months on admission most recently
complicated by shortness of breath and diaphoresis. She was
found to have acute pulmonary edema as well as acute coronary
syndrome. She was admitted to the ICU for further treatment.
In the ICU, she was treated for acute on chronic decompensated
systolic congestive heart failure with pulmonary edema. She was
diuresed with lasix approximately 4 L net negative. Her pOx was
90 % on 2 L NC, and weaning of O2 failed. She would drop to pOx
87 % at rest. She was continued on lasix in addition to
spironolactone on discharge.
Patient also experienced NSTEMI with maximum troponin of 0.176.
She was started on a heparin infusion. The family decided
against intervention and favored medical management at the time.
She was also noted to have anemia with a Hct drop by 9 points
with discontinuation of heparin. She was also treated with a
nitroglycerin infusion to treat recurrent chest pain. Stool
guiaics were negative. She was given one unit of pRBC with
discharge Hct of 36.7.
She was placed on aspirin, plavix, and a statin. She was also
discharged on lisionpril as well and a small dose of
beta-blocker.
The patient was evaluated by Cardiology, Dr. [**Last Name (STitle) **] on
[**2141-4-10**] for
intermittent and atrial fibrillation. No need for treatment was
recommended. Heart rate is well controlled. The patient will
follow up as an outpatient with both primary care physician and
Cardiology.
Echocardiogram showed hypokinesis in the mid anterolateral wall,
the distal lateral wall and the apex. Ejection fraction was
approximately 45%.
The patient weight on discharge was 112 pounds ([**2141-4-11**]), which
seems to be her baseline.
Patient was brought in by ambulance to [**Location (un) 620**] today for chest
pain. Initial VS were 97.0 HR: 90 BP: 145/85 Resp: 17 O(2)Sat:
94 Low. She reported intermittent chest pain for the last week
and was discharged from [**Location (un) 620**] as above. Yesterday, her pain
returned with 3-4 episodes of chest pain occuring at rest. This
morning while she was walking back from the bathroom very
slowly, the pain returned and it had been persistent since that
time. Initial troponin was 0.046.
Impression was that patient was presenting with her typical
anginal symptoms but that they were not occurring at rest and
with minimal exertion. ECG (not available for review, per
reports ST-depressions primarily in V3-V6 that resolved. )
showed ST depressions while having pain (distribution unknown).
She was given aspirin, NTG, heparin. It was discussed that
intervention was advisable, and patient was transferred to
[**Hospital1 18**].
Initial VS on arrival were HR 67 RR 14 BP 127/62 pOx 94 on 3 L.
Pain was 0/10. She arrived on heparin insuion at 700 units and
nitroglycerin infusion at 20 mcgs down to 14 mcgs at admission.
Per reports, there were new ST depressions in I, aVL, and V3-V6.
Patient was pain free. CXR was performed showing moderate
pulmonary edema.
She was taken to the c. cath lab on arrival.
C. cath with left radial approach showed 99 % distal left main
into the proximal LAD. LAD was 99 % at origin followed by
proximal 60 % involving D1. LCx had ostial occlusion.
Collaterals fill a diseased OM1 and OM2 from RCA. RCA had mild
luminal irregularties. Left subclavian was 70-80 % at origin.
BMS x 2 was performed to left main/proximal LAD.
During the procedure, she had transient hypotension while
catheter was in the RCA, which could have represented ?
dampening on the catheter while in RCA - which resolved within
30 seconds. She also had bradycardia while in RCA, which
resolved within 30 seconds. It was favored that this was
probably catheter induced.
After procedure, patient had a small amount of chest pain that
was improved from pre-procedure chest pain. She was sent to the
CCU with nitroglycerin infusion. She was given ASA 325 mg PO x 1
and plavix 75 mg PO x 1. Heparin infusion was discontinued at 1
PM.
On arrival to CCU, CCU team met with patient and family. Per
family, patient not complaining of any chest discomfort but does
feel slightly "faint."
.
On review of systems, patient unable to provide comprehensive
review of systems. She denies any chest pain.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
- Acute-on-chronic systolic congestive heart failure.
- Recent Acute coronary syndrome, status post non-ST elevation
myocardial infarction.
- History of paroxysmal atrial fibrillation.
- Anemia.
- Poor functional status.
- Hypertension
- Arthritis
- Hypothyroidism
- Hyperlipidemia
- Fasting glucose intolerance based on A1c 6.2 on [**2141-4-7**]
PAST SURGICAL HISTORY:
- Hysterectomy
Social History:
She denies tobacco, alcohol, or illicit drug usage.
Family History:
Mother: Unknown history
Father: Unknown history
Siblings: She has one sister who died at age [**Age over 90 **]
Children: Three children, two sons and one daughter. [**Name (NI) **]
daughter developed arthritis in her mid 50s
Physical Exam:
General: No acute distress,
HEENT: PERRL, MMM, OP clear, sclera anicteric
Cardio: RRR, nl s1s2, no m/r/g
Resp: Clear b/l.
Abdominal: soft, non-tender
Extremities: WWP, no edema
Pertinent Results:
[**2141-4-17**] ECHO
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thicknesses and
cavity size are normal. There is mild regional left ventricular
systolic dysfunction with severe hypokinesis of the basal half
of the inferolateral wall and mild dyskinesis of the distal
inferior wall. The remaining segments contract normally (LVEF =
45-50 %). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. Trace aortic regurgitation is
seen. The mitral valve leaflets are structurally normal. There
is no mitral valve prolapse. Mild to moderate ([**1-16**]+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with mild
regional systolic dysfunction c/w CAD (PDA distribution).
Mild-moderate mitral regurgitation. Pulmonary artery
hypertension. Increased PCWP.
[**2141-4-14**] CARDIAC CATH
Patient brought urgently to the cath lab given rest angina in
the
holding area despite maximal medical therapy. She had chest
pain
ongoing at the time of arrival to the catheterization
laboratory.
Subclavian angiography performed during entry due to difficulty
advancing the guide wire to the ascending aorta. This revealed
an origin 70-80% stenosis. An angled glide wire was advanced
past the blockage and into the ascending aorta easily. A 6
French JL3.5 guide provided good support. A ChoICE PT XS wire
was advanced into the diagonal and the lesion was predilated
with
a 2.0 balloon which improved chest pain symptoms. The ChoICE PT
XS [**Name (NI) **] was redirected into the distal LAD. A 3.5 x 12 mm
Integriti stent was deployed and a more distal overlapping 2.5 x
18 mm Integriti stent. The Proximal portion of the distal stent
and the 3.5 mm stent were postdilated with a 3.5 mm balloon.
The
distal portion of the proximal stent was postdilated with a 4.0
mm balloon. Final angiography revealed normal flow, no
dissection and 0% residual stenosis in the stent. The patient
tolerated the procedure well and left the laboratory in stable
condition with almost complete relief of her chest pain.
[**2141-4-17**] 07:10AM BLOOD WBC-9.0 RBC-3.91* Hgb-10.8* Hct-34.5*
MCV-88 MCH-27.7 MCHC-31.4 RDW-14.6 Plt Ct-330
[**2141-4-15**] 06:31AM BLOOD PT-11.1 PTT-27.1 INR(PT)-1.0
[**2141-4-17**] 07:10AM BLOOD Glucose-100 UreaN-9 Creat-0.7 Na-125*
K-4.6 Cl-93* HCO3-24 AnGap-13
[**2141-4-15**] 06:31AM BLOOD CK-MB-4 cTropnT-0.07*
[**2141-4-14**] 09:50PM BLOOD CK-MB-3 cTropnT-0.07*
[**2141-4-14**] 11:10AM BLOOD cTropnT-0.04*
Brief Hospital Course:
[**Age over 90 **] female with h/o HTN, HLD, recent NSTEMI, and sCHF (45-50%)
presented to [**Hospital1 **] [**Location (un) 620**] with UA, transferred for c. cath
showing significant left main and LAD disease s/p BMSx2 with
transient hypotension/bradycardia during procedure attributed to
catheter placement.
.
# CAD
Patient had NSTEMI that was medically managed a week prior to
admission. She presented again with chest pain consistent with
unstable angina, associated with ECG changes and borderline
cardiac biomarkers. She was started on heparin and
nitroglycerin infusion and transferred to [**Hospital1 18**]. After
discussions with her family, a cardiac catheterization was
performed revealing significant left main and LAD disease. Two
BMS were placed in the left circumflex ostial occlusion with
collaterals. The patient had transient hypotension/bradycardiac
during her procedure attributed to catheter placement. She was
monitored in the CCU after and her vital signs remained stable.
She is to continue ASA 325 mg indefinitely and will require
plavix 75 mg daily for at least 1 month, but preferably for 12
months. She was continued on metoprolol with a goal heart rate
of 60-70. She was also continued on lisinopril and started on
atorvastatin for optimal medical management. She remained chest
pain free during her stay.
.
# Acute on chronic systolic heart failure (Most recent EF
45-50%)
Pt was recently discharged from [**Hospital1 **]-Neeham with a documented
weight of 112 lbs (50.9 kg). She had recently been started on
lasix, lisinopril and spironolactone. She did not appear
overtly fluid overloaded on admission, and her admission weight
was 107.8 lbs (49 kgs). Her admission CXR revealed some
evidence of mild-moderate pulmonary edema, which may reflect
diastolic dysfunction from demand ischemia. Her I/O were
monitoered and she was weighed daily. Lasix and spironoloactone
were held. A repeat TTE revealed Normal left ventricular cavity
size with mild regional systolic dysfunction c/w CAD (PDA
distribution).
.
# RHYTHM:
The patient has known paroxysmal AF, but was in NSR upon
admission. The morning of [**4-16**], she was noted to be in atrial
fibrillation with rapid ventricular response. She was
hemodynamically stable. She was given metoprolol 5 mg IV x2
with out a significant drop in her heart rate. She was then
loaded with amiodarone (initially IV, later transitioned to po
when she converted back to sinus). She remained in NSR
throughout the rest of her hospital course and is to continue on
amiodarone upon discharge.
.
# Hyponatremia
The patient's admission Na was 127, and initially thought to be
secondary to intravascular volume depletion with non-osmotic
release of ADH given active usage of diuretic regimen.
Her sodium continued to trend down. Urine electrolytes were
consistent with diuresis leading to hyponatremia.
Her fluids were restricted and she was given small boluses of
IVF given likely hypovolemia. Her sodium stabilized to 125.
.
# HTN
The patient was continued on her home metoprolol and lisinopril.
As above, her furosemide and spironolactone here held. She
remained normotensive throughout her CCU and floor stay.
.
# HLD
Her most recent lipid panel ([**2141-4-8**]) revealed good lipid
control (chol 134, TG 57, HDL 71, LDL 43). She was continued on
atorvastatin 80 mg given her ACS.
.
# Left subclavian stenosis
Her BP was monitored on her right arm. This should be monitored
as an outpatient.
.
# History of fasting glucose intolerance
Her most recent HbA1c was 6.2 on [**2141-4-7**]. Her morning glucose
ranged from 100-140s on average.
Medications on Admission:
- Spironolactone 12.5 mg p.o. daily.
- Lasix 20 mg p.o. daily.
- Tylenol 650 mg p.o. 3 times daily.
- Metoprolol 12.5 mg p.o. twice daily.
- Plavix 75 mg p.o. daily.
- Aspirin 325 mg p.o. daily.
- Zocor 20 mg p.o. daily.
- Lisinopril 10 mg p.o. daily.
- Tramadol p.r.n.
- Calcium with vitamin D, one combo tab p.o. twice daily.
- Multivitamin 1 tablet p.o. daily.
- Conjugated Premarin cream twice daily.
Discharge Medications:
1. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
1.5 Tablet Extended Release 24 hrs PO DAILY (Daily).
Disp:*45 Tablet Extended Release 24 hr(s)* Refills:*0*
2. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. lisinopril 10 mg Tablet Sig: 0.5 Tablet PO once a day: until
you follow-up with your primary doctor.
6. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 1 months: with meals.
Disp:*60 Tablet(s)* Refills:*0*
7. calcium carbonate-vitamin D3 Oral
8. multivitamin Tablet Sig: One (1) Tablet PO once a day.
9. Outpatient Lab Work
Please obtain chemistry panel including BUN/Cr on Monday
[**2141-4-24**] and have the results sent to [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 17194**], MD
[**Telephone/Fax (1) 3070**]
10. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
TO START 1 MONTH AFTER 200mg [**Hospital1 **].
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Myocardial infarction
Hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for a heart attack. You had a procedure called
a cardiac catheterization to place a stent to open up some of
the clogged arteries which supply blood to the heart. Because
of this procedure, it will be extremely important to follow-up
with your primary doctor and to establish care with a
cardiologist. You should also continue to take your medications
exactly as prescribed to prevent complications.
.
You were also found to have a low sodium level, which was
probably due to being dehydrated. Because of this, you should
STOP taking your water pills (diuretics, called lasix). It will
be very important to have labs checked with your primary doctor,
and to discuss whether to re-start your water pills at your
follow-up appointment
.
Please note the following medication changes:
-STOP taking lasix and spironolactone (the water pills) until
you speak with your primary doctor at your follow-up appointment
.
-STOP taking metoprolol TARTRATE and
-START taking metoprolol SUCCINATE
.
-START taking plavix
-START taking Aspirin 325mg daily
-START taking atorvastatin 80mg daily
-START taking amiodarone 200mg twice daily with meals for 1
month. After one month, decrease amiodarone to 200mg ONCE daily
with meals.
.
-STOP taking zocor
-DECREASE lisinopril to 5mg daily until you follow-up with your
primary doctor at the end of the week
Followup Instructions:
Department: [**Hospital **] HEALTHCARE OF [**Location (un) **]
When: MONDAY [**2141-4-24**] at 10:10 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 17194**], MD [**Telephone/Fax (1) 3070**]
Building: [**Street Address(2) 8172**] ([**Location (un) 620**], MA) Ground
Campus: OFF CAMPUS Best Parking: Parking on Site
**Please speak with your Dr [**Last Name (STitle) **] the need for a cardiology
appointment within 2 weeks.**
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47,978
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20206
|
Discharge summary
|
report
|
Admission Date: [**2124-3-17**] Discharge Date: [**2124-4-1**]
Date of Birth: [**2054-12-28**] Sex: F
Service: MEDICINE
Allergies:
Coumadin / Latex
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
TRANSFER FOR ICD PLACEMENT AND PCI
Major Surgical or Invasive Procedure:
ICD PLACEMENT
CARDIAC CATHETERIZATION
History of Present Illness:
69F with hx CAD, LBBB, CHF with LVEF 35% and LV dysynchrony, CVA
s/p bilateral CEAs recently admitted to [**Hospital1 1516**] service 3 weeks ago
for NSTEMI ([**2124-2-21**]), found to have 3VD, now transferred from
OSH w/request for BiV pacemaker placement.
.
During last admission, complex 3VD thought not amenable to
either operative or PCI management, so she was diuresed
significantly, medically optimized, and discharged to rehab.
Readmitted to [**Hospital6 3105**] 10d ago ([**2124-3-14**]) with
another NSTEMI and CHF flare. NSTEMI p/w dizziness,
lightheadedness, nausea, jaw pain then retrosternal chest
pressure. Improved w/nitro paste in the OSH ED. CHF treatment
w/Treated w/BB limited by bradycardia to the 30s. Repeat TTE
showed LVEF 20%. One episode CP without ischemic EKG changes
overnight [**3-16**] while at [**Hospital3 **], which responded to
morphine but she developed bradycardia to HR 30s immediately
afterwards (vs baseline 70s on telemetry). No further chest
pain. Today's 4 AM labs notable for HCT 25.2 (27.5 yesterday),
Cr 1.75 (renal US wnl), troponin 1.55, CK 88, BNP 460, K 5.9.
Had been on heparin gtt which was stopped this morning. Now
transferred for BiV pacemaker placement for known LBBB and
cardiac dyssynchrony, then possible PCI by Dr. [**Last Name (STitle) **] on Monday.
Today underwent CXR-J (St. [**Male First Name (un) 923**]) device without complication
today. Transfer VS 96/45, HR 68 SR, 17, 100%/2L.
Past Medical History:
CARDIAC RISK FACTORS:
+Diabetes + HTN + HLD
CARDIAC HISTORY:
- 3V CAD s/p MI [**2116**], now w/ NSTEMI [**2124-2-21**] & NSTEMI [**2124-3-14**]
- sCHF, global LV hypokinesis LVEF 35%->20% 1+ MR 1+ TR
- possible atrial fibrillation
CABG/PCI: none
LAST CATH [**2-/2124**]:
---short LMain
---LAD 50% hazy ostial/proximal disease
---LCX 70% ostial/proximal dz involves origin of large
bifurcating OM branch with ostial 90% lesion
---RCA not injected, known 90% ostial disease
OTHER MEDICAL HISTORY:
- Morbid Obesity
- Papillary thyroid cancer s/p thyroidectomy, RAI ablation
- COPD
- OSA on home CPAP
- CVA s/p bilateral CEA (L [**2121**], R [**2123**])
- R rectus abdominus mass (noted on imaging [**2124-2-2**])
- CKD
- chronic anemia
Social History:
Lives with her husband in [**Name (NI) 487**], MA (45m-1h away). 10
children, 2 deceased including loss of 1 daughter within past
year. Two sons live nearby. On disability due to Charcot foot.
Tobacco 1 ppd x 20 years. No ETOH.
Family History:
Mother: Died at 87 from complications related to diabetes
Father: Died at 42 in an accident
Physical Exam:
ADMISSION EXAM
VS: 98.4 105/58 75 18 97/2L FS 232
GENERAL: WDWN female lying in bed, fatigued-appearing but NAD.
Oriented x3. Mood, affect appropriate.
HEENT: NCAT, PERRL, EOMI. MMM. neck obese & supple, JVP to ear.
CARDIAC: RRR, normal S1, S2. No m/r/g. No S3 or S4.
LUNGS: CTAB, no crackles, wheezes or rhonchi (anterior exam
only). L chest wall +ICD device w/dressing c/d/i, no surrounding
tenderness
ABD: Soft, NTND. normoactive BS, no bruit
EXT: 1+ symmetric bilateral edema, peripheral pulses intact, no
stasis dermatitis or ulcers.
.
DISCHARGE EXAM
vital sings stable, afebrile, BP 100s-130s/60s, HR 60s
exam unchanged except right HD line (already removed) but with
clean dressing where it was located
Pertinent Results:
ADMISSION LABS
[**2124-3-18**] 09:00AM BLOOD WBC-8.1 RBC-2.60* Hgb-7.6* Hct-24.2*
MCV-93 MCH-29.4 MCHC-31.6 RDW-14.1 Plt Ct-250
[**2124-3-17**] 05:00PM BLOOD Glucose-196* UreaN-68* Creat-1.9* Na-136
K-5.5* Cl-102 HCO3-28 AnGap-12
.
DISCHARGE LABS
[**2124-3-31**] 05:02AM BLOOD WBC-7.1 RBC-3.11* Hgb-9.2* Hct-29.4*
MCV-94 MCH-29.4 MCHC-31.2 RDW-14.2 Plt Ct-347
[**2124-4-1**] 05:43AM BLOOD Glucose-130* UreaN-36* Creat-1.6* Na-139
K-4.3 Cl-102 HCO3-29 AnGap-12
[**2124-4-1**] 05:43AM BLOOD Calcium-8.9 Phos-4.2 Mg-2.0
.
OTHER PERTINENT LABS
[**2124-3-18**] 09:00AM BLOOD [**Month/Day/Year 8675**]-0.51
[**2124-3-18**] 09:00AM BLOOD ALT-37 AST-157* LD(LDH)-579* AlkPhos-56
TotBili-0.7
[**2124-3-20**] 04:59PM BLOOD Hapto-343*
[**2124-3-20**] 05:48AM BLOOD Ret Aut-1.6
[**2124-3-20**] 05:48AM BLOOD Hypochr-OCCASIONAL Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
[**2124-3-20**] 05:48AM BLOOD DIRECT COOMBS - NEGATIVE
.
EKG [**2124-3-17**] (INITIAL EKG, POST ICD PLACEMENT)
Sinus rhythm. Ventricular pacing, probably biventricular. Since
the previous
tracing of [**2123-2-25**] bivenetricular pacing is now present.
.
[**2124-3-18**] CXR (POST-PROCEDURE)
FINDINGS: As compared to the previous radiograph, the right
internal jugular vein catheter has been removed. Patient has
received a new left pectoral pacemaker. The leads of the
pacemaker are in expected position.
Like on the previous radiograph, there is evidence of
mild-to-moderate fluid overload. Pleural effusions are not
present. No evidence of pneumonia.
.
[**2124-3-19**] LUE DOPPLER ULTRASOUND
FINDINGS: [**Doctor Last Name **]-scale and color Doppler son[**Name (NI) 1417**] were performed
of the leftupper extremity, demonstrating normal color-flow and
compressibility andinternal jugular, subclavian, axillary,
basilic, and cephalic veins. Note is made of slow flow within
the left axillary vein which is mildly tortuous and patulous,
which compress normally on live exam, consistent with patent
vessel.
IMPRESSION: No evidence of DVT in the left upper extremity.
.
3/19-20/[**2124**] THALLIUM VIABILITY STUDY
IMPRESSION: Moderate, mid and basilar inferolateral wall
perfusion defect whichshows no redistribution on 4-hour delayed
images. Left ventricular enlargement.
ADDENDUM: 24-hour images were obtained. The image quality is
somewhat degraded related to soft tissue attenuation and the
usual washout of thallium from the heart. However, again noted
is the moderate, mid and basilar inferolateral wall perfusion
defect. There is no delayed redistribution into this defect.
.
[**3-22**] CARDIAC CATHETERIZATION
1. Diagnostic coronary angiograms obtained using a 4 Fr JR 4
catheter
and a 6 Fr XBLAD 3.5 guide catheter (for right and the left
coronary
artery respectively) revealed a left dominant circulation. RCA
had an
ostial 90% stenosis. The left main was short and had a 99%
stenosis
extending into the proximal LAD which had a 90% ostial and
proximal
stenosis. The left circumflex had a diffuse 60-70%
proximal/ostial
stenosis and a 90% ostial OM1 stenosis.
2. Successful PCI to left main/LAD 99% stenosis with deployment
of a 3.0
x 16 mm Promus element drug-eluting stent.
3. Successful deployment of a 2.25 x 32 mm Promus element stent
across
the Proximal diffuse 70% stenosis in the circumflex into the 90%
ostial
OM1 stenosis.
4. Successful placement of Impella 2.5 LV support catheter into
the left
ventricle for high risk multivessel PCI, via left femoral
arterial
access site.
5. Successful preclosure of the left femoral arterial access
site with 2
Perclose proglide sute-mediated closure devices.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Critical stenosis in the left main and proximal LAD was
successfully
treated with a 3.0 x 16 mm Promus element drug-eluting stent.
3. Critical stenosis in the left circumflex and ostial OM1 was
successfully treated with a 2.25 x 32 mm Promus element
drug-eluting
stent.
.
[**2124-3-23**] ECHO:
This study was compared to the prior study of [**2124-2-22**].
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV.
LEFT VENTRICLE: Suboptimal technical quality, a focal LV wall
motion abnormality cannot be fully excluded. Moderately
depressed LVEF. No resting LVOT gradient.
RIGHT VENTRICLE: RV not well seen.
AORTIC VALVE: Mild AS (area 1.2-1.9cm2). No AR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
[1+] TR. Moderate PA systolic hypertension.
GENERAL COMMENTS: Suboptimal image quality - body habitus.
Conclusions
The left atrium is mildly dilated. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is
moderately depressed (LVEF= 30-40 %). There is mild aortic valve
stenosis (valve area 1.2-1.9cm2). No aortic regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is moderate pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of [**2124-2-22**],
the image quality remains very poor. Findings are broadly
similar
.
Brief Hospital Course:
Ms. [**Known lastname 20400**] is a 69 year old female w/ history of wide left
bundle branch block (LBBB), diffuse 3-vessel coronary artery
disease (CAD) and chronic systolic heart failure (sCHF)
w/acutely-worsening LVEF 35% ->20% over past month, transferred
from OSH for the 2nd time in 2 mos for a 2nd NSTEMI ([**2124-3-14**])
and acute-on-chronic systolic heart failure for ICD/PPM
placement (dysynchrony) and revascularization; [**Hospital **]
hospital course complicated by acute renal failure felt to be
due to contrast nephropathy.
.
#WIDE LBBB W/DYSSYNCHRONY, NOW S/P ICD/PPM PLACEMENT:
Admitted to cardiology service after transfer directly to EP lab
for BiV pacemaker placement. Procedure well-tolerated; started
metoprolol succinate 25 mg daily thereafter. CXRs showed proper
lead placement. Pocket site initially tender but improved. She
also had some asymmetric left upper extremity edema but
ultrasound was negative for L arm DVT.
.
#3V CAD
Known 3V CAD visualized on coronary angiography here 1 month
ago. No intervention at that time because PCI considered high
risk and cardiac surgery deferred intervention for similar
reasons (cardiac and extra-cardiac comorbidities). Two recent
NSTEMIs (one on [**2-21**] prompting recent admission, now a 2nd on
[**2124-3-14**]). No chest pain/pressure or SOB here. After ICD
placement, she was stared on ASA 325 mg daily, atorvastatin 80
mg daily, and metoprolol succinate 25 mg daily - all
well-tolerated. Pre-PCI thallium viability study showed
"Moderate, mid and basilar inferolateral wall perfusion defect
which shows no redistribution on 4-hour delayed images. Left
ventricular enlargement." Cath was performed which showed
severe multi vessel disease. She received 2 DES to LMCA-LAD and
OM1. Impella was used peri-procedurally but was discontinued
after the procedure. RCA was not stented as it was
non-dominant. Left groin site oozed following procedure, which
improved with pressure dressing.
.
# SEVERE CHRONIC SYSTOLIC CHF, LVEF 20%
Known sCHF, TTE here 1 month ago showed LVEF 35%, now 20% by
repeat TTE performed at [**Hospital 487**] Hospital on [**2124-3-15**]. On
admission she was 23 lb up from her dry weight of 293 lbs.
Worsening pump function suspected to underlie worsening CHF
symptoms, the result of recent NSTEMIs and/or ventricular
dyssyncrony. She diuresed very well (4-5L/day) on lasix gtt with
simultaneous improvement in renal function (prior to PCI). Also
did well on metoprolol succinate 25 mg daily. She will need to
be started on ACEi after renal function recovers (see below).
.
#ACUTE-ON-CHRONIC KIDNEY DISEASE:
Baseline unknown. Last month during admission Cr ranged 1.3-1.4
then rose to 1.9-2.0 w/lasix gtt. At 1.9 on admission, Cr
improved to 1.5 with diuresis. She did received two contrast
loads within a week, one for biV pacer, then again for cath.
Creatinine on admission to CCU initially 1.7, but patient was
then noted to be oliguric and prerenal on labs, lasix drip held
and patient was given 1 L of fluid without significant urinary
output. Creatinine rose to 3.4, still without any urinary
output. Renal consulted and felt renal failure most likely
related to contrast nephropathy. Patient required brief duration
of hemodialysis for hyperkalemia and symptomatic uremia (HD on
[**3-26**] and [**3-27**] after which she started making up to a liter of
urine per day). HD was subsequently stopped, and on [**3-29**],
patient was restarted on lasix 40mg PO with appropriate urine
output and improving/stable creatinine. She was discharged on
[**4-1**] with stable labs and urine output. She should have labs
checked 3x/week at rehab in the first week to ensure that her
labs continue to be stable.
#ANEMIA:
Chronic; PCP reported that this is usually only a problem in the
hospital. Patient reported frequent in-hospital transfusions,
and reported that her mother had similar problems. MCV 90. [**Name2 (NI) **]
e/o hemolysis including a negative Coombs. Suspect some effect
of hemodilution when volume overloaded. She received blood
transfusions twice, on [**3-18**] and [**3-20**], for Hct >25 in the setting
of recent end-organ ischemia.
.
#Type 2 diabetes mellitus:
A1c 7.3 on last admission, suggests poor glucose control at
home. Some confusion over documented latex allergy in
childhood/tolerance of humulin/humalog in hospital - patient
tolerated humalog here without any evidence of allergy (given
after she reported no prior history of allergic reaction to any
of several insulin preparations over the past several years).
.
#HYPOTHYROIDISM
Confirmed dosing of 112 mcg levothyroxine [**Hospital1 **] w/PCP. [**Name10 (NameIs) 8675**] wnl.
.
#COPD
Pt was noted to be recently s/p steroid taper & antibiotics for
recent COPD flare. Off inhaled steroid + tiotropium QD since
last discharge. No signs COPD on exam.
Continued albuterol nebs PRN, flovent [**Hospital1 **] inhaler. Restarted
ipratoprium inhaler. Continued home CPAP.
.
#KNOWN L CAROTID STENOSIS
One of the contraindications to CABG in this patient. 99%
stenosis documented during last admission but not intervened
upon given no plan for surgery. Repeat carotid US at [**Hospital1 487**]
yesterday suggests stenosis 60-90% in L ICA. Had outpatient
vascular f/u arranged on [**3-22**] w/Dr. [**Last Name (STitle) 1391**] which will need to
be rescheduled.
.
TRANSITIONAL ISSUES
- follow-up labs two days after d/c to rehab and then 3
times/week to ensure renal failure is stable
- daily weights, I/O's monitoring
- trend Hct at least weekly with goal >25 in light of recent
NSTEMI
- ensure f/u appointments with cardiology, electrophysiology,
renal, and vascular surgery. Patient has been given this contact
information.
- start ACEI when renal function stabilizes
Medications on Admission:
HOME MEDS
Omega-3 QD
plavix 75mg QD
zetia 10 mg QD
MV QD
Vitamin A 4000 QD
Guaifenesin 200 mg liquid PRN
lisinopril 20 QD
synthroid 125 mcg QD
insulin 70/30, 35U [**Hospital1 **]
cholecalciferol [**2112**] QD
ASA 325 QD
albuterol inh PRN, nebs PRN
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. omega-3 fatty acids Capsule Sig: One (1) Capsule PO once
a day.
5. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: Thirty Five (35) units Subcutaneous twice a day.
6. insulin aspart 100 unit/mL Solution Sig: as directed units
Subcutaneous three times a day: FBS:
100-150=2U, 151-200=4U, 201-250=6U, 251-300=8U, 301-350=10U,
351-400=12U, >401=[**Name8 (MD) 138**] MD.
7. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
10. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
11. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
12. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
16. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
17. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
18. nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
19. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for when not using nystatin cream.
20. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheeze.
21. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
22. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
PRIMARY DIAGNOSES
acute on chronic systolic heart failure
acute on chronic kidney disease
coronary artery disease s/p Non-ST elevation myocardial
infarction
.
SECONDARY DIAGNOSES
anemia
diabetes mellitus, type 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname 20400**],
.
You were admitted to the hospital because you were having small
heart attacks. You had a procedure (called cardiac
catheterization) where they placed 2 stents in the arteries of
your heart to open them up. You have more plaques and narrowing
the other arteries of your heart, however, so it is important to
make sure you continue to take medications that control your
blood pressure, blood sugar, and cholesterol.
.
You also have heart failure and you were found to be very volume
overloaded during this admission. You were treated with
aggressive diuretics and your breathing improved.
.
Unfortunately, due to a combination of heart failure, diuretics,
and the procedure needed for your heart attacks your kidneys
were injured. You had to have some sessions of dialysis to help
the kidneys recover. It is possible that you will need more
dialysis in the future because your heart failure will continue.
.
The following changes were made to your medications:
- STOP taking vitamin A
- STOP taking ezetimibe
- STOP taking lisinopril, this is a blood pressure medication
that you should use for heart failure but it also damages your
kidneys
- START taking atorvastatin 80 mg daily for your cholesterol
- START taking calcium carbonate 500 mg three time a day for
bone strength
- START taking metoprolol succinate 25 mg daily for heart
failure
- START taking sevelamer 800 mg three times a day for your
kidneys
- START taking acetaminophen 650 mg every 6 hours as needed for
pain
- START taking docusate and senna one tab each day for
constipation
- START taking bisacodyl 10 mg daily as needed for constipation
- START using miconazole powder 2% applied twice daily or
nystatin cream applied once daily to groin
- START taking ipratropium nebulizers
- START taking lasix 40mg daily
Followup Instructions:
Follow-up labs 2 days from discharge, to include chemistry 7.
You will subsequently need labs three times/week while your
kidney function is recovering and you are on diuretics.
Name: [**Last Name (LF) 5423**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD
Location: [**Location (un) **] CARDIOLOGY
Address: [**Last Name (un) 39144**], STE#404, [**Hospital1 **],[**Numeric Identifier 39146**]
Phone: [**Telephone/Fax (1) 5424**]
*We are working on a follow up appointment for your
hospitalization with your cardiologist. You need to be seen
within 1-2 weeks. The office will contact you at the facility
with the appointment. If you have not heard within 2 business
days please call the office at the above number.
Name: [**Last Name (LF) 17354**],[**First Name3 (LF) **]
Location: BRANCH INTERNAL MEDICINE
Address: [**Street Address(2) 54294**], [**Location (un) **],[**Numeric Identifier 10768**]
Phone: [**Telephone/Fax (1) 17355**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
You need to see a nephrologist in your area within 2 weeks of
hospital discharge. Please call your primary care provider [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] who will provide you with the information needed
to book that appointment.
Name: [**Last Name (LF) 1391**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 **]
Address: [**Doctor First Name **] STE 5C, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 1393**]
Appointment: Wednesday [**2124-4-19**] 9:15am
Call [**Telephone/Fax (1) 62**] to schedule a device clinic follow-up for your
new pacer. You will need an interrogation within the next [**1-3**]
weeks.
|
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42,858
| 112,227
|
32045
|
Discharge summary
|
report
|
Admission Date: [**2117-6-18**] Discharge Date: [**2117-6-24**]
Date of Birth: [**2051-3-8**] Sex: F
Service: MEDICINE
Allergies:
Cephalosporins / Ace Inhibitors / Penicillins / Benzodiazepines
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Somnolence
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy x 2
Transthoracic Echocardiography
PICC Line Placement
Arterial line placement
Tracheal Intubation with eventual extubation
History of Present Illness:
66 yo F with history of DM2, portal HTN from EtOh cirrhosis,
prior right hepatectomy for HCC, and hx of encephalopathy who
was admitted to OSH this AM after being more somnolent this AM.
On arrival to OSH her vitals were 97.4, HR 68, BP 116/45, RR 12,
100% on RA, GCS 6. She was found to be "gurgling" with breathing
and was given etomidate, versed, propofol and intubated for
airway protection. Also received IV flagyl and levofloxacin, and
lactulose, and 2L NS. Her HCT was 20.3, Na 133, BUN/Cr 45/2.0.
Trop was elevated at 2.55 and ECG showing new lateral TWI.
Patient was transferred to [**Hospital1 18**] via [**Location (un) **] for management of
upper GIB.
.
Yesterday, per sister patient seemed more tired but went outside
in wheelchair and was interactive and oriented. She did not seem
confused. She has been unresponsive with encephalopathy in the
past in the setting of UTIs. Per the sister she has had chronic
"blood in stool" and has been getting "almost weekly"
transfusions for past 1 year.
.
In the emergency department, vitals were: HR 59, BP 104/57, RR
14, O2 100% on vent (AC 500x14+5). She received lactulose, ASA.
She got 5L NS, 50mcg fentanyl IV, 1g ceftriaxone and 1U RBCs.
HCT was 18.5 and Cr 1.8. NG tube initially did not show any
blood or coffee grounds but subsequently returned frank blood.
CXR was obtained and showed mild pulmonary edema without
consolidations. U/A was positive with 180 WBCs, many bacteria,
and large leuk.
.
Vitals prior to transfer to the floor were: HR 57, BP 105/51, RR
13, O2Sat 100% on PEEP 5 and FiO2 of 40%.
.
REVIEW OF SYSTEMS:
(+)ve:
(-)ve: fever, chills, night sweats, loss of appetite, fatigue,
chest pain, palpitations, rhinorrhea, nasal congestion, cough,
sputum production, hemoptysis, dyspnea, orthopnea, paroxysmal
nocturnal dyspnea, nausea, vomiting, diarrhea, constipation,
hematochezia, melena, dysuria, urinary frequency, urinary
urgency, focal numbness, focal weakness, myalgias, arthralgias
Past Medical History:
1. Cirrhosis c/b encephalopathy
2. Hepatocellular CA s/p resection
3. Diabetes
4. Hypertension
5. Congestive heart failure, EF 55% TTE [**2108**]
6. Coronary artery disease
7. Chronic kidney disease stage III baseline creatinine 1.4
8. s/p ORIF L hip
9. History of gluteal muscle bleed secondary to coagulopathy
10.Gastropathy
Social History:
The patient does not smoke. She did drink alcohol but has not
since developing liver disease. According to prior discharge
summaries she has not had any illicit drug use. She is a
resident of [**Location 582**] [**Location (un) 620**].
Family History:
Non-contributory.
Physical Exam:
On Admission:
VS: T 96, HR 65, BP 108/60, RR 8, 99%
GEN: intubated, does not open eyes or respond to verbal
commands, in no distress
HEENT: lateral eye movements, R pupil 4mm and reactive, L pupil
3mm and reactive, dry mucosa
NECK: supple, no cervical LAD, R IJ in place
PULM: anterior breath sounds symmetrical and clear, no rhonchi
or rales
CARD: nl S1/S2, no m/r/g
ABD: tense, non-distended, obese, no fluid wave appreciated,
sluggish BS, no grimace to deep palpation
EXT: 2+ pitting edema in upper and lower extremities, 1+ distal
pulses
SKIN: no rashes
NEURO: pupils anisicoric and reactive, patient withdraws to pain
On Discharge:
VS: T 98.3 HR 62, BP 116/56, RR 18, 99% RA
GEN: Anasarcous. Opens eyes spontaneously. No acute distress.
HEENT: Dry lips but wet mucuous membranes. PERRLA. No cervical
lymphadenopathy.
NECK: supple, no cervical LAD
PULM: Bilateral crackles up to midlung fields. No wheezes or
rhonchi appreciated.
CARD: Distant heart sounds. Normal S1/S2. No MRG apprecaited.
ABD: Large, soft obese abdomen. No shifting dullness
appreciated. NBS. Nontender to palpation
EXT: 3+ pitting edema in upper and lower extremities
bilaterally. Right PICC line in place. Right UE slightly more
swollen than left UE, with tenderness to pressure. No evidence
of erythema. 1+ radial/posterior tibial pulses.
GU: Foley in place (since admission- discharged on 6 days of
foley)
SKIN: no rashes noted.
NEURO: Alert and oriented to person and time. Confused to
place/hospital setting. Cannot do serial sevens or days of the
week backwards. No asterixis. Moving all extremities.
Pertinent Results:
Laboratory Data:
Trop/CK/MB:
[**2117-6-18**] 01:00PM BLOOD CK-MB-6 cTropnT-2.45*
[**2117-6-19**] 11:30AM BLOOD CK-MB-8 cTropnT-1.97*
[**2117-6-19**] 06:35PM BLOOD CK-MB-7 cTropnT-2.07*
[**2117-6-20**] 05:36AM BLOOD CK-MB-6 cTropnT-1.83*
CBC
[**2117-6-18**] 01:00PM BLOOD WBC-3.4* RBC-1.83* Hgb-6.3* Hct-18.5*
MCV-102* MCH-34.6* MCHC-34.1 RDW-21.8* Plt Ct-100*
[**2117-6-24**] 06:08AM BLOOD WBC-4.5 RBC-2.77* Hgb-9.5* Hct-26.7*
MCV-97 MCH-34.5* MCHC-35.7* RDW-21.3* Plt Ct-89*
COAGS
[**2117-6-18**] 01:00PM BLOOD PT-16.0* PTT-32.2 INR(PT)-1.4*
[**2117-6-24**] 06:08AM BLOOD PT-17.8* INR(PT)-1.6*
METABOLIC PANEL
[**2117-6-19**] 11:30AM BLOOD Glucose-256* UreaN-54* Creat-2.0* Na-137
K-5.0 Cl-112* HCO3-14* AnGap-16
[**2117-6-24**] 06:08AM BLOOD UreaN-32* Creat-1.4* Na-134 K-4.3 Cl-109*
HCO3-18* AnGap-11
[**2117-6-19**] 11:30AM BLOOD Calcium-7.8* Phos-4.3# Mg-1.9
[**2117-6-24**] 06:08AM BLOOD Phos-3.4 Mg-1.7
[**2117-6-20**] 06:59PM BLOOD freeCa-1.16
LIVER FUNCTION TESTS
[**2117-6-19**] 11:30AM BLOOD ALT-26 AST-32 CK(CPK)-108 AlkPhos-104
TotBili-1.8*
[**2117-6-24**] 06:08AM BLOOD ALT-22 AST-35 TotBili-1.6*
ABG'S
[**2117-6-18**] 02:36PM BLOOD Type-ART Rates-14/ Tidal V-500 PEEP-5
FiO2-100 pO2-580* pCO2-19* pH-7.50* calTCO2-15* Base XS--5
AADO2-129 REQ O2-31 -ASSIST/CON Intubat-INTUBATED
[**2117-6-21**] 04:39PM BLOOD Type-[**Last Name (un) **] pO2-208* pCO2-34* pH-7.26*
calTCO2-16* Base XS--10
URINE TESTS
[**2117-6-18**] 01:00PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.012
[**2117-6-21**] 10:00AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
[**2117-6-18**] 01:00PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
[**2117-6-21**] 10:00AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2117-6-18**] 01:00PM URINE RBC-3* WBC->182* Bacteri-MANY Yeast-NONE
Epi-0
[**2117-6-18**] 01:00PM URINE CastHy-6*
[**2117-6-18**] 01:00PM URINE WBC Clm-MANY
[**2117-6-21**] 10:00AM URINE Hours-RANDOM UreaN-665 Creat-56 Na-51
K-15 Cl-36 HCO3-LESS THAN
[**2117-6-21**] 10:00AM URINE Osmolal-451
MICROBIOLOGY
URINE ADDED TO 64689E [**2117-6-18**].
**FINAL REPORT [**2117-6-22**]**
URINE CULTURE (Final [**2117-6-22**]):
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I 8 S
CEFAZOLIN------------- 8 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN--------- 2 I <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 64 I
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- 8 R <=1 S
RADIOGRAPHIC/IMAGING DATA
Chest X-Ray [**2117-6-18**]
IMPRESSION: Mild pulmonary edema with small bilateral pleural
effusions.
Endotracheal tube and nasogastric tube are in standard
positions.
Chest X-Ray [**2117-6-20**]
Endotracheal tube and nasogastric tube have been removed. Heart
is mildly
enlarged, and is accompanied by mild pulmonary vascular
congestion. Small
right pleural effusion is present and has likely decreased in
size compared to
prior study, although positional differences limit comparisons.
Minor areas
of atelectasis are present at the lung bases, right greater than
left.
RUQ ULTRASOUND [**2117-6-19**]
RIGHT UPPER QUADRANT ULTRASOUND: Changes of right hepatectomy
are present.
The liver is coarsened and nodular, consistent with cirrhosis.
Again seen is
a 2.3 x 1.9 x 1.6 cm hypoechoic mass in segment III, with mild
peripheral
vascularity.
Normal flow and Doppler waveforms are seen in the main and left
portal veins,
with wall-to-wall hepatopetal flow. Color flow is also noted in
the hepatic
arteries, hepatic veins, and IVC. There is no intrahepatic or
common biliary
ductal dilation.
The pancreatic head and body are normal, and the tail is not
well visualized
due to shadowing bowel gas. The spleen is stably enlarged at
14.7 cm. There
is mild ascites, concentrated in the right lower quadrant.
IMPRESSION:
1. Cirrhosis post right hepatectomy, with patent main and left
portal veins.
2. 2.3-cm mass in segment III, concerning for HCC.
3. Splenomegaly.
4. Mild ascites.
EKG [**2117-6-21**]
Sinus bradycardia. QTc interval prolongation. Loss of R waves in
leads I, aVL and V3-V6 consistent with extensive anterolateral
myocardial
infarction, age undetermined but possibly acute. Compared to the
previous
tracing of [**2116-6-9**] these changes are present.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
59 158 84 504/502 4 -138 165
EKG [**2117-6-22**]
Sinus bradycardia. Marked right superior axis. Consider a
lateral myocardial infarction. Q-T interval prolongation. T wave
abnormalities. Since the previous tracing of [**2117-6-21**] probably no
significant change from previously noted findings.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
55 164 84 518/509 50 -157 162
PICC LINE PLACEMENT
TECHNIQUE: Using sterile technique and local anesthesia, the
right basilic
vein was punctured under direct ultrasound guidance using a
micropuncture set. Hard copies of ultrasound images were
obtained before and immediately after establishing intravenous
access are on file. A peel-away sheath was then placed over a
guide wire and a double lumen PICC line measuring 43 cm in
length was then placed through the peel-away sheath with its tip
positioned in the SVC under fluoroscopic guidance. Position of
the catheter was confirmed by a fluoroscopic spot film of the
chest.
The peel-away sheath and guide wire were then removed. The
catheter was
secured to the skin, flushed, and a sterile dressing applied.
The patient tolerated the procedure well. There were no
immediate
complications.
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided
5 French
double lumen PICC line placement via the right basilic venous
approach. Final internal length is 43 cm, with the tip
positioned in SVC. The line is ready
to use.
ECHOCARDIOGRAPHY [**2117-6-22**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.4 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.9 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.3 m/s
Left Atrium - Peak Pulm Vein D: 0.6 m/s
Right Atrium - Four Chamber Length: *5.5 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 25% to 30% >= 55%
Left Ventricle - Septal Peak E': *0.06 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': *18 < 15
Aorta - Sinus Level: 2.7 cm <= 3.6 cm
Aorta - Ascending: 2.9 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.2 m/sec <= 2.0 m/sec
Mitral Valve - E Wave: 1.1 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A ratio: 1.57
Mitral Valve - E Wave deceleration time: 140 ms 140-250 ms
Mitral Valve - [**Last Name (un) **]: 0.20 cm2
Mitral Valve - Regurgitation Volume: 29 ml
TR Gradient (+ RA = PASP): *43 mm Hg <= 25 mm Hg
Findings
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size.
Severe regional LV systolic dysfunction. No resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Moderate (2+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Moderate [2+] TR. Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
REGIONAL LEFT VENTRICULAR WALL MOTION:
Conclusions
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is severe regional left ventricular systolic
dysfunction with akinesis of the mid- and distal LV segments.
This most compatible with either LAD-territory myocardial
infarction or Takotsubo cardiomyopathy. The remaining segments
contract normally (LVEF = 25-30%). Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Moderate
(2+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. Moderate [2+] tricuspid regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: Severe regional left ventricular systolic
dysfunction, c/w LAD-territory infarction or Takotsubo
cardiomyopathy. Moderate mitral and tricuspid regurgitation.
Mild pulmonary hypertension.
Findings discussed with Dr. [**First Name8 (NamePattern2) 7306**] [**Last Name (NamePattern1) 805**] at 1550 hours on the
day of the study.
EGD [**2117-6-15**]
Findings: Esophagus: Normal esophagus.
Stomach:
Mucosa: Friability, erythema, congestion and mosaic appearance
of the mucosa with contact bleeding were noted in the stomach
body and antrum. These findings are compatible with hypertensive
gastropathy.
Duodenum:
Mucosa: Erythema and congestion of the mucosa were noted in the
second part of the duodenum.
Other
findings: No varices noted.
Impression: Gastritis, Duodenitis (Portal hypertensive
gastropathy)
No varices noted.
Otherwise normal EGD to third part of the duodenum
egd [**2117-6-18**]
Findings: Esophagus:
Contents: Clotted blood was seen in the lower third of the
esophagus.
Mucosa: Normal mucosa was noted in the whole esophagus.
Stomach:
Contents: Coffee ground heme was seen in the fundus.
Mucosa: Diffuse continuous congestion, erythema and mosaic
appearance of the mucosa with spontaneous bleeding were noted in
the antrum, stomach body and fundus. These findings are
compatible with severe portal hypertensive gastropathy.
Duodenum:
Mucosa: Normal mucosa was noted in the whole duodenum.
Impression: Normal mucosa in the whole esophagus
Blood clot in the lower third of the esophagus
Old blood in the fundus
Congestion, erythema and mosaic appearance in the antrum,
stomach body and fundus compatible with severe portal
hypertensive gastropathy
Normal mucosa in the whole duodenum
Otherwise normal EGD to third part of the duodenum
Additional notes: specimens: none
blood loss: none
final diagnosis: severe portal hypertensive gastropathy causing
GI bleed
The attending was present for the entire procedure
Brief Hospital Course:
# Upper GI bleed - Presented from OSH with HCT of 18. Required
a total of 6 red blood cell transfusion during her stay. EGD
was negative for varices, but did show Diffuse continuous
congestion, erythema and mosaic appearance of the mucosa with
spontaneous bleeding noted in the antrum, stomach body and
fundus compatible with severe portal hypertensive gastropathy.
Initially maintained on PPI on Octreotide drip. Allergic to
cephalosporins, so given ciprofloxacin for SBP prophylaxis in
presence of GIB. Outside of hospital, she has been on near
weekly blood transfusions for chronic slow GIB. Her baseline HCT
is around 30, and is around 26 prior to discharge. Colonoscopy
not perfromed in house. No melena, hematachezia, or hematemesis
in house.
*Follow daily CBC's, decrease frequency if stable
*Sufferred NSTEMI (see below). Should keep HCT greater than 25
to optimize coronary oxygen delivery.
*Please set up follow up with her [**Hospital1 882**] gastroenterologist,
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 75046**], within 1-2 weeks.
Encephalopathy - patient has many previous admissions for
hepatic encephalopathy which typically presents as
unresponsiveness. Likely precipitated by GI bleed and urinary
tract infection (see below). She was intubated for airway
protection at OSH prior to arrival at [**Hospital1 18**]. At home patient is
on lactulose and rifaximin. Became more alert/oriented after
lactulose administration and blood transfusions.
Patient was treated with lactulose 30 mg q3h, which was titrated
to 3 - 4 bowel movements daily. Continued home dose of
rifaximin. Her UTI was treated (see below). RUQ US showed
cirrhosis post right hepatectomy, with patent main and left
portal veins. Incidenetally, 2.3-cm mass in segment III was
seen concerning for HCC (see below). Splenomegaly and mild
ascites was also identified.
*Continue lactulose administration to titrate to [**4-16**] bowel
movements per day.
*Continue Rifaxamin dosing
*Note, patient had Non-Gap metabolic acidosis after leaving the
ICU, probably from fluid boluses with NS and diarrhea from
lactulose. Consider non-saline IVF repletion if necessary and
having diarrhea.
Urinary tract infection- Patient has history of UTIs, no
previous culture date available in online medical record. U/A
positive on admission. Started on IV ciprofloxacin for SBP ppx
as well as UTI treatment. Cultures grew out P.Mirabilis
with intermediate sensitivity to ciprofloxacin, and K.Pneumoniae
sensitivity to cipro. Please note, has documented cephalosproin
allergy.
*Please perform UA and UCx prior to cessation of ciprofloxacin
(last day [**2117-7-3**])
NSTEMI - Trop elevated to 2.55 at OSH with CK 58, new lateral
TWI in V3-6 and AvL with no ST-T changes. Likely in setting of
demand from acute GI bleed as well as documented history of
coronary artery disease. Troponin trended 2.45 to 1.97 to 2.07,
CK and MB remained flat. Patient was not started on
antithrombotic therapy due to GI bleed. TTE showed anterior
wall akinesis as well as worsening depression in EF to 25-30%.
Restarted propanolol for beta blockade/portal hypertension, and
started losartan 12.5 mg as well as pravastatin 40 mg qhs. Also
on spironolactone for diuresis.
*Please continue above medications. Please note patient has a
documented allergy history to ACE-I.
*Patient has severe anasarca from fluid boluses. Will need
daily diuresis and monitoring of Ins/Outs until achieves
euvolemia. Also need to monitor renal function and
electrolytes. Currently on Furosemide 40 mg po daily as well as
spironolactone 25 mg daily. [**Month (only) 116**] want to increase if patient
requiring additional diuretic boluses. Was on 50 mg of
spironolactone prior to admission.
EtOH cirrhosis - history of right hepatectomy for HCC, hepatic
encephalopathy and portal hypertension with portal gastropathy.
No fluid wave appreciated on exam and encephalopathy as above
likely due to acute GI bleed and UTI. Continued thiamine and
folic acid. Continued lactulose and rifaxamin for hepatic
encephalopathy. Baseline mental status is mild to moderately
confused, with occassional visual hallucinations
(puppies/putting away jewlry)
*Regarding US liver lesion, patient is aware and says it has
been biopsied at [**Hospital1 2025**] in [**Location (un) 86**] [**State 350**] and is non
cancerous. Please reference [**Hospital1 2025**] hepatologists for further
details.
*Monitor LFTs
Diabetes Mellitus II: Discontinued original NPH insulin and
transitioned to Glargine Insulin while in house. Glucoses
marginally controlled. Increased Glargine to 20 U qhs and also
increased sliding scale (please reference medication list)
*Check for appropriate glucose control and increase long
acting/SSI prn
T12/L1 compression fracture: Seen on radiographic imaging from
prior hospitalization. Should wear TLSO brace while ambulating.
Goals of care- patient has had progressive decline in function
and is not a transplant or TIPS candidate. She has recurrent
severe encephalopathy with multiple prior admissions. Per sister
they have discussed with patient goals of care. Family meeting
occurred prior to discharge resulted in patient requesting to be
full code. Should continue to have ongoing discussion as most
likely will continue to need frequent hospital readmissions
given patient's multiple comorbidities.
Given overall poor prognosis and poor functional status, need to
discuss limitations of treatments without transplant.
*Should attempt to have repeated goals of care discussions with
the patient and family as will most likely require frequent
repeated hospitalizations based on morbidity of current illness.
TRANSITIONAL ISSUES: Please see asterisks with individual
issues.
PENDING LABS: None
Medications on Admission:
lactulose 10 gram/15 mL Syrup 30ml QID
rifaximin 550 mg [**Hospital1 **]
thiamine HCl 100 mg daily
folic acid 1 mg daily
propranolol 40 mg [**Hospital1 **]
venlafaxine 37.5 mg [**Hospital1 **]
aripiprazole 5 mg daily
omeprazole 40 mg [**Hospital1 **]
Lasix 40 mg daily
spironolactone 50 mg daily
Klonopin 0.5 mg qhs
NPH insulin human recomb 100 unit/mL 35 units [**Hospital1 **]
insulin lispro 100 unit/mL per sliding scale
Iron (ferrous sulfate) 325 mg daily
multivitamin
ergocalciferol (vitamin D2) 50,000 unit weekly
Discharge Medications:
1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. propranolol 10 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
6. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
7. insulin glargine 100 unit/mL Solution Sig: Twenty (20)
Subcutaneous at bedtime.
8. insulin lispro 100 unit/mL Solution Sig: Per sliding scale
Subcutaneous qachs: BRKFAST,LNCH,DNER SSI
101-150 3 Units
151-200 5 Units
201-250 7 Units
251-300 9 Units
301-350 11 Units
351-400 13 Units
BEDTIME SSI
101-150 0 Units
151-200 2 Units
201-250 3 Units
251-300 4 Units
301-350 5 Units
351-400 6 Units
.
9. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Hold for SBP<100.
10. losartan 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): Hold
for SBP<100.
11. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): Please continue up to and including [**2117-7-3**]
for total 2 week treatment of complicated UTI. Please renally
dose with changes in renal function.
12. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
15. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
17. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a week.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
Hepatic Encephalopathy
Non-ST Elevation Myocardial Infarction
Urinary Tract Infection
Gastrointestinal Bleed
.
Secondary:
1. Cirrhosis
2. Hepatocellular cancer status post resection
3. Diabetes
4. Hypertension
5. Coronary artery disease
6. Chronic kidney disease stage III baseline creatinine 1.4
7. Gastropathy
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:
Ms. [**Known lastname 40860**],
You presented to the hospital due to being more somnolent.
You were found to have multiple issues, including a
gastrointestinal bleed, a urinary tract infection, and you also
sufferred a heart attack. You were evaluated in the cardiac ICU
then transferred to the Liver service.
You had an endoscopy performed which did not show any evidence
of acute bleeding, but rather slow oozing bleeds in your
stomach.
Your heart attack was medically managed as best possible, but
given your risk for bleeding we do not suggest you take a daily
aspirin. Your urinary tract infection was treated with
antibiotics.
You had imaging of your heart after your heart attack which
showed compromised function, giving you a diagnosis of systolic
heart failure. You will need to take some new medications to
help your heart.
You were also found to have compound fractures in your back
requiring a brace for you to wear when you walk around. Please
work with physical therapy to help gain your strength.
Lastly, you were given lots of fluids when you came to the
hospital to keep your blood pressure up. You will require
medication to help urinate off the extra fluid that has
accumulated in your body over the last several days.
Some of your medications have changed.
1) We have DECREASED your dosing of Omeprazole 40 mg [**Hospital1 **] to 20
mg [**Hospital1 **].
2) We have DECREASED you dose of spironolactone from 50 mg daily
to 25 mg daily.
3) Please STOP taking your Klonopin 0.5 mg at night
4) We have changed your Insulin. Please STOP taking NPH insulin
human recomb 100 unit/mL 35 units twice a day. Please START
taking Glargine Insulin 20 U at night with Insulin lispro 100
unit/mL per sliding scale
5) Please DECREASE your propanolol from 40 mg twice a day to 10
mg twice a day
6) Please START taking pravastatin 40 mg at night
7) Please START taking losartan 12.5 mg daily.
8) Please CONTINUE to take your antibiotic ciprofloxacin up to
an including [**2117-7-3**]
9) Please STOP taking your venlafaxine 37.5 mg twice a day
10) Please STOP taking aripiprazole 5 mg daily.
Please continue to take the rest of your medications as
prescribed.
.
While in the hospital, you had a family meeting with your
medical team and your sister. [**Name (NI) **] understand that you are not a
surgical candidate for liver transplant. You determined that
you would like to continue with medical therapy and physical
rehab, and rehospitalizations if necessary. You will be going
to physical therapy for strengthening.
.
It has been a pleasure taking care of you Ms. [**Known lastname 40860**]!
this AM. On arrival to OSH her vitals were 97.4, HR 68, BP
116/45, RR 12, 100% on RA, GCS 6. She was found to be "gurgling"
with breathing and was given etomidate, versed, propofol and
intubated for airway protection. Also received IV flagyl and
levofloxacin, and lactulose, and 2L NS. Her HCT was 20.3, Na
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
You have the following follow up appointments:
Department: ORTHOPEDICS
When: FRIDAY [**2117-7-9**] at 9:05 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: FRIDAY [**2117-7-9**] at 9:25 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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"537.89",
"410.71",
"303.93",
"041.4",
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"789.2",
"572.2",
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"276.2",
"572.3",
"410.11",
"041.3",
"250.00",
"280.0",
"041.6",
"285.21",
"414.01",
"578.1",
"584.9",
"585.3",
"571.2",
"789.59",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.97",
"45.13",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
24171, 24243
|
15990, 21718
|
333, 486
|
24608, 24608
|
4755, 13103
|
27828, 27851
|
3098, 3117
|
22375, 24148
|
24264, 24587
|
21831, 22352
|
15855, 15967
|
24785, 27805
|
13143, 15838
|
3132, 3132
|
3770, 4736
|
21740, 21805
|
2101, 2479
|
283, 295
|
27876, 28424
|
514, 2082
|
3146, 3756
|
24623, 24761
|
2501, 2829
|
2845, 3082
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,575
| 190,771
|
34226
|
Discharge summary
|
report
|
Admission Date: [**2182-4-13**] Discharge Date: [**2182-4-24**]
Date of Birth: [**2133-1-10**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Fever, lethargy, nausea, vomiting
Major Surgical or Invasive Procedure:
Spinal tap [**2182-4-13**]
History of Present Illness:
No family available, Hx from chart review. Patient was in her
USOH until 2 days ago, when she developed fever, anorexia, dry
cough, N, V, HA, somnolence. Went to [**Hospital 1263**] Hospital, given
Tamiflu and Tylenol. Symptoms did not respond but progressed, so
next day presented to [**Hospital3 **], where she was admitted in
the early AM of Sat [**2182-4-13**]. In ED, CT reportedly negative, "LP
negative for infection", given Dilaudid 1mg IM, CTX 2 gram IV
Q12, Vancomycin 1000 mg IV Q12, Ampicillin 2 gram IV Q4,
Doxycyclin 100 mg IV Q12, Acyclovir 600 mg (10 mg/kg) Q8,
Dexamethasone 10 mg PO x 1, Zofran, Tylenol, dextrose D5W 200 cc
Qshift, Zocor 10 QD. Reportedly no sick contacts, no unusual
exposures. Travel Hx not documented.
Exam per notes in [**Hospital3 **] T 101.8, 116/94, HR 95, A + O
to self, unable to examine CN [**12-29**] somnolence, obeying some
commands, neck stiffness by manual exam. Imaging studies were
performed (see below), ID was consulted, who recommended tx to
[**Hospital1 18**] Neurosurgery since there was reportedly some hemorrhagic
component on the MRI (read says bilateral T2 prolongation
temporal lobes, BG, cerebellum - GRE* shows subtle hemorrhagic
components R parietotemporal and parietal regions and in the L
temporal lobe). Neurosurgery here sees no blood and asks us to
take patient.
Past Medical History:
Hypercholesterolemia
Social History:
Lives with husband. [**Name (NI) 482**] only Vietnamese.
Family History:
non-contributory
Physical Exam:
T 104.1 141/60 105/min RR 28/33 98-100% RA
Ill-appearing, deliriously ranting in Vietnamese, diaphoretic.
Neck stiffness but in all directions.
Cardiac S1S2 no MGR, RRR
Pulm CTA all fields
Abdomen B, NT/ND BS+
Extremities warm and well-perfused, no splinter hemorrhages
NE
Grimaces to noxious and may on occasion briefly open eyes, does
not regard, attends only to midline and R, rarely explores L.
Does not follow commands. Pitch and speed of ranting increases
with agitation. Fumbles with both hands at baseline, picking
blanket. OCR intact with ?mild L VI deficit. Corneals intact.
PERRL. Face symmetric. At baseline moves R arm more purposeful
than L, and the L leg is externally rotated (subtle). She
withdraws all 4's to noxious purposefully but less brisk on the
L. Reflexes brisk and symmetric, toes down.
Pertinent Results:
TTE no vegetations
EEG This is an abnormal portable EEG in the waking and sleeping
states due to sharp transient discharges in the bioccipital
regions,
particularly during drowsiness. These discharges were not
clearly
epileptiform. Would recommend a follow-up study to check for
progression given the clinical history. No electrographic
seizure
activity was noted. Second 24-hr EEG: A 24-hour video EEG
telemetry demonstrated normal posterior predominant background
rhythms during wakefulness. A few interictal discharges were
observed in the automatic spike detection files ( A few files
showed generalized discharges with a left frontal predominance.
There were also some isolated left frontal epileptiform
discharges observed ) No electrographic or clinical seizures
were seen.
CXR Heart size top normal. Mild pulmonary and mediastinal
vascular congestion suggest mild cardiac decompensation or
volume overload. No pleural effusion or pneumothorax.
ECHO The left atrium is normal in size. No atrial septal defect
is seen by 2D or color Doppler. The estimated right atrial
pressure is 0-5 mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%) There is no ventricular septal defect. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. No masses or vegetations
are seen on the aortic valve. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. No mass or vegetation is seen on the
mitral valve. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
Repeat MRI [**4-18**]: There has been mild progression of lesions
along the lateral aspect of the right temporal [**Doctor Last Name 534**] as well as
in the left putamen. Essentially stable hyperintensity is seen
in the bilateral right greater than left medial temporal lobes,
bilateral caudate heads,pons, bilateral thalami, right caudate,
right putamen and bilateral corona radiata. A right frontal
periventricular lesion is also enlarged slightly. No avid
enhancement is seen in these lesions. There is faint enhancement
in the right frontal periventricular lesion which has slightly
increased in size. Right parietal corona radiata and the left
parietal corona radiata lesions also demonstrate faint
enhancement. Many of the lesions demonstrate central restricted
diffusion. Susceptibility dropout is noted in many of these
lesions. This can be seen with fungal and brain infections.
The ventricles are unchanged in size.
IMPRESSION:
Mild interval progression of some lesions in the brain.
Differential includes viral encephalitis, fungal infection.
vasculitis, or ADEM. Given the acute symptoms, neoplasm is
thought to be unlikely.
2nd repeat MRI [**4-23**]: No new lesions are seen compared to the
most recent study of [**2182-4-18**]. Small lesions within the pons
appear more discrete and a small lesion in the left centrum
semiovale has decreased in size slightly. Otherwise, lesions are
largely unchanged in the periventricular right frontal lobe,
right greater than left medial temporal lobes, bilateral caudate
heads, bilateral putamen, bilateral thalami, and bilateral
corona radiata. Again faint enhancement is seen in many of these
lesions. Many lesions demonstrate central regions of restricted
diffusion. Susceptibility dropout is again noted in many of
these lesions as well. The appearance of the ventricles and
extra-axial CSF spaces is unchanged. The soft tissue and osseous
structures are unremarkable. There is minimal mucosal thickening
in some ethmoid air cells.
IMPRESSION: Overall, little change to multiple lesions in the
brain; findings again may be consistent with ADEM.
Brief Hospital Course:
BRIEF ICU COURSE
NEURO
Improved markedly, following commands, alert and attentive
within
2 days, but remained disoriented. EEG was done showing no PLEDS
or triphasic waves, but some in [**Doctor Last Name 2434**] sharp transients in the
occipital leads, not interpreted as epileptic but also not
classic POSTs. 3 pushbutton events for increased HR and and
bilateral arm shaking NOS had no EEG correlate suspect for
seizure activity. No AEDs were started. Repeat LP opening
pressure 16.5 cm H2O, 176 WBC (mono 81% lymph 17%) 33 RBC Prot
125 Glc 78. Started on steroids 1000 mg MP for 5 days for a
suspicion of ADEM. CSF MS package negative. Read of EEG from
days
following pending.
ID
Febrile up to 104.1, now afebrile. White count on arrival 18.6
with left shift (86% PMN), now 9.6. Repeat LP opening pressure
16.5 cm H2O, 176 WBC (mono 81% lymph 17%) 33 RBC Prot 125 Glc
78.UCx [**4-13**] negative. BCx [**4-13**], 18, 19, 20 x 2 (PICC and periph
IV) NGTD. [**4-15**] VRE and MRSA x 2 pending. HSV PCR -1 and -2 OSH
(Per Dr [**Last Name (STitle) 51919**] fax [**Telephone/Fax (1) 78834**]) negative. CSF studies sent
here AF Cx-, viral Cx-, bact Cx-, fungal Cx-. Gram stain no
organisms, 2+ PMN. HSV, CMV, EBV, HHV-6, VZV, Lyme pending. CSF
cryptococcal Ag negative. EEE and West-[**Doctor First Name **] not sent. On
Vancomycin 1000 Q12, Ceftriaxone [**2173**] Q12, Acyclovir 600 Q8.
CARDIO
TTE negative. No active issues. Bloodpressures well controlled
w/o medication.
PULM
CXR negative for infiltration on [**4-13**].
FEN/Endo/Tox
Started on TF, Replete w/fiber full strength goal of 60 cc but
now waking up. Maintenance IVF 40 cc/hr with 20 KCl, now off. No
electrolyte abnormalities. Utox and Stox on arrival negative.
B-HCG negative.
GI
On bowel regimen. No issues reported by nursing.
HEME
Stable Hct/Hb. White count normalized. Coags normal.
PPx
Pneumoboots, bowel regimen, SC Heparin
EXAM ON TRANSFER TO FLOOR:
Tm 97.8 63-81 RR 19-28 BP 100-117/50-65
NAD No diaphoresis
Nuchal rigidity
Cardiac S1S2 RRR no MGR
Pulm CTA anteriorly
Abdomen supple, NT/ND. BS+,
Skin no rashes, extremities warm, no splinter hemorrhages
Alert and attentive, denies weakness, HA, pain. Following
commands in English and better in Vietnamese. Motor
impersistence, difficlut to instruct. PERRL, EOMI, smile
symmetric, tongue straight, shoulder shrug symmetric. Upward
pronator drift on L. Give way weakness diffusely, no formal
strength testing, L appears weaker but unable to quantify.
Registers touch bilaterally. FTN intact on R but dysmetric on
the
L. Reflexes brisk and symmetric, toes down.
BRIEF FLOOR COURSE:
NEURO Continued to rapidly improve on steroids. Bradyphrenic.
Mild fluctuations in the general level of arousal. No new
memory encoding - she could not remember who visited her the day
prior, even if this was family or close friends. [**Name (NI) **] neglect
diminshed but clinically she continued to have a subtle L
hemiparesis, best seen on pronator drift. Formal strength
testing difficult [**12-29**] motor impersistence.
Repeat MRI formally showed no change but our own impression was
a very mild improvement. There was a discrete non-descript
enhancement in some of the lesions, which does not have a
clinical correlation. She was continued on Prednisone, with a
long and slow taper. She was closely monitored (including but
not limited to glucose, bloodpressure, electrolytes) for
side-effects, and we advise to continue to do so. She will need
follow-up closely after discharge from rehab with her PCP for
continued monitoring, especially when coming off - watch for
adrenal insufficiency and for relapse of her ADEM.
ID Infectious Disease was consulted. EEE, Lyme, Mycoplasma,
TB-PCR were sent at their recommendation. Acyclovir, ceftriaxone
and Vancomycin were discontinued stepwise as all results were
coming back negative.
GI She came off the TF and is eating a normal diet.
UG Her Foley was D/C'd.
Medications on Admission:
Zocor 10 QD
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) 10mL PO BID (2
times a day).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000
units Injection TID (3 times a day).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for perianal rash.
7. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Topical
PRN (as needed) as needed for perianal rash.
8. Prednisone Oral
9. Schedule for 6 week Prednisone Taper
Week 1 40 mg QD -
Week 2 30 mg QD -
Week 3 20 mg QD -
Week 4 10 mg QD -
Week 5 5 mg QD -
Week 6 Day 1 5 mg Day 2+3 2 mg [**Hospital1 **] Day 4 + 5 2 mg QD Day 6 + 7 1
mg QD Day 8 Off.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Acute disseminating encephalomyelitis (ADEM)
Discharge Condition:
Stable. For details regarding neuro-exam, see [**Hospital **] hospital
course'.
Discharge Instructions:
You have been admitted with a diagnosis of acute disseminating
encephalomyelitis, which is a post-infectious auto-immune
reaction that affects your brain. You will need intensive rehab,
with an emphasis on cognition. You will be on steroids for quite
a while, and will need to be tapered very slowy. Please make
sure you follow up with your doctor very closely since steroids
have many potential side-effects. Your doctors in rehab [**Name5 (PTitle) **]
keep an eye on the steroid effects too, including but not
limited to bloodsugar values, bloodpressure and electrolyte
levels in your blood.
Please take all your medications excactly as directed and
please attend all your follow-up appointments.
Please report to the nearest ER or call 911 or your PCP
immediately when you experience recurrence of weakness,
numbness, tingling, problems with vision, speech, language,
walking, thinking, headache, or difficulties arousing, or any
other signs or symptoms of concern.
Followup Instructions:
1 Please follow-up with your PCP closely regarding the steroid
use (see above).
2 Neurology - Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) **]:[**Telephone/Fax (1) 657**] Date/Time:[**2182-6-25**] 2:30
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2182-4-24**]
|
[
"782.1",
"272.0",
"136.9",
"323.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"38.93",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
11611, 11708
|
6622, 10551
|
351, 380
|
11797, 11879
|
2751, 6599
|
12899, 13300
|
1882, 1900
|
10614, 11588
|
11729, 11776
|
10577, 10591
|
11903, 12876
|
1915, 2732
|
277, 313
|
408, 1746
|
1768, 1791
|
1807, 1866
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,302
| 146,999
|
50868
|
Discharge summary
|
report
|
Admission Date: [**2114-8-22**] Discharge Date: [**2114-10-2**]
Date of Birth: [**2064-6-6**] Sex: F
Service: NEUROLOGY
Allergies:
Dilantin / Tegretol / Gold Salts
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
HA and visual field cut at neurology clinic
Major Surgical or Invasive Procedure:
Ventricular Drain placement [**2114-8-23**]
MRI
History of Present Illness:
50 year old RH woman with h/o protein C defficiency and
venous sinus thrombosis. Was recently discharged [**2114-8-7**] on
lovenox and reportedly was doing fine initially. [**Name (NI) **]
sister and mother at bedside report that she first started
comlaining of headache 2-3 days ago. Also complained that she
couldn't see characters on the right side of the TV. She
presented today in neurology clinic for follow up where she
complained of headache and was noted to have a right field cut
on
exam. Patient is inattentive, aphasic and perseverating so
unable to give a coherent history other than talking about her
headache. Describes the headache as "hurts on the top of my
head" and reports that its worse when she's lying down in bed.
Complains of nausea but started vomitting only after coming to
ED.
According to sister and mother, the patient was looking better
this AM and was only complaining of "feeling terrible" and her
headache. Was more attentive and able to express herself.
Was discharged on lovenox rather than coumadin reportedly
because
the thrombus was not responding to coumadin.
For further details of initial presentation on [**2114-8-1**] please
see
admission note from that date.
Patient unable to give coherent ROS.
Past Medical History:
-Cortical venous thrombosis [**2105**] and associated stroke - had
presented with L leg clumsiness, slurred speech, headaches; on
coumadin therapy since
-Venous sagittal sinus thrombosis [**2107**] with associated venous
infarcts, on neurology service - had presented with left sided
weakness
-Seizures since [**2100**] (during pregnancy), with several seizure
types including staring, focal LUE sz, and "complex partial with
secondary generalization"
-Headaches, on ppx with verapamil
-Protein C deficiency
-Gestational DM
-Juvenile rheumatoid arthritis
Social History:
Lives with son; has boyfriend [**Name (NI) **]. [**Name2 (NI) **] tob, no etoh, no drugs.
Currently disabled
Family History:
aternal and paternal grandparents with strokes, per old notes
Physical Exam:
T 97.6 HR 72-81 BP 153-170/86-98 RR 14-18 93-98% RA
General appearance: looks somnolent, pale and has emesis basin
in
hand.
HEENT: moist mucus membranes, clear oropharynx
Neck: supple, no bruits
Heart: regular rate and rhythm, no murmurs
Lungs: clear to auscultation bilaterally
Abdomen: soft, nontender +bs
Extremities: warm, well-perfused
Skull & Spine: Neck movements are full and not painful to
palpation in the paraspinal soft tissues
Mental Status: The patient is somnolent but awakens to voice and
can stay awake for conversation during parts of the exam, and at
other times falls asleep in exam. Able to follow some simple
commands but not all. Unable to follow complex commands and
inattentive throughout exam. Oriented to person, but names
"[**Hospital1 **]" as hospital and cannot say date. Appears unable to
convey her thoughts/questions and perseverates frequently. No
dysarthria. Memory unable to be tested as inattentive.
Cranial Nerves: The visual fields show right homonymous
hemianopsia, although testing accurately was difficult given her
inattentiveness. Patient not able to cooperate with fundoscopic
exam, but portions of disc visualized did not appear crisp. Eye
movements are normal, with no nystagmus. Pupils
react equally to light, both directly and consensually, 4->2.
Sensation on the face is intact to light touch bilat. No drpp[
and muscles of facial expression intact bilaterally. Hearing
is intact to voice. The palate elevates in the midline. The
tongue protrudes in the midline and is of normal appearance. Gag
is intact.
Motor System: Strength was full and equal in deltoids, triceps,
biceps. Full and equal in IPs, quads, dorsiflexors and plantar
flexors. 5- weakness bilaterally in hamstrings. Tone was
increased in right lower extremity just slightly. Normal
otherwise.
Reflexes: The tendon reflexes are 1+ at biceps, triceps and BR
bilaterally. 3+ at left patella and 2 on left. Ankles 1
bilaterally. The plantar reflexes are flexor.
Sensory: Sensation is intact to LT, "equal" in extremities, no
ext to DSS; could not test other modalities due to
inattentiveness and problems with comprehension.
Coordination: There is no ataxia on FNF and could not assess HS.
Gait: deferred for now.
Pertinent Results:
[**2114-8-22**] 10:27PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2114-8-22**] 01:02PM GLUCOSE-119* UREA N-12 CREAT-0.9 SODIUM-136
POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-21* ANION GAP-18
[**2114-8-22**] 01:02PM CK(CPK)-48
[**2114-8-22**] 01:02PM cTropnT-<0.01
[**2114-8-22**] 01:02PM CK-MB-NotDone
[**2114-8-22**] 01:02PM CALCIUM-9.3 PHOSPHATE-3.5 MAGNESIUM-2.2
[**2114-8-22**] 01:02PM WBC-7.0 RBC-4.06* HGB-12.6 HCT-36.8 MCV-91
MCH-31.1 MCHC-34.3 RDW-14.7
[**2114-8-22**] 01:02PM NEUTS-84.2* LYMPHS-12.0* MONOS-2.2 EOS-0.3
BASOS-1.1
[**2114-8-22**] 01:02PM PT-14.8* PTT-34.5 INR(PT)-1.3*
[**2114-8-22**] 01:02PM LMWH-GREATER TH
Head CT([**2114-8-22**]): Large hemorrhage within previous edematous
region in the left temporal/occipital portion of the brain, as
well as intraventricular hemorrhage. In the setting of a known
hypercoagulable state, an infarct, probably of venous origin,
with hemorrhagic transformation is suspected, with
neoplastic disease a secondary diagnostic consideration.
Brief Hospital Course:
1. Neurologically: Was not reversed with any agents and did not
receive any blood products. HOB was elevated and initially was
hyperventilated. Received several doses Mannitol over first 24
hours and then was weaned off on day 3. Systolic pressures
controlled with RTC metoprolol and prn Labetolol/metoprolol with
goal SBP around 140-150 and MAP to be less than 130.
Over the first several hours of admission mental status
waxed and wained. In the late hours of [**2114-8-22**] was reportedly
more somnolent. Had the ventricular drain placed at around 0100
on [**8-23**] based on her worsening clincal exam. Was placed
contralaterally (on right) without complication. Went into
respiratory distress shortly after vent drain placement and was
emergently intubated. Follow up CTs over the next 24 hours
showed increaseing hemorrhage and mass effect. Scans eventually
stablilized and she remained intubated, eventually without
propofol, and an exam showing spontaneous left sided movements
but unresponsiveness. Around days [**2-11**], pupils were unequal with
left 1.5mm larger than right and sluggish. Also had bilaterally
upgoing toes temporarily. Around [**8-28**], left toe was noted to be
down going on plantar response and pupils were noted to be equal
and brisk bilaterally.
She was given cefazolin IV daily for CNS vent drain
infection prophylaxis. Also received 3 days of 1mg TPA to vent
drain to prevent clotting off of drain. Additional ipsilateral
drain was consdiered and discussed with neurosurgery but thought
not to be indicated. ICPs were initially around 30s for first 12
hours but came down to 4-10 after vent drain adjusment in the
first 12 hours. Vent drain output was initially low but
increased to 1800cc/day on day 6 of the vent drain. Plan on
[**8-28**] was to increase ICP to around 20 and use TPA to try and
lyse the intraventricular clot on the left side.
Received seizure prophylaxis with Topamax which was
increased from 100 [**Hospital1 **] to 200 [**Hospital1 **]. Gabapentin was also
increased to 900 TID. All anticoagulation was held initially.
Eventually received prophylactic doses of heparin (5000 u SC
TID) starting [**8-25**]).
Became more arousable and with more left sided spontaneous
movemnts on [**8-28**] with CT scan essentially unchanged. From [**8-28**]
to [**8-31**] CTs essentially unchanged except for some small edema.
Mannitol restarted [**8-29**] at 12.5 grams IV Q6. ICP goal changed
from 10 to 20 on [**8-29**] with hope that ventricular TPA
administration will break hematoma in contralateral ventricle.
On Day 9 ([**8-31**]) of vent drain, tubing replaced at bedside by
Neurosurg. EVD was ultimately discontinued on [**2114-9-7**].
EEG performed [**8-30**] with some spike/sharp wave activity in
right frontal region but no clear epileptiform activity but
correlating with head and shoulder shaking. She will continue on
Topamax and Gabapentin at current doses.
2. Cardiovascular: Ruled out for MI. Pressures controlled with
Metoprolol, Verapamil 80mg NG Q8 as well as prn IV doses of
labetolol and metoprolol. Was on telemetry. Had pneumoboots
throughout the admission. Had negative dopplers for DVTs. On
[**9-24**],m she had episode of supraventricular tachycardia to 190s,
converted by cardiology via adenosine 6 mg IV x one and then
transiently on Diltiazem. Diltiazem ultimately discontinued per
cardiology recommendations and Metoprolol discontinued after
patient persistently normotensive. Transthoracic echocardiogram
was unrevealing.
3. Respiratory: Intubated for respiratory distress within 12
hours of admission. Developed fevers around day 5 and sputum
sample showed multiple organisms with cultures pending at this
time. Was started on levaquin [**8-27**]. CXR on [**8-28**] looked clear.
Was to be extubated [**8-30**] but waiting for vent drain to be
replaced, so extubated [**8-31**]. She underwent tracheostomy
placement on [**2114-9-14**], with downsizing of trach on [**9-19**]. A
cuffless trach was placed on [**2114-9-25**]. However, patient was
unable to use Passy Muir valve; ENT was consulted at found a
large granuloma in the airway, likely secondary to intubation.
She will see Dr. [**First Name (STitle) **] of ENT for follow-up as an outpatient.
ENT would like her on [**Hospital1 **] proton pump inhibitor for reflux
treatment.
4. GI: Was started on tube feeds around 24 hours after
intubation and tolerated. GI prophylaxis with famotidine. PEG
was placed on [**2114-9-14**]. She should continue on [**Hospital1 **] proton pump
inhibitor therapy until ENT follow up. Reglan started for
nausea out of concern for motility issues. Liver function tests
and abdominal imaging were unremarkable.
5. Endocrine: Received RISS with QID accuchecks. Had some
borderline hyponatremia off and on which was just managed with
fluid restriction.
6. Renal: Stable.
7. Infectious disesae: Received levaquin for suspected
pneumonia and was on prophylactic cephazolin for vent drain.
Blood cultures were negative times 2 and urine negative x 1.
Continued to be febrile on levaquin and cephazolin so ID
consulted on [**8-30**] and recommended d/c cefazolin and start Vanco
1gm IV Q12 in addition to the levaquin. Continued to
pan-culture including CSF and stool studies (with Cdiff) but no
clear infectious source. ID agrees that fever and white count
can be as a result of the ICH itself. She also underwent a
course of acyclovir for vesicular appearing lesions on her
buttocks in setting of HSV1 direct antigen positivity, but HSV
CSF PCR returned negative so acyclovir discontinued.
8. Hematology: Protein C defficiency. Hematology consulted day
1 and agreed with holding any further anticoagulation but not
reversing initially. Was initially given no heparin. Did not
receive any reversing agents. Factor 10A level returned 2.0
which is supratherapeutic. Hematology recommended that
anticoagulation could be reconsidered after the hemorrhage had
been stable at least 7 days. Prophylactic doses of heaprin SC
started [**8-25**]. Also, 1mg [**Hospital1 **] doses of tPA given for several days
through ventricular drain initially to prevent clotting of drain
and later with the intention of lysis of the intraventricular
hematoma. Heparin gtt was restarted on [**2114-8-25**]. It was
discontinued on [**9-24**] in setting of therapeutic INR while on
couamadin. Goal INR will be 2.5-3.0 on coumadin.
She was also anemic at times during this admission.
Underwent transfusion of one unit on [**2114-9-8**]. Iron was low and
supplementation was started.
9. Psych: Patient started on Valium and Celexa for depression
and anxiety.
Medications on Admission:
1. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
[**Hospital1 **] (2 times a day).
Disp:*40 syringes* Refills:*0*
4. Indomethacin 50 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. TOPAMAX 100 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day.
7. Glycerin 50 % Solution Sig: One (1) oz PO TID (3 times a
day). (did not take yet today)
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
Disp:*60 1* Refills:*2*
3. Topiramate 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
Disp:*1 inhaler* Refills:*0*
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY
(Daily).
Disp:*30 1* Refills:*2*
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl
Topical PRN (as needed).
10. Diazepam 2 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
11. Diazepam 2 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for anxiety.
12. Dolasetron 12.5 mg/0.625 mL Solution Sig: 12.5 mg
Intravenous Q8H (every 8 hours) as needed.
13. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime):
Goal INR is 2.5 -3.0.
14. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-8**]
Drops Ophthalmic PRN (as needed).
15. Gabapentin 250 mg/5 mL Solution Sig: 1000 (1000) mg PO TID
(3 times a day).
16. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig:
Thirty (30) mg PO BID (2 times a day).
17. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane PRN
(as needed).
18. Metoclopramide 10 mg Tablet Sig: Ten (10) Tablet PO QID (4
times a day).
19. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
20. Mineral Oil-Hydrophil Petrolat Ointment Sig: One (1)
Appl Topical TID (3 times a day) as needed for dry skin.
21. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: Five (5)
ML PO Q6H (every 6 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
1. Intracranial hemorrhage
2. History of sinus venous thrombosis
3. Protein C deficiency
Discharge Condition:
Fair. Making improvements in function and mobility. Ambulating
well with assistance and following commands. Unable to speek
secondary to trach.
Discharge Instructions:
Please return to ED or call EMS if significant changes in level
of function, new weakness, sensory changes, or if headache and
nausea/vomiting develop. Follow up with appointments as below.
Followup Instructions:
1. [**Name6 (MD) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2114-10-17**] 10:45
2. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 1694**]
Date/Time:[**2114-11-19**] 1:00
3. Dr. [**First Name (STitle) **] from ENT at Monday [**10-22**] at 8:45 at [**Location (un) 66073**]in [**Location (un) 55**], MA. Call [**Telephone/Fax (1) 2349**] with
questions.
|
[
"486",
"518.5",
"280.9",
"289.81",
"780.39",
"054.9",
"714.30",
"427.89",
"431",
"325",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"33.24",
"38.93",
"96.6",
"02.42",
"43.11",
"99.10",
"02.39",
"99.04",
"02.43",
"96.04",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
15242, 15321
|
5805, 12484
|
337, 386
|
15454, 15603
|
4740, 5782
|
15841, 16339
|
2390, 2453
|
13132, 15219
|
15342, 15433
|
12510, 13109
|
15627, 15818
|
2468, 2913
|
254, 299
|
414, 1667
|
3433, 4721
|
2928, 3416
|
1689, 2246
|
2262, 2374
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,000
| 199,292
|
37279
|
Discharge summary
|
report
|
Admission Date: [**2127-4-21**] Discharge Date: [**2127-4-28**]
Date of Birth: [**2041-2-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Aspirin / Gantrisin / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
1. Aortic valve replacement with a 25-mm St. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 4041**]
tissue valve, reference number [**Serial Number **], serial number
[**Serial Number 83899**].
2. Coronary artery bypass grafting times 1 with left
internal mammary artery to left anterior descending
artery.
History of Present Illness:
Mr. [**Known lastname 83900**] who is an 86-year-old male with past medical
history of atrial fibrillation, First and second-degree
Wenckebach AV block, severe aortic valve stenosis, systolic
congestive heart failure, presents with worsening dyspnea on
exertion and need of tissue AVR scheduled for [**2127-4-21**] presenting
to CCU for aspirin desensitization. His history of aspirin
"allergy" was from >40 yrs ago where he reports ?shortness of
breath, but unclear if had true anaphylaxis- regardless he was
told not to ever take the drug again. From an AS standpoint, he
was not deemed high enough surgical risk for Core Valve and thus
given his progression of symptoms with dyspnea with minimal
exertion, decision was made to proceed with AVR. Cardiac surgery
was consulted for evaluation of aortic valve replacement.
Past Medical History:
PAD
Status post AAA repair (endovascular [**2120**] [**Hospital1 2025**])
hypertension
Dyslipidemia
Aortic stenosis
PAF (warfarin)
Coronary artery disease
Probable ischemic cardiomyopathy with chronic systolic heart
failure and LVEF of 30%
Gout
Steroid-dependent asthma
Mild obesity
First and second-degree Wenckebach AV block. Not on beta
blockers due AV block/bradycardia
Nephrolithiasis
tuberculosis (45yrs ago - treated)
ventral hernia repair
rt inguinal hernia repair x 2
left wrist ganglion removal
left antecubital nerve severed, s/p repair
rt heel spurs repair
Social History:
non-smoker, 2-3oz wine per day, married, 3 daughters
Family History:
father MI age 52, brother MI age 58
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 97.6 46 105/55 14 99 3L
GENERAL: 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: lying flat for post cath and thus no JVD appreciated..
CARDIAC: irreg irregular ryhthm, bradycardic, 3/6 SEM LSB, no S3
or thrills.
LUNGS: CTA B/L anterior lung fields.
ABDOMEN: Soft, NT/ND.
EXTREMITIES: [**1-24**]+ edema to knees B/L
NEURO: AAOx3, CNII-XII intact, 5/5 strength biceps
PULSES: DP/PT 2+ B/L
.
Pertinent Results:
ADMISSION LABS:
[**2127-4-21**] 02:00PM BLOOD WBC-7.4 RBC-3.55* Hgb-10.6* Hct-34.7*
MCV-98# MCH-29.9 MCHC-30.5* RDW-16.8* Plt Ct-166
[**2127-4-21**] 08:00AM BLOOD PT-11.6 INR(PT)-1.1
[**2127-4-21**] 02:00PM BLOOD Glucose-89 UreaN-20 Creat-0.9 Na-137
K-4.2 Cl-105 HCO3-29 AnGap-7*
[**2127-4-21**] 09:35AM BLOOD ALT-14 AST-14 CK(CPK)-27* AlkPhos-88
TotBili-0.4 DirBili-0.2 IndBili-0.2
[**2127-4-21**] 02:00PM BLOOD Calcium-9.0 Phos-2.7 Mg-2.1
[**2127-4-21**] 09:35AM BLOOD VitB12-353
[**2127-4-21**] 09:35AM BLOOD %HbA1c-6.2* eAG-131*
[**2127-4-21**] 09:35AM BLOOD Triglyc-111 HDL-50 CHOL/HD-2.5 LDLcalc-54
.
IMAGING:
.
[**4-21**] Cath:
FINAL DIAGNOSIS:
1. Moderate 2 vessel coronary artery disease with diffuse
atherosclerosis.
2. Mild pulmonary arterial hypertension.
3. Reinforce secondary preventative measures against CAD.
4. Additional plans per Dr. [**Last Name (STitle) **] and [**Doctor Last Name 171**].
5. Would advocate ASA desensitization in CVICU post-AVR so that
patient
can be discharged on aspirin 81mg daily rather than clopidogrel.
6. F/U with Dr. [**Last Name (STitle) 171**].
.
[**4-21**] CXR:
Since the prior study, there is interval progression of
bilateral interstitial opacities most likely representing
chronic interstitial lung disease, potentially fibrosis. Heart
size and mediastinum are unchanged including cardiomegaly. No
pleural effusion or pneumothorax is seen. The lung volumes are
low. Assessment of the patient with chest CT for precise
characterization of the severity and extent of pulmonary
abnormalities might be considered.
[**4-27**] CXR:
The left lower chest tube has been removed. The left upper chest
tube is still in place. There is a small left apical
pneumothorax, similar in size compared to the study from the
prior day. Mild pulmonary vascular
redistribution and volume loss in both lower lobes. Sternal
wires are again visualized.
[**4-28**] CXR:
Brief Hospital Course:
Mr. [**Known lastname 83900**] presented to CCU on [**2127-4-21**] for aspirin
desensitization. On [**2127-4-23**] he was taken to the operating room
and underwent the following:Aortic valve replacement with a
25-mm St. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 4041**] tissue valve,Coronary artery bypass
grafting times 1 with left internal mammary artery to left
anterior descending artery.CROSS-CLAMP TIME: 85 minutes. PUMP
TIME: 98 minutes. He tolerated the procedure well and was
transferred to the CVICU intubated and sedated in critical but
stable condition. He was initially requiring Phenylephrine with
sedation. He awoke neurologically intact and was weaned to
extubation early on POD#1. Pressor support was weaned off and
gentle diuresis begun. No beta-blockers initiated due to the
patient's history of first and second degree AV block. Pacing
wires were removed on POD#2 and he was started on coumadin for
pre-op a-fib. He was transferred to the floor on POD#2 with
chest tubes in place. A PICC line was placed for intravenous
access. On post-operative day number 3, the patient remained
hemodynamically stable with pAF. Coumadin therapy was continued.
The foley catheter was discontinued and the patient was started
on Cipro for a positive UA, urine culture was pending ([**4-26**]
results showed yeast). The patient sternal incision showed a
small amount of seroud drainage, and he was started on Kefzol.
Chest tubes were discontinued on post-op day 4 without
complication. Decreased steranl drainaeg, the Kefzol was
discontinued. The urine culture only showed yeast, and the
Cipro was also discontinued. Lopressor was discontinued for
intermittent Type II heart block. Continue to hold beta
blockers.
The patient INR is 2.2 today ([**2127-4-28**]), and he is
hemodynamically stable. He will be dischared on Lasix 80mg IV
BID x 7 days for his CXR and peripheral edema. Follow-up in
wound clinic in one week. The PICC line will remain in place
upon discharge to rehabilitation, the rehab center will be
advised to discontinue the PICC line once the course of IV Lasix
is complete. It is felt that he is safe to be discharged to New
[**Hospital 83901**] rehabilitation center in [**Location (un) 246**] on POD #5.
Medications on Admission:
Allopurinol 300 mg p.o. daily
Lipitor 80 mg p.o. q.h.s.
Atacand 4 mg tablet one p.o. q.h.s.
Plavix 75 mg p.o. daily
Colchicine/Probenecid combination 0.5 mg/500 mg one p.o. daily,
Finasteride 5 mg tablet one p.o. daily
Prednisone 5 mg tablet one p.o. daily with 2.5 mg tablet p.o.
q.h.s.
Flomax 0.4 mg capsule extended release one p.o. daily
Torsemide 20 mg tablet one p.o. daily
Warfarin daily as directed
Ranitidine
Hydrochloride extended release tablet one p.o. daily.
Discharge Medications:
1. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
4. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. probenecid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. prednisone 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
9. prednisone 5 mg Tablet Sig: 0.5 Tablet PO QPM (once a day (in
the evening)).
10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
12. Lasix Sig: Eighty (80) mg Intravenous twice a day for 7
days.
13. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
Two (2) Tablet, ER Particles/Crystals PO twice a day for 7 days.
14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for dyspnea.
15. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for dyspnea.
16. warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day:
Please take 1mg on [**2127-4-28**]. Check INR on [**2127-4-29**] and dose per
INR level.
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
Primary:
status post Aortic Valve Replacement/Coronary artrey bypass
grafting
Secondary:
1. Aortic stenosis
2. Peripheral vascular disease.
3. Status post abdominal aortic aneurysm repair (endovascular
repair in [**2120**] at [**Hospital1 2025**]).
4. Hypertension.
5. Dyslipidemia, moderate.
6. Paroxysmal atrial fibrillation on Warfarin.
7. Coronary artery disease
8. Probable ischemic cardiomyopathy with chronic systolic heart
failure with left ventricular ejection fraction of 30%.
9. Gout.
10. Steroid-dependent asthma.
11. Mild obesity.
12. First and second degree Wenckebach.
13. Nephrolithiasis.
14. Tuberculosis (45 years ago treated with INH).
15. Status post ventral hernia repair.
16. Status post right inguinal hernia repair x2.
17. Status post left wrist ganglion removal.
18. Left antecubital nerve repair, right heel spur.
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
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**
Recommended Follow-up:
You are scheduled for the following appointments
Surgeon:
Cardiologist:
Please call to schedule appointments with your
Primary Care Dr..... in [**12-23**] 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
Goal INR
First draw
Results to phone fax
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**2127-5-1**] at 10:00am for Wound Check
Surgeon: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**2127-5-29**] at 1:00pm
Cardiologist: [**Last Name (LF) 171**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], #[**Telephone/Fax (1) 62**]
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] within 1-2 weeks,
#[**Telephone/Fax (1) 4018**]
**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: Post-operative Atrial
Fibrillation.
Goal INR 2.0 - 2.5
First draw on [**2127-4-29**]
***Please chem 10 on [**2127-4-30**] to monitor renal function and
potassium.
Completed by:[**2127-4-28**]
|
[
"414.8",
"427.89",
"280.0",
"V45.89",
"733.00",
"117.9",
"592.0",
"V45.82",
"998.59",
"428.23",
"V12.01",
"E878.2",
"272.4",
"496",
"440.9",
"440.20",
"599.0",
"414.01",
"426.13",
"V58.61",
"V14.6",
"427.31",
"401.9",
"458.29",
"V58.65",
"493.20",
"274.9",
"424.1",
"278.00",
"428.0",
"V70.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"35.21",
"36.11",
"99.12",
"38.93",
"39.61",
"37.23",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
9115, 9145
|
4778, 7042
|
340, 684
|
10029, 10241
|
2851, 2851
|
11599, 12625
|
2216, 2253
|
7565, 9092
|
9166, 10008
|
7068, 7542
|
3503, 4755
|
10265, 11576
|
2268, 2278
|
2300, 2832
|
280, 302
|
712, 1536
|
2867, 3486
|
1558, 2129
|
2145, 2200
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,206
| 162,850
|
37835
|
Discharge summary
|
report
|
Admission Date: [**2145-9-20**] [**Month/Day/Year **] Date: [**2145-9-30**]
Date of Birth: [**2089-9-25**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ciprofloxacin / Lisinopril
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms [**Known lastname **] is a 55 yo F with h/o remote etoh abuse, colon
cancer, treated in [**2141**]-[**2142**] with resection and chemotherapy,
complicated by cirrhosis. She has had no evidence recurrence on
imaging including PET scan, but CEAs have been trending upward
(thought to be due to liver inflammation).
.
Pt admitted intially on [**8-27**] for shortness of breath, AMS,
confusion, lethargy x 48hrs thought to be hepatic
encephalopathy, given elevated ammonia, treated with Lactulose.
Also given fluids, dopamine, Levo/Vanco for hypotension. On
[**8-30**], pt developed respiratory distress and hypoxemia, was
intubated and treated for ARDS. Pt improved and vent was weaned
but pt's mental status did not improve with removal of sedation.
She was worked up with EEG (toxic metabolic slowing), head CT
(negative), Neuro consult (brain stem reflexes intact but
decreased higher cortical function. Considered etiologies
remained hepatic encephalopathy with ongoing treatment with
Lactulose and Rifaximin and good stooling response, as well as
slowed clearance of sedating medications used while intubated
given obesity. Pt continued to have daily spontaneous breathing
trials which she passed easily but given mental status was
maintained on minimal ventilator support and was trached on
[**9-17**] with Shiley trach. Pt repeatedly sedated with propofol and
ativan drip given agitation and fighting of vent.
.
Course also complicated by recurrent fevers to 101-102. All
cultures negative, including lines (central line pulled last
week). Bronchoscopy negative except [**Female First Name (un) **]. No evidence of
ascites on US or abd scans. Gallbladder was shown to be enlarged
and PCBD was placed on [**9-2**], ultimatelly gram stain negative and
no WBCs, 1wk later grew staph and thought to be contaminant.
Received off and on broad antibiotics, ultimately on Linezolid
and Aztreonam restarted on [**9-19**].
.
[**Name (NI) **], pt persistently had normal renal function (Cr 0.7-1)
and good urine output, until day of transfer when Cr bumped to
1.5 and pt developed hematuria.
.
Other issues have been persistent thrombocytopenia (60s-120s),
coagulopathy (INR 1.5-1.7, no bleeding). Given h/o gastric lap
banding, surgery had to release band for OG placement.
Past Medical History:
1) Nephrolithiasis
2) HTN
3) Sleep apnea on CPAP at home
4) DM insulin dependent
5) Anxiety
6) Hyperlipidemia
7) Osteoarthritis
8) Herniated Disc at C4-5
9) ESWL several times LTL85
10) s/p breast reduction
11) s/p herniorraphy
12) s/p appendectomy
13) depression
14) Colon cancer dx in [**2140**] ([**Location (un) **] C), s/p Right colectomy,
chemo +/-radiation. Known mets to omentum.
15) s/p lap band surgery
[**51**]) Cryptogenic cirrhosis, dx by biopsy in [**2142**], thought to be
due to steatohepatitis or chemo induced.
17) Chronic thrombocytopenia likely due to hypersplenism
18) Asthma
Social History:
Married, part time Delta reservations [**Doctor Last Name 360**], currently disabled,
[**12-4**] ppd smoker until [**2138**], none since. From [**Doctor Last Name **] [**Country **], in
[**Location (un) 86**] taking care of elderly mother, remainder of family in
[**Name (NI) **] [**Country **], here while pt ill.
Family History:
Mother and father with DM and Lung cancer.
Sister DM and breast cancer.
Physical Exam:
GENERAL: Obese, white female, moving all extremities, grimacing
to pain.
HEENT: Eyes open, sclera anicteric, dry oral mucosa, multiple
dry lesions over lower face, small papules without erythematous
base. Also acne appearing lesions over forehead. Trach in place,
skin breakdown around neck at site of attachment.
CARDIAC: RRR, no MRG.
LUNGS: CTAB, good air movement bilaterally
ABDOMEN: NABS. Soft, NT, ND. No HSM
BACK: PCBD in place, no surrounding erythema
EXTREMITIES: No edema, strong distal pulses, darkened skin over
feet.
SKIN: 3 decubitous ulcers over buttocks, one with central area
of necrosis.
NEURO: No purposeful movement but moves all 4 extremities. No
blink reflex
Pertinent Results:
WBC 7.3 on admission, stayed in [**6-11**] range through admission and
was 11.4 on d/c. N85 B0 L8 M3 E3 B0 Atyp0 Metas1 Myelos 0
Hct 30.3 on admission and 28.9 on d/c, MCV 95
Plts 70 on admission and 80 on d/c
Coags on d/c PT 21.0 PTT 44.2 INR 2.0
Fibrino 254
ESR 80
Retic 5.0
BUN/Cr 59/1.4 on admit 24/0.6 on dc
HyperNa on admission 147, peaked at 152 and dc was 145
ALT/AST 81/176 on admit and 82/127 on d/c
LDH 297 --> 244
AlkP 97 --> 164
Tbili 8.9 --> 16.8 --> at 14.3, was direct 10.0 and indirect
4.3
Amylase 71
Lipase 83
Last albumin 2.6 on [**9-28**]
Iron 146
Hapto <20 x2
TIBC 166
Ferritin 554
Transferrin 128
B12 1782
Folate 8.4
Trigly 193
TSH 1.6
T4 2.7
IgM HAV negative
AMA negative
[**Doctor First Name **] negative
CRP 22.0
CEA 29
anti TPO less than 10
HCV Ab negative
STUDIES:
CT head and torso on [**8-30**]: PNA, ARDS, cannot exclude pulm mets,
splenomegally, distended gallbladder, small ascites.
.
Head CT [**9-5**]: Neg
.
EEG: Encephalopathic without burst suppression pattern.
.
Chest CT [**9-13**]: Mild cardiomegally, trace bilateral pleural
effusions, bilateral dependent lower lobe consolidation or
atelectasis, diffuse ground glass appearance c/w interstitial
pneumonitis or ARDS. Extensive perivascular anterior mediastinal
nodes stable.
.
Abd CT: Small ascites, nodular liver, BIIIIG spleen, s/p PCBD,
no LAD, stones, masses
.
ECHO [**9-13**]: EF 60%, mild LVH, mild MR
.
CXR [**9-20**]: Rotated to the right, bibasilar consolidation vs
fluid overload. Trach, OG and PICC in place.
.
[**2145-9-21**] Abdomen U/S
IMPRESSION:
1) Cholecystostomy tube not visualized.
2) Soft tissue thickening anterior to the anterior surface of
the liver which
could represent omental metastases in light of history of colon
carcinoma as
suggested by OMR note, although the PET scan was reported as
negative. Repaet
CT scan may be of value.
3) Mild splenomegaly.
4) No source of sepsis identified.
[**2145-9-21**] CT head
IMPRESSION:
1. No acute intracranial process.
2. Paranasal sinus minor inflammatory disease, and partial
fluid-
opacification of the mastoid air cells, some of which may relate
to
intubation.
[**2145-9-21**] CT abdomen
IMPRESSION:
1. Percutaneous cholecystostomy tube adjacent to a collapsed
gallbladder. It
is unclear whether the tip is barely within the collapsed
gallbladder or just
out side. As the tube was not visualized on ultrasound this is
concerning for
tube malpositioning. Further evaluation with tube cholangiogram
under
fluoroscopy is recommended.
2. No evidence of omental mass or thickening in the upper
abdomen (note that
the pelvis was not imaged)
3. Splenomegaly.
4. Trace amount of perihepatic fluid.
5. Bibasilar pulmonary consolidations. Considerations include
atelectasis
and/or infection and these must be placed in clinical context.
[**2145-9-22**] Spinal fluid
Cerebrospinal fluid (LP):
NEGATIVE FOR MALIGNANT CELLS.
Many lymphocytes and monocytes.
[**2145-9-23**] MRI head
IMPRESSION:
1. No evidence of intracranial mass or abnormal enhancement.
2. Diffuse thickening of the calvarium with decrease dsignal-
nonspeciifc
finding and can be seen with anemia, myeloproliferative or
infiltrative
malignancies/disorders- to correlate with labs.
3. Diffuse mucosal thickening/ fluid within bilateral mastoid
air cells.
Clinical correlation is recommended.
[**2145-9-24**] EEG
IMPRESSION: This is an abnormal portable EEG study due to
slowing and
disorganization of the background activity. These findings
suggest a
moderate encephalopathy involving cortical and subcortical
structures.
Medications, toxic/metabolic disturbances, and infection are the
most
common causes. There were no areas of prominent focal slowing
although
encephalopathies can obscure focal findings. No epileptiform
features
were noted during this recording.
[**2145-9-24**] Peritoneal fluid
Peritoneal fluid:
ATYPICAL.
Rare cluster of atypical epithelioid cells, cannot exclude
carcinoma.
[**2145-9-24**] Echo
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Left ventricular systolic
function is hyperdynamic (EF 70-80%). Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
masses or vegetations are seen on the aortic valve, but cannot
be fully excluded due to suboptimal image quality. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. No masses or vegetations are seen on the mitral
valve, but cannot be fully excluded due to suboptimal image
quality. No masses or vegetations are seen on the tricuspid
valve, but cannot be fully excluded due to suboptimal image
quality. The pulmonary artery systolic pressure could not be
determined. No masses or vegetations are seen on the pulmonic
valve, but cannot be fully excluded due to suboptimal image
quality. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. No obvious vegetation
[**2145-9-29**] RUQ u/s
IMPRESSION: Small amount of pericholecystic fluid. Otherwise, no
significant
change since prior studies.
Brief Hospital Course:
.
MICU Course
1. Pt arrived to MICU from OSH with altered mental status likely
from a combination of medication overload in the setting of
liver dysfunction and hepatic encephalopathy. Lactulose and
rifaximin where continued, sedation was decreased and mental
status began to improve with some clearing and purposeful
movements but unable to follow commands. Moderate
encephalopathy on EEG. Was also started on acyclovir given rash
on face and +Ab to HSV2 in [**Last Name (LF) **], [**First Name3 (LF) **] continue for 7d (last
dose 10/28). Also started on thiamine given questionable
nutrition status in setting of lap band. To date, blood, urine,
spututm cultures negative.
2. Cirrhosis with etiology likely combination of chemotherapy
induced and fatty liver, also with component of active liver
inflammation and rising bilirubin. Had a perc chole drain
placed at OSH, which was pulled in house after a CT scan showed
that it may have been out of place. Viral studies negative or
pending. Followed by the liver sevice and not a transplant
canditated given h/o metastatic colon cancer history w/ < 5 yrs
from colectomy and diagnosis.
3. Pt arrived with trach in place with minimal ventilator
support and was eventually able to breath with only a trach
mask.
4. Thrombocytopenia and coagulopathy stable since arrival and
thought likely secondary to underlying cirrhosis.
5. Arrived with several decubitous ulcers, one Stage II. Wound
care following and some improvement reported. Has had daily
dressing changes and a flexiseal for stool.
6. Initially with an elevated creatinine and hematuria.
Creatinine improved and hematuria resolved. Also with
hypernatermia likely from volume resucitation and inability to
take po, Sodium improved with free water and is now normal. Pt
was maintained on insulin sliding scale and lantus for diabetes.
Medications on Admission:
1. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
2. Albuterol-Ipratropium 10 PUFF IH Q6H
3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
4. Propofol 5-20 mcg/kg/min IV DRIP TITRATE TO sedation
5. Docusate Sodium (Liquid) 100 mg PO BID
6. Quetiapine Fumarate 50 mg PO BID
7. Heparin 5000 UNIT SC TID
8. Rifaximin 400 mg PO TID
9. Insulin SC
10. Senna 1 TAB PO BID:PRN Constipation
11. Lactulose 30 mL PO TID
[**First Name3 (LF) **] Medications:
1. Thiamine HCl 100 mg Tablet [**First Name3 (LF) **]: One (1) Tablet PO DAILY
(Daily) for 30 days.
2. Rifaximin 200 mg Tablet [**First Name3 (LF) **]: Two (2) Tablet PO TID (3 times a
day).
3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
4. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [**Last Name (STitle) **]: Ten
(10) Puff Inhalation Q6H (every 6 hours).
5. Lactulose 10 gram/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO TID (3
times a day): goal minimal bowel movement of >1.5 liter or 4
bowel movements per day.
6. Quetiapine 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2 times a
day) as needed for agitation.
7. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Two (2) 5 mL PO BID (2
times a day). 5 mL
8. Therapeutic Multivitamin Liquid [**Last Name (STitle) **]: Five (5) ML PO DAILY
(Daily) for 5 days.
9. Ursodiol 300 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO TID (3 times
a day).
10. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: see standard
hospital sliding scale units Injection qacqhs: By disharge pt
was receiving 40U Glargine at bedtime and Regular ISS 6U
starting at 81 mg/dL and increasing 2U every 40mg/dL.
11. PICC line
Care per protocol
12. PICC line flush
Flush PICC with 10cc normal saline followed by 2cc 100unit/cc
heparin in each lumen daily and after intermittant
infusion/transfusion/blood draw.
13. Nadolol 20 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily).
[**Last Name (STitle) **] Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
[**Location (un) **] Diagnosis:
1. Cirrhosis
2. Altered Mental Status
3. Respiratory Failure
4. Thrombocytopenia
5. Acute Renal Failure
6. Diabetes
[**Location (un) **] Condition:
By the time of [**Location (un) **] the pt's vital signs were stable
however mental status was poor, she responded to voice and
minimal verbal commands
[**Location (un) **] Instructions:
You were seen in the MICU after transfer from [**Hospital1 5109**] for changes in your mental status in the setting of
liver failure. It is thought that since your liver is not
working well, toxins are building up in your body and affecting
your brain and your ability to think clearly. Also you received
a lot of medications when you had to be intubated that took a
long time to clear out of your body because your liver is not
working.
You were evaluated by the liver doctors and it was determined
that you are currently not a candidate for a liver transplant
because you had cancer within the past five years. The reason
that you have liver failure is not entirely clear at this time,
but is thought to be related to the chemotherapy you received
for the cancer as well as to fat build up in your liver. There
have been many tests that have been done, that can be followed
up with the liver doctors [**First Name (Titles) **] [**Last Name (Titles) **].
Please return to the hospital if you experience any fevers,
chills, night sweats, worsening of your mental status,
Followup Instructions:
Please follow up with Heptology on [**2145-10-22**] at 3:20pm, with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**], at the Liver Center, at [**Hospital **] Medical Building,
[**Location (un) **].
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2145-9-30**]
|
[
"V44.0",
"285.9",
"707.23",
"715.90",
"311",
"584.5",
"V10.05",
"197.6",
"493.90",
"287.5",
"V45.72",
"518.81",
"V15.3",
"250.01",
"327.23",
"V87.41",
"V58.67",
"599.70",
"572.2",
"286.9",
"571.5",
"054.9",
"707.03",
"722.0",
"272.4",
"276.0",
"707.05",
"278.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.72",
"96.08",
"03.31",
"87.65"
] |
icd9pcs
|
[
[
[]
]
] |
9628, 11487
|
342, 348
|
4407, 9605
|
15179, 15568
|
3617, 3690
|
11513, 13707
|
3705, 4388
|
13739, 13857
|
281, 304
|
13889, 14043
|
14078, 15156
|
376, 2649
|
2671, 3269
|
3285, 3601
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,475
| 127,730
|
47268
|
Discharge summary
|
report
|
Admission Date: [**2146-1-17**] [**Month/Day/Year **] Date: [**2146-1-22**]
Service: MEDICINE
Allergies:
Iodine Containing Agents Classifier
Attending:[**First Name3 (LF) 2167**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
85 year old female with CAD s/p NSTEMI, PVD s/p left BKA, ESRD
on HD presenting from a [**Hospital1 1501**] with hypotension. This is her third
hospitalization this month. From [**Date range (1) 94282**] she was
hospitalized for lower GI bleed, complicated by hypoxemia. The
hypoxemia was attributed to volume overload/CHF and was found to
have bilateral pleural effusions--she responded to
ultrafiltration/hemodialysis. In regards to the GIB, she was
transfused 1 u prbc for HCT of 25. She prepped for colonoscopy
multiple times, but was unsuccessful. She was discharged to
rehab with a plan for outpatient colonoscopy.
She was hospitalized again on [**1-12**] for lower GI bleed/guaiac
positive stool at [**Hospital1 1501**]. Her HCT was stable. She refused
preparation for colonoscopy and refused further work up of her
effusions. She was discharged home with plan for outpatient
colonoscopy.
The day prior to admission, she went to HD and reports being
fatigued out of proportion to her baseline. She was in bed all
day, with decreased po intake. She was told her stool was
guaiac positive--but she did not see it. On routine vitals, the
day of admission, she was found to be hypotensive--per report
from the ED, was 74/42. No [**Hospital1 1501**] documentation accompanies
patient. She denied any symptoms at the time, but when she sat
up in bed to eat breakfast, she reports dizziness. This symptom
accompanied movement during the course of the day, but was not
constant. She denied vertigo, blurry vision, chest pain,
shortness of breath, abdominal pain or any other specific
symptoms. She also reports a large stool this morning--but did
not see it and cannot tell if it was bloody/black/loose.
At arrival to the ED, her vitals were 97.8 95/50 82 18 100% 2L.
She had a single decrease in her BP to 89/34, but responded to
500 cc bolus. Her BP ranged 94-106/34-48. She was given 1 gram
of Ceftriaxone for presumed pneumonia given her leukocytosis and
left shift. CXR demonstrated bilateral effusions and CT abdomen
demonstrated bilateral effusions without an acute process.
Currently, she reports discomfort on her left hip from the bed.
She is hungry. She denies chest pain, lightheadedness, shortness
of breath, abdominal pain, ongoing loose stool, ongoing
dizziness or any other complaints.
Past Medical History:
1.CAD s/p NSTEMI in [**4-27**]. Medically managed, felt not to be
candidate for catheterization. Plavix had to be stopped due to
rectus sheath hematoma. Post-MI echocardiogram demonstrated
regional LV systolic dysfunction with inferolateral/basal
inferior wall hypokinesis with EF of 50-55%, elevated LV filling
pressure and 1+ MR.
2. PVD s/p left BKA with Dr. [**Last Name (STitle) **]
3. Insulin dependent diabetes mellitus
4. Hypertension
5. Hyperlipidemia
6. ESRD on HD M/W/F
7. Positive PPD -- hospitalized at [**Hospital1 2025**], had 3 negative sputum
8. Lower GI Bleed--unable to tolerate colonoscopy prep as
inpatient, plan for outpatient procedure
9. Stage IV Decubitus ulcer, 2 ischial ulcers and heel ulcer.
10. Depression
11. Colon cancer s/p resection
Social History:
currently at rehab, lives alone with son in apartment below, no
tobacco, alcohol or drugs. Widowed
Family History:
Parents lived until 95. Cause of death is unknown, but patient
denies a family history of CAD/MI or early cardiac death.
Physical Exam:
VS: 99 123/40 79 16 100% 2L
Gen: well appearing, no distress, speaking in complete
sentences, hard of hearing
HEENT: EOMI, MM dry/OP clear
Neck: no JVD visible
Chest: HD line c/d/i, nontender
Car: Regular, distant, no murmur
Resp: markedly decreased BS on left, with audible sounds at apex
posteriorly and audible over anterior, [**Month (only) **] BS on right 1/2 up
with crackles, no wheeze, no ronchi
Abd: s/nt/nd/nabs, ecchymoses over abdominal wall, liver
palpable, nontender, small, nonbleeding external hemorrhoids
Ext: s/p BKA on left--incision well healed. Right leg in boot,
ulcer is clean based and covered with gauze, no surrounding
erythema, no edema
Back: dressed wounds
Neuro: CN II-XII intact except hearing decreased bilaterally,
strength 5/5 in UE, [**2-24**] LE bilaterally
Pertinent Results:
Admission Labs:
[**2146-1-17**] 10:45AM WBC-13.1*# RBC-3.04* HGB-7.8* HCT-25.7*
MCV-85 MCH-25.7* MCHC-30.4* RDW-18.4*
[**2146-1-17**] 10:45AM NEUTS-91.0* LYMPHS-5.7* MONOS-2.7 EOS-0.2
BASOS-0.3
[**2146-1-17**] 10:45AM PLT COUNT-251
[**2146-1-17**] 10:45AM PT-15.2* PTT-27.1 INR(PT)-1.3*
[**2146-1-17**] 10:45AM cTropnT-0.29*
[**2146-1-17**] 10:45AM GLUCOSE-167* UREA N-18 CREAT-2.6* SODIUM-143
POTASSIUM-3.3 CHLORIDE-100 TOTAL CO2-34* ANION GAP-12
.
CT abdomen: 1. Significant bibasilar pleural effusions with mass
effect on the adjacent lung parenchyma as described above. 2. No
evidence of free air or fluid in the intra-abdominal cavity. 3.
Interval decrease of the right rectus sheath hematoma. 4. Rectal
wall thickening. Recommend clinical correlation of possible
prolapse. 5. Diffuse diverticular disease without evidence of
acute diverticulitis. 6. Unchanged moderate-to-severe
degenerative diseases.
.
CXR: There is a large left pleural effusion and moderate right
pleural effusion with obscuration of bilateral hemidiaphragms.
No pneumothorax is detected. The heart is not well delineated
given effusions. A repeat chest radiograph may be helpful after
left thoracentesis.
.
Echo:
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is 0-10mmHg. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is mild regional left ventricular systolic dysfunction
with hypokinesis of the basal 2/3rds of the inferior and
inferolatreal walls. The remaining segments contract normally
(LVEF = 45 %). 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) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
moderate pulmonary artery systolic hypertension. There is a
prominent anterior fat pad..
Compared with the prior study (images reviewed) of [**2145-5-1**],
moderate pulmonary artery systolic hypertension is now
identified. Regional and global left ventricular systolic
function are similar.
.
Urine cultures: preliminary staphylococcus and streptococcus.
Brief Hospital Course:
1. Hypotension: Patient had an associated leukocytosis with left
shift concerning for infectious source. The patient remained
normotensive during her hospital stay. She received 1 bolus of
500cc NS, and did not require any pressors. She was noted to
have stage III ulcerations on admission, and wound care was
consulted. Blood cultures were drawn and were negative at time
of [**Year (4 digits) **]. She was found on urine culture to grow
staphyloccocus and streptococcus, speciation pending at time of
[**Year (4 digits) **], and is being treated empirically with vancomycin for
a total 10 day course, to be completed at dialysis. She was also
transfused 1 u prbc for HCT of 23, and hematocrit remained
stable thereafter.
.
2. Bilateral effusions: noted over the last several admissions.
Likely related to volume overload/diastolic CHF. Patient has
refused work up/thoracentesis in the past, and continues to
refuse on this admission. She was weaned to 2L of oxygen at time
of [**Year (4 digits) **]. She will need continued fluid removed at dialysis.
.
3. LGIB: recent admissions for lower GI bleed. Unable to
tolerate colonoscopy prep as inpatient, procedure scheduled for
early [**Month (only) 404**]. No stool in vault in ED for guaiac. HCT was 23
on [**1-17**] and patient given 1 u prbc given hypotension, positive
troponin and history of bleeding. She remained stable throughout
the remainder of her hospital stay. Aspirin was held.
.
4. CAD: Patient was noted to have an elevation in her troponin
compared to baseline without comparable change in creatinine.
Had medically-managed MI in [**4-27**]. Continue beta blocker and
statin. She was transiently given aspirin 325 mg daily, which
was held again after she completed her rule out for an MI. She
had an echo which was unchanged, and her EKG was unchanged as
well.
5. Hypertension: Her antihypertensives were held transiently,
but restarted after stabilization.
6. DM2: continued on outpatient Lantus and SSI, with a slight
decrease in the Lantus dose.
.
7. Depression: Continued remeron and celexa
8. ESRD: She received hemodialysis while inpatient.
9. PVD: She was evaluated by vascular surgery during her
inpatient stay. She will need to follow up with vascular surgery
two weeks after [**Date Range **].
.
10. Wounds: Wound care was consulted. Their recommendations for
care of her stage III ulcers were followed. She had no signs of
infection in her ulcers.
.
11. Chest pain. Patient had a transient episode of chest
pressure the night prior to [**Date Range **], which caused a delay in
her [**Date Range **]. Her EKG was unchanged, three sets of cardiac
enzymes were negative, and her chest x-ray showed no new
evidence of consolidation or worsening of her known effusions.
She does have evidence of continued large left sided effusion
and perihilar congestion, which will require fluid removal at
dialysis to help resolve. Given the highly atypical nature of
her pain, and the fact that it improved once she fell asleep, it
may have been related to anxiety around the process of
[**Date Range **].
.
She remained full code throughout her stay.
Medications on Admission:
Celexa 15 mg po qhs
Simvastatin 40 mg qhs
Remeron 7.5 mg qhs
Oxycodone 5 mg po q6h prn
Metoprolol tartrate 25 mg po tid
Albuterol neb q4h prn wheeze
Guaifenasin 5 cc po q6h prn
NTG SL prn
SSI
Dulcolax prn, MOM prn
Acetaminophen prn
Ativan 0.5 mg po prior to HD
ECASA 325 mg daily--on hold until after colonoscopy
Lantus 10 u qhs
Nephrocaps
Omeprazole 20 mg daily
Sevelamer 800 mg tid
Lisinopril 5 mg po daily
[**Date Range **] Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed.
7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
15. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. Insulin Glargine 100 unit/mL Solution Sig: Per scale Per
scale Subcutaneous four times a day.
17. Vancomycin 1,000 mg Recon Soln Sig: One (1) gm Intravenous
every seventy-two (72) hours for 5 days: Per HD protocol, dose
for vanc level <15. .
[**Date Range **] Disposition:
Extended Care
Facility:
[**Hospital3 9475**] Care Center - [**Location (un) 3146**]
[**Location (un) **] Diagnosis:
1. Hypotension
2. ESRD on HD
3. Acute blood loss anemia
4. Lower GI bleed
5. Stage III pressure ulcers
6. Bilateral pleural effusions
7. Urinary tract infection
[**Location (un) **] Condition:
Stable
[**Location (un) **] Instructions:
You were admitted with low blood pressures, which is likely from
a urinary tract infection. You were treated with vancomycin
which you will need to continue for a total of 10 days. This
will be given to you at dialysis.
Followup Instructions:
Please follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **]
from your rehabilitation facility.
You have an appointment for a colonoscopy to be performed as an
outpatient. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2146-1-27**] 10:00
You will need to follow up with vascular surgery in 2 weeks
after [**Year/Month/Day **]. Please call to make an appointment with Dr.
[**Last Name (STitle) **] at [**Telephone/Fax (1) 2395**].
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2146-1-27**] 10:00
|
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69,011
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16364
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Discharge summary
|
report
|
Admission Date: [**2156-2-14**] Discharge Date: [**2156-2-27**]
Date of Birth: [**2080-11-20**] Sex: F
Service: MEDICINE
Allergies:
Premarin
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Reason for Transfer: CHF/Respiratory Distress
Major Surgical or Invasive Procedure:
Right-to-left femoral-to-femoral bypass
with polytetrafluorethylene. (PTFE)
History of Present Illness:
75F y/o with HTN, HLD, s/p endovasculary repaired AAA [**2151-5-20**],
CAD s/p emergent CABGX4 for STEMI [**1-19**], CHF (EF = 20-25%),
readmitted [**2-14**] w/ LLE vasc occlusion, s/p fem-[**Doctor Last Name **] [**2-18**] now with
worsening SOB, episodic hypotension and worsening L pleural
effusion.
Recently admitted in [**2155-12-28**] for STEMI, went to CABG from cath
lab, required 3 pressors + a balloon pump pre-operatively and
several days post-op. She had a post-operative EF of 20%.
Post-operative course was notable for fluid overload and need
for diureses which was difficult given marginal cardiac output.
Extubated on post-op day 10. Discharged home on [**2-4**]. She was
re-admitted [**Date range (1) 5553**] for progressive SOB since discharge, was
found to have a L pleural effusion, underwent successful
thoracentesis, repeat echo again showed her EF to be 20-25%.
On [**2-13**] presented to OSH, was readmitted [**2-14**] with progressive
dyspnea, N&V, RLQ pain and LLE pain and numbness. [**Last Name (un) **] as found
to have a cold left extremity and loss of distal LLE and was
admitted to vascular surgery. Prior to surgery, patient
received 3L volume, interspersed with lasix. On [**2156-2-18**], patient
went to OR for R to L fem-fem bypass with PTFE. EF was 15%
intra-op and patient received albumin and fluid. POD1, she had a
thoracentesis that drained -1L cc simple fluid and felt a lot
better. In subsequent days, however, patient became
progressively more tachypnic, and under the guidance of the IP
team, patient was aggressively diured with progressively higher
doses of IV lasix. Throughout her entire hospital course
(cardiac surgery team, vasc surgery team), she appears to be
currently net even.
On the morning of transfer, patient was in severe respiratory
distress with RR 30s, desatting, and hypotensive with SBP 70s
(after receiving 20mg IV lasix and carvedilol 3.125), limiting
diuresis. She has an IJ in place, showing CVP 15-17. On exam,
she had no LE edema, but does have significant sacral edema.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
- CABG: CABG x4(LIMA->LAD, svg->OM1,svg-Y-graft->diag, svg->pda)
[**2156-1-19**]
-Atrial Fibrillation
3. OTHER PAST MEDICAL HISTORY:
H pylori
Back pain
Osteopenia
Pancreatic cyst
AAA s/p endovascular repair [**2151-5-20**]
Social History:
She exercises three times a week at her adult day center. She is
a nonsmoker. She does not drink alcohol or use illicit drugs.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
PHYSICAL EXAMINATION on admit:
VS: T=98.7 BP=96/67 HR=91 RR=23 O2 sat= 98(3L)
GENERAL: [**Location 7972**]/Portuguese-speaking only. NAD. Oriented
x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM.
NECK: Supple with JVP of 12 cm.
CARDIAC: RRR, distant heart sounds, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4. sternotomy wound non-healing
distally with serous drainage.
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: normoactive bowel sounds, soft, NTND.
EXTREMITIES: 2+ sacral edema, no peripheral edema, peripheries
are warm, well-perfused. left fem-[**Doctor Last Name **] scar healing well.
PHYSICAL EXAM on Discharge:
Vitals - Tm/Tc: 98.4/98.5 HR:67-83 BP:83-90/57-61 RR:18 02 sat:
95% RA
In/Out:
Last 24H:[**Telephone/Fax (1) 46592**]
Last 8H:290/600
Weight:61.9 (61.9)
Tele: SR, 80-100, bigeminy
GENERAL: 75 yo F in no acute distress
HEENT: mucous membs moist, no lymphadenopathy, JVP non elevated
CHEST: CTABL no wheezes, no rales, no rhonchi. sternotomy
approximated.
CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or
gallops
ABD: soft, non-tender, non-distended, BS normoactive.
EXT: bilat groins with dressing, no recent bleeding.
NEURO: 4/5 strength in U/L extremities. gait WNL.
SKIN: no rash
PSYCH: concerned, alert, oriented per interpreter
Pertinent Results:
LABS ON ADMIT:
[**2156-2-14**] 01:03PM BLOOD WBC-8.7 RBC-3.83* Hgb-12.0 Hct-38.3
MCV-100*# MCH-31.5 MCHC-31.5 RDW-17.2* Plt Ct-190
[**2156-2-14**] 01:03PM BLOOD Neuts-77.5* Bands-0 Lymphs-17.9*
Monos-3.3 Eos-0.5 Baso-0.7
[**2156-2-14**] 01:55PM BLOOD PT-14.8* PTT-32.2 INR(PT)-1.4*
[**2156-2-14**] 01:03PM BLOOD Glucose-158* UreaN-24* Creat-1.2* Na-130*
K-5.4* Cl-96 HCO3-13* AnGap-26*
[**2156-2-14**] 05:32PM BLOOD ALT-76* AST-128* LD(LDH)-433*
AlkPhos-123* Amylase-68 TotBili-1.0
[**2156-2-14**] 05:32PM BLOOD Lipase-71*
[**2156-2-14**] 01:55PM BLOOD cTropnT-0.06*
[**2156-2-18**] 03:40AM BLOOD proBNP-[**Numeric Identifier 46593**]*
[**2156-2-18**] 02:20PM BLOOD CK-MB-3 cTropnT-0.03*
[**2156-2-18**] 10:32PM BLOOD CK-MB-3 cTropnT-0.04*
[**2156-2-14**] 01:03PM BLOOD Calcium-9.4 Phos-5.0*# Mg-2.2
[**2156-2-14**] 02:11PM BLOOD Type-CENTRAL VE pO2-44* pCO2-39 pH-7.31*
calTCO2-21 Base XS--6
[**2156-2-14**] 02:11PM BLOOD Lactate-6.2* K-6.1*
LABS ON DC:
[**2156-2-27**] 07:00AM BLOOD WBC-6.0 RBC-3.86* Hgb-12.2 Hct-36.5
MCV-95 MCH-31.5 MCHC-33.3 RDW-18.0* Plt Ct-290
[**2156-2-27**] 07:00AM BLOOD PT-13.6* INR(PT)-1.3*
[**2156-2-27**] 07:00AM BLOOD Glucose-94 UreaN-10 Creat-0.6 Na-138
K-4.5 Cl-100 HCO3-29 AnGap-14
[**2156-2-27**] 07:00AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.3
CXR [**2156-2-14**]:
1. Increased moderate left pleural effusion with overlying
atelectasis,
underlying consolidation can not be excluded. Possibly small
right pleural
effusion.
2. Right lower lobe atelectasis versus infection. Clinical
correlation is
recommended.
CTA AORTA/BIFEM/ILIAC [**2156-2-17**]:
1. Bilateral pleural effusions with a large left nonhemorrhagic
pleural
effusion and moderate right pleural effusion.
2. Mild right renal artery stenosis.
3. Subcentimeter hypodensities within the liver and right kidney
which remain
too small to characterize, statistically representing cysts.
4. Replaced left hepatic artery arising from the left gastric
artery.
5. Thrombosis of the left common iliac artery with
reconstitution of the
distal common iliac artery at the bifurcation. slow flow within
the left
extremity vessels. There is two-vessel runoff on the left. The
posterior
tibial artery is not visualized.
PLEURAL FLUID [**2156-2-19**]:
NEGATIVE FOR MALIGNANT CELLS. Mesothelial cells, macrophages,
neutrophils and lymphocytes.
CXR [**2156-2-23**]:
Moderate left pleural effusion which reaccumulated following
thoracentesis is Stable since [**2-22**], as are
small-to-moderate right pleural effusion, severe cardiomegaly,
and pulmonary vascular engorgement. Today, there is no finding
of interstitial pulmonary edema. Right jugular line ends
centrally. No pneumothorax.
Brief Hospital Course:
HOSPITAL COURSE: 75F y/o with HTN, HLD, s/p endovasculary
repaired AAA [**2151-5-20**], CAD s/p emergent CABGX4 for STEMI [**1-19**],
CHF (EF = 20-25%), who was readmitted on [**2-14**] w/ LLE vasc
occlusion, s/p fem-[**Doctor Last Name **] [**2-18**] transferred to the CCU for worsening
dyspnea, likely secondary to pulmonary edema, complicated by
hypotension. Was diuresed and dc/ed in stable condition.
ACTIVE ISSUES:
# Acute on Chronic systolic CHF: Patient's last TTE showed EF
15-20% and she is frequently noted to be hypervolemic secondary
to CHF. She appeared euvolemic at dc. She was on low dose
furosemide and captopril for afterload reduction. Digoxin
started this admission as well. Holding off on aldactone. Low
dose BB.
# CAD: Patient is s/p CABGX4 for STEMI [**1-19**]. Sternotomy wound
appears to be healing. We dced her on Aspirin EC 325 mg PO
DAILY, Atorvastatin 20 mg PO/NG DAILY, Clopidogrel 75 mg PO/NG
DAILY, Lisinopril 5mg, Digoxin 0.125 mg PO/NG DAILY and
metoprolol XL
#Atrial Fibrillation/Low EF/akinesis of apex: Patient was noted
on discharge from cardiac surgery service on [**2156-2-12**] to have
been in afib so she was started on amiodarone 200mg [**Hospital1 **]. Patient
converted back to sinus rhythm by the time of discharge and has
not been noted to be back in afib during this current
hospitalization. Coumadin was started for combination of apical
hypokinesis and PAF.
# Respiratory Distress: resolved on d/c, breathing 93-98% on RA,
can tolerate lying flat.
# s/p fem-fem bypass: Revascularized and good 1+ DP/PT pulses
b/l. Left-sided surgical scar was dry and healing. Per vascular
surgery, no special wound care is necessary.
# HLD: we continue home atorvastatin 20mg daily
TRANSITIONAL ISSUES: The pt was set up for f/up with PCP, [**Name10 (NameIs) **]
[**First Name (STitle) 437**] for CHF and Vascular Surgery.
Medications on Admission:
HOME MEDICATIONS:
1. aspirin 81 daily
2. docusate sodium 100 mg [**Hospital1 **]
3. atorvastatin 20 mg daily
4. amiodarone 200 mg [**Hospital1 **]
5. ipratropium-albuterol 18-103 mcg/actuation 2 puffs q4h
6. carvedilol 3.125 mg [**Hospital1 **]
7. tramadol 50 mg Q4H
8. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**12-29**]
drops Ophthalmic QID
9. furosemide 40 mg PO DAILY
10. potassium chloride 20 mEq DAILY
Transfer Meds:
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN bronchospasm
Artificial Tears Preserv. Free 1-2 DROP BOTH EYES PRN dry eyes
Aspirin EC 325 mg PO DAILY
Acetaminophen 650 mg PO/NG TID pain
Albumin 5% (25g / 500mL) 25 g IV ONCE Duration: 1 Doses
Cepacol (Menthol) 1 LOZ PO PRN sore throat
Carvedilol 3.125 mg PO/NG [**Hospital1 **]
Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
Docusate Sodium 100 mg PO BID
Furosemide 20 mg IV BID
Furosemide 20 mg IV ONCE Duration: 1 Doses
Furosemide 1-10 mg/hr IV DRIP INFUSION
Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
Heparin Flush (10 units/ml) 1 mL IV PRN line flush Temporary
Central Access-Floor: Flush with 10 mL Normal Saline followed by
Heparin daily and PRN.
Heparin 5000 UNIT SC TID Start: In am
Ipratropium Bromide Neb 1 NEB IH Q6H:PRN bronchospasm
Insulin SC (per Insulin Flowsheet) Sliding Scale
Morphine Sulfate 1 mg IV Q4H:PRN breakthrough pain
Ondansetron 4 mg IV ONCE Duration: 1 Doses
Senna 1 TAB PO/NG [**Hospital1 **]
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. ipratropium-albuterol 18-103 mcg/actuation Aerosol Sig: Two
(2) puffs Inhalation every four (4) hours.
4. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
0.5 Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*15 Tablet Extended Release 24 hr(s)* Refills:*2*
5. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Outpatient Lab Work
please check Chem-7 and INR on Monday [**2156-3-1**] with results to Dr.
[**Last Name (STitle) **] at Phone: [**Telephone/Fax (1) 7976**]
Fax: [**Telephone/Fax (1) 13238**]
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for constipation. Tablet(s)
10. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
11. warfarin 2 mg Tablet Sig: 2.5 Tablets PO once a day.
Disp:*75 Tablet(s)* Refills:*2*
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
-Acute on Chronic systolic congestive heart failure
-Left lower extremity ischemia with
occluded left limb of a prior aortic endograft
- Diabetes
- Hypertension
- Coronary artery disease
- Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 2470**],
You were admitted to the vascular service for left lower
extremity vascular occlusion. You underwent a surggical bypass
procedure in your leg to help your symptoms. You were
transferred to the cardiology service, since you developed
shortness of breath and extra fluid around your lungs.
.
In the ICU, you had this fluid removed with diuretics. You
developed an abnormal heart rhythm called atrial fibrillation,
but this went back to a normal rhythm prior to discharge. You
had an echocardiogram of your heart, which showed that the
function of the heart is somewhat depressed. Due to the above,
we discussed using a blood thinner to prevent risk of stroke
with your primary care doctor, and you will start a medication
called coumadin for this.
.
MEDICATION CHANGES:
- STOP amiodarone for your atrial fibrillation
- STOP carvedilol, START metoprolol succinate instead to lower
your heart rate
- START coumadin (warfarin)to prevent a stroke from the atrial
fibrillation
- START digoxin to help your heart pump better
- START lisinopril to help your heart pump better
- START plavix after your operation
- CHANGE furosemide (lasix) to 20 mg daily instead of 40 mg
daily
- STOP taking potassium
- START taking senna as needed to prevent constipation
h yourself every morning, call Dr. [**First Name (STitle) 437**] if weight goes up more
than 3 lbs in 1 day or 5 pounds in 3 days.
Followup Instructions:
Department: [**Hospital1 7975**] INTERNAL MEDICINE
When: FRIDAY [**2156-3-5**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: CARDIAC SERVICES
When: MONDAY [**2156-3-8**] at 11:30 AM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: VASCULAR SURGERY
When: THURSDAY [**2156-3-4**] at 1:15 PM
With: VASCULAR LAB [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: VASCULAR SURGERY
When: THURSDAY [**2156-3-4**] at 2:00 PM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1490**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
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icd9cm
|
[
[
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[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,343
| 160,605
|
54887+59638
|
Discharge summary
|
report+addendum
|
Admission Date: [**2199-8-24**] Discharge Date: [**2199-9-6**]
Date of Birth: [**2141-6-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
critical aortic stenosis
Major Surgical or Invasive Procedure:
[**2199-8-26**] Left + Right Heart Cath
[**2199-8-26**] right IJ cordis line temporary pacer wire
[**2199-8-29**]:
1. Aortic valve replacement with a size 23-mm [**Last Name (un) 3843**]-
[**Doctor Last Name **] Magna tissue valve.
2. Coronary artery bypass graft x2: Left internal mammary
artery to left anterior descending artery, and saphenous
vein graft to diagonal artery.
History of Present Illness:
58 y/o old man with history of hypertension, CKD and alcohol
abuse who was transfered from [**Hospital **] hospital with severe AS
after admission for pre-syncopal event. On [**2199-8-22**] patient had
pre-syncopal episode after drinking at a bar around noon. After
leaving the bar around 1:30 and walking a short distance he was
overcome by sudden weakness and "leg buckling", he lowered
himself to the ground, he did not fall or lose consiousness. He
denies any associated palpitations, chest pain or SOB. In the
field EMS recorded BP 132/80 and good sats on RA, rythm strip
reportedly showed sinus rythm 96 with occasional ectopy.
.
At OSH ED patient had normal VS and neuro exam, BUN/Cr 45/2.3,
CBC macrocytic to 108 but otherwise normal (patient reports
being told he had abnormal renal functions in [**3-/2199**] and
referral to US which he did not complete), CE were normal. EKG
reportedly showed sinus rythm < 1.5mm ST depressons in II,I,AVL,
biphasic T waves in I, AVL, <0.5mm ST depressions in V5-V6. He
was given Aspirin 325 and admitted to LGH.
.
Echo demonstrated severe aortic stenosis with valva area of 0.5
cm^2 with asymptomatic diastolic dysfunction on echocardiogram
with EF of 55%. While there he was given IVF fluids and his
kidney function improved (per verbal signout with transferring
physician). HCTZ and Lisinopril was held. He was given thiamine
100mg and folic acid.
.
Patient had repeat TTE today which showed critical aortic
stenosis with valve area of 0.6 and peak gradient of 111 and
mean gradient of 63. He was taken to the perioperative RHC/LHC
today and found to have 90% in the proximal LAD prior to a large
diagonal branch with a 60% stenosis in its origin. While
crossing AV, he developed sudden complete heart block on cardiac
monitor with a ventricular rate in the 40s. Temporary RV pacing
wire was placed (lower rate 60, threshold 0.5mV), and he was
transferred to the CCU for further management.
.
Patient was transfered to CCU in stable condition. Patient HR
is in the 90s not being paced. he denies any chest pain,
shortness of breath, orthopnea, PND or peripherla edema.
Cardiac cath was done and multivessel coronary artery disease
was revealed. Cardiac surgery was consulted for coronary artery
revascularization and aortic valve replacement.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- ETOH abuse: two DUI charges, patient denies alcohol problem,
denies h/o detox, DT's or seziures.
- Obesity
- CKD: diagnosed [**3-/2199**]
Social History:
Lives by himself in a trailer in [**Location (un) 26671**], unemployed for the
past 3 years. ADL independent.
-Tobacco history: 30 pack year hx, quit 20 years ago.
-ETOH: 3-4 beers per day for 30 years, two brandy shots weekly,
CAGE positive only for feeling need to cut back.
-Illicit drugs: denies.
Family History:
Mother and sister both had valve repair procedures.
CAD, grandfather died of heart attack possibly in the 60s or
70s.
Physical Exam:
Admission Physical Exam
GENERAL: Appears well in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple; obese neck, no JVD appreciated
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. [**3-5**] cresendo-decresendo systolic murmur
radiating to carotids. No thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, obese. Non-tender. No HSM or tenderness. Abd
aorta not enlarged by palpation. No abdominial bruits.
EXTREMITIES: Warm and well perfused. No femoral bruits.
SKIN: Areas of hyperpigmentaion in the legs.
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 112123**] (Congenital)
Done [**2199-8-29**] at 9:03:55 AM PRELIMINARY
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2141-6-23**]
Age (years): 58 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Intraoperative TEE for AVR, CABG
ICD-9 Codes: 424.1
Test Information
Date/Time: [**2199-8-29**] at 09:03 Interpret MD: [**First Name8 (NamePattern2) **] [**Name8 (MD) 17792**], MD
Test Type: TEE (Congenital) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 17792**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2012AW2-: Machine: u/s 2
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.6 cm <= 4.0 cm
Left Ventricle - Septal Wall Thickness: *1.6 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.7 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.7 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.5 cm
Left Ventricle - Fractional Shortening: *0.26 >= 0.29
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Annulus: 2.5 cm <= 3.0 cm
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.7 cm <= 3.0 cm
Aorta - Ascending: *3.5 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *4.8 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *94 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 62 mm Hg
Aortic Valve - LVOT diam: 2.7 cm
Aortic Valve - Valve Area: *0.6 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: Normal LA size. Good (>20 cm/s) LAA ejection
velocity. No thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA and extending into the RV. No ASD
by 2D or color Doppler.
LEFT VENTRICLE: Moderate symmetric LVH. Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Simple atheroma in
ascending aorta. Normal descending aorta diameter. Simple
atheroma in descending aorta. No thoracic aortic dissection.
AORTIC VALVE: Bicuspid aortic valve. Severely thickened/deformed
aortic valve leaflets. Bioprosthetic aortic valve prosthesis
(AVR). Critical AS (area <0.8cm2).
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Written informed consent was obtained from the
patient. The patient was under general anesthesia throughout the
procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications. Results were personally reviewed with the MD
caring for the patient.
Conclusions
Prebypass:
The left atrium is normal in size. No thrombus is seen in the
left atrial appendage. There is no ASD by 2D and color Doppler.
There is moderate symmetric left ventricular hypertrophy.
Overall estimated left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal.
There are simple atheroma in the ascending aorta. There are
simple atheroma in the descending thoracic aorta. The aortic
valve is bicuspid with a horizontal commissure. The aortic valve
leaflets are severely thickened/deformed. There is critical
aortic valve stenosis (valve area <0.8cm2).
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results on
[**2199-8-29**] at 0900.
Postbypass:
There is a bioprosthetic valve in the aortic position. The valve
appears to be well--seated with normal leaflet function. There
is no evidence of paravalvular leak. There is no AI. The peak
gradient across the aortic valve is mmHg, the mean gradient is
mmHg, with CO of 4.3L/min.
There is preserved left ventricular function that is unchanged
from prebyass.
The other valves are unchanged from prebypass. There is no
evidence of aortic dissection.
At the end of the procedure, mild hypokinesis is noted in the
mid inferoseptal wall segment. The overal LVEF remains normal.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**First Name8 (NamePattern2) **] [**Name8 (MD) 17792**], MD, Interpreting physician
?????? [**2189**] CareGroup IS. All rights reserved.
.
[**2199-9-4**] 05:27AM BLOOD WBC-7.6 RBC-3.21* Hgb-10.2* Hct-30.5*
MCV-95 MCH-31.9 MCHC-33.5 RDW-16.1* Plt Ct-160
[**2199-9-3**] 04:19AM BLOOD WBC-7.2 RBC-3.09* Hgb-9.8* Hct-29.6*
MCV-96 MCH-31.9 MCHC-33.3 RDW-16.3* Plt Ct-124*
[**2199-9-4**] 05:27AM BLOOD Plt Ct-160
[**2199-9-3**] 04:19AM BLOOD Plt Ct-124*
[**2199-9-4**] 05:27AM BLOOD Glucose-94 UreaN-28* Creat-1.3* Na-142
K-4.8 Cl-107 HCO3-28 AnGap-12
[**2199-9-3**] 04:19AM BLOOD Glucose-123* UreaN-33* Creat-1.4* Na-140
K-4.1 Cl-107
[**2199-9-2**] 05:45AM BLOOD UreaN-30* Creat-1.2 Na-138 K-4.1 Cl-106
Brief Hospital Course:
MEDICAL COURSE:
58 y/o old man who is transferred from [**Hospital **] hospital with
severe AS here for eval. Had cath [**2199-8-26**] which showed severe
stenosis of LAD and severe critical aortic stenosis. Procedure
complicated by AV node irritation with cathether leading to
complete heart block. In the unit, NSR with occasional ectopy
overnight, heart block resolved. Right IJ cordis and temporary
pacing wire removed on [**2199-8-27**]. Patient transfered to floor on
[**2199-8-27**].
#Severe AS/[**Name (NI) **] Pt had 2 episodes of presyncope on [**2199-8-22**] which
prompted echocardiography. Denied CP, SOB, or HF sxs. LHC
showed Aortic valve area of 0.45 cm^2 with 90% stenosis of LAD
prox to 1st diag. Valve replacement/bypass planned for [**2199-8-28**].
# Complete Heart Block s/p temporary pacer wire: Cath
complicated by irritation of AV node leading to complete heart
block s/p temporary pacer placement. On transfer to floor,
patient's heat rate in the 90s sinus rythm self-paced and
conducting 1:1.
# HTN- He is on 3 medications at home (lisinopril 40mg, HCT 25mg
and clonidine 0.3mg TID) for HTN. During his hospital course
his clonidine was reduced to 0.1 mg TID. Amlodipine 5mg daily,
metoprolol 12.5mg [**Hospital1 **] were started. Lisinipril was held
secondary to elevated Cr and K.
# alcohol use- the patient has 2 [**Last Name (un) 20934**] and he is in a court
ordered program. He reportedly drinks 3-4 beers daily, but has
no signs of ETOH withdrawal currently and no h/o withdrawal
sx's.
SURGICAL COURSE:
Mr.[**Known lastname 44696**] is a 58-year-old patient who suffered a presyncopal
event secondary to bicuspid aortic stenosis, was admitted and
was further investigated and
coronary angiogram showed a significant lesion in the left
anterior descending artery of the diagonal artery. Left
ventricular function was well preserved. He was kept in-house
for urgent aortic valve replacement and coronary artery
bypass grafting. He has a history of alcoholism and had a
recent fall and is unemployed. Given his background, after much
discussion with the patient and the family, mainly his brother,
it was decided to use a tissue valve given his
unreliability in taking Coumadin. The patient and the family,
after discussing, wanted a tissue valve.
On [**2199-8-29**] Mr.[**Known lastname **] was taken to the operating room and
underwent 1. Aortic valve replacement with a size 23-mm
[**Last Name (un) 3843**]-[**Doctor Last Name **] Magna tissue valve.
2. Coronary artery bypass graft x2: Left internal mammary
artery to left anterior descending artery, and saphenous vein
graft to diagonal artery. He tolerated the procedure well and
was transferred to the CVICU in critical condition. He was
hemodynamically unstable requiring multiple blood products for
coagulopathy and bleeding, as well as pressor support. On POD#1
he awoke neurologically intact and was weaned to extubation. All
lines and drains were discontinued per protocol. He weaned off
pressor support and Beta-blocker/Statin/ASA and diuresis were
initiated. POD#2 he was transferred to the step down unit for
further monitoring.Physical Therapy was consulted for evaluation
of stregnth and mobiltiy. Over the remainder of his hospital
course he was weaned off oxygen, diuresed and slowly progressed.
He developed erythema about the inferior sternal pole and was
started on Keflex. He remained afebrile with a normal white
blood cell count. On POD 8 he was ambulating and incisions were
healing well. He was discharged to the [**Hospital1 **] Hoapital.
All follow up appointments were advised.
Medications on Admission:
1. Hydrochlorothiazide 25 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
3. CloniDINE 0.3 mg PO TID
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain/temp
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze
3. Albuterol-Ipratropium [**12-31**] PUFF IH Q6H:PRN dyspnea
4. Aspirin EC 81 mg PO DAILY
5. Atorvastatin 80 mg PO DAILY
6. Bisacodyl 10 mg PR DAILY:PRN constipation
7. Cephalexin 500 mg PO Q6H sternal erythema
8. DiphenhydrAMINE 25 mg PO Q6H:PRN itching
9. Docusate Sodium 100 mg PO BID
10. FoLIC Acid 1 mg PO DAILY
11. HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN pain
RX *hydromorphone 2 mg [**12-31**] tablet(s) by mouth q3h Disp #*60
Tablet Refills:*0
12. Ipratropium Bromide Neb 1 NEB IH Q6H
13. Lorazepam 0.5 mg PO BID:PRN anxiety
14. Metoprolol Tartrate 75 mg PO TID
Hold for HR < 55 or SBP < 90 and call medical provider.
15. Milk of Magnesia 30 ml PO HS:PRN constipation
16. Ranitidine 150 mg PO BID
17. Sarna Lotion 1 Appl TP QID rash
18. Thiamine 100 mg PO DAILY
19. Hydrochlorothiazide 25 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
s/p 1.Aortic valve replacement with a size 23-mm
[**Last Name (un) 3843**]-[**Doctor Last Name **] Magna tissue valve.
2. Coronary artery bypass graft x2: Left internal mammary
artery to left anterior descending artery, and saphenous vein
graft to diagonal artery.
PMH:
CAD/AS
Hypertension
Obesity
CRI diagnosed [**3-/2199**]
ETOH abuse
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, 2cm erythema lower [**2-1**] sternal wound.
Multiple skin tears-abdomen
Leg Right/Left - healing well, no erythema or drainage.
Edema- 1+ pedal edema bilat
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 appointment:
Surgeon: Dr. [**First Name (STitle) **], [**Telephone/Fax (1) 170**], Tuesday, [**2199-10-8**], 1:00
Please call to schedule appointments with your:
Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**3-3**] weeks, [**Telephone/Fax (1) 62**]
Primary Care: MED ASSOC OF [**Location (un) **] in [**12-31**] 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**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2199-9-6**] Name: [**Known lastname 18418**],[**Known firstname 193**] Unit No: [**Numeric Identifier 18419**]
Admission Date: [**2199-8-24**] Discharge Date: [**2199-9-6**]
Date of Birth: [**2141-6-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 265**]
Addendum:
Medications have been adjusted, see below.
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain/temp
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze
3. Albuterol-Ipratropium [**12-31**] PUFF IH Q6H:PRN dyspnea
4. Aspirin EC 81 mg PO DAILY
5. Atorvastatin 80 mg PO DAILY
6. Bisacodyl 10 mg PR DAILY:PRN constipation
7. Cephalexin 500 mg PO Q6H sternal erythema Duration: 7 Days
8. DiphenhydrAMINE 25 mg PO Q6H:PRN itching
9. Docusate Sodium 100 mg PO BID
10. FoLIC Acid 1 mg PO DAILY
11. HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN pain
RX *hydromorphone 2 mg [**12-31**] tablet(s) by mouth q3h Disp #*60
Tablet Refills:*0
12. Ipratropium Bromide Neb 1 NEB IH Q6H
13. Lorazepam 0.5 mg PO BID:PRN anxiety
14. Metoprolol Tartrate 75 mg PO TID
Hold for HR < 55 or SBP < 90 and call medical provider.
15. Milk of Magnesia 30 ml PO HS:PRN constipation
16. Ranitidine 150 mg PO BID
17. Sarna Lotion 1 Appl TP QID rash
18. Thiamine 100 mg PO DAILY
19. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QTHUR
20. Furosemide 40 mg PO DAILY Duration: 10 Days
Please re-assess need for ongiong diuresis (pt was on HCTZ daily
pre-op)
21. Potassium Chloride 40 mEq PO DAILY Duration: 10 Days
Hold for K+ > 4.5
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 4356**] - [**Location (un) 164**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2199-9-6**]
|
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icd9cm
|
[
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icd9pcs
|
[
[
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]
] |
18799, 18991
|
10145, 13752
|
333, 727
|
15287, 15582
|
4612, 10122
|
16506, 17618
|
3741, 3860
|
17641, 18776
|
14926, 15266
|
13778, 13874
|
15606, 16483
|
3875, 4593
|
3159, 3235
|
269, 295
|
755, 3051
|
3266, 3407
|
3073, 3139
|
3423, 3725
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,285
| 148,050
|
49653
|
Discharge summary
|
report
|
Admission Date: [**2163-11-3**] Discharge Date: [**2163-11-15**]
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: This is a very pleasant
84-year-old right handed man was admitted to the Medicine
service with a syncopal episode. He reported that he had not
been feeling himself for the last week. He felt unsteady and
slow. He had fallen. In addition, he states that for the
last 6-8 months, he has noted a gradual decline in his
energy, and has not felt right. He stopped going to the gym
for his usual workouts.
A cardiac evaluation was largely unremarkable. A CT scan of
the head was obtained. This showed an enormous, loculated,
mixed density right subdural hematoma. There is massive
right to left shift. In addition, there is a much smaller
left sided subdural hematoma. The patient therefore, was
admitted for further evaluation.
CURRENT MEDICATIONS:
1. Labetalol.
2. Hydrochlorothiazide.
3. Lasix.
4. Isosorbide.
5. Norvasc.
6. Hydralazine.
7. Colchicine.
8. Aspirin.
9. Allopurinol.
10. Nitroglycerin.
11. Timoptic.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient takes care of his wife, who is
home with dementia. He drinks [**1-6**] vodkas per night. He
denies tobacco use. He was able to do all of his activities
of daily living. The patient is retired from the military.
PHYSICAL EXAMINATION: The patient is awake and alert. He
has no external signs of trauma. He is complaining of a bit
of headache and not feeling quite himself. He is a bit
confused and cannot name the hospital. His short-term memory
is [**2-9**] at five minutes. He has a slight pronator drift on
the left. He is easily distracted and has difficulty
cooperating with many of the tests of cognitive function.
His neck is supple. His chest is clear. Cardiac: Regular,
rate, and rhythm. Abdomen is soft and nontender.
Extremities: No clubbing, cyanosis, or edema. He has
reflexes which are 2+ in the upper extremities and absent in
the lower extremities. His right toe is upgoing.
HOSPITAL COURSE: The patient was taken to the operating room
on [**2163-11-4**]. At that time, he underwent a right sided
craniotomy for an enormous right sided subdural hematoma and
placement of a burr hole on the left. He tolerated this
procedure well. Because of the massive shift, a subdural
drain was left in place. Immediately after surgery, the
patient was awake and alert. He was complaining of
incisional pain and headache.
Over the course of the next 24 hours, he became extremely
agitated and confused. This required enormous amounts of
sedation. The patient was requiring Valium and Haldol
around-the-clock. When he was allowed to wake, he would be
restless and thrashing. He had a single focal motor seizure,
and was started on Dilantin.
During his hospital course, he had no further seizures. The
patient largely remained afebrile. He required some oxygen,
but his O2 saturations were good and his chest x-rays
remained clear. He was started on tube feeds. Over the next
week, his sedation was gradually lightened. A followup CT
scan of the head was obtained. This showed a dramatic
improvement in the subdural hematoma and mass effect. There
was no shift and very minimal mass effect. The subdural
fluid collection on the left was a tiny bit larger.
Over the 48 hours prior to discharge, the patient's mental
status improved significantly. He had his eyes open. He
would speak in [**2-7**] word phrases. He began answering
questions, although was clearly confused. He was seen by
Physical Therapy. He got up to a chair and tolerated this
well for five or six hours. He walked short distance with a
rolling walker with the minimal assistance of the physical
therapist. It was felt that the patient was an excellent
candidate for rehabilitation, and that his mental status
could continue to improve.
FINAL DISCHARGE DIAGNOSIS:
1. Subdural hematoma bilateral.
2. Hypertension.
3. Gout.
4. Glaucoma.
5. Coronary artery disease.
6. Seizure.
CONDITION ON DISCHARGE: Fair.
FOLLOW-UP PLANS: The patient is being discharged to
inpatient rehabilitation. He is felt to be an excellent
rehabilitation candidate.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3653**], M.D. [**MD Number(1) 3654**]
Dictated By:[**Last Name (NamePattern4) 3655**]
MEDQUIST36
D: [**2163-11-15**] 11:15
T: [**2163-11-15**] 11:13
JOB#: [**Job Number 103828**]
|
[
"496",
"303.90",
"291.81",
"852.22",
"250.00",
"780.39",
"518.0",
"432.1",
"E884.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.51",
"01.31",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
3913, 4025
|
2062, 3892
|
1374, 2044
|
4075, 4475
|
884, 1106
|
128, 863
|
1123, 1351
|
4050, 4057
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,536
| 168,340
|
18319
|
Discharge summary
|
report
|
Admission Date: [**2101-6-30**] Discharge Date: [**2101-7-9**]
Date of Birth: [**2064-2-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6780**]
Chief Complaint:
Back Pain and weakness
Major Surgical or Invasive Procedure:
T7 emoblization, T3-T11 spinal fusion and T8 decompression.
History of Present Illness:
This is a 37 y/o M w/metastatic renal cell carcinoma
(lung/liver/C7 lytic lesion) who presented to the ED on [**2101-6-29**]
c/o worsening back pain, difficulty walking, and trouble
urinating. He stated he was lying in bed 3 days PTA and had
acute onset of mid back pain. He also reports lower extremity
weakness, only able to walk with assistance, constipation,
difficulty with urination, and tingling in his feet. He denied
any fever, chills, nausea, vomiting, headache, dysarthria, or
other concerns. He has metastatic RCC of unclear histology, and
is on his second cycle of Sutent (sunitinib, a TK inhibitor).
His most recent imaging was on [**2101-3-29**] which revealed a new C7
lytic lesion.
.
He has had a hospital course to date that included an evaluation
by neurology and imaging studies revealed a large T7 metastatic
lesion with an associated pathologic fracture and soft tissue
component encroaching the cord, with cord compression and
displacement. He was given decadron 4 mg IV, and then given 40
mg IV decadron per neuro recs after MRI findings. He was taken
to Interventional Neuroradiology, where his T7 lesion was
embolized. He was then transferred to the MICU for frequent
neuro checks after the embolization. He then had a T3-T11 spinal
fusion and T8 decompression by ortho
Past Medical History:
Asthma
Type II diabetes
GERD
Social History:
Denies smoking, drug use. Occasional EtOH
Family History:
Negative for renal cancers or disorders.
Physical Exam:
T:97.8 BP:130/90 HR:86 RR:20 O2:100%3L
Gen: awake, alert male, in some moderate discomfort
HEENT: dry MM, dry oropharynx
Neck: no LAD, central line still in place
Lungs: CTA anteriorly/laterally
CV: RRR, no m/r/g
Abd: soft, NT/ND, no masses
Ext: compression boots and stockings on. Good pulses
Neuro: CN II-XII intact, strength exam deffereed due to pain.
Will re-asses in AM.
Pertinent Results:
Labs on admission:
[**2101-6-29**] 10:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2101-6-29**] 10:25PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2101-6-29**] 10:25PM PLT COUNT-218
[**2101-6-29**] 10:25PM NEUTS-57.8 LYMPHS-32.3 MONOS-7.7 EOS-1.0
BASOS-1.2
[**2101-6-29**] 10:25PM WBC-7.9 RBC-4.36* HGB-12.9* HCT-38.4* MCV-88
MCH-29.6 MCHC-33.6 RDW-15.3
[**2101-6-29**] 10:25PM CALCIUM-10.5* PHOSPHATE-3.2 MAGNESIUM-2.0
[**2101-6-29**] 10:25PM CK-MB-NotDone cTropnT-<0.01
[**2101-6-29**] 10:25PM LIPASE-15
[**2101-6-29**] 10:25PM ALT(SGPT)-45* AST(SGOT)-22 CK(CPK)-48 ALK
PHOS-140* AMYLASE-31 TOT BILI-0.4
[**2101-6-29**] 10:25PM GLUCOSE-118* UREA N-16 CREAT-1.5* SODIUM-135
POTASSIUM-3.9 CHLORIDE-95* TOTAL CO2-26 ANION GAP-18
[**2101-6-29**] 10:37PM LACTATE-2.3*
[**2101-6-29**] 10:37PM LACTATE-2.3*
[**2101-6-30**] 12:30PM PT-14.2* INR(PT)-1.3*
[**2101-6-30**] 05:58PM PLT COUNT-212
.
Labs on Discharge:
[**2101-7-9**] 03:18PM BLOOD WBC-13.5* RBC-3.58* Hgb-10.3* Hct-30.6*
MCV-86 MCH-28.9 MCHC-33.8 RDW-15.9* Plt Ct-243
[**2101-7-9**] 03:18PM BLOOD Plt Ct-243
[**2101-7-9**] 06:25AM BLOOD Glucose-135* UreaN-9 Creat-1.1 Na-137
K-4.6 Cl-98 HCO3-28 AnGap-16
[**2101-7-9**] 06:25AM BLOOD Calcium-9.1 Phos-3.1 Mg-2.3
[**2101-7-2**] 01:30AM BLOOD Type-ART pO2-131* pCO2-46* pH-7.38
calTCO2-28 Base XS-1
Brief Hospital Course:
Spinal Metastasis: The patient was admitted to the floor s/p
tumor embolization, decompression, and fusion procedure. He was
admitted for pain contorl and medical monitoring. He was taken
off of bedrest and allowed to ambulate with assist. His pain
was contorlled initially with a dilaudid PCA with morphine prn
for breakthrough pain. This provided good relief, allthough
movement was painfull. Physical therapy was consulted and
assisted the patient with ambulation. He was transitioned over
to oral pain management including MS Contin 30mg TID and oral
dilaudid for breakthrough pain.
.
One active issue was a decreased hematocrit and persistant
tachycardia. Given recent surgery, and imobility, a CTA was
ordered which was negative for PE. He was trnasfused a total of
two units with good effect. He has anemia at baseline, likely
secondary to chronic disease from RCC, and we were comfortbale
with a Hct of ~30. He was discharged with a Hct of 30.6. His
tachycardia was helped both with fluid recusitation and with
adequate pain control. On discharge his HR was in the 80s.
.
He was ambulating slowley but effectivly on his own. He
tolerated pain well. He moved his bowels and tolerated po
intake. He was discharged to follow up both with Ooncology and
with Radiation Oncology. Specifically he had an appointment on
[**7-13**] with the radiation oncologist.
.
Medications on Admission:
Dilaudid PCA - basal rate 1mg/hr, .12mg/application
Cefazolin x 3 doses s/p procedure
Dexamethasone 10mg IV q 6h
Insulin sliding scale
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*qs * Refills:*0*
3. Hydromorphone 2 mg Tablet Sig: 2-4 Tablets PO Q3H (every 3
hours) as needed.
Disp:*100 Tablet(s)* Refills:*0*
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
6. MS Contin 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO three times a day.
Disp:*90 Tablet Sustained Release(s)* Refills:*0*
7. metformin
Please continue dose prior to admission to hospital.
8. Dulcolax Stool Softener 100 mg Capsule Sig: One (1) Capsule
PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Metastatic Renal Cell Carcinoma
Discharge Condition:
Stable, pain well-controlled, afebrile.
Discharge Instructions:
1. Please take all medications as directed
2. Please keep all of your appointments
3. Call your doctor or go to the ER for any of the following:
back pain, numbness or weakness in your legs, urinary/bowel
incontinence, shortness of breath, chest pain or any other
concerning symptoms.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8941**], MD Phone:[**Telephone/Fax (1) 6317**]
Date/Time:[**2101-7-26**] 8:00
Call Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 6820**]) on Monday, [**7-11**] to make an
appointment.
|
[
"427.89",
"285.1",
"V10.53",
"288.8",
"197.7",
"197.0",
"564.09",
"493.90",
"198.5",
"998.11",
"530.81",
"250.00",
"585.9",
"596.55",
"276.50",
"733.13",
"285.22",
"198.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.29",
"88.49",
"99.04",
"77.79",
"81.05",
"88.44",
"81.63"
] |
icd9pcs
|
[
[
[]
]
] |
6358, 6416
|
3758, 5140
|
337, 399
|
6492, 6534
|
2308, 2313
|
6867, 7135
|
1853, 1895
|
5326, 6335
|
6437, 6471
|
5166, 5303
|
6558, 6844
|
1910, 2289
|
275, 299
|
3340, 3735
|
427, 1725
|
2328, 3320
|
1747, 1777
|
1793, 1837
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,734
| 110,128
|
684
|
Discharge summary
|
report
|
Admission Date: [**2187-8-7**] Discharge Date: [**2187-8-9**]
Date of Birth: [**2131-1-2**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 56 year old man who has been seen in the Ed on
multiple occasions for frequent falls while intoxicated. He fell
from standing the night of admission and this was witnessed by
friends. [**Name (NI) **] was transferred to [**Hospital1 18**] for evaluation. CT head
showed bilateral SDH. He received Dilantin 1gm IV x1.
Neurosurgery was consulted.
Past Medical History:
1. Alcoholism, prior MICU admission for airway protection during
acute intoxication (w/ valium overdose).
2. Hepatitis C.
3. Seizure disorder.
4. Status post depressed skull fracture in [**2162**].
5. Status post right craniotomy.
6. Status post C4 fracture in [**2173**].
7. Status post delirium tremens.
8. H/o Aspiration pneumonia.
9. Hypertension.
10. Right ankle fracture.
11. Right arm thrombophlebitis.
Social History:
He is homeless and currently staying with friends. [**Name (NI) **] reports
to parole services. He is not currently working. He has a 43
year smoking history, currently smokes <[**12-10**] PPD. He drinks up to
3 quarts of vodka daily. He has a history of occasional
marijauna use. No documentation of cocaine or heroin use, but
patient has h/o IVDU is his teens. His sister managed his
finances.
Family History:
Mother has h/o alcoholism, HTN.
Physical Exam:
On Admission:
O: T: 97.6 BP: 165/106 HR: 55 R 14 O2Sats 100%
Neuro:
Mental status: Intoxicated
Orientation: Oriented to person, place, and date.
Language: Speech thick/slurred
Given patient's intoxication, neuro exam is limited. Pt opens
eyes to voice, oriented x3, follows commands w/prompting, pupils
2mm reactive bilaterally, BUE antigravity- full motor assessment
limited from lack of effort/intoxication; BLE slightly
antigravity but briskly withdraws to noxious. Face appears
symmetric and tongue midline.
At Discharge:
Patient left AMA
Pertinent Results:
[**2187-8-7**] 02:20AM PT-12.1 PTT-31.2 INR(PT)-1.0
[**2187-8-7**] 02:20AM PLT COUNT-133*
[**2187-8-7**] 02:20AM NEUTS-46.5* LYMPHS-46.3* MONOS-5.2 EOS-1.4
BASOS-0.6
[**2187-8-7**] 02:20AM WBC-3.2* RBC-3.94* HGB-13.6* HCT-38.9*
MCV-99* MCH-34.6* MCHC-35.0 RDW-14.4
[**2187-8-7**] 02:20AM ASA-NEG ETHANOL-295* ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2187-8-7**] 02:20AM PHENYTOIN-LESS THAN
[**2187-8-7**] 02:20AM estGFR-Using this
[**2187-8-7**] 02:20AM GLUCOSE-85 UREA N-10 CREAT-0.9 SODIUM-148*
POTASSIUM-3.5 CHLORIDE-107 TOTAL CO2-31 ANION GAP-14
[**2187-8-7**] 02:27AM GLUCOSE-78
[**2187-8-7**] 02:27AM COMMENTS-GREEN TOP
[**2187-8-7**] 02:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.0
LEUK-NEG
[**2187-8-7**] 02:40AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2187-8-7**] 02:40AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2187-8-7**] 02:40AM URINE HOURS-RANDOM
CT head [**2187-8-7**]
1. Acute small bifrontal subdural hematomas with small amounts
of adjacent
subarachnoid blood.
2. Non-displaced left superior frontal fracture extending to the
sagittal
suture at the vertex, with overlying subgaleal hematoma.
3. This patient had 32 prior head CTs since [**2184-1-13**], and 9
additional prior
head CTs between [**2175-4-27**] and [**2179-12-11**].
CT C-spine [**2187-8-7**]
1. No acute fracture or subluxation.
2. Unchanged chronic dens fracture and posterior fusion of
C1-C3, without
evidence of hardware related complications.
3. This patient had 19 prior cervical spine CTs since [**2184-2-2**].
CT head [**2187-8-7**]
1. Stable appearance of right frontal hemorrhagic contusion
which exerts mass effect on the frontal [**Doctor Last Name 534**] of the right
lateral ventricle. Adjacent
subarachnoid hemorrhage shows mild increase.
2. Nondisplaced left superior frontal bone fracture, better
demonstrated on prior bone algorithm-reconstructed images.
Brief Hospital Course:
//Mr. [**Known lastname 5126**] was admitted to [**Hospital1 18**] on [**8-7**] for bilateral SDH's.
He was in a cervical /collar for CT finding of stable C2
fracture and posterior cervical fusion. Repeat CT findings
showed a large increase in right SDH. He remained neurologically
unchnaged with LUE weakness and drift.
Patient left on [**2187-8-9**] against medical advice.
Medications on Admission:
Unknown, patient has not been compliant in the past.
Discharge Medications:
Patient left AMA
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Bilateral SDH
Cervical Fracture
Discharge Condition:
Patient Left AMA
Discharge Instructions:
Patient left AMA
Followup Instructions:
Patient Left AMA
Completed by:[**2187-10-11**]
|
[
"303.01",
"276.0",
"E888.9",
"E849.8",
"070.70",
"345.90",
"V60.0",
"801.21",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
4767, 4782
|
4244, 4622
|
308, 314
|
4858, 4876
|
2192, 4221
|
4942, 4990
|
1568, 1601
|
4726, 4744
|
4803, 4837
|
4648, 4703
|
4900, 4919
|
1616, 1616
|
2155, 2173
|
264, 270
|
342, 699
|
1630, 1695
|
1710, 2141
|
721, 1133
|
1149, 1552
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,832
| 142,771
|
4391
|
Discharge summary
|
report
|
Admission Date: [**2135-6-24**] Discharge Date: [**2135-7-11**]
Date of Birth: [**2071-1-11**] Sex: M
Service: SURGERY
Allergies:
Renografin-76 / Iodine; Iodine Containing / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
TRANSFERRED FROM OUTSIDE HOSPITAL FOR CLOSTRIDIUM DIFFICILE (D.
DIF) COLITIS
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
64 [**Hospital **] [**Hospital **] TRANSFER FROM AN OUTSIDE HOSPITAL FOR C.
COLITIS IN WHICH DEVELOPED TWO WEEKS AFTER BEING TREATED WITH
ANTIBIOTICS FOR PNEUMONIA.
Past Medical History:
1. DIABETES MELLITUS W/ CHRONIC RENAL FAILURE ON DIALYSIS,
POST-RENAL TRANSPLANT
2. DYSARRYTHMIA(AFIB/FLUTTER)
3. CORANARY ARTERY DISEASE
4. HYPERTENSION
5. HYPERLIPIDEMIA
6. DEPRESSION
Social History:
MARRIED. FORMER SMOKER. DENIES ALCOHOL AND RECREATIONAL DRUG
USE.
Family History:
NON-CONTRIBUTORY
Physical Exam:
ON ADMISSION:
TEMP 98.3F PULSE 67 IN AFLUTTER 102/48 RESP RATE 23
OXYGEN SAT 97% 4 LITERS CANNULA
GENERAL: NON-DISTRESSED
HEART: REGULARLY IRREGULAR
RESPIRATORY: BILATERAL CRACKLES AND COARSE BREATH SOUNDS
ABDOMEN: SOFT, TENDER TO PALPATION LEFT LOWER QUADRANT,
NON-DISTENDED, NO REBOUND OR GUARDING
EXTREMITIES: NO EDEMA, CLUBBING, CYANOSIS
Pertinent Results:
[**2135-7-11**] 09:30AM BLOOD WBC-6.8 RBC-2.92* Hgb-9.9* Hct-30.4*
MCV-104* MCH-34.0* MCHC-32.5 RDW-24.9* Plt Ct-185
[**2135-7-7**] 06:00AM BLOOD WBC-5.4 RBC-3.13* Hgb-9.8* Hct-32.0*
MCV-102* MCH-31.5 MCHC-30.8* RDW-25.1* Plt Ct-179
[**2135-7-4**] 04:18AM BLOOD WBC-6.4 RBC-3.13* Hgb-9.9* Hct-31.2*
MCV-100* MCH-31.7 MCHC-31.8 RDW-26.7* Plt Ct-180
[**2135-7-2**] 05:08AM BLOOD WBC-6.3 RBC-2.86* Hgb-9.1* Hct-27.8*
MCV-97 MCH-31.9 MCHC-32.9 RDW-27.2* Plt Ct-223
[**2135-6-29**] 01:31AM BLOOD WBC-7.9 RBC-3.20*# Hgb-10.1*# Hct-29.3*
MCV-91 MCH-31.6 MCHC-34.6 RDW-26.8* Plt Ct-221
[**2135-6-25**] 12:10PM BLOOD WBC-4.0 RBC-2.56* Hgb-8.1* Hct-23.6*
MCV-92 MCH-31.5 MCHC-34.2 RDW-25.2* Plt Ct-137*
[**2135-6-25**] 01:36AM BLOOD WBC-4.3 RBC-2.58*# Hgb-8.1*# Hct-23.4*#
MCV-91 MCH-31.4 MCHC-34.5 RDW-24.9* Plt Ct-127*
[**2135-7-11**] 09:30AM BLOOD Glucose-95 UreaN-27* Creat-3.8* Na-138
K-4.1 Cl-101 HCO3-28 AnGap-13
[**2135-7-7**] 06:00AM BLOOD Glucose-104 UreaN-39* Creat-3.6* Na-140
K-3.6 Cl-97 HCO3-31 AnGap-16
[**2135-6-25**] 01:36AM BLOOD Glucose-202* UreaN-64* Creat-3.5*#
Na-132* K-3.8 Cl-95* HCO3-30 AnGap-11
[**2135-7-9**] 08:51AM BLOOD CK(CPK)-17*
[**2135-6-30**] 03:10AM BLOOD ALT-18 AST-26 LD(LDH)-201 AlkPhos-751*
Amylase-21 TotBili-0.5
[**2135-6-29**] 01:31AM BLOOD ALT-18 AST-25 LD(LDH)-221 AlkPhos-712*
Amylase-21 TotBili-0.5
[**2135-6-25**] 09:11PM BLOOD CK(CPK)-10*
[**2135-6-25**] 12:10PM BLOOD CK(CPK)-10*
[**2135-6-25**] 01:36AM BLOOD ALT-14 AST-26 LD(LDH)-169 AlkPhos-817*
Amylase-18 TotBili-0.8
[**2135-6-30**] 03:10AM BLOOD Lipase-18
[**2135-7-9**] 08:51AM BLOOD cTropnT-0.43*DIAGNOSIS:
[**2135-7-7**] 04:20PM BLOOD CK-MB-NotDone cTropnT-0.47*
[**2135-7-4**] Pathology Tissue: COLONOSCOPY :
Focal crypt regeneration. Multiple levels are examined.
No ulcer or viral inclusions seen.
The specimen is received in formalin in one part, labeled with
"[**Known lastname 18907**], [**Known firstname 5586**]" and "sigmoid ulcer" and consists of multiple
tissue fragments measuring up to 0.4 cm entirely submitted into
cassette c
[**2135-6-29**] ABDOMEN U.S. (COMPLETE STUDY) :
1. No evidence of biliary dilatation. The details available are
that the patient has had a prior cholecystectomy.
2. Moderate amount of intra-abdominal ascites and right basal
pleural effusion
[**2135-7-5**] Cardiology ECHO: The left atrium is dilated. The right
atrium is dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall
left ventricular systolic function is low normal (LVEF 50-55%).
Right
ventricular chamber size and free wall motion are normal. The
aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no
aortic regurgitation. The mitral valve leaflets are structurally
normal. Mild
(1+) mitral regurgitation is seen. There is mild pulmonary
artery systolic
hypertension. There is no pericardial effusion.
Cardiology Report ECG Study Date of [**2135-7-2**] 2:02:28 AM
Atrial flutter with some R-R interval variablity. Since the
previous tracing
of [**2135-6-25**] no significant change. The recent tracing shows limb
and lateral
lead low voltage. Intervals Axes
Rate PR QRS QT/QTc P QRS T
86 0 92 376/419.28 0 85 -50
COLONOSCOPY [**7-4**]: CIRCULAR NON-BLEEDING ULCERS FOUND IN THE
SIGMOID COLON. NO PSUEDOMEMBRANES WERE SEEN
Brief Hospital Course:
UPON ADMISSION, THE PATIENT WAS IMMEDIATELY PLACED ON ORAL
VANCOMYCIN AND INTRAVENOUS METRONIDAZOLE AS WELL AS NOTHING PER
ORAL/INTRAVENOUS (IV) FLUIDS. HE WAS KEPT IN ISOLATION AND
SUBSEQUENTLY UNDERWENT A COLONOSCOPY, WHICH SHOWED CIRCULAR
NON-BLEEDING ULCERS FOUND IN THE SIGMOID COLON. NO
PSUEDOMEMBRANES WERE SEEN. LESIONS WERE BIOPSIED WHICH SHOWED
FOCAL CRYPT REGENERATION WITHOUT ULCER OR VIRAL INCLUSIONS SEEN.
AFTER SEVERAL DAYS OF BOWEL REST, THE PATIENT IMPROVED AND
CLEARS LIQUID DIET WAS STARTED. HE EVENTRUALLY STARTED EATING A
REGULAR HEART-HEALTHY DIET WITHOUT ANY NAUSEA, VOMITING,
ABDOMENAL PAIN, OR DIARRHEA. HE HAS RECENTLY RE-STARTED
DIALYSIS AND HAS BEEN OUT OF BED, AMBULATING.
HIS HOSPITAL COURSE WAS COMPLICATED BY HIS CHRONIC ATRIAL
FLUTTER WITH VENTRICULAR TACHYCARDIA, HYPERGLYCEMIA, AND
DEPRESSION. HIS ATRIAL FLUTTER AND TACHYCARDIA WAS CONTROLLED
BY INCREASING HIS METOPROLOL TO 100MG THREE TIMES A DAY AS WELL
AS DILTIAZAM 120MG TWICE A DAY. HIS HIGH GLUCOSE WAS CONTROLLED
WITH STRICT INSULIN REGIMENT. HIS DEPRESSION IMPROVED WITH
SEROQUEL.
HE WILL BE DISCHARGED TODAY IN GOOD CONDITION.
Discharge Medications:
1. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
ASDIR (AS DIRECTED).
2. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl
Topical PRN (as needed).
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO QAM
(once a day (in the morning)).
Disp:*30 Tablet(s)* Refills:*2*
5. Quetiapine Fumarate 25 mg Tablet Sig: Three (3) Tablet PO QHS
(once a day (at bedtime)).
Disp:*90 Tablet(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*15 Tablet(s)* Refills:*0*
7. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO BID (2 times a day).
Disp:*60 Capsule, Sustained Release(s)* Refills:*2*
8. Calcium Acetate 667 mg Tablet Sig: Three (3) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
three times a day.
Disp:*90 Tablet(s)* Refills:*2*
10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. INSULIN SC PER SLIDIDNG SCALE Sig: One (1) PER SLIDING
SCALE.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
COLITIS
Discharge Condition:
GOOD
Discharge Instructions:
PLEASE TAKE MEDICATIONS AS PRESCRIBED AND READ WARNING LABELS
CAREFULLY. IF SYMPTOMS WORSEN, INCLUDING FEVER/CHILLS,
INCREASED ABDOMENAL PAIN, NAUSEA/VOMITING, PLEASE GO TO THE
EMERGENCY ROOM OR CALL IMMEDIATELY. [**Month (only) **] RESUME NORMAL
ACTIVITIES, AS TOLERATED. DO NOT NEED TO FOLLOW WITH DR. [**Last Name (STitle) **]
(SURGEON) OR WITH THE GASTROENTERLOGIST, BUT SHOULD FOLLOW UP
WITH PRIMARY CARE PHYSICIAN TO ENSURE OPTIMAL CARE.
Followup Instructions:
AS ABOVE
Completed by:[**2135-7-11**]
|
[
"V45.81",
"427.32",
"263.9",
"427.31",
"414.00",
"272.4",
"250.40",
"311",
"996.81",
"008.45",
"427.0",
"403.91",
"428.0",
"285.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"39.95",
"45.25",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7060, 7107
|
4667, 5802
|
401, 408
|
7159, 7165
|
1320, 4644
|
7659, 7699
|
911, 929
|
5825, 7037
|
7128, 7138
|
7189, 7636
|
944, 944
|
285, 363
|
436, 602
|
958, 1301
|
624, 812
|
828, 895
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,808
| 115,642
|
3561
|
Discharge summary
|
report
|
Admission Date: [**2149-11-21**] Discharge Date: [**2149-12-1**]
Date of Birth: [**2084-1-3**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Hickman Catheter placement
History of Present Illness:
Patient is a 65 year old male who has a history of an
enterocutaneous fistula with a hickman catheter in place for TPN
administration. He presented on [**2149-11-21**] with symptoms of
fever, chills, and fatigue. He denied any other localizing
symptoms of infection. No headache, shortness-of-breath, chest
pain, nausea, vomiting, diarrhea, or urinary frequency.
Past Medical History:
Rectal CA
s/p [**Month (only) **]
s/p Bowel resections x 2 with Colostomy
Mechanical Mitral Valve
Parastomal hernia
Small Bowel Obstruction
NIDDM
Social History:
Pt denies tobacco, etoh, and illicit drug use.
Family History:
CAD
Physical Exam:
103.0 122 89/52 25 95%RA
AOx3, appears ill
Anicteric, MMM
tachycardic, no murmer, no JVD
increased RR, lungs clear however
Abd: soft, NT, ND
Foley in place
No rectum
Pertinent Results:
[**2149-11-27**] 04:49AM BLOOD WBC-6.9 RBC-3.10* Hgb-9.3* Hct-28.3*
MCV-91 MCH-30.0 MCHC-32.9 RDW-15.9* Plt Ct-157
[**2149-11-22**] 03:24AM BLOOD Neuts-92.7* Bands-0 Lymphs-3.8* Monos-3.1
Eos-0.3 Baso-0.1
[**2149-11-27**] 04:49AM BLOOD PT-16.9* PTT-70.7* INR(PT)-1.8
[**2149-11-27**] 04:49AM BLOOD Glucose-117* UreaN-37* Creat-1.2 Na-138
K-4.9 Cl-111* HCO3-21* AnGap-11
[**2149-11-22**] 03:24AM BLOOD ALT-56* AST-41* CK(CPK)-66 AlkPhos-216*
Amylase-43 TotBili-3.3*
[**2149-11-22**] 03:24AM BLOOD Lipase-35
[**2149-11-22**] 03:24AM BLOOD CK-MB-NotDone cTropnT-0.10*
[**2149-11-27**] 04:49AM BLOOD Calcium-8.3* Phos-4.3 Mg-2.6
[**2149-11-26**] 05:53PM BLOOD Vanco-23.8*
[**2149-11-21**] 01:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2149-11-22**] 02:18AM BLOOD Lactate-2.7*
Brief Hospital Course:
Due to the patients borderline hemodynamic status, the patient
was admitted the the SICU. His blood was cultured which was
still pending at time of discharge. His line was cultured
however which grew MRSA. This line was pulled and he was
started on Vancomycin. His hemodynamic status improved with
fluid and he was sent to the floor on HD2. He was started on
Heparin (60-80) while in house to allow his coumadin to be
d/c'ed for line change. After his line was changed, his
coumadin was restarted. He had a history of an INR which was
somewhat difficult to manage, and at the time of discharge, he
had been receiving daily coumadin doses of 7.5. He was stable
at the time of discharge with an INR of 2.1, on TPN, tolerating
a regular diet, and ambulating with assistance.
Medications on Admission:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q4-6H
(every 4 to 6 hours) 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. Octreotide Acetate 0.05 mg/mL Solution Sig: One (1) Dose
Injection Q8H (every 8 hours).
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
6. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO HS
(at bedtime) as needed for sleep.
7. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
8. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
9. Insulin
Please use attached sliding scale for insulin
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q4-6H
(every 4 to 6 hours) 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. Octreotide Acetate 0.05 mg/mL Solution Sig: One (1) Dose
Injection Q8H (every 8 hours).
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
6. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO HS
(at bedtime) as needed for sleep.
7. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
8. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
9. Insulin
Please use attached sliding scale for insulin
10. Heparin Sod (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: As directed Intravenous ASDIR (AS DIRECTED): Until
coumadin theraputic.
11. Vancomycin HCl 1,000 mg Recon Soln Sig: One (1) gram
Intravenous Q36H (every 36 hours): Please check trough before
3rd dose.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
Rectal cancer
Enterocutaneous fistula
line sepsis
Discharge Condition:
good
Discharge Instructions:
Please change dressing every 2 days as necessary. Please keep
PTT between 60-80 until INR is reliably between [**1-1**].
Followup Instructions:
in 2 weeks with Dr. [**Last Name (STitle) **]. Call his office for an appointment.
([**Telephone/Fax (1) 6449**]
|
[
"E879.9",
"995.92",
"996.62",
"V10.06",
"250.00",
"V09.0",
"V44.3",
"569.81",
"038.11",
"785.52",
"V58.67",
"V43.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.15",
"97.49",
"86.07"
] |
icd9pcs
|
[
[
[]
]
] |
4757, 4800
|
1996, 2777
|
277, 306
|
4894, 4900
|
1161, 1973
|
5070, 5187
|
951, 956
|
3642, 4734
|
4821, 4873
|
2803, 3619
|
4924, 5047
|
971, 1142
|
232, 239
|
334, 702
|
724, 871
|
887, 935
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,348
| 137,305
|
46445
|
Discharge summary
|
report
|
Admission Date: [**2197-8-4**] Discharge Date: [**2197-8-7**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac cath with stent placement to right coronary artery
History of Present Illness:
82 year old male with hx of CAD, known RAC disease presented
with substernal chest pain last night and was taken by his wife
to [**Name2 (NI) **] ER. In the ER, patient was urgently intubated due to VF
arrest, was cardioverted 1X with 200 J with success. Patient
had marked ST elevations in inferior leads and taken urgently to
cardiac catheterization. In the cath lab he was found to have
moderate disease of the LAD and 90% stenosis of the RCA at the
bifurcation of the posterolateral branch. During the procedure
the patient returned to VF and was shocked again with 200 J and
was started on lidocaine. 3-4mm STE continued in III>II,F.
Past Medical History:
Hypertension
High cholesterol
Renal Cancer
PVD
s/p hernia repair
s/p R nephrectomy
s/p prostatectomy
s/p bifemoral bypass
Social History:
Married, lives with wife. + Tobacco use in the past, no current
use. No EtOH, no recreational drug use.
Family History:
non-contributory
Physical Exam:
Vit: afebrile 112/56 60
Gen: on ventilator
CV: irregular rhythm, nl S1, S2, no extra heart sounds, no
murmur
Pulm: CTAB
Abd: + BS, soft, nondistended
Ext: 2+ femoral and DP pulses bilaterally
Pertinent Results:
ADMIT LABS:
WBC-16.7* RBC-4.40* Hgb-14.3 Hct-42.4# MCV-96 MCHC-33.7 RDW-13.0
Plt Ct-256
Neuts-39.6* Lymphs-50.7* Monos-3.2 Eos-5.6* Baso-0.9
PT-12.3 PTT-24.4 INR(PT)-1.0
Glucose-210* UreaN-29* Creat-0.4* Na-135 K-4.6 Cl-107 HCO3-19*
Mg-1.5
CK(CPK)-120 --> 2653* --> 3996* --> 3256*
CK-MB-357* --> 484* --> 210*
MB Indx-13.5* --> 12.1* --> 6.4*
.
EKG on admission [**8-4**]:
Sinus rhythm
Long QTc interval
Possible inferior infarct - age undetermined
Lateral ST elevation - repeat if myocardial injury is suspected
Lateral T wave changes offer additional evidence of ischemia
Low QRS voltages in limb leads
Compared to previous ECG, inferolateral ST segment elevation and
anteroseptal
ST depression resolved
.
Cath [**2197-8-4**]:
"The LMCA was without flow limiting
disease. The LAD was diffusely diseased with a 50% mid lesion.
The LCX
was a small caliber vessel giving off an occluded OM2 with
collaterals
(likely a chronic lesion). The RCA was a large dominant vessel
with a
hazy 90% lesion distally at the bifurcation of the PL branch.
2. Left ventriculography was not performed.
3. Resting hemodynamics revealed an elevated mean PCPW of
16mmHG.
Cardiac Index was low at 2.0 l/min/m2 via the Fick method.
4. Successful PCI of the RPDA/RPL bifurcation with a 3.0 x 18 mm
Cypher"
.
ECHO LVEF 15-20%
1. The left atrium is mildly dilated. The left atrium is
elongated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is severe global left
ventricular hypokinesis with relative preservation of the sepum
and anterior walls and akinesis of the inferoposterior, lateral
and apical walls. Overall left ventricular systolic function is
severely depressed.
3. The aortic valve leaflets are mildly thickened. No aortic
regurgitation is seen.
4.The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
5.There is no pericardial effusion.
.
FEMORAL ARTERIAL U/S:
1) Patent grafted common femoral artery and common femoral vein,
without evidence of traumatic pseudoaneurysm or AV malformation.
2) Second graft which appears clotted off; correlate with
clinical and surgical history.
.
CXR [**8-4**]
1. NG tube tip is in the stomach. ET tube in good position.
2. Bilateral alveolar opacities most likely represent pulmonary
edema. There are more patchy areas in the left upper lobe and
left lower lobe that most likely represent aspiration.
.
CXR [**8-5**]
Right lower lung volume loss. Small left effusion.
.
CXR [**8-6**]
Slight interval worsening with mild CHF
Brief Hospital Course:
82 year old male with h/o CAD who was admitted to the CCU with
an IMI s/p RCA stenting.
# CAD/IMI - After the cardiac catheterization and stent
placement (see report in results section) the patient was
transferred to the CCU and started on ASA, plavix, atorvastatin,
metoprolol, lisinopril, and sliding scale insulin. Blood
pressure medications were titrated up as tolerated. Due to
continued bleeding after catheter removal and development of a
femoral hematoma, an U/S of the fem-fem bypass was ordered to
rule out AV fistula. The study showed no traumatic
pseudoaneurysm or AV malformation and a patent grafted common
femoral artery and common femoral vein.
He had no further chest pain or pressure during this admission.
Patient should continue his plavix until further notice. Note
that he takes simvastatin as an outpatient. Will have him
continue on the simvastatin instead of switching to atorvastatin
as outpatient due to VA prescription coverage. Will have pt
follow up with his cardiologist Dr. [**Last Name (STitle) 11679**] [**Name (STitle) 98665**] any
further increase in his BP medications or his statin.
.
# Pump - EF 15-20%, (see report in results). Will have patient
obtain a repeat ECHO in 2 weeks with his outpatient cardiologist
to assess for improvement in LVEF. Would not recommend heparin
long term as anterior hypokinesis and akinesis seen on echo are
unlikely due to a new inferior infarction. If EF is still
significantly diminished, would consider ICD placement.
.
# Rhythm - Patient was continued on lidocaine for 12 hours post
cath and was monitored throughout remaining hospitalization for
ectopy. He had one run of NSVT in the 48 hours following his
catheterization, and only 1 PVC in the 24 hours prior to
discharge.
.
# Pulm - Patient was extubated on HD#2 without difficulty. He
was treated for pneumonia based on opacity seen on chest xray,
elevated WBC, and productive cough. He was started on
Levo/Flagyl and will continue for 7 days. Patient was afebrile
with a downtrending WBC count by the time of discharge.
.
# Anemia - Patient's hct dropped from 42 pre-cath to 28.8
post-cath. Patient was transfused 1 unit, hct then remained
stable at greater than 30.
.
# FEN - Electrolytes were maintained at K >4 and Mg >2. Patient
was advanced to a heart healthy diet without difficulty.
.
# Prophylaxis: Patient was started on PPI during admission for
gastric ulcer prophylaxis until he was able to eat. He was also
kept on pneumatic boots for DVT prophylaxis.
.
# Code Status: full
.
# Dispo: Patient was cleared by physical therapy and discharged
to home.
Medications on Admission:
Toprol
Folic Acid
Vitamin E
Vitamin C
Lisinopril
Simvastatin
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
5. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*6 Tablet(s)* Refills:*0*
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 6 days.
Disp:*18 Tablet(s)* Refills:*0*
7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Inferior myocardial infarction
Coronary artery disease
Discharge Condition:
Stable
Discharge Instructions:
shortness of breath, or dizziness.
Please see pamphlet on activity guidelines following heart
attack.
Followup Instructions:
Please follow up with your cardiologist Dr. [**Last Name (STitle) 11679**]
([**Telephone/Fax (1) 98666**] within two weeks to have a repeat echocardiogram
and recheck of blood pressure.
Completed by:[**2197-8-7**]
|
[
"E879.0",
"401.9",
"998.12",
"V10.52",
"272.0",
"410.41",
"285.1",
"414.01",
"443.9",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.20",
"88.55",
"36.07",
"36.01",
"88.52",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
7716, 7722
|
4100, 6712
|
271, 332
|
7821, 7829
|
1540, 4077
|
7979, 8196
|
1289, 1307
|
6823, 7693
|
7743, 7800
|
6738, 6800
|
7853, 7956
|
1322, 1521
|
221, 233
|
360, 1005
|
1027, 1150
|
1166, 1273
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,529
| 193,388
|
33395
|
Discharge summary
|
report
|
Admission Date: [**2144-4-15**] Discharge Date: [**2144-4-26**]
Date of Birth: [**2075-8-24**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Bactrim / Naprosyn / Keflex / Celebrex / Noroxin
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
OPCABGx3(LIMA-LAD,SVG-OM,SVG-PDA)[**4-20**]
History of Present Illness:
Ms. [**Known lastname **] is a 68F with DM, CRI, CAD, CHF (EF 35%) initially
admitted to OSH with SOB who is transferred for cardiac
catheterization and stenting of her LAD.
.
Four days prior to her presentation at the OSH, the patient
presented to her PCP with complaints of dysuria and was
empirically started on Bactrim. She apparently was taking
naproxen at home prior to admission for hip pain. The day of
admission [**4-8**] she woke up, smoked a cigarette, and became
acutely short of breath. She did have a nonproductive cough. She
denied any associated chest discomfort, nausea, vomiting, or
palpitations. She did feel a little sweaty. She apparently had
been feeling well the day before, although had noticed increased
swelling in her legs and a 20lb weight gain over the previous
month for which she had received lasix intermittently. Has had
PND, no orthopnea. Has been taking her medications with
assistance of her daughters, but has not been compliant with low
sodium diet.
.
Her SOB worsened leading her to call 911. Upon EMS evaluation
she was tachycardic and tachypneic. She was administered
nitroglycerin, combivent, 80mg IV lasix, and morphine. She
apparently became nonresponsive and was intubated in the field
and brought to an OSH.
.
At the OSH, vitals on admission to the ICU were T 98.2 P 80 BP
156/74 O2 not recorded. ED vitals not included in transfer
paperwork. Per ICU admission note, patient had BP 240/110 at one
point but not at all clear when this occured.
Admission labs notable for ABG 7.22/53/466; K 6.5; BUN/Cr
50/3.1; WBC 21k (decreasing to 11k subsequently) and Hct 38.9.
Initial troponin was 0.02 rising to peak of 0.26 on [**4-9**]. EKG
done showed ST depressions and T wave inversions in
anterolateral leads. CXR reportedly c/w pulmonary edema. She was
admitted to the ICU and extubated on [**4-9**].
.
She underwent cardiac catheterization on [**4-13**] at the OSH which
was remarkable for 95% stenosis of the LAD after D2, 55-60%
stenosis of LCX with long tubular stenosis 60% after the large
OM, diffuse disease of the RCA with sequential moderate stenoses
with 85% mid RCA and 75% at takeoff of PLV. No interventions
were performed at time of cardiac catheterization. She was
loaded with plavix 600mg and transferred to [**Hospital1 18**] for stenting
of her LAD.
.
Here at [**Hospital1 18**], patient underwent repeat cardiac cath. Attempted
to access graft from right side was unsuccessful so catheter
introduced on left. Cath notable for 90% stenosis of the mid
LAD. The balloon could not be advanced across the lesion. As the
patient had CRI and had received 160cc of contrast already,
decision was made to abort the procedure.
.
On ROS: No history of thrombosis or PE, recent URI/flu, fevers,
chills, diarrhea/constipation, hematochezia, melena, or other
bleeding, claudication (had prior to vascular bypass surgery).
Had "small stroke" in past and subsequently underwent CEA.
Past Medical History:
* CAD
--told she had a "silent MI" at [**2-/2144**] admission
--persantine MIBI [**3-28**]
by report showed fixed defect distal anterolateral wall
* CHF
--TTE [**2-28**] at OSH showed EF 55% with apical akinesis, mild MR
and TR
* Diabetes w/ peripheral neuropathy HbA1c 7.1 [**2-28**]
* Aortobifemoral bypass surgery and femoral stents
* Hypertension
* Hyperlipidemia
* ?COPD
* CRI with baseline creatinine 2.5-3.0, diabetic nephropathy
* Diverticulitis
* s/p spinal fusion, s/p disk removal
* s/p carotid endarterectomy
* s/p Hysterectomy
Social History:
Lives alone, smokes [**1-22**] PPD, denies EtOH use.
Family History:
n/c
Physical Exam:
Post cath in recovery room
Vitals T not recorded P 62 BP 150/65 RR 21 O2 100% on 2L
General Pleasant elderly woman appearing older than her stated
age in no acute distress lying flat as sheaths not yet removed
HEENT Sclera white, conjunctiva pink, dry MM.
Neck Scar R lateral neck at site of CEA, no bruits appreciated,
JVP difficult to appreciate [**2-22**] habitus, no goiter
Pulm Lungs clear bilaterally on limited supine exam
CV Regular rate S1 S2 no m/r/g, PMI nondisplaced, no
heaves/thrills
Abd Obese, +bowel sounds, nontender without masses or
organomegally. midline scar well healed.
Extrem Warm, well perfused, full distal pulses, 1+ bilateral
lower extremity pitting edema.
Neuro Alert and interactive
Pertinent Results:
[**2144-4-25**] 07:25AM BLOOD WBC-8.9 RBC-3.31* Hgb-9.6* Hct-30.1*
MCV-91 MCH-29.1 MCHC-32.0 RDW-14.7 Plt Ct-543*
[**2144-4-15**] 05:51PM BLOOD WBC-7.7 RBC-3.71* Hgb-10.7* Hct-33.6*
MCV-91 MCH-28.8 MCHC-31.8 RDW-14.4 Plt Ct-415
[**2144-4-15**] 05:51PM BLOOD Neuts-76.3* Lymphs-15.9* Monos-4.0
Eos-3.6 Baso-0.2
[**2144-4-25**] 07:25AM BLOOD Plt Ct-543*
[**2144-4-20**] 05:36PM BLOOD Fibrino-555*
[**2144-4-26**] 07:00AM BLOOD Glucose-90 UreaN-54* Creat-2.4* Na-144
K-4.3 Cl-106 HCO3-27 AnGap-15
[**2144-4-16**] 05:50AM BLOOD Glucose-132* UreaN-42* Creat-2.5* Na-137
K-5.3* Cl-100 HCO3-29 AnGap-13
[**2144-4-21**] 03:36AM BLOOD ALT-17 AST-28 AlkPhos-45 Amylase-23
TotBili-0.5
[**2144-4-25**] 07:25AM BLOOD Mg-2.5
[**2144-4-17**] 07:50AM BLOOD TSH-4.4*
[**2144-4-17**] 07:50AM BLOOD Free T4-1.2
RADIOLOGY Final Report
CHEST (PA & LAT) [**2144-4-25**] 4:20 PM
CHEST (PA & LAT)
Reason: r/o inf, eff
[**Hospital 93**] MEDICAL CONDITION:
68 year old woman with
REASON FOR THIS EXAMINATION:
r/o inf, eff
EXAMINATION: PA and lateral chest.
INDICATION: Shortness of breath.
PA and lateral views of the chest are obtained on [**2144-4-25**] at 1622
hours and compared with the most recent radiograph of [**2144-4-22**].
Again is seen diffuse enlargement of the cardiac silhouette
consistent with cardiomegaly and/or pericardial effusion.
Right-sided IJ line has been removed. There is a persistent
left-sided pleural effusion together with increased retrocardiac
density, which allowing for technical changes may have improved
since the prior radiograph. There appears to be a tiny
right-sided pleural effusion which is improved since the prior
study. There is no evidence of pneumothorax.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Approved: SAT [**2144-4-25**] 6:23 PM
Sinus rhythm
Nonspecific anterolateral T wave changes
Since previous tracing of [**2144-4-18**], less suggestive of left
atrial abnormality
and ST-T wave changes appear decreased
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
93 146 74 384/441 64 48 89
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 77496**] [**Hospital1 18**] [**Numeric Identifier 77497**]
(Complete) Done [**2144-4-20**] at 2:29:35 PM PRELIMINARY
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2075-8-24**]
Age (years): 68 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Aortic valve disease. Coronary artery disease. Left
ventricular function. Mitral valve disease. Valvular heart
disease.
ICD-9 Codes: 440.0, 396.9
Test Information
Date/Time: [**2144-4-20**] at 14:29 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW02-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *0.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.2 cm
Left Ventricle - Fractional Shortening: 0.36 >= 0.29
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Left Ventricle - Peak Resting LVOT gradient: 3 mm Hg <= 10 mm
Hg
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.3 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 7 mm Hg < 20 mm Hg
Aortic Valve - Valve Area: *2.3 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast
or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. All four pulmonary
veins not identified.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness and cavity
size. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic
function.
AORTA: Normal ascending aorta diameter. Focal calcifications in
ascending aorta. Normal aortic arch diameter. Complex (>4mm)
atheroma in the aortic arch. Normal descending aorta diameter.
Complex (>4mm) atheroma in the descending thoracic aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets. No AS. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS.
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.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-BYPASS: The left atrium is mildly dilated. No spontaneous
echo contrast or thrombus is seen in the body of the left atrium
or left atrial appendage. No atrial septal defect is seen by 2D
or color Doppler. Left ventricular wall thicknesses and cavity
size are normal. Overall left ventricular systolic function is
normal (LVEF>55%). The right ventricular cavity is mildly
dilated with normal free wall contractility. There are complex
atheroma in the descending thoracic aorta and aortic arch. There
are three aortic valve leaflets. The aortic valve leaflets are
mildly thickened. There is no aortic valve stenosis. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. There is
no pericardial effusion.
Post off pump bypass: Perserved biventricular function. LVEF
>55%. Aortic contours intact. Remaining exam is unchanged. All
findings discussed with surgeon at the time of the exam.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician
Brief Hospital Course:
She was seen by cardiac surgery. She was seen by ET for
evaluation of thyroid nodules and will need outpatient follow
up. Her hematacrit dropped and CT scane showed RP hematoma, she
was transfused and her hematacrit remained stable. She was
taken to the operating room on [**4-20**] where she underwent an
off-pump CABG x 3. She was transferred to the ICU in stable
condition. She was extubated on POD #1. Her vasoactive drips
were weaned to off on POD #2. She was transferred to the floor
on POD #3. Physical therapy worked with her for strength and
mobility. She continued to progress and was ready for discharge
home with VNA services. She will be staying with her daughter
temporarily.
Medications on Admission:
Home meds
Cardizem CD 240mg PO daily
Lisinopril 5mg PO daily
Colace 100mg PO BID
Omeprazole 20mg PO daily
Tricor 145mg PO daily
Clonidine 0.1mg daily
Zetia 10mg PO daily
Celexa 40mg PO daily
Klonapin 0.5mg PO BID
Xanax 1mg PO TID
Insulin 75/25 10units qam
Albuterol prn
VitD 50,000units qTuesday
Reglan 5mg PO QID
Ultram 100mg PO daily
Neurontin, dose uncertain
.
Medications on transfer
Plavix 75mg PO daily
Clonidine 0.1mg PO BID
Lopressor 75mg PO TID
Hydralazine 10mg PO q6
Norvasc 5mg PO daily
Tricor 145mg PO daily
Zocor 80mg PO daily
ASA 325mg PO daily
Colace 100mg PO BID
Atrovent q6
Atrovent [**Hospital1 **]
Insulin SS
Neurontin 300mg PO daily
Oxycodone 10mg PO q4 prn for arthritic pain
Celexa 40mg PO daily
Xanax 1mg PO TID
Klonapin 0.5mg PO BID
Vitamin D
Protonix 40mg PO daily,
Nicotine patch 14mg daily
Morphine prn
Tylenol prn
IV nitro @ 20mcg/min, IV heparin @ 1400 units/hr
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
[**Hospital1 **]:*60 Capsule(s)* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every six (6) hours as needed for pain.
[**Hospital1 **]:*30 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
[**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily) for 2 weeks: follow up with PCP.
[**Name Initial (NameIs) **]:*14 Patch 24 hr(s)* Refills:*0*
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 months.
[**Name Initial (NameIs) **]:*90 Tablet(s)* Refills:*0*
6. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day.
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
three times a day.
[**Name Initial (NameIs) **]:*90 Tablet(s)* Refills:*0*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks.
[**Name Initial (NameIs) **]:*14 Tablet(s)* Refills:*0*
9. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*0*
10. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
[**Name Initial (NameIs) **]:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
11. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*0*
12. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day.
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*0*
13. Clonazepam 0.25 mg Tablet, Rapid Dissolve Sig: One (1)
Tablet, Rapid Dissolve PO once a day.
[**Name Initial (NameIs) **]:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
14. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) puffs
Inhalation four times a day as needed for shortness of breath or
wheezing.
[**Name Initial (NameIs) **]:*qs qs* Refills:*0*
15. Reglan 5 mg Tablet Sig: One (1) Tablet PO four times a day.
[**Name Initial (NameIs) **]:*120 Tablet(s)* Refills:*0*
16. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours).
[**Name Initial (NameIs) **]:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
CAD s/p CABG
PVD, Htn, CRI, DM, Diverticulitis, neuropathy, MI, mild MR,
aortobifem '[**39**], L CEA, hysterectomy, 2 back surgeries
Discharge Condition:
Good
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**Last Name (STitle) 77498**] 2 weeks
Dr. [**First Name (STitle) **] 4 weeks
Dr. [**First Name (STitle) **] (ENT) for follow up of thyroid nodules. [**Telephone/Fax (1) 2349**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2144-4-26**]
|
[
"584.9",
"357.2",
"585.9",
"272.4",
"496",
"414.01",
"250.60",
"428.33",
"285.9",
"403.90",
"428.0",
"998.12",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"36.15",
"00.40",
"00.66",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
15369, 15431
|
11403, 12097
|
318, 364
|
15608, 15615
|
4722, 5626
|
15928, 16270
|
3969, 3974
|
13038, 15346
|
5663, 5686
|
15452, 15587
|
12123, 13015
|
15639, 15905
|
10142, 11380
|
3989, 4703
|
275, 280
|
5715, 10093
|
392, 3320
|
3342, 3883
|
3899, 3953
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,992
| 161,385
|
2810+55411
|
Discharge summary
|
report+addendum
|
Admission Date: [**2153-8-19**] Discharge Date: [**2153-8-24**]
Date of Birth: [**2074-11-10**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Mesenteric and Celiac Angiogram ([**2153-8-20**])
History of Present Illness:
This is a 78 Russian-speaking lady with a history of GIST s/p
resection in [**2143**] with recurrence with omental metastasis s/p
resection [**3-/2153**] who reports sudden
onset dull, diffuse abdominal pain starting at 3 AM on the day
of presentation. She reports 1 episode of emesis near onset of
pain. Denies chest pain or shortness of breath, no change in
bowel habits and had a normal, non-bloody BM the previous day.
Of note, she was recently admitted [**Date range (1) 13759**] as a transfer from
an OSH for intraperitoneal bleeding from tumor in the setting of
an INR of 4.0 on coumadin for atrial fibrillation. She received
a total of 2 units of blood and 1 unit of FFP, was stabilized,
then dc'd. She has restarted her coumadin in the interim and
restarted on her Gleevac at 200 mg daily.
Past Medical History:
PMH: DM, HTN, HLD, paroxysmal Afib, CVA [**2136**], TIA [**2138**],
hypothyroidism, GIST (dx in [**2143**], treated with surgery and
multiple intermittent courses of Gleevac, doses adjusted due to
side effects
PSH: partial gastrectomy/GIST resection, [**2143**]; incisional hernia
repair, [**2144**]; GIST omental met resection, [**3-/2153**]
Social History:
Lives alone. Has 2 daughters. Moved from [**Country **] in [**2137**]. Has
grandchildren who visit her.
-Tobacco history: negative
-ETOH: negative
-Illicit drugs: negative
Family History:
No family history of cancer, lung disease or heart disease. +
for DM.
Physical Exam:
VS: 97.6, 71, 116/70, 18, 96% RA
Gen: alert, russian speaking only, NAD
CV: irregularly irregular, no m/r/g
Pulm: mild crackles to bases otherwise CTAB
Abd: obese, soft, non-tender, non-distended, +BS
Ext: warm, 1+ LE edema, 2+dp/pt
Pertinent Results:
[**2153-8-24**] 07:35AM BLOOD WBC-6.2 RBC-3.81* Hgb-11.5* Hct-33.9*
MCV-89 MCH-30.1 MCHC-33.8 RDW-15.8* Plt Ct-196
[**2153-8-23**] 05:46AM BLOOD PT-12.6 PTT-23.8 INR(PT)-1.1
[**2153-8-24**] 07:35AM BLOOD Glucose-117* UreaN-20 Creat-1.1 Na-141
K-3.8 Cl-99 HCO3-34* AnGap-12
[**2153-8-24**] 07:35AM BLOOD Calcium-9.0 Phos-2.0* Mg-2.0
Brief Hospital Course:
Mrs [**Known lastname 13755**] was admitted to the surgical intensive care unit on
[**2153-8-19**] after presententing to the Emergency Room with severe
abdominal pain. A CT scan was performed on that occasion and
revealed marked progression of her GIST tumor as compared to
[**5-/2153**] and within this tumor an area of central hyperdensity in
a blush-like pattern was identified,concerning for active
intratumoral extravasation. There was also a moderate amount of
hyperdense free fluid consistent with intraperitoneal
hemorrhage.
The patient was made NPO, on IVF and a foley catheter was placed
for urine output monitoring. Overnight serial Hct were obtained
and she was given 2U of PRBC and 1U FFP.
On HD 2 since her INR continued to be high (1.9)she was given
10mg of Vit K IV. IR was consulted for possible embolization of
bleeding source. A selective angiogram was performed but no
bleeding source was identified at that time.
Between HD2 and 3 the patient's O2 requiremets increased and her
CXR showed minimally progressive pulmonary edema. Mrs [**Known lastname 13755**] is
on Lasix at home; she was therefore cautiously diuresed to
improve her respiratory status.
Overnight on HD2 and early morning on HD 3 she received a total
of 3 more Units os PRBC with good Hct response. An echo was also
performed on HD 3 and showed a mildly dilated L atrium, moderate
symmetric L ventricular hyperthrophy and a LVEF >50%. It did
show some moderate L diastolic dysfunction. The pulmonary artery
pressure was higher compared to previous examinations.
Mrs [**Known lastname 13755**] showed signs of improvement with decreasing O2
requirements and resolved abdominal pain on HD4. Her Hct had
remained stable around 30 on repeated checks and she was
therefore advanced to a clear liquid diet, which was well
tolerated and transferred to the regular floor later that night.
On HD5 the patient was advanced to a regular diet and her home
medications were resumed. Her foley catheter was discontinued
and she was able to void regularly. Physical therapy was
consulted for evaluation and she was cleared for home. She was
noted to desaturate to 86% while ambulating and would quickly
recover back to baseline of 96% on RA. She was given an
additional 80mg lasix which provided good diuresis. On HD#6 she
continued to do well, she was ambulating independently with her
walker, tolerating regular diet, and passing flatus. Her
anticoagulation use was discussed with her cardiologist who
recommended aspirin/plavix instead of coumadin. The surgery
service feels strongly about no further anticoagulation in this
patient, now with her second episode of life threatening
intra-abdominal bleeding. The patient was instructed to stop
taking her coumadin and follow up with her cardiologist in 1
week to discuss the treatment of her AFib at that time. This was
explained to the patient with the aid of the russian interpretor
and the patient expressed understanding and agreement of this
treatment plan. She was discharged home with her regular VNA
services.
Medications on Admission:
gleevac 200', coumadin 3', januvia 25', diltiazem 150',
lasix 80', lisinopril 2.4', ambien 10', levothyroxine 200',
colace, senna
Discharge Medications:
1. Gleevec 100 mg Tablet Sig: Two (2) Tablet PO once a day.
2. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
3. Januvia 25 mg Tablet Sig: One (1) Tablet PO once a day.
4. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily) as needed for a fib.
5. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. levothyroxine 200 mcg Tablet Sig: One (1) Tablet PO once a
day.
7. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily) as
needed for HTN.
8. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO 2-3 tabs per day
as needed for constipation.
11. bimatoprost 0.03 % Drops Sig: One (1) drop in left eye
Ophthalmic nightly ().
Discharge Disposition:
Home With Service
Facility:
Family Care Extended
Discharge Diagnosis:
intraabdominal hemorrhage
atrial fibrillation
Pulmonary edema
GIST
Diabetes
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the surgery service for intra-abdominal
bleeding. You were treated with plasma to correct your INR and
blood transfusions to keep your blood levels normal. An
angiogram was done to indentify any bleeding blood vessel but it
did not locate one.
Do not take coumadin. You should call your cardiologist to make
an appointment in 1 week to discuss treatment options for your
atrial fibrillation.
Call your PCP or return to the Emergency Department for:
temperature greater than 101.4, chest pain, increasing shortness
of breath, wheezing, increasing leg swelling, weight gain of
3lbs or more, abdominal pain, inability to tolerate food or
drink, bloody or black tarry stools, blood in your urine, or any
other concerns.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Call Dr.[**Name (NI) 5103**] office to make an appointment in 1 week.
Provider: [**Name10 (NameIs) 191**] POST [**Hospital 894**] CLINIC Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2153-8-30**] 8:10
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2153-10-31**]
11:20
Provider: [**Name10 (NameIs) 3150**],[**Name11 (NameIs) **] MD Phone:[**Telephone/Fax (1) 11133**]
Date/Time:[**2153-11-9**] 2:30
Completed by:[**2153-8-25**] Name: [**Known lastname 2104**],[**Known firstname 2105**] Y Unit No: [**Numeric Identifier 2106**]
Admission Date: [**2153-8-19**] Discharge Date: [**2153-8-24**]
Date of Birth: [**2074-11-10**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 203**]
Addendum:
Patient has significant congestive heart failure, diastolic
dysfunction, and developed pulmonary edema due to this
underlying process and the resuscitation and transfusions she
required.
Discharge Disposition:
Home With Service
Facility:
Family Care Extended
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 206**] MD [**MD Number(1) 207**]
Completed by:[**2153-10-13**]
|
[
"428.31",
"401.9",
"250.00",
"244.9",
"V58.61",
"V10.04",
"568.81",
"427.31",
"790.92",
"428.0",
"272.4",
"197.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
8912, 9119
|
2472, 5518
|
319, 371
|
6775, 6775
|
2116, 2449
|
7810, 8889
|
1777, 1848
|
5699, 6568
|
6663, 6754
|
5544, 5676
|
6958, 7787
|
1863, 2097
|
265, 281
|
399, 1201
|
6790, 6934
|
1223, 1569
|
1585, 1761
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,833
| 185,790
|
33044
|
Discharge summary
|
report
|
Admission Date: [**2150-2-27**] Discharge Date: [**2150-3-10**]
Date of Birth: [**2095-8-24**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
CC:[**CC Contact Info **]
Major Surgical or Invasive Procedure:
CPR, Intubation
History of Present Illness:
HPI: Patient is a 54 yo female with 3 days of nausea, vomiting
and diarrhea with any po intake who presents to the ED with
hypotension. Has chronic cough, worse in past few days
productive of yellow-green sputum (non-bloody), chest pain
radiating to back, worse with deep breathing. Patient also
reports headache, neck pain and stiffness, photophobia all of
which are new. Also reports pain with movement of her eyes. No
joint or muscle pain. Reports that abdomen is distended and full
but is nontender on exam. Denies dysuria and UA was negative.
Also denies vaginal discharge, dyspareunia, recents STDs. Has
had stds in the past. No recent trauma or falls. Pt also
complains of sore throat. Last LMP 3 months ago, does not use
tampons. Pt reports sick contact with roommate, who was
diagnosed with PNA and also suffered from N, V, diarrhea. No
recent travel.
.
In the ED, CTA and CXR were negative. WBC= 5.9 with 38%
bandemia. Temp= 99.2 initiall, then up to 100.8. Initially HR=
150 with sbp 70-80 with rate related ST-segment depressions,
initial set of cardiac enzymes negative. After 3 liters of IVF,
patient remained hypotensive to 70s systolic and HR remained
120-140s. Pt ultimately received 6 units of IVF and is maxed is
on neosynephrine and levophed was started. Subclavian line
placed. Lactate 1.4. Stat echo was done showing normal valves
and function. Patient was given dexamethasone per septic
protocol.
Past Medical History:
Past Medical History:
bipolar depression
spinal stenosis
HTN
etoh abuse
OA
Asthma
Social History:
Social History: Pt lives in sober house, started in her teens
and quit 6 months ago. Smokes daily about 2 cigs. No IVDA or
cocaine. Pt has boyfriend who is with her today
Family History:
Family History: mother has heart disease
Physical Exam:
Physical Exam:
VS: Temp: 101.2 BP:142/64 HR:120 RR:25 O2sat 95% NRB
GEN: patient is mildly lethargic, but answers all questions
appropriately and is oriented x 3
HEENT: NCAT, anicteric, no injections, PERRL, EOMI but pt has
pain with eye movement, MM dry, op without lesions, no tonsillar
erythema or exudate.
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly
RESP: wheeze at right base, otherwise clear
CV: RR, tacchy, S1 and S2 wnl, no m/r/g
ABD: mildly distended, +b/s, soft, nt, no masses or
hepatosplenomegaly
Vaginitis:
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated.
RECTAL: done in ED and was guaic negative
Pertinent Results:
ADMISSION LABS:
.
[**2150-2-27**] 11:25AM BLOOD WBC-5.9 RBC-4.79 Hgb-15.0 Hct-46.2 MCV-97
MCH-31.3 MCHC-32.4 RDW-13.6 Plt Ct-318
[**2150-2-27**] 11:25AM BLOOD Neuts-57 Bands-38* Lymphs-1* Monos-0
Eos-1 Baso-0 Atyps-0 Metas-3* Myelos-0
[**2150-2-27**] 11:25AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2150-2-27**] 11:25AM BLOOD PT-12.3 PTT-24.9 INR(PT)-1.0
[**2150-2-27**] 05:01PM BLOOD Glucose-137* Na-143 K-2.8* Cl-117*
HCO3-16* AnGap-13
[**2150-2-27**] 11:25AM BLOOD ALT-22 AST-27 CK(CPK)-21* AlkPhos-106
TotBili-0.4
[**2150-2-27**] 11:25AM BLOOD cTropnT-<0.01
[**2150-2-27**] 11:25AM BLOOD Lipase-50
[**2150-2-27**] 05:01PM BLOOD Albumin-2.4* Calcium-6.0* Phos-1.2*
Mg-0.9*
[**2150-2-27**] 11:25AM BLOOD TSH-1.1
[**2150-2-28**] 02:10AM BLOOD Cortsol-16.3
[**2150-2-27**] 05:01PM BLOOD HCG-LESS THAN
[**2150-2-28**] 03:45AM BLOOD HIV Ab-NEGATIVE
[**2150-2-27**] 11:25AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-POS
[**2150-2-27**] 06:08PM BLOOD Type-ART pO2-108* pCO2-31* pH-7.28*
calTCO2-15* Base XS--10
[**2150-2-27**] 05:22PM BLOOD Hgb-10.5* calcHCT-32 O2 Sat-98
[**2150-2-27**] 05:18PM BLOOD freeCa-0.99*
.
MICROBIOLOGY:
.
Blood Cultures 1/18 NG x 3
Blood Cultures 1/19 NG x 2
Blood Cultures 1/25 NG x 2
Blood Cultures 1/27 NG x 2
Urine antigen negative [**3-8**]
Cdiff EIA neg [**3-8**]
MRSA screen neg
BAL [**3-9**], 2+PMNs, no organisms, neg for PCP, [**Name10 (NameIs) **] acid fast
**Viral Antigen Test Positive for Influenza A
.
LUMBAR PUNCTURE
.
[**2150-2-28**] 03:38AM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-1* Polys-0
Lymphs-44 Monos-56
[**2150-2-28**] 03:38AM CEREBROSPINAL FLUID (CSF) TotProt-37 Glucose-78
LD(LDH)-15
.
.
[**2150-2-28**]
CT HEAD W/O CONTRAST
FINDINGS: This study is somewhat limited by motion artifact.
There is no evidence of intracranial hemorrhage, shift of
normally midline structures, mass effect, hydrocephalus, or
acute major vascular territorial infarction. The ventricular
system is normal in size and configuration. There are small
fluid levels in the left maxillary sinus and left sphenoid sinus
air cell. A few of the ethmoid air cells are opacified. The
mastoid air cells remain clear. There is no concerning osseous
or surrounding soft tissue abnormality.
.
IMPRESSION: No intracranial hemorrhage, evidence of cerebral
edema or acute major vascular territorial infarction. Small
fluid levels in the left maxillary and sphenoid sinuses.
.
[**2150-2-28**]
CT OF THE ABDOMEN WITH IV CONTRAST: The visualized lung bases
demonstrate pleural effusions, moderate on the right and small
on the left. There is associated compressive atelectasis of the
dependent lower lobes. The gallbladder appears to be intact with
normal wall enhancement and no evidence of cholelithiasis or
appreciable wall thickening. A small amount of fluid layers
around the liver into [**Location (un) 6813**] pouch. The liver is
unremarkable without focal lesion. The portal vein is patent.
The spleen, pancreas and adrenal glands are unremarkable. There
are bilateral subcentimeter scattered hypodensities of each
kidney which are too small to characterize but probably cysts.
Kidneys enhance and excrete contrast symmetrically and the
ureters fill with contrast and are of normal caliber. Evaluation
of the large and small bowel is limited without oral contrast.
Intraluminal fluid is noted throughout the entire colon as well
as several loops of small bowel. There is pancolonic wall
thickening. The terminal ileum is unremarkable. There is no
evidence of obstruction or focally dilated loops.
.
CT OF THE PELVIS WITH IV CONTRAST: A small amount of low-density
fluid layers into the pelvis. The rectum, uterus, adnexa are
unremarkable. There is a Foley catheter within the decompressed
urinary bladder.
.
BONE WINDOWS: No concerning lesions are seen.
.
IMPRESSION:
1. No CT evidence of gallbladder perforation. Findings on
ultrasound probably relate to the presence of small amount of
free fluid surrounding the liver and extending into the
gallbladder fossa in combination with partial imaging of
adjacent fluid filled colon.
2. Pancolonic wall thickening consistent with colitis.
Infectious etiology considered more likely
3. Bilateral pleural effusions, moderate on the right and small
on the left.
.
[**2150-2-27**]
CTA CHEST W/ AND W/O CONTRAST
FINDINGS: The heart and great vessels are unremarkable. There is
no evidence of thoracic aortic dissection or pulmonary embolism.
No pericardial effusion is seen. The lungs are grossly clear,
with only minimal dependent atelectasis and no focal
consolidation (note that the full lung bases are included only
on the low-dose acquisition). No pleural effusion is seen. A few
non- pathologically enlarged mediastinal lymph nodes identified.
.
This examination is not tailored for detailed evaluation of
subdiaphragmatic regions. The visualized portions of the liver,
spleen and stomach are grossly unremarkable, with no extreme
upper abdominal ascites.
.
Osseous structures are unremarkable without suspicious lytic or
sclerotic lesion identified. There is suggestion of a rounded 2
cm low-attenuation lesion within the left lobe of the thyroid.
.
IMPRESSION:
1. No acute cardiopulmonary p rocess identified. Specifically,
no evidence of dissection or other acute aortic process, or PE.
.
2. Suggestion of cystic nodule in the left lobe of the thyroid.
Recommend correlation with physical exam and [**Name (NI) 13416**], when
feasible (given the patient's clinical presentation, is there
any possibility of underlying thyroid, or adrenal, disease?).
.
CHEST [**2150-3-10**] 4:31 AM
.
[**Hospital 93**] MEDICAL CONDITION:
54 year old woman with intubation, ards, sudden hypoxia
REASON FOR THIS EXAMINATION:
?change
.
FINDINGS: In comparison with earlier study of this date, there
is little overall change in the diffuse bilateral pulmonary
opacifications that only spare the left lower lung.
Brief Hospital Course:
Ms. [**Known lastname **] was a 54 y/o female admitted for hypotension to SBP
70-80s. She received 3 liters of IVF in the ED. Neosynpherine
was maxed out in the ED with SBP still in the 80s. At that time
levophed was started. Pt was also started on the sepsis steroid
protocol. Central line was placed. She received empirically
vancomycin, levofloxicin, flagyl, ceftriaxone, and azithromycin.
Many of these were added or discontinued during her course as
there was no isolated organism other than influenza.
.
During her hospital stay patient has a persistent tachycardia
that did not respond to fluids, antibiotics, analgesics,
beta-blockers, or anxiolytics. She developed increasing oxygen
requirements during her hospitalization. She develloped
bilateral pulmonary infiltrates during her hospitalization
consistent with ARDS. On [**3-9**] She had to be intubated for
hypoxic respiratory failure. She continued to have poor
oxygenation despite high FiO2 and PEEP settings. She did not
respond to nebulizers/inhalers. She was maintained on ARDS
protocol of a TV of 7cc/kg. Patient was unable to maintain sats
unless, and with paralysis/neuromuscular blockade was able to
maintain saturations. On the night of [**3-9**] to [**3-10**] she went into
PEA arrest, which resolved with 60 seconds of CPR, one round of
epinephrine and one round of atropine. She continued to have an
acidemia from this point until her death.
.
During this point in time her antibiotic coverage was broadened
to Meropenem and Vancomycin to cover possible gram negative
respiratory nosocomial infections as well as Flagyl to cover
colonic anaerobes as pt was noted to have dilated colon on
xrays, and likely illeus. Cdiff toxin was negative.
.
At this point patient developed an increasing leukocytosis from
17 on the [**3-7**] to 27 on [**3-10**]. No elevation in lactates. No free
air in abdomen. Pt was noted to have pleural effusions. The plan
was to tap these as soon as pt was stable to rule out empyema.
.
On [**3-10**], given patients worsening ARDS, and recent extubation it
was felt that her lung function might improve if she was started
on prone ventilation. Immediately following her transfer to the
prone bed, pt developed hypotension to the SBP of 50s while
receiving maximum levophed and neosynephrine. CPR was started,
many rounds of epi and atropine were given. Patient developed
PEA. Several times patient redeveloped a pulse, but continued to
remain hypoxic through out most of the code despite our best
efforts to ventilate the patient. She continued to return to PEA
arrest. The code was run off and on for 1.5 hours. She was
pronounced dead following the code. The fiance was brought into
the code, so that he might see that everything that possibly
could be done was done for the patient.
.
She died of hypoxic respiratory failure consistent with ARDS.
The ARDS was probably secondary to influenza pneumonia.
.
A post-mortem was requested to help confirm this diagnosis or
rule out any other more immediate cause of her death.
.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8952**] MD
Medications on Admission:
-seroquel 100mg QHS
-lisinopril 5mg daily
-Oxcarbazepine (Trileptal) 150mg [**Hospital1 **]
-Potassium 10meq daily
-Bupropion SR 100mg [**Hospital1 **]
-Hydrochlorothiazide 25mg daily
Campral 666mg TID (HELD)
Nabumetone 500-1000mg [**Hospital1 **] (has not taken recently - HELD-)
-Amitriptyline 50mg [**Hospital1 **]
darvocet 3 tabs per day (HELD)
-Prozac 60mg daily
Discharge Disposition:
Expired
Discharge Diagnosis:
ARDS
Respiratory Failure
Influenza pneumonia
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
none
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"785.59",
"584.9",
"518.81",
"511.9",
"276.2",
"008.8",
"401.9",
"427.5",
"300.00",
"493.20",
"038.9",
"995.92",
"715.90",
"487.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"33.23",
"00.17",
"03.31",
"96.71",
"99.60",
"99.04",
"96.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12458, 12467
|
8939, 12040
|
340, 357
|
12555, 12565
|
2975, 2975
|
12622, 12755
|
2133, 2159
|
8644, 8700
|
12488, 12534
|
12066, 12435
|
12589, 12599
|
2189, 2956
|
276, 302
|
8729, 8916
|
385, 1807
|
2991, 8607
|
1851, 1913
|
1945, 2101
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,293
| 194,192
|
16742
|
Discharge summary
|
report
|
Admission Date: [**2156-6-19**] Discharge Date: [**2156-6-30**]
Date of Birth: [**2081-5-29**] Sex: M
Service: [**Last Name (un) **]
BRIEF CLINICAL HISTORY: Mr. [**Known lastname 1511**] is a 75-year-old Caucasian
male with a prior medical history significant for Clostridium
difficile colitis. He is status post colectomy and ileostomy
at the [**Hospital1 18**] [**Last Name (un) 4068**] on [**2156-6-5**]. He subsequently had a small
bowel obstruction with a white blood cell count of 22,000. A
CT scan at that time showed a clear transition point after
two days of conservative therapy. He was taken to the
Operating Room at that time for an exploratory
laparotomy/lysis of adhesions, placement of a G tube, repair
of enterostomy. The postoperative course was not noted to be
unusual. However, on or about postoperative day number 12,
the patient was transferred to the Intensive Care Unit with a
hypotension and positive cardiac enzymes. At that time, it
was noted that the patient had evolved into a septic picture,
precipitating an MI or the reverse.
Records from that time showed that the patient went into
atrial fibrillation, although there was a prior history of
atrial fibrillation. He subsequently ruled in for a
myocardial infarction. Full workup at that time including a
CT scan and reciting of his central line did not show any
clear sources for his septic picture. Subsequent cultures
did become positive for MRSA pneumonia. On [**2156-6-19**], the
patient was transferred to [**Hospital1 18**] for further management.
PRIOR MEDICAL HISTORY: Troponin leak.
MRSA pneumonia.
Intermittent atrial fibrillation.
Congestive heart failure.
Chronic renal insufficiency.
Alcoholism.
Ulcerative colitis.
Hypertension.
TIA/prior stroke.
Cerebrovascular accident.
PRIOR SURGICAL HISTORY: Total colectomy.
Lysis of adhesions.
ALLERGIES: the patient has no known drug allergies.
MEDICATIONS:
1. Regular sliding scale insulin.
2. Lipitor.
3. Diltiazem.
4. Ceftazidime.
5. Lopressor.
6. Protonix.
7. Morphine.
LABORATORY RESULTS ON ADMISSION: White blood cell count
21.6, hematocrit 29.6, platelets 730,000. Sodium 139,
potassium 2.0, chloride 108, C02 12, BUN 40, creatinine 1.2,
glucose 104. CK MB was found to be 90, troponin 12, and then
ultimately 8.7.
RADIOLOGY: CT scan on [**2156-6-5**] showed evidence of a hiatal
hernia and bilateral effusions. However, there was no small
bowel obstruction; however, no other possible sources for
infection.
On [**2156-6-15**], a CT scan of the head was performed. This was
negative.
On [**2156-6-18**], another CT scan showed a large left chest
pleural effusion; however, this was not thought to be
tappable.
EXAMINATION ON PRESENTATION: Upon this presentation to the
[**Hospital1 18**] Intensive Care Unit, the temperature was 98.9, pulse
83, blood pressure 118/62, respirations 30, saturating 100
percent on room air. He was at that time intubated and on a
ventilator with an SIMV setting of 500 cc tidal volume, rate
24. In general, the patient is described as sedated and
intubated. Examination showed the pupils to be equal and
reactive bilaterally. The sclerae were nonicteric. The
lungs had clear sounds in the apices; however, decreased
breath sounds at the bases. The cardiac examination revealed
a regular rate and rhythm. No evidence of any murmurs, rubs,
or gallops. The abdomen was soft, nontender, with a healing
midline incision. The ileostomy was pink, healthy appearing,
with an appliance placed. Lower extremities were somewhat
edematous but otherwise unremarkable.
HOSPITAL COURSE: Soon after his arrival to the [**Hospital1 18**], the
patient had a Thoracic Surgery consult. Based on the
recommendations of these, it was felt that the patient's
findings were consistent with a known pneumonia and a
loculated left pleural effusion. Long-term, it was felt that
the patient would likely need that but might consider chest
tube placement in the interim. This plan was acknowledged by
the primary team; however, no chest tubes were placed at that
time. The patient was maintained on empiric treatment with
vancomycin and Zosyn for a known MRSA infection and
presumption of a possible other infection source.
On hospital day number two, after further evaluation of the
radiographic findings, the attending thoracic surgeon felt
that what had been presumed to be a left collection in the
chest rather than being an empyema or other collection was
most likely a hiatal hernia. Nevertheless, there was
recognized the presence of the two rather smaller pleural
effusions. The Cardiology workup consult recommended that
the patient be continued on Lopressor and be anticoagulated
when possible.
With regards to the positive cardiac enzymes, their feeling
was that this was most likely a demand ischemia and not
associated with a plaque rupture. Recommendations were to
continue aspirin and a beta blocker and possibly after the
patient recovers from the acute phase of his illness can
consider an ischemic workup as an outpatient with a P MIBI
versus a possible catheterization.
On hospital day number two through three, the patient
gradually stabilized. Starting on hospital day number three,
his ventilator was gradually weaned and on the evening of
hospital day number three he was ultimately weaned from the
ventilator. On hospital day number four, he was started on
tube feeds and these were gradually increased until goal was
met.
Attention then turned to the treatment of the patient's
atrial fibrillation. He was started on heparin for
anticoagulation. Per Cardiology recommendations, he was
started on Amiodarone 200 mg q.d. on [**2156-6-22**]. The plan was
after one week of b.i.d. dosing the patient could be switched
to 200 mg p.o. q.d. Lopressor was continued. The patient
was maintained on anticoagulation with heparin to a goal PTT
of 60-80.
On [**2156-6-21**], the patient underwent a cardiac echocardiogram
to assess any changes in his cardiac function. This showed
that the left ventricular wall thickness, cavity size, and
systolic function were normal with an LV ejection fraction of
greater than 55 percent. The only notable change was a
moderate to severe 3+ mitral regurgitation. The patient was
started on Enalapril which could be titrated upwards as
tolerated for the mitral regurgitation.
On [**2156-6-23**], it became increasingly clear that the patient
had some residual neurological deficits. While his
examination was never focal and there could not be any
specific deficits found, he remained unresponsive and
persistently confused. A Neurology consult was sought and
thorough workup including all relevant blood tests were sent.
These were all shown to be negative. The patient went on to
have an MR scan which other than some nonspecific atrophy and
old lacunar infarcts did not show any specific etiologies
that would explain his change in mental status. The
diagnosis of exclusion of post Intensive Care Unit psychosis
was assigned with the hope that the patient's mental status
would gradually improved as he spent more time outside the
Intensive Care Unit.
Indeed, over the next 72 hours, as the patient's day and
night schedule has continued to normalize, he has become more
alert and oriented and is now conversant with some effort.
On [**2156-6-27**], there became increasing concern about the
patient's ostomy output which was reaching as high as 2
liters per day. He was subsequently bolused with an
appropriate amount of IV fluids to maintain his fluid
balance. A small amount of tincture of morphine was also
added to his tube feeds. This subsequently resolved over the
next 48-72 hours.
On [**2156-6-29**], there was again concern that there might be an
underlying infection or fluid collection which might explain
the slow return to mental function. Plans were made for an
ultrasound-guided pleurocentesis. Following informed consent
provided by the patient's wife, he was evaluated for this.
After several views with the attending radiologist, it was
felt that none of the collections were substantial enough for
a tap. The patient was subsequently returned to his room.
On [**2156-6-30**], after final evaluation by Dr. [**First Name (STitle) 2819**] and the rest
of the surgical team, it was felt that the patient could be
returned to the [**Last Name (un) 4068**]. This had been an issue that had been
voiced on several occasions by the family, in particular his
wife who has a very difficult time visiting him at the [**Hospital 18**]
[**Hospital 1426**] Campus. At the time of discharge, there were no
major medical or surgical issues that needed to be resolved
and it appeared that the hospital course at this time was a
watch and wait process as his mental status continued to
improve.
FOLLOW UP:
1. Ostomy care as directed.
2. Physical therapy as directed.
3. The patient should be considered for a neuropsychiatric
evaluation to be able to establish progression of his
mental status resolution.
4. Wound care as directed by Dr. [**First Name (STitle) 2819**].
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg p.o. q.d.
2. Regular sliding scale insulin per schedule attached.
3. Amiodarone 200 mg one p.o. q.d.
4. Lansoprazole 30 mg p.o. q.d.
5. Opium 10 percent tincture 15 drops via tube feeds q. four
to six hours as needed to limit tube feed output.
6. Zosyn 4.5 grams every eight hours.
7. Morphine 1-2 mg IV q. 1-2 hours p.r.n. pain.
8. Vancomycin 1 gram IV q. 12 hours.
9. Hydralazine 10 mg IV q. six hours.
It should be noted that the patient was not transferred on
Enalapril, although this was part of Cardiology
recommendations. It was felt that this could be adjusted as
an outpatient.
DIAGNOSIS ON DISCHARGE:
Troponin leak/MI
MRSA/Pseudomonas pneumonia.
Intermittent atrial fibrillation.
Congestive heart failure.
Chronic renal insufficiency.
Alcoholism.
Ulcerative colitis.
Delirium
Hypertension.
TIA/prior stroke/Cerebrovascular accident.
Intensive Care Unit psychosis.
Mild Dementia.
NUTRITION: The patient's diet has been maintained on Impact
with fiber full-strength 60 milliliters an hour, residuals
checked every six hours.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 18475**]
Dictated By:[**Last Name (NamePattern1) 9178**]
MEDQUIST36
D: [**2156-6-30**] 16:54:35
T: [**2156-6-30**] 18:13:36
Job#: [**Job Number **]
|
[
"482.1",
"428.0",
"038.9",
"511.9",
"410.71",
"427.31",
"997.3",
"997.1",
"482.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.15",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
9120, 9741
|
3621, 8810
|
8821, 9094
|
9755, 10451
|
2097, 3603
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,795
| 196,779
|
36519
|
Discharge summary
|
report
|
Admission Date: [**2169-12-29**] Discharge Date: [**2170-1-12**]
Date of Birth: [**2124-1-22**] Sex: M
Service: MEDICINE
Allergies:
Bactrim / Sulfa (Sulfonamide Antibiotics) / Clindamycin /
Prochlorperazine / Penicillins / Quinolones
Attending:[**First Name3 (LF) 11892**]
Chief Complaint:
Altered mental status.
Major Surgical or Invasive Procedure:
1. Intubation
2. Lumbar puncture
3. Central Line Placement and removal
History of Present Illness:
45 y/o M with HIV on HAART, brought to ED by EMS after
reportedly injecting cocaine last night, and subsequently
developing substernal chest pain. He was given nitro spray x2 by
EMS, with no result.
.
On arrival to the ED, triage vital signs included BP 150/80, HR
170, RR 14, and PO2 79% on NRB. He was also reportedly altered.
He was later found to be febrile to 107.8. He was given 0.4 mg
of narcan, with marginal improvement in his mental status. As
the ED team was preparing to intubate the patient for airway
protection, he developed seizure like activity. He was given
lorazepam, and subsequently intubated. He was started on a
midazolam gtt, and was also given propofol. CXR revealed
bilateral lower lobe infiltrates, for which the patient was
given ceftriazone, azithromycin, and vancomycin. Interestingly,
the patient's tox screen was negative for cocaine, but positive
for opiates and amphetamines. Toxicology was consulted, and
recommended treating the patient with benzodiazepines. The
patient underwent aggressive cooling, with subsequent
improvement in his fever, tachycardia, and hypertension. ECG
revealed sinus tachycardia rate-related ST depressions in the
lateral leads. At around 0600, the patient became hypotensive
and he was given aggressive IVF resuscitation with 5L
crystalloid. A CVL was placed, and the patient was started on a
norepinephrine gtt.
.
ABG at 4:30 am on 550x20, PEEP 10, FIO2 100% was 7.22/62/155/27.
He was then switched to 550x26, PEEP 10, FIO2 100%.
.
On arrival to the [**Hospital Unit Name 153**], patient is following commands and nods
his head to denote that he is not having any pain.
Past Medical History:
HIV/AIDS hx PCP PNA and CMV PNA, last CD4 600, VL undetectable
HCV
DM: on lantus and aspart sliding scale
Major Depressive Disorder
Daily migraines on prophylaxis
Chronic sinusitis s/p surgery [**4-20**]
Thigh cellulitis
Substance Abuse
Social History:
Smokes 1 ppd, no etoh, remote history of IV drug use (had a 2
day relapse in 2/[**2169**]). Unemployed, used to work in catering
management, on disability. Recently denied temporary housing.
Lives with roommates at halfway house named [**Name (NI) 35095**] house.
Followed closely by his counselor [**Doctor Last Name 636**].
Family History:
Unable to obtain.
Physical Exam:
Upon admission:
GEN: intubated, opens eyes to voice and follows commands
HEENT: OP without lesions, pupils constricted
RESP: rhochi b/l
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, hypoactive BS, soft, nt, no masses or
hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters, some pinpoint lesions
on left thigh
GU: foley in place with good UOP
Neuro: 2+ patellar and biceps reflexes, minimal rigidity (not
lead pipe), no clonus
At discharge:
VS: Tm98.3, Tc95.7, BP110s-130s/70s-80s, P80s-90s, 20, 93/RA
Gen: Well appearing, stutters frequently
HEENT: MMM, small scab over prior RIJ site, pupils 2mm b/l
Lungs: CTAB, no rhonchi, rales, wheezes
CV: RRR, normal S1/S2, no m/r/b
Abdomen: +BS, soft, nt/nd
Ext: no edema, 2+ DP's bilaterally
Pertinent Results:
Labs upon admission:
[**2169-12-29**] 03:30AM BLOOD WBC-8.1 RBC-4.84 Hgb-13.7* Hct-41.3
MCV-85 MCH-28.3 MCHC-33.2 RDW-16.6* Plt Ct-212
[**2169-12-29**] 03:30AM BLOOD Neuts-73.2* Lymphs-22.3 Monos-3.0 Eos-0.6
Baso-0.8
[**2169-12-29**] 03:30AM BLOOD PT-14.4* PTT-32.4 INR(PT)-1.2*
[**2169-12-29**] 10:43AM BLOOD Fibrino-368
[**2169-12-29**] 03:30AM BLOOD WBC-8.1 Lymph-22 Abs [**Last Name (un) **]-1782 CD3%-76
Abs CD3-1347 CD4%-12 Abs CD4-215* CD8%-62 Abs CD8-1101*
CD4/CD8-0.2*
[**2169-12-29**] 03:30AM BLOOD Glucose-71 UreaN-23* Creat-1.1 Na-139
K-4.1 Cl-105 HCO3-26 AnGap-12
[**2169-12-29**] 03:30AM BLOOD ALT-209* AST-246* LD(LDH)-378*
CK(CPK)-3195* TotBili-0.7
[**2169-12-29**] 03:30AM BLOOD CK-MB-17* MB Indx-0.5
[**2169-12-29**] 03:30AM BLOOD cTropnT-<0.01
[**2169-12-29**] 10:43AM BLOOD CK-MB-7 cTropnT-<0.01
[**2169-12-29**] 05:01PM BLOOD CK-MB-7 cTropnT-<0.01
[**2169-12-29**] 03:30AM BLOOD Albumin-4.0 Calcium-8.5 Phos-1.4*# Mg-1.7
[**2170-1-3**] 04:47AM BLOOD TSH-3.2
[**2169-12-29**] 03:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2169-12-29**] 04:06AM BLOOD Type-ART Temp-40.2 Rates-/20 Tidal V-550
PEEP-10 FiO2-100 pO2-155* pCO2-62* pH-7.22* calTCO2-27 Base
XS--3 AADO2-508 REQ O2-84 -ASSIST/CON Intubat-INTUBATED
[**2169-12-29**] 03:34AM BLOOD Lactate-1.5
[**2169-12-29**] 05:25PM BLOOD O2 Sat-91
[**2169-12-29**] 11:07AM BLOOD freeCa-1.12
.
Other:
[**2169-12-29**] 03:30AM BLOOD WBC-8.1 Lymph-22 Abs [**Last Name (un) **]-1782 CD3%-76
Abs CD3-1347 CD4%-12 Abs CD4-215* CD8%-62 Abs CD8-1101*
CD4/CD8-0.2*
[**2169-12-29**] 03:30AM BLOOD Lipase-17
[**2169-12-29**] 03:30AM BLOOD CK-MB-17* MB Indx-0.5
[**2169-12-29**] 03:30AM BLOOD cTropnT-<0.01
[**2169-12-29**] 10:43AM BLOOD CK-MB-7 cTropnT-<0.01
[**2169-12-29**] 05:01PM BLOOD CK-MB-7 cTropnT-<0.01
[**2170-1-3**] 04:47AM BLOOD TSH-3.2
[**2169-12-29**] 03:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2169-12-29**] 03:34AM BLOOD Lactate-1.5
[**2169-12-29**] 11:07AM BLOOD Lactate-0.6
[**2169-12-29**] 12:47PM BLOOD Lactate-0.6
[**2169-12-29**] 05:25PM BLOOD Lactate-0.6
[**2169-12-29**] 07:32PM BLOOD Lactate-0.8
[**2169-12-30**] 05:31PM BLOOD Lactate-0.5
.
ABGs
[**2169-12-29**] 04:06AM BLOOD Type-ART Temp-40.2 Rates-/20 Tidal V-550
PEEP-10 FiO2-100 pO2-155* pCO2-62* pH-7.22* calTCO2-27 Base
XS--3 AADO2-508 REQ O2-84 -ASSIST/CON Intubat-INTUBATED
[**2169-12-29**] 11:07AM BLOOD Type-ART pO2-211* pCO2-49* pH-7.30*
calTCO2-25 Base XS--2
[**2169-12-29**] 12:47PM BLOOD Type-ART pO2-74* pCO2-42 pH-7.34*
calTCO2-24 Base XS--2
[**2169-12-29**] 05:25PM BLOOD Type-ART Temp-38.8 pO2-60* pCO2-41
pH-7.37 calTCO2-25 Base XS--1 Intubat-INTUBATED
[**2169-12-29**] 07:32PM BLOOD Type-ART pO2-114* pCO2-39 pH-7.37
calTCO2-23 Base XS--2
[**2169-12-30**] 01:12AM BLOOD Type-ART Temp-38.3 Rates-22/ PEEP-10
FiO2-50 pO2-97 pCO2-43 pH-7.34* calTCO2-24 Base XS--2
Intubat-INTUBATED Vent-CONTROLLED
[**2169-12-30**] 10:49AM BLOOD Type-ART Temp-38.1 Rates-/18 PEEP-10
pO2-121* pCO2-38 pH-7.35 calTCO2-22 Base XS--3 Intubat-INTUBATED
Vent-SPONTANEOU
[**2169-12-30**] 05:31PM BLOOD Type-ART pO2-102 pCO2-40 pH-7.43
calTCO2-27 Base XS-1
[**2169-12-31**] 09:07AM BLOOD Type-ART Temp-37.1 Rates-/19 Tidal V-461
PEEP-5 FiO2-40 pO2-105 pCO2-49* pH-7.39 calTCO2-31* Base XS-3
Intubat-INTUBATED Vent-SPONTANEOU
[**2170-1-1**] 04:00AM BLOOD Type-ART pO2-89 pCO2-48* pH-7.43
calTCO2-33* Base XS-6
[**2170-1-1**] 11:41AM BLOOD Type-ART Temp-37.6 Rates-/35 Tidal V-563
PEEP-5 FiO2-40 pO2-98 pCO2-36 pH-7.50* calTCO2-29 Base XS-4
Intubat-INTUBATED Vent-SPONTANEOU
[**2170-1-1**] 01:28PM BLOOD Type-ART Temp-37.0 Rates-/32 PEEP-5
pO2-99 pCO2-34* pH-7.49* calTCO2-27 Base XS-2
[**2170-1-1**] 05:08PM BLOOD Type-ART Temp-37.2 Rates-/27 Tidal V-459
PEEP-5 FiO2-40 pO2-126* pCO2-42 pH-7.44 calTCO2-29 Base XS-4
Intubat-INTUBATED Vent-SPONTANEOU
[**2170-1-2**] 04:21AM BLOOD Type-ART pO2-116* pCO2-38 pH-7.45
calTCO2-27 Base XS-3
[**2170-1-2**] 06:40PM BLOOD Type-ART Temp-39.1 pO2-78* pCO2-29*
pH-7.53* calTCO2-25 Base XS-2 Intubat-NOT INTUBA
[**2170-1-3**] 02:29PM BLOOD Type-ART pO2-113* pCO2-35 pH-7.46*
calTCO2-26 Base XS-1 Comment-SPECIMEN I
[**2170-1-4**] 04:46PM BLOOD Type-ART pO2-75* pCO2-36 pH-7.48*
calTCO2-28 Base XS-3
.
.
Urine:
[**2169-12-29**] 03:50AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
[**2169-12-29**] 03:50AM URINE Blood-SM Nitrite-NEG Protein-25
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2169-12-29**] 03:50AM URINE RBC-0-2 WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-0-2
[**2170-1-3**] 02:07AM URINE Color-Amber Appear-Cloudy Sp [**Last Name (un) **]-1.020
[**2170-1-3**] 02:07AM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-0.2 pH-6.0 Leuks-NEG
[**2170-1-3**] 02:07AM URINE RBC-18* WBC-18* Bacteri-NONE Yeast-NONE
Epi-0
[**2170-1-5**] 09:35PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.024
[**2170-1-5**] 09:35PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2170-1-5**] 09:35PM URINE RBC-11* WBC-1 Bacteri-FEW Yeast-NONE
Epi-0 TransE-<1
[**2170-1-5**] 09:35PM URINE Mucous-FEW
[**2169-12-29**] 06:05PM URINE Hours-RANDOM UreaN-713 Creat-113 Na-106
K-57 Cl-145
[**2169-12-29**] 06:05PM URINE Osmolal-673
[**2169-12-29**] 03:50AM URINE bnzodzp-POS barbitr-NEG opiates-POS
cocaine-NEG amphetm-POS mthdone-NEG
[**2170-1-3**] 02:07AM URINE cocaine-NEG
.
.
BC [**12-29**] x2, [**12-31**] x2 -ve
BC [**1-3**] [**1-5**] NG to date
UCx [**1-5**] -ve
.
[**2169-12-29**] 4:30 am SPUTUM
**FINAL REPORT [**2169-12-31**]**
GRAM STAIN (Final [**2169-12-29**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2169-12-31**]):
SPARSE GROWTH Commensal Respiratory Flora.
.
[**2170-1-3**] 4:47 am SEROLOGY/BLOOD RPR ADDED TO CHEM#[**Serial Number 82687**]H.
**FINAL REPORT [**2170-1-4**]**
RAPID PLASMA REAGIN TEST (Final [**2170-1-4**]):
NONREACTIVE.
Reference Range: Non-Reactive.
.
[**2170-1-3**] 8:35 pm CSF;SPINAL FLUID Source: LP #4.
**FINAL REPORT [**2170-1-4**]**
CRYPTOCOCCAL ANTIGEN (Final [**2170-1-4**]):
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
.
[**2170-1-3**] 8:35 pm CSF;SPINAL FLUID SOURCE; LP #2.
GRAM STAIN (Final [**2170-1-3**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2170-1-6**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
.
[**2170-1-4**] 10:29 am STOOL CONSISTENCY: SOFT Source:
Stool.
**FINAL REPORT [**2170-1-5**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2170-1-5**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
[**2170-1-5**] 9:49 pm SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2170-1-5**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2170-1-7**]):
SPARSE GROWTH Commensal Respiratory Flora.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
FUNGAL CULTURE (Preliminary):
YEAST.
[**2170-1-6**] 12:12 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2170-1-10**]**
Blood Culture, Routine (Final [**2170-1-10**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final [**2170-1-7**]):
GRAM POSITIVE COCCI IN CLUSTERS.
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20**] ON [**2170-1-7**] AT [**2094**].
Anaerobic Bottle Gram Stain (Final [**2170-1-8**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
[**2170-1-10**] 5:47 pm SPUTUM Source: Induced.
**FINAL REPORT [**2170-1-11**]**
GRAM STAIN (Final [**2170-1-10**]):
[**10-30**] PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final [**2170-1-10**]):
TEST CANCELLED, PATIENT CREDITED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2170-1-11**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
PERTINENT LABS
[**2169-12-29**] 03:30AM BLOOD WBC-8.1 Lymph-22 Abs [**Last Name (un) **]-1782 CD3%-76
Abs CD3-1347 CD4%-12 Abs CD4-215* CD8%-62 Abs CD8-1101*
CD4/CD8-0.2*
[**2170-1-10**] 07:20AM BLOOD CRP-35.3*
[**2170-1-10**] 07:20AM BLOOD ESR-65*
[**2170-1-10**] 10:29AM BLOOD B-GLUCAN-Test
[**2170-1-4**] 04:31AM BLOOD ALT-92* AST-79* LD(LDH)-466* AlkPhos-130
TotBili-0.6
ADMISSION CXR
IMPRESSION:
1. Multifocal pneumonia.
2. Central pulmonary vascular congestion with moderate pulmonary
edema.
3. ET tube terminating 6.6 cm above the carina.
CXR DAY PRIOR TO DISCHARGE
FINDINGS: In comparison with the study of [**1-8**], there is still
some mild
opacification in the right upper lobe that could reflect some
clearing
consolidation. Minimal increased opacification in the left upper
zone also may reflect clearing infectious process. There is
better aeration at the left base with only mild atelectatic
changes. The region of the azygos node and vein is within normal
limits at this time.
If there is serious clinical concern for an underlying
infectious process or lymphadenopathy, CT would be the next
imaging procedure.
ECHOCARDIOGRAM [**2170-1-8**]
The left atrium is dilated. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF>55%).
Transmitral and tissue Doppler imaging suggests normal diastolic
function, and a normal left ventricular filling pressure
(PCWP<12mmHg). The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No masses or
vegetations are seen on the aortic valve. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve.
The tricuspid valve leaflets are mildly thickened. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: No echocardiographic evidence of endocarditis.
Normal regional and global biventricular systolic function. No
pathologic valvular abnormality seen.
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
Compared with the report of the prior study (images unavailable
for review) of [**2169-10-4**], the findings are similar.
RENAL US [**2170-1-9**]
IMPRESSION:
Unremarkable renal ultrasound.
CT CHEST [**2170-1-9**]
IMPRESSION:
1. Bilateral upper lobe ground-glass opacities suggest improving
infection.
These could be followed with standard radiograph, beginning with
a radiograph
today to serve as a baseline for comparison with this study.
2. Overall stable mediastinal lymph node enlargement except for
slight
increase in subcarinal node, now 16 mm.
Brief Hospital Course:
45 year old male with HIV, HCV, DM, presenting with altered
mental status and seizures, with hypertension, tachycardia, and
severe hyperthermia.
# Altered mental status: On initial presentation, the patient
was hypertensive, tachycardic, tremulous, and febrile, all of
which were consistent with amphetamine toxicity per his tox
screen. The patient was initially intubated in the ED for
airway protection, and was extubated on [**1-1**]; unfortunately he
had to be re-intubated on [**2170-1-2**] for agitation. The [**2170-1-2**]
reintubation was in the setting of having received several doses
of valium, as well as three doses of Haldol, but to no effect.
During hospitialization, the patient was also tried on precedex,
although this was not able to control his AMS/HTN/Tachycardia.
The patient's HR and HTN resolved on propofol, which sedated him
while he was intubated. Given intermittent fevers, an LP at the
time was unrevealing. The patient was extubated on [**2170-1-5**],
and was AAOx3. On [**2169-1-6**], the patient once again became
tachycardiac and hypertensive, but this time presented with
paranoia and fear. Psychiatry was consulted, who recommended
holding venlafaxine in setting of altered mental status.
Toxicology was consulted and felt that this was consistent with
benzodiazepine withdrawal as he only received occaisional doses
of valium on [**1-2**] and he typically takes Klonopin 2mg [**Hospital1 **] at
home. Subsequently, the patient was placed on an aggressive
Valium scale Q30min for agitation. He required extremely high
doses of valium but responded well. His mental status continued
to improve throughout his ICU stay with Valium weaned. Prior to
transfer he was alert and oriented X3, back at his baseline per
his outpatient counselor.
.
After transfer to the medicine floor, his valium was weaned to
Q6H prn. Of note, he usually takes Clonazepam at home, however
given that he will soon be in the [**Hospital **] clinic, they felt
that valium would be easier to taper over time. Psychiatry c/s
continued to follow and felt that the stuttering that restarted
may be a lingering manifestation of ICU stress, anoxic brain
injury, or possible [**2-7**] venlafaxine discontinuation. They
recommended commencing venlafaxine administration which was
done. The patient was noted to be AAOx3 throughout his stay on
the medicine floor.
.
# Respiratory Failure: Patient initially intubated in ED for
airway protection, and a CXR at that time showed some pulmonary
edema and a retrocardiac opacity. The patient was started on
broad HCAP coverage given a recent hopsitalization with
Vanc/Meropenam/Azithro given a documented allergy to penicillins
and quinolones. These antibiotics were continued until [**2170-1-5**]
for a total 8 day course. The patient was initally extubated on
[**1-1**], but had to be reinbuated on [**2170-1-2**] for agitation. He
was then extubated on [**2170-1-5**]. On [**2169-1-6**] the patient was noted
to have a slight O2 requirement of 2L, satting 93. Respiratory
status continued to improve during hospitalization. A chest
xray should be obtained in six weeks for follow up of his
radiographic findings.
.
Upon transfer to the Medicine floor, the patient continued to
sat in the mid to upper 90s on room air. A CT chest that was
done in the unit revealed GGO thought to be resolving PNA vs.
PCP. [**Name10 (NameIs) 6**] ambulatory sat was done which was nonrevealing (pt
remained 100% on RA throughout). The CT chest final read felt
the GGO are likely [**2-7**] resolving PNA. A baseline CXR was
obtained on [**2170-1-11**], and a repeat CXR can be obtained in ~6 weeks
time.
.
# Fevers/Infectious work-up. Throughout MICU stay patient
experienced intermittent fevers. On admission, CXR revealed
bilateral lower lobe infiltrates, for which the patient was
given ceftriaxone, azithromycin, and vancomycin initially. The
patient's tox screen was negative for cocaine despite reporting
IV cocaine use. The tox screen was positive for opiates and
amphetamines. It was thought that his initial fever to 108 was
likely amphetamine toxicity. The patient underwent aggressive
cooling, with subsequent improvement in his fever, tachycardia,
and hypertension. He then became hypotensive and he was given
aggressive IVF resuscitation with 5L crystalloid. He was
started on a norepinephrine gtt. On admission to the ICU, he
was continued on Vancomycin but changed to Meropenem for the
concern of PNA. He was delirious on [**1-2**] which raised concern
for meningitis as he was persistently spiking fevers. The
patient was continued on Vancomycin, Meropenem (allergy to PCN
and sulfa), and started on Acyclovir although HSV was felt to be
unlikely in the context of daily Valacyclovir suppressive
therapy. Acyclovir was stopped when HSV PCR returned negative.
On [**1-3**] the patient underwent LP with results 0 WBC (PMN 0, L
94), 1 RBC, protein 46, glucose 58. With these results, his
antibiotics were changed back to PNA dosing and his CVL was
discontinued. On [**1-5**] the patient's antibiotics were
discontinued and he was extubated. The patient had persistent
fever with Tm of 102.1 on [**1-6**] and blood culture returned with
GPC in clusters in [**2-7**] bottles. Vancomycin was restarted and ID
was consulted. TTE was performed without evidence of
vegetation. Acyclovir was discontinued on [**1-8**] after return of
negative HSV PCR. On transfer to floor patient was still
receiving vancomycin for total 5 day course treatment of
presumed line infection. His fevers subsided during this
course.
.
On the medicine floor, he remained afebrile. A work up of
possible PCP was undertaken, and results in the previous section
reveal that immunofluoresence for PCP on induced sputum was
negative, ambulatory sat was wnl. His vancomycin was d/c'ed
after 5 days (as above).
.
# Hypotension: On presentation patient was hypotensive and
aggressively fluid resuscitated and started on levophed. The
patient's LFTs were elevated, but this was thought secondary to
muscle etiology, rather than shock liver given the degree of
elevation, the elevated CPK, the appropriate UOP, and lactate
levels. The patient's hypotension was initially thought
secondary to sedation. Hypotension quickly improved and patient
weaned off pressors.
.
# Hypertension/Tachycardia: Patient without history of essential
hypertension. The patient was noted on multiple occasions during
ICU stay to be both tachycardic and severly hypertensive. His
clinical presentation appeared to be a likely sympathomimetic
toxidrome in setting of amphetamine use. Later in
hospitalization recurrent hypertension/agitation was thought
secondary to a benzodiazpine withdrawal. Over the course of his
stay, he was briefly started on hydralazine and captopril in
addition to propofol gtt. Toxicology consult favored frequent
checks for tachycardia/hypertension/tremulousness, and to treat
aggressively with Valium, which was done. The patient's
HTN/Tachycardia ultimately improved and at time of transfer to
the floor. His VS remained stable on the floor.
.
# Chest pain: Rate related lateral ST depressions on initial
EKG, now resolved and patient in sinus rhythm. Cardiac enzymes
were negative and the patient did not complain of any chest pain
throughout the rest of his admission.
.
# HIV: Patient reported last known CD4 to be 600 with an
undetectable viral load. Patient's CD4 was repeated in hospital
and was 215, clearly in the setting of acute illness. A viral
load was not obtained. He was continued on his home HIV
medications of Darunavir, Ritonavir, and Truvada. Per his PCP
at [**Name9 (PRE) 778**], Bactrim PPX for PCP was not started. Further w/u of
HIV and cause of drop in CD4 was deferred for the outpatient
arena.
.
# DM: Borderline hypoglycemia on admission labs. On
basal/sliding scale insulin as outpatient. Patient was on SSI
during admission. At the end of his admission, he was not
requiring any SSI so his outpatient long and short acting
insulin was discontinued at time of discharge.
.
# Seizure: On admission the patient was hypoxic and with an
altered mental status. He was found to be febrile to 107.8. The
patient subsequently developed seizure like activity prior to
intubation. He was given lorazepam, and subsequently intubated.
He was started on a midazolam gtt, and was also given propofol.
Initial seizure likely secondary to hyperthermia from
amphetamine toxicity.
.
# Elevated transaminases: Patient has had elevations in
transaminases in the past secondary to HCV, but current
elevation on admission was felt secondary to muscle breakdown in
the setting of withdrawal/seizures, as both transaminitis and CK
improved over the course of hosptialization with hydration. LFTs
were trending down and improved prior to discharge.
.
# Elevated Creatinine: Creatinine elevated on admission to 1.1
from baseline of 0.9. Initially improved with hydration however
bumped again thought secondary to ATN (FEUrea >36% and FENa >1 %
in keeping with ATN) with iatrogenic contribution from
vancomycin or captopril. Renal function trended, nephrotoxic
drus were avoided. Upon discharge, Cr improved to 1.4. Further
w/u was deferred to the outpatient setting.
.
# Depression: Initially held antidepressive medications
(venlafaxine/trazadone) in the setting of concern for seritonin
syndrome. Psychaitry was consulted, who recommended holding
Effexor in the MICU in setting of altered mental status. As
above, Effexor was restarted on the floor as per psych
recomendations.
.
# Chronic pain syndrome: He was continued on his home dose of
gabapentin and oxycodone. Oxycontin was stopped given its
extreme sedative effect on the patient, and adequate control
with prn oxycodone. His oxycodone was tapered to Q6h, however
he required oxycodone more frequently at Q4h. He ultimately is
hoping to enter the [**Hospital **] clinic, and as such will continue
tapering the medications in the outpatient setting with his PCP.
[**Name10 (NameIs) **] was discharged on 10 mg oxycodone Q4-6h prn pain with a
short course to f/u with his PCP.
.
# HA: Pt noted to have HA on the medicine floor. Of note, tests
for nuchal rigidity and meningismus were non revealing (negative
Kernig, Brudzinski, Jolt signs). Pt was treated with Norflex
and oxycodone for HA. Of note, had nausea as well, but is
allergic to compazine which would have been ideal to treat both.
Zofran prn upon discharge for nausea.
.
# FOLLOWUP
- CXR should be obtained 6 weeks after discharge regarding
resolving infx.
- HIV (drop in CD4) and ARF w/u pending outpatient work up.
Medications on Admission:
-venlafaxine 150 mg PO daily
-oxycodone 40 mg Sustained Release Q12H
-oxycodone 10 mg PO Q4-6 hours PRN
-pseudoephedrine HCl 30 mg PO Q6H PRN
-omeprazole 40 mg PO DAILY
-insulin glargine 30 units SC QHS
-Novolog sliding scale
-cyclobenzaprine 10 mg PO HS
-gabapentin 600 mg PO Q8H
-Norflex 30 mg/mL Solution Inj QID PRN
-zolpidem 10 mg PO HS PRN
-atorvastatin 40 mg PO DAILY
-verapamil 240 mg Tablet Sustained Release PO daily
-valacyclovir 1000 mg PO QDAILY
-darunavir 800 mg PO daily
-ritonavir 100 mg PO DAILY
-emtricitabine-tenofovir 200-300 mg PO DAILY
-aspirin 81 mg PO daily
-clonazepam 2 mg PO BID
-albuterol sulfate HFA Two Puff Q4H PRN SOB
- advair [**Hospital1 **]
-EpiPen PRN
Discharge Medications:
1. venlafaxine 150 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
2. oxycodone 10 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
Disp:*40 Tablet(s)* Refills:*1*
3. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. gabapentin 600 mg Tablet Sig: One (1) Tablet PO three times a
day.
5. orphenadrine citrate 30 mg/mL Solution Injection
6. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. verapamil 240 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
8. pseudoephedrine HCl Oral
9. zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
10. valacyclovir 1 g Tablet Sig: One (1) Tablet PO once a day.
11. darunavir 400 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
13. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
15. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea for
14 days.
Disp:*40 Tablet, Rapid Dissolve(s)* Refills:*0*
16. diazepam 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for agitation/anxiety for 14 days.
Disp:*30 Tablet(s)* Refills:*1*
17. EpiPen Intramuscular
18. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO at
bedtime.
19. Advair Diskus 250-50 mcg/dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
Disp:*1 disk* Refills:*2*
20. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Amphetamine overdose
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to [**Hospital1 18**] for hypertension, fast heart rate,
and a fever due to an overdose. You were intubated for airway
protection and kept safe in the ICU. After you were able to be
weaned from the machine, you were transferred to the floor for
further titrating of your valium and oxycodone. You had a lung
and blood infection and these were treated with antibiotics. We
also monitored you to make sure you did not have PCP [**Name Initial (PRE) 1064**].
Your blood sugars in the hospital have been fine, so we stopped
your insulin.
PLEASE MAKE THE FOLLOWING CHANGES TO YOUR MEDICATIONS
- STOP taking your LANTUS
- STOP taking your NOVOLOG
- STOP taking KLONOPIN
- STOP taking OXYCONTIN
- START taking VALIUM 10 mg every 6 hours as needed for anxiety
- CONTINUE taking OXYCODONE 10 mg every 4 hours as needed for
pain
- START taking ZOFRAN 4 mg every 8 hours as needed for nausea
Please follow up with your physicians as indicated below.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 6420**] to see if you can get an earlier
appointment.
Name: [**Last Name (LF) **],[**First Name3 (LF) **] R.
Location: [**Location (un) **] ASSOCIATES OF [**Hospital1 **] HEALTH
Address: [**Street Address(2) **], 2ND FL, [**Location (un) **],[**Numeric Identifier 2900**]
Phone: [**Telephone/Fax (1) 5723**]
When: [**Last Name (LF) 2974**], [**2170-1-26**]:50AM
Name: [**Last Name (LF) **], [**First Name3 (LF) **]
Location: [**Hospital6 **] Center
Address: [**Location (un) **]., [**Location (un) **],[**Numeric Identifier 6425**]
Phone: [**Telephone/Fax (1) 798**]
*Someone from [**Hospital1 778**] will contact you to schedule an
appointment. If you dont hear from them by Monday, [**1-15**], please
call Dr. [**Last Name (STitle) **] to schedule an appointment within 2-4 weeks.
[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DO 12-BDU
Completed by:[**2170-1-12**]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,473
| 150,768
|
38525
|
Discharge summary
|
report
|
Admission Date: [**2189-5-22**] Discharge Date: [**2189-5-24**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
NSTEMI/Transfer for cath
Major Surgical or Invasive Procedure:
Cardiac catheterization with stent placement to the mid-LAD.
History of Present Illness:
88 year old male with past history of DM, CHF, PVD s/p stents on
both lower extremities, multiple amputations of his toes
transferred from [**Hospital6 5016**] for cardiac
catheterization after presenting with NSTEMI. Mr. [**Known lastname **]
reports 2 episodes of chest pain over the past week, responsive
to sublingual nitroglycerin. On morning of admission, he
experienced chest pain for 15 minutes that also responded to
nitroglycerin, he spoke with his PCP, [**Name10 (NameIs) 1023**] instructed him to call
the ambulance. He recieved 243 mg aspirin in the ambulance. He
was seen in [**Hospital6 5016**] ED, initial vitals 148/68 55 16
97.4 100% on 2L. He recieved nitro paste x 1. EKG showed
normal sinus rhythm at 55 with TWI in v3-v6 with no ST elevation
or depression. Troponin was 3.3 and he was transferred to [**Hospital1 18**]
for catheterization.
In the cath lab, he was noted to have a totally occluded RCA,
99% stenosis of mid-LAD, 30% eccentric plaque in LMCA, and
60-70% proximal disease of left circumflex. Performed PTCA and
stenting using 3 overlapping DES to the prox-mid LAD. Good
angiographic result. Severe HTN during the procedure (250mmHg
systolic) treated w/ IV NTG, IA nicardipine. He is transferred
to the CCU for further management of his BP.
On arrival to the CCU, initial vitals were T 96.3 HR 58 BP
148/48 RR 18 O2Sat 98%RA. He is complaining of chronic lower
back pain, otherwise no pain at site of cardiac cath (left
groin).
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, - Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
- Congestive Heart Failure (EF unkown)
3. OTHER PAST MEDICAL HISTORY:
- Diabetes Type 2
- Peripheral Vascular Disease s/p stents to bilateral lower
extremities and multiple amputations of toes
- GERD
- Anxiety
Social History:
- Tobacco history: 40 year smoking history, quit many years
ago.
- ETOH: occasional alcohol use
- Illicit drugs: Denies
Family History:
NC
Physical Exam:
VS: T= 96.3 BP=148/48 HR=58 RR=18 O2 sat=98%RA
GENERAL: Thin elderly 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.
NECK: Supple, JVP not elevated, no cervical LAD
CARDIAC: PMI 5th intercostal space. Reg Rate, bradycardic,
normal S1, S2. 1/6 systolic murmur heard best at tricuspid area.
No thrills, lifts. No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. decreased
BS throughout but CTAB with no crackles, wheezes or rhonchi
appreciated on auscultation.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits. +lipoma in
epigastric area.
EXTREMITIES: No cyanosis or edema; multiple amputated toes on
right and left foot. No left femoral bruit or hematoma; arterial
sheath in place in left groin; left femoral pulse palpable.
PULSES: Right: Carotid 2+ Femoral 2+ DP by doppler
Left: Carotid 2+ Femoral 2+ DP by doppler
Pertinent Results:
Admission Labs:
[**2189-5-22**] 09:29PM BLOOD WBC-9.1 RBC-3.63* Hgb-9.0* Hct-27.6*
MCV-76* MCH-24.7* MCHC-32.5 RDW-16.4* Plt Ct-278
[**2189-5-22**] 09:29PM BLOOD Glucose-155* UreaN-21* Creat-1.3* Na-138
K-4.4 Cl-103 HCO3-26 AnGap-13
[**2189-5-22**] 09:29PM BLOOD Calcium-8.3* Phos-3.7 Mg-2.0 Cholest-PND
[**2189-5-22**] 09:29PM BLOOD CK(CPK)-126
Cardiac Cath [**2189-5-22**]: 1. Coronary angiography in this
co-dominant system demonstrated three vessel disease. The LMCA
had a 30% eccentric plaque. The LAD had a 99% mid stenosis and
was diffusely diseased throughout. The LCx had a 60-70% proximal
stenosis and moderate distal disease. The OM1 had an 80%
stenosis. The RCA was occluded and filled via left to right
collaterals. 2. Limited resting hemodynamics revealed severe
systemic arterial hypertension with SBP 215mmHg and DBP 74mmHg.
FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2.
Severe systemic arterial hypertension.
TTE [**2189-5-23**]:
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is moderate
regional left ventricular systolic dysfunction with focal
hypokinesis of the mid to distal anterior wall, lateral wall,
and apex. The remaining segments contract normally (LVEF ~35 %).
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). The remaining left ventricular
segments contract normally. Right ventricular chamber size and
free wall motion are normal. The aortic root is mildly dilated
at the sinus level. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace 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 [2+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is no pericardial effusion.
Discharge labs:
notable for Cr of 1.5 up from baseline of 1.3. See attached
heme print out for details of other labs.
Brief Hospital Course:
Mr. [**Known lastname **] is an 88-year old gentleman w/ CHF, DM2, and PVD who
was transferred to [**Hospital1 18**] from [**Hospital6 5016**] for cardiac
catheterization following NSTEMI.
1. NSTEMI- Mr. [**Known lastname **] [**Last Name (Titles) 1801**] had TWI in v3-v6 with no ST
elevation or depressions. Troponin was 3.3 on admission. He was
taken to the catheterization lab and was found to have diffuse
3-vessel coronary artery disease. He received 3 drug eluting
stents to the LAD and was chest pain free following the
procedure. His CAD history was unclear, but patient denies
previous MIs or angina. He was evaluated by CT [**Doctor First Name **] and was
found to not be a surgical candidate. [**Hospital 49578**] medical therapy
was maximized with high-dose aspirin, plavix, metoprolol xl 50mg
daily and high dose statin (lipitor 80mg). His medications were
changed in the following ways:
1. We INCREASED Aspirin to 325mg daily
2. Please CONTINUE to take your PLAVIX 75mg daily, as this is
very important to keep your stent open.
3. We ADDED lisinopril 5mg daily (helps w/ blood pressure)
4. We ADDED Toprol XL 50mg daily (heart rate control) instead of
your Atenolol. (stop taking atenolol)
5. We ADDED Lipitor 80mg daily (helps w/ cholesterol)
6. We DISCONTINUED Diltiazem
7. We DISCONTINUED digoxin for now because of your kidney
function. You will discuss this with your primary care doctor
8. We ADDED Ranitidine 150mg daily for your stomach acid- take
this instead of the omeprazole you were on. (Plavix interacts
with omeprazole).
9. We ADDED Flomax 0.4 mg daily for your urinary retention.
TTE was done following catheterization which showed focal
hypokinesis of the mid to distal anterior wall, lateral wall,
and apex, with LVEF 35%. Digoxin was held due to renal function
following cath and diltiazem was held as well since beta blocker
was continued and pt was bradycardic on presentation.
2. HYPERTENSION: On diltiazem and atenolol as outpatient.
SBP>200 in cath lab, treated with nitro gtt and IA nicardapine.
On arrival to CCU BP 140/50's on nitro gtt, will defer starting
nicardapine gtt, nitro gtt was weaned quickly over the course of
hours. Atenolol was switched to metoprolol for better control.
BP was well-controlled on Metoprolol. Lisinopril was added for
BP control as well as improved heart remodeling as he has a
depressed EF. We also stopped his diltiazem.
3. URINARY RETENTION: Patient had foley catheter placed during
procedure. After pulling the catheter he developed retention
and needed a straight cath x1. He voided only a few cc's of
urine after his 6 hour post foley trial and had a second bladder
scan that showed 800 cc of urine. An indwelling foley was
placed with a leg bag to be worn home. Flomax was started for
his enlarged prostate. He is to keep the indwelling foley for
approximately 4-5 days and then have another voiding trial with
urology. He was given the number of the urologists here, but
could be seen closer to home with the help of a referral from
his PCP. [**Name10 (NameIs) **] PCP's office was called to help him find an
outpatient urologist.
4. DIABETES - Type 2, control unknown, placed on humalog insulin
SS and monitor.
5. ANXIETY - Continued Xanax daily prn as outpatient.
Patient was discharged feeling well with the above medication
changes. He is to follow up in the next few days with his PCP
and he is aware of this.
Medications on Admission:
Glyburide 5 mg qday for BS > 140
Plavix 75 mg qday
Isosorbide Mononitrate 30 mg qday
Xanax 0.25 mg qday
Atenolol 25 mg qday
diltiazem 180 mg qday
NTG SL 0.4 prn
Omeprazole 20 mg qday
Lasix 40 mg qday
Digiter ([**1-17**] pill)
Ecotrin
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for anxiety.
5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
10. 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:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Non ST elevation myocardial infarction
Discharge Condition:
stable, pain free
Discharge Instructions:
You were admitted to the hospital with chest pain and found to
have a heart attack. You were treated with a cardiac
catheterization and underwent a stent placement.
Some of your medications were changed as follows:
1. We INCREASED Aspirin to 325mg daily
2. Please CONTINUE to take your PLAVIX 75mg daily, as this is
very important to keep your stent open.
3. We ADDED lisinopril 5mg daily (helps w/ blood pressure)
4. We ADDED Toprol XL 50mg daily (heart rate control) instead of
your Atenolol. (stop taking atenolol)
5. We ADDED Lipitor 80mg daily (helps w/ cholesterol)
6. We DISCONTINUED Diltiazem
7. We DISCONTINUED digoxin for now because of your kidney
function. You will discuss this with your primary care doctor
8. We ADDED Ranitidine 150mg daily for your stomach acid- take
this instead of the omeprazole you were on. (Plavix interacts
with omeprazole).
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **], VARTAN [**Telephone/Fax (1) 12551**]
within 2 weeks of your discharge from the hospital. Call him
tomorrow to make an appointment.
Please follow up with a urologist about your new foley catheter
and enlarged prostate. You should be seen on Thursday or Friday
of this upcoming week. You can either be seen here at [**Hospital1 18**] and
call the urology office at ([**Telephone/Fax (1) 772**] or talk to your
primary care doctor about seeing a urologist closer to home. Be
sure to be seen at the end of the week. They may be able to
take your foley catheter out at that time.
Please have outpatient lab work done (CBC, Electrolytes, kidney
function BUN/Cr) and have it faxed to your PCP or see your PCP
either [**Name9 (PRE) 766**] or Tuesday and have blood work at that time:
[**Name9 (PRE) **],VARTAN
Address: [**Location (un) 80096**], [**Location (un) **],[**Numeric Identifier 10768**]
Phone: [**Telephone/Fax (1) 12551**]
Fax: [**Telephone/Fax (1) 84110**]
Completed by:[**2189-5-25**]
|
[
"414.2",
"788.20",
"410.71",
"530.81",
"414.01",
"440.4",
"401.9",
"300.00",
"250.00",
"440.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"00.40",
"00.66",
"00.47",
"37.22",
"36.07",
"57.94"
] |
icd9pcs
|
[
[
[]
]
] |
10283, 10332
|
5452, 8869
|
287, 350
|
10415, 10435
|
3370, 3370
|
11349, 12403
|
2330, 2334
|
9154, 10260
|
10353, 10394
|
8895, 9131
|
4232, 5309
|
10459, 11326
|
5325, 5429
|
2349, 3351
|
1962, 2001
|
223, 249
|
378, 1853
|
3387, 4213
|
2032, 2174
|
1875, 1942
|
2190, 2314
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,763
| 182,101
|
13075
|
Discharge summary
|
report
|
Admission Date: [**2126-8-19**] Discharge Date: [**2126-8-24**]
Date of Birth: [**2062-9-2**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Ativan / Ceftriaxone
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Fever, new-onset rash
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
63 yoF with history of CAD who was admitted to the [**Hospital Unit Name 153**] in
[**2126-8-19**] for fevers to 103 and new onset rash that was concerning
for Sweet's syndrome. Of note, patient had been hospitalized
from [**Date range (1) 39981**] for new onset of diplopia, CN 6 palsy, and
spastic paraperesis of unknown etiology. An LP had demonstrated
few WBCs and the patient was treated with a course of steroids
and ceftriaxone for presumptive Lyme disease which he completed
on [**8-14**]. The patient then noticed the development of a papular,
mildly pruritic rash one week prior to admission that originally
began on his thighs but soon spread to his trunk and upper
extremities. He also deceloped fevers to 103 and was taken to as
OSH on [**8-18**]. At the OSH he was found to be neutropenic (WBC 3.6,
10%PMNs) and he was started on ceftriaxone and acylcovir which
was switched to imipenem, acyclovir, and vancomycin and he was
transferred to [**Hospital1 18**] for further management.
Past Medical History:
- HTN
- Hypercholesterolemia
- CAD s/p MI [**2114**] s/p angioplasty, had stents [**2119**]
- Kidney stones removed [**2120**]
Social History:
Lives with wife, retired corrections officer; tob [**3-23**] ppd x
25yrs, no etoh, no drugs. Has seen chiropractor for back, neck
in past, though no hx injuries to either.
Family History:
Niece died of lupus, uncle had cancer (unknown type, elderly),
father d. brain hemorrhage (elderly). No other strokes, sz,
neuro d/o incl MS, MG, no blood/clotting d/o, and no other
autoimmune d/o.
Physical Exam:
VS: T 99.6 BP 145/72 HR 93 RR 17 O2sat 99%RA
General: Pleasant, comfortable, in no acute distress
HEENT: Anicteric, MMM, OP without lesions
Neck: Supple, no JVD
Heart: RRR, no m/r/g
Lungs: CTAB
Abdomen: +bs, soft, NTND, no HSM
Extremities: No c/c/e
Skin: Multiple 0.5-1 erythematous/violaceous pustular and
papular lesions/erosions worst on thighs, also on lower legs,
upper extremities, chest and trunk with relative sparing of face
and back
Neurologic: AAOx3. CN II-XII intact. 5/5 strength BUE/LE.
Sensation intact throughout. [**2-23**] Patellar and biceps reflexes.
Finger-to-nose intact.
Pertinent Results:
Initial results on admission:
[**2126-8-19**] 01:33AM WBC-3.8*# RBC-3.65* HGB-11.5* HCT-32.1*
MCV-88 MCH-31.6 MCHC-35.9* RDW-13.8
[**2126-8-19**] 01:33AM PLT COUNT-220
[**2126-8-19**] 01:33AM NEUTS-10* BANDS-1 LYMPHS-48* MONOS-28* EOS-4
BASOS-0 ATYPS-4* METAS-3* MYELOS-2* NUC RBCS-2*
[**2126-8-19**] 01:33AM PT-14.7* PTT-28.6 INR(PT)-1.3*
[**2126-8-19**] 01:33AM RET AUT-3.5*
[**2126-8-19**] 01:33AM GLUCOSE-177* UREA N-12 CREAT-1.1 SODIUM-137
POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-25 ANION GAP-16
[**2126-8-19**] 01:33AM ALBUMIN-3.7 CALCIUM-8.4 PHOSPHATE-2.9
MAGNESIUM-1.3*
[**2126-8-19**] 01:33AM VIT B12-542 FOLATE-13.0 HAPTOGLOB-248*
[**2126-8-19**] 05:59PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2126-8-19**] 05:59PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-8* PH-5.0 LEUK-SM
[**2126-8-19**] 05:59PM URINE RBC-28* WBC-0 BACTERIA-FEW YEAST-NONE
EPI-<1
[**2126-8-19**] 05:59PM URINE MUCOUS-RARE.
.
Biopsy skin, left forearm [**2126-8-19**]:
.
Marked papillary dermal edema and dermal eosinophilic infiltrate
(see note).
Note: A neutrophilic infiltrate is not seen, arguing against a
diagnosis of Sweet's syndrome. The presence of numerous dermal
eosinophils raises the possibility of Well's syndrome.
Additional diagnostic considerations include a bullous
drug/hypersensitivity reaction or, less likely, an immunobullous
disorder such as bullous pemphigoid. Dr. [**Last Name (STitle) 24991**] notified of
diagnosis on [**2126-8-20**].
.
Wound culture [**2126-8-19**]: MRSA
.
Biopsy skin, left calf, punch biopsy [**2126-8-21**]:
.
Intraepidermal pustules, subepidermal edema, and dermal
eosinophilic infiltrate.
Note: A few clusters of bacteria are seen within the pustule
and likely represent surface 'colonization'. The presence of an
intraepidermal pustule raises the possibility of Sweet's
syndrome with eosinophils, a histologic variant that has been
noted by some authors in the literature. Dr. [**First Name (STitle) **] notified on
[**2126-8-22**].
.
CT ABD W&W/O C [**2126-8-21**]
IMPRESSION:
1. Multiple brightly enhancing but nonpathologic inguinal lymph
nodes. No pathologic adenopathy in the abdomen or pelvis.
2. Diverticulosis.
3. Multiple small hypodense liver lesions, too small to
characterize.
4. 5mm nodular opacity left lower lobe, likely atelectasis. If
there is high suspicion, a one-year follow-up can be performed
to ascertain resolution/stability.
.
CSF [**2126-8-22**]
Total Protein, CSF 34 mg/dL 15 - 45
PERFORMED AT WEST STAT LAB
Glucose, CSF 89 mg/dL
PERFORMED AT WEST STAT LAB
Gram stain negative
Cytology sent
.
CHEST (PA & LAT) [**2126-8-24**]
IMPRESSION: PA and lateral chest compared to [**2126-7-31**]:
Lungs are clear. Heart is normal size. There is no pleural
abnormality or change in hilar or mediastinal contours to
suggest progressive adenopathy.
Lateral view shows moderate degenerative change in the mid and
lower thoracic spine.
.
Results on discharge:
[**2126-8-24**] 06:58AM BLOOD WBC-11.6* RBC-3.52* Hgb-11.2* Hct-31.2*
MCV-89 MCH-31.8 MCHC-35.9* RDW-14.7 Plt Ct-366
[**2126-8-24**] 06:58AM BLOOD Neuts-45* Bands-2 Lymphs-26 Monos-17*
Eos-5* Baso-0 Atyps-3* Metas-2* Myelos-0
[**2126-8-24**] 06:58AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-NORMAL
Macrocy-OCCASIONAL Microcy-2+ Polychr-1+
[**2126-8-24**] 06:58AM BLOOD Plt Smr-NORMAL Plt Ct-366
[**2126-8-24**] 06:58AM BLOOD Glucose-112* UreaN-9 Creat-0.9 Na-141
K-4.1 Cl-104 HCO3-28 AnGap-13
[**2126-8-24**] 06:58AM BLOOD Mg-1.8
Brief Hospital Course:
A/P: 63yoM with history of CAD admitted to the [**Hospital Unit Name 153**] [**8-19**] for
neutropenic fevers 103 and new onset rash. Transferred to floor
[**8-21**].
.
1. Rash. Described above. The etiology of the rash remains
unknown. Dermatology, Neurology, and Infectious Disease were
consulted during this hospitalization. The patient was treated
with vancomycin and acyclovir early in the hospitalization; both
medications were discontinued prior to discharge. Dermatology
felt that while the biopsy and clinial presentation were not
pathomneumonic, the case likely represented an atypical
eosinophilic presentation of Sweet's syndrome. Most likely, the
presentation was secondary to Sweet's syndrome in the setting of
previous infection, most likely viral or Lyme; Lyme titers sent
on previous hospitalization were negative and repeat Lyme titers
were sent on this hospitalization and were pending upon
discharge. Because of the association between Sweet's syndrome
and malignancy, a CT abdomen was performed, which was negative
as above. CSF was sent for cytology, which was pending at the
time of discharge. Wound culture from the original biopsy was
positive for MRSA, and the patient was placed on contact
precautions. Disseminated herpes zoster was originally in the
differential diagnosis, but the direct antigen test for
varicella zoster virus was negative. Lower on the differential
were erlichia and babesiosis, with titers sent and pending upon
discharge. The patient will follow-up with neurology regarding
the results of his Lyme titers and CSF studies. Dermatology and
Infectious Disease felt follow-up was unnecessary at the time of
discharge.
.
2. Febrile neutropenia. The patient originally presented with
fever and neutropenia. The patient was placed on neutropenic
precautions and treated with vancomycin and acyclovir while in
the intensive care unit. The neutropenia resolved the second day
of admission and the patient's neutrophils remained stable
throughout hospitalization. The patient's vancomycin and
neutropenic precautions were subsequently discontinued.
Acyclovir was discontinued prior to discharge. The patient's
differential showed bandemia early during the hospitalization,
which was believed to be consistent with marrow reaction to
neutropenia. The etiology of the neutropenia remains unclear,
but most likely represents a reaction to ceftriaxone or acute
illness.
.
3. Anemia. The patient had a normocytic anemia. The patient's
hematocrit remained in the low 30s throughout this
hospitalization from baseline low 40s in [**7-25**]. Iron studies
showed anemia of chronic disease. His anemia showed be
followed-up as an outpatient.
.
4. CAD. The patient remained asymptomatic and had no changes on
EKG. His home regimen was continued.
.
5. Lower extremity spasticity. Lumbar puncture was repeated on
this admission, with results as above. The CSF was sent for Lyme
titers, which were pending upon discharge. The patient's
pre-existing lower extremitiy spasticity remained stable
throughout hospitalization. His baclofen and valium were
continued. The patient will follow-up with Neurology.
.
6. Hypertension. The patient's outpatient regimen was continued
with SBP < 140s throughout hospitalization.
.
7. Hyperlipidemia. The patient's outpatient regimen was
continued.
.
8. MRSA. As above, would culture from skin biopsy [**2126-8-19**] was
positive for MRSA, and the patient was placed on contact
precautions.
Medications on Admission:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
5. Baclofen 10 mg Tablet Sig: 1.5 Tablets PO QHS (once a day (at
bedtime)).
6. Diazepam 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for spasticity.
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
5. Baclofen 10 mg Tablet Sig: 1.5 Tablets PO QHS (once a day (at
bedtime)).
6. Diazepam 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for spasticity.
7. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical TID (3
times a day).
Disp:*QS QS* Refills:*2*
8. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed.
Disp:*100 Capsule(s)* Refills:*3*
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Primary:
1. Eosinophic variant Sweet's syndrome - tentative diagnosis.
2. Fever and Neutropenia.
Secondary:
1. Right 6th nerve palsy and bilateral lower extremity
spasticity NOS.
2. MRSA colonization.
3. Hypertension.
4. CAD s/p MI [**2114**] s/p angioplasty. PCI and stents [**2119**]
5. Nephrolithiasis.
6. Hyperlipidemia.
Discharge Condition:
Afebrile, vital signs stable. Stable white blood cell count and
improving rash.
Discharge Instructions:
Please contact a physician if you experience fevers, increasing
weakness, worsening rash, or any other concerning signs or
symptoms.
.
Please take your medications as prescribed.
.
Please keep your scheduled follow-up appointments.
Followup Instructions:
Please see your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **], in clinic on Thursday morning,
[**8-29**]. He has clinic from 9 AM-10 AM. Please call him at
[**Telephone/Fax (1) 8129**] confirm that you will be coming.
.
Please follow-up with neurology: DRS. [**Name5 (PTitle) 43**]/REUBENS
Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2126-9-20**] 4:30
.
Provider: [**Name10 (NameIs) 6131**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2126-9-12**]
2:30
|
[
"378.54",
"V45.82",
"412",
"414.01",
"695.89",
"284.8",
"272.4",
"401.9",
"288.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.11",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
10757, 10818
|
6110, 9563
|
323, 341
|
11191, 11273
|
2555, 2571
|
11553, 12062
|
1725, 1926
|
10058, 10734
|
10839, 11170
|
9589, 10035
|
11297, 11530
|
1941, 2536
|
5558, 6087
|
262, 285
|
369, 1367
|
2585, 5544
|
1389, 1518
|
1534, 1709
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,611
| 131,243
|
29184
|
Discharge summary
|
report
|
Admission Date: [**2123-1-31**] Discharge Date: [**2123-2-10**]
Date of Birth: [**2056-4-30**] Sex: F
Service: MEDICINE
Allergies:
Heparin Agents / Ceftriaxone
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Intermittent fevers/chills [**1-30**] candidemia
Major Surgical or Invasive Procedure:
Insertion of tunneled HD line via IR guidance on [**2123-2-9**]
History of Present Illness:
66 yo F with multiple medical problems including SLE with ESRD
on HD with VIP triple lumen cath in RIJ (present since mid-[**Month (only) **]
when tunnelled line was pulled and replaced w/ VIP), PUD s/p
Billroth II gastrecomy, chronic C. diff colitis non-responsive
to IV Flagyl, and recent HAP s/p Zosyn course, who presented
with intermittent fevers for one week. She had no other
localizing infectious symptoms (i.e., for PNA, UTI, wound,
etc.). Blood cultures in mid-[**Month (only) **]. were negative. Blood
cultures from her HD line on [**1-28**] showed yeast, which has not
yet been speciated. Initial V/S in ED were BP 130/85 HR 85. Pt
was given Caspofungin 70 mg IV x 1 empirically. She transiently
dropped her pressures to the 70's systolic and was given 1 L of
NS. Pressure went up to 120's systolic. At that time she was
given one dose of Vancomycin (1g) and Caspofungin (70mg), and
BCx were sent. Renal was called in the ED and recommended
admission, dialysis in AM, and pulling line after HD for 2-day
line holiday. Either Tx service or IR will replace line 48
hours after line is pulled per their consult note. ID has been
seeing the patient in consultation, and is recommending
Caspofungin until yeast is speciated, and holding off on IV
vancomycin. Ophtho consulted and exam is WNL. HD catheter
removed today with IR for line holiday until Friday (per renal
recs). Her line status currently is one peripheral.
On admission to the MICU (for episode of hypotension), initial
vs. were: T 99.9 P 102 BP 138/85 R 18 O2 sat 98% RA. She
reported feeling cold and thirsty but otherwise had no
dizziness, CP, SOB, abd pain, nausea, vomiting. Occasional
diarrhea per patient. Pt reports that she does not make urine.
Pt has since been transferred to the floor.
Past Medical History:
1. s/p CVA ([**5-4**], with left facial drop)
2. HIT Ab + ([**2120**], s/p treatment with argatroban and Coumadin,
PF4+ in [**4-5**])
3. TTP (s/p plasmapheresis *10)
4. ESRD on HD (first HD, [**2121-9-5**], HD three days/week)
5. VRE septic thrombophlebitis in IJ ([**1-4**]) s/p linezolid)
6. C. difficile colitis with h/o failed flagyl
7. SLE (diagnosed [**2119**])
8. HTN
9. ACD (baseline Hct from [**Date range (1) 70208**], 26---37)
10. Bowel and bladder incontinence
11. Peripheral vascular disease
12. Diverticulosis
13. Peptic ulcer disease
14. s/p Billroth II gastrectomy ([**2118**])
15. Gout
16. ETOH abuse
17. Depression
18. s/p hysterectomy
19. h/o PE
Social History:
Pt worked as a nurse for [**Hospital6 70211**] in
[**Location (un) 86**], but is currently retired. She came from [**Hospital1 **] prior
to this admission. Her husband passed away 3 years ago. She
has a son and two daughters, [**Name (NI) 24592**] and [**Name (NI) **]; daughter [**Name (NI) **]
[**Last Name (NamePattern1) **] is her HCP. [**Name (NI) **] son lives locally with his wife, and
they are supportive. She smoked for 8 years, [**1-31**] cigs/day, but
quit ~40 years ago. She quit EtOH ~1 year ago, with previously
heavy use. She denies illicit drug use. Pt states that she can
obtain support from her relatives and friends.
Family History:
Non-contributory; daughter has scleroderma
Physical Exam:
V/S: Temp: 97.2 HR: 80 BP: 112/64 RR: 16 O2sat: 99% RA
Gen: Fatigued-appearing but non-toxic, cachectic woman with
tardive dyskinesia movements (but able to communicate) and
constant scratching [**1-30**] pruritus
Skin: Dialysis catheter nontender, no erythema; WWP, no
rashes/lesions/discolorations
HEENT: NCAT, anicteric, no conjunctival suffusion, PERRLA, EOMI,
MMM, OP clear; marked repetitive facial contractions with
rhythmic movements and tongue involvement
Neck: Supple, no thyromegaly/[**Doctor First Name **]/carotid bruits, no JVD
(difficult to examine as pt in constant motion)
Pulm: CTAB (difficult to examine as pt in constant motion)
CV: Mildly tachycardic, nl S1 and S2, no M/R/G (although
difficult to examine as pt in constant motion)
Abd: Scaphoid, +BS, soft, NT/ND, no masses or organomegaly
Ext: No C/C/E, warm, 2+ DP pulses bilat
Neuro: A&O x 3; able to answers questions but severely
dysarthric, tardive dyskinesia w/ constant motion; CN II vision
20/200 bilat. and 20/70 if used simultaneously; CN III-XII
intact throughout; sensory and motor intact throughout; reflexes
2+ throughout; coordination intact
Pertinent Results:
[**2123-1-31**] 01:53PM PT-25.5* PTT-37.6* INR(PT)-2.5*
[**2123-1-31**] 01:12PM LACTATE-1.4
[**2123-1-31**] 01:05PM GLUCOSE-81 UREA N-18 CREAT-4.3*# SODIUM-133
POTASSIUM-3.9 CHLORIDE-94* TOTAL CO2-27 ANION GAP-16
[**2123-1-31**] 01:05PM estGFR-Using this
[**2123-1-31**] 01:05PM ALT(SGPT)-7 AST(SGOT)-26 LD(LDH)-295* ALK
PHOS-202* TOT BILI-0.4
[**2123-1-31**] 01:05PM ALBUMIN-2.8* CALCIUM-8.2* PHOSPHATE-3.2
MAGNESIUM-1.7
[**2123-1-31**] 01:05PM WBC-4.8 RBC-3.20* HGB-9.4* HCT-29.1* MCV-91#
MCH-29.3 MCHC-32.2 RDW-18.0*
[**2123-1-31**] 01:05PM NEUTS-77.5* BANDS-0 LYMPHS-19.5 MONOS-2.3
EOS-0.3 BASOS-0.4
[**2123-1-31**] 01:05PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-OCCASIONAL
MACROCYT-OCCASIONAL MICROCYT-NORMAL POLYCHROM-NORMAL
OVALOCYT-OCCASIONAL SCHISTOCY-OCCASIONAL
[**2123-1-31**] 01:05PM PLT COUNT-156
.
Abdominal ultrasound:
1. Liver and spleen show no focal abnormality.
2. Small right pleural effusion.
3. Small and echogenic right kidney consistent with history of
end-stage
renal disease.
.
Ultrasound of upper extremities:
1. Patent right IJ/subclavian vessels.
2. Recanalized left subclavian vein with chronic thrombus along
the side
wall.
3. Incompletely demonstrated left IJ system, with partial
thrombus seen
within, and multiple surrounding collateral vessels, compatible
with chronic thrombus.
.
Echocardiogram:
The left atrium is elongated. 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
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
Catheter tip culture:
[**Female First Name (un) 564**] not albicans
.
Blood cultures: [**Date range (1) 70212**]/08 finally negative
Brief Hospital Course:
66 yo F with multiple medical problems, including SLE with ESRD
on HD requiring a VIP triple lumen cath in RIJ, PUD s/p Billroth
II gastrecomy, C. diff colitis non-responsive to IV flagyl, and
recent HAP s/p Zosyn course, presented with intermittent
fevers/chills x 1 week and positive blood cultures for yeast on
[**1-28**] from HD catheter.
.
# Candidemia: Pt presented with 1 week of intermittent F/C but
no localizing infectious symptoms, with negative CXR and U/A in
ED. Blood cultures (drawn by Quest Labs) from her HD line on
[**1-28**] grew [**Female First Name (un) 564**] "not albicans", speciation is still pending at
this time. Pt's systolic BP dropped to 70's in ED and pt
required short MICU stay, but pressures responded quickly to
fluids. Ophtho evaluation was negative for chorioretinitis and
endophthalmitis. ID consult recommended Caspofungin (70 mg
loading dose with 50 mg IV daily until 14 days after the first
negative culture). Renal consult has followed pt daily
throughout hospital course. A TTE on [**2-2**] showed no vegetations
and no significant abnormalities. U/S of great vessels (per ID
recs) on [**2-2**] showed chronic thrombi in LIJ and L collateral
veins. Surveillance cultures were negative from [**Date range (1) 70212**]. A
tunneled HD line was replaced by IR on [**2123-2-9**] for hemodialysis.
LFT's were checked every few days per ID recs for Caspofungin
hepatotoxicity and remained WNL.
.
# ESRD: Pt has a h/o of SLE with ESRD on HD [**Date Range 12075**]. Her Cr was 4.3
on admission on [**2123-1-31**] and rose to 5.2 on [**2123-2-1**], likely due to
lack of HD line and cessation of hemodialysis that week.
Nephrocaps was continued, and Phoslo and Calcium acetate were
added subsequently. Electrolytes were checked twice a day.
.
# C. diff: Pt has a h/o chronic C. diff colitis unresponsive to
Flagyl. She was placed on a tapering course of PO Vanco, which
was continued throughout her hospital course.
.
# h/o DVTs and PE: Pt has a h/o DVT's and PE's and is s/p an IVC
filter and has been anticoagulated with Coumadin. Coumadin was
held during this hospital stay to prepare for insertion of a
tunneled HD line on [**2123-2-9**], with resumption following
successful line insertion.
.
# Tardive dyskinesia: Pt has a h/o of tardive dyskinesia,
followed by neurology as an outpatient. Pt was continued on her
home regimen of Benztropine and Clonazepam. All
anti-dopaminergic meds, SSRIs, and anti-emetics were avoided as
they may worsen TD.
.
# h/o TTP: Pt has a long h/o thrombocytopenia, HIT, and TTP.
Patient's platelets (150) are at or slightly above her most
recent baseline (70's-120). Hct (at 29.1 on admission, baseline
28-35) and plts were stable. This was not an active issue
during this hospitalization and pt was followed with a daily
CBC.
.
# h/o GI bleed: Pt had an acute Hct drop from 26-->19 from
[**2122-12-3**] to [**2122-12-6**]. She had melanotic stools and was guaiac
positive. She has h/o PUD s/p Billroth II procedure. Coumadin
was stopped at this time. Hct on admission was 29.1, baseline
28-35. Stool guaiac was negative on [**2-2**], and CBC was monitored
daily.
.
# Pruritis: Pt has had generalized pruritus possibly secondary
to uremia from ESRD. Pt was continued on her home regimen of
Benadryl and Hydroxyzine.
.
# HTN: Pt is currently normotensive and her home regimen of
metoprolol and amlodipine was restarted when BP became
persistently stable.
.
# h/o CVA: Pt was kept off Coumadin for line insertion on
[**2123-2-8**], but was subsequently restarted on 2.5mg PO QD.
.
# h/o PUD: Pt has a h/o PUD s/p Billroth II gastrectomy. She
was continued on Protonix per her home regimen.
.
# F/E/N: Pt was maintained on a renal diet and nutrition consult
was obtained for her decreased PO intake. Supplements were
added and nutrition continued to follow throughout her remaining
hospital course.
.
# PPx: Pt received IV Protonix [**Hospital1 **]. No SC heparin was given due
to her h/o HIT.
Medications on Admission:
acidophilus QID
Mg-oxide 400 mg [**Hospital1 **]
Na biphos/Kphos TID
nystatin 5 ml QID
protonix 40 mg qhs
vancomycin 125 mg po QID
coumadin 2.5 mg qd
tylenol 325-650 mg q4 prn
Clonazepam 0.25 mg PO q8
benadryl 25 mg q8
loperamide 2 mg q2 prn
zofran 4 mg q6 prn
metoprolol 50 mg [**Hospital1 **]
Benztropine 1 mg PO TID
Hydroxyzine HCl 25 mg PO Q6H prn
Epoetin with HD
Amlodipine 2.5 mg PO DAILY
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Vancomycin 125 mg Capsule [**Hospital1 **]: One (1) Capsule PO Q6H (every
6 hours).
3. Warfarin 2.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY16 (Once
Daily at 16). Tablet(s)
4. Clonazepam 0.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times
a day).
5. Diphenhydramine HCl 25 mg Capsule [**Hospital1 **]: One (1) Capsule PO Q6H
(every 6 hours) as needed for pruritis.
6. Hydroxyzine HCl 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H
(every 6 hours) as needed for pruritis.
7. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID
(2 times a day).
8. Benztropine 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a
day).
9. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Hospital1 **]: One (1) Cap
PO DAILY (Daily).
10. Amlodipine 2.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
11. Calcium Acetate 667 mg Capsule [**Hospital1 **]: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
- Candidemia
- C. difficile colitis - refractory
.
Secondary:
- Systemic lupus erythematosis
- Rheumatoid arthritis
- CKD stage V on hemodialysis
- Infected AV fistula
- CVA, left facial drop and dysarthria
- PF4 Antibody positive - likely false positive
- TTP rx plasmaphersis x 10 ([**Hospital1 2177**])
- RUL Pulmonary embolism
- Bilateral DVT
- S/P IVC filter
- Right IJ VRE septic thrombophlebitis
- Idiopathic tardive dyskinesia
- Hypetension
- Anemia, CKD and chronic disease
- Peripheral vascular disease
- Bowel and bladder incontinence
- GI bleed, work-up negative
- Gout
- ETOH abuse
- Depression
- Peptic ulcer disease
- S/P Billroth II gastrectomy ([**2118**])
- S/P hysterectomy
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with yeast in your blood. We think this is
from your hemodyalysis line. We replaced the line and treated
you with intravenous anti-fungals. You will need to complete a
four week course of this.
.
Please resume your hemodialysis at [**Hospital1 **] as you had prior to
admission, and follow up as indicated below. You will need INR
monitoring for adjustments in your coumadin. Upon discharge
from [**Hospital1 **], you will need to resume coumadin clinic at [**Company 191**].
.
Take all of your medications as directed.
.
Return to the ED if your fevers return, or if you develop any
concerning symptoms.
Followup Instructions:
Please follow up with your primary care providers listed below.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2123-3-26**] 1:30
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 16624**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2123-3-22**] 1:00
|
[
"438.19",
"E934.2",
"V58.61",
"274.9",
"333.85",
"585.6",
"403.91",
"287.4",
"E947.9",
"438.83",
"999.31",
"112.5",
"996.62",
"451.89",
"562.10",
"443.9",
"710.0",
"V12.51",
"285.21",
"008.45",
"714.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"86.05",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
12447, 12526
|
6885, 10873
|
336, 401
|
13272, 13280
|
4795, 6862
|
13957, 14313
|
3582, 3626
|
11320, 12424
|
12547, 13251
|
10899, 11297
|
13304, 13934
|
3641, 4776
|
248, 298
|
429, 2216
|
2238, 2904
|
2920, 3566
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,705
| 194,844
|
30997
|
Discharge summary
|
report
|
Admission Date: [**2149-1-24**] Discharge Date: [**2149-2-14**]
Date of Birth: [**2084-1-31**] Sex: F
Service: SURGERY
Allergies:
Keflex
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
wound drainage after fall
Major Surgical or Invasive Procedure:
[**2149-1-24**] peri-pancreatic drain placement
[**2149-1-25**] I&D of abdominal wall abscess
History of Present Illness:
64 F s/p distal panc/splenectromy complicated by wound abscess
with spontaneous wound drainage with blood and pus. She
presented to [**Hospital **] Hospital and was transferred here. CT from
OSH showed recurrence of abd wall abscess to level of fascia and
3x10x10 fluid collection with surrounding rim enhancemdnt in
surgical bed. Patient notes no constitutional symptoms.
Afebrile/no nausea/v/d/HA/chills/sob/
Past Medical History:
DM x 15 years, hyperlipidemia, Child's A cirrhosis,
splenomegaly, splenic varices, nonalcoholic steatohepatitis,
cholecystitis, foot ulcer, neuropathy, obesity, s/p
cholecystectomy [**2106**].
PE
[**2148-7-19**] ccy, distal panc/splenectomy for cystic neoplasm
Social History:
She is married and has one adopted 30-year-old child. Currently
not working. No history of ETOH use, She quit smoking six weeks
ago, smoking history: [**Date range (1) 8642**] of a pack per day for 48 years.
She has no history of IV drug use, marijuana use, tattoos, or
hepatitis. She has pierced ears and she is uncertain whether she
has had blood transfusions in the past.
Family History:
Father deceased DM and MI age 67. Mother died at 80 of a CVA.
three uncles and two aunts with carcinomas of unknown etiology
Physical Exam:
98.7 79 128/80 16 100%RA
A&O, NAD
RRR, [**1-3**] murmur
abd: lateral aspect of surgical wound with erythema & induration
draining pus & blood
MAE, edematous limbs
Pertinent Results:
[**2149-1-24**] 03:50AM BLOOD WBC-21.9* RBC-3.81* Hgb-10.9* Hct-32.5*
MCV-85 MCH-28.6 MCHC-33.5 RDW-15.4 Plt Ct-808*
[**2149-1-28**] 06:15AM BLOOD WBC-19.8* RBC-3.79* Hgb-10.2* Hct-31.7*
MCV-84 MCH-26.8* MCHC-32.0 RDW-15.1 Plt Ct-1148*
[**2149-1-24**] 03:50AM BLOOD PT-27.6* PTT-34.6 INR(PT)-2.8*
[**2149-1-28**] 06:15AM BLOOD PT-23.4* INR(PT)-2.3*
[**2149-1-28**] 06:15AM BLOOD Glucose-50* UreaN-24* Creat-1.1 Na-133
K-3.8 Cl-97 HCO3-26 AnGap-14
[**2149-1-28**] 06:15AM BLOOD Lipase-9
[**2149-1-28**] 06:15AM BLOOD ALT-14 AST-25 AlkPhos-135* Amylase-7
TotBili-0.5
Brief Hospital Course:
Upon admission, she was cultured then started on Unasyn. INR was
2.8. She was given 2 bags of FFP in anticipation for CT guided
drainage of the peri-pancreas collection. CT showed marked
interval increase in degree of organized collection within the
pancreatic tail and splenectomy surgical bed with some reactive
mesenteric nodes and thickening of the greater curvature of the
stomach that was not significantly changed. There was interval
improvement in the previously cystic and rim-enhancing anterior
abdominal wall abscess. A French 3 inch catheter was placed
within the left-sided fluid collection. Sample sent for gram
stain, culture and amalase. Amylase was 3. The gram stain showed
1+ gram positive cocci and 4+ gram negative rods, however the
culture itself only grew out staph aureus coag + (MSSA). IV
Vancomycin and Zosyn were started. The pigtail drainage appeared
dark bloody. Fevers resolved. Hematocrit remained stable.
Temperature max was 102.5 on day of admission. Blood cultures
were sent and have been negative to date. On [**1-25**] she was taken
to the OR by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] who performed an I&D of the
abdominal wall abscess for a pancreas leak. A wound vac was
applied.
Coumadin was discontinued as she had received 6 months of
therapy for a PE.
She received IV morphine for incisional and drain site pain. On
[**1-27**], serum sodium was 130 and creatinine was elevated to 1.3
from baseline of 0.9. IV Normal saline was run at 50cc/hr x 24
hours and lasix was held for mild dehydration. Vancomycin levels
were check and vanco adjusted. This was changed to IV Nafcillin
for the MSSA.
Abdominal CT was obtained on [**1-29**] for re-evaluation of the
abdominal abscess. This appeared well drained but a new left
pleural fluid collection was noted and she underwent drainage
and placement of a pigtail drain. 500 cc of dark straw colored
clear fluid was withdrawn at the time and then drain placed to
bag drainage with an additional 80 cc drainaed overnight. The
gram stain showed no PMNs or organisms.
However, another culture was taken from the abscess drain
showing 3+ PMNs and 1+ budding yeast presumptive [**Female First Name (un) 564**]
Albicans.
In addition she spiked a fever to 102.8 and hypotensive on [**1-30**]
prompting a fever workup. WBC 45.9 and creatinine increased to
2.6 form 1.0. She was pan-cultured and bolused with IV fluid. IV
vanco and zosyn were started as well as fluconazole. She was
transferred to the SICU for fever and hypotension. A Chest CT
was done to evaluate for a loculated effusion as the CXR
appeared to have a loculated effusion. CT demonstrated a
moderate, partially loculated left effusion.
On [**1-31**] a flexible bronchoscopy and video-assisted thoracic
surgery decortication and evacuation of pleural effusion was
performed by surgeon [**Doctor First Name **] [**Doctor Last Name **]. Pleural fluid was
aspirated for serosanguineous-appearing pleural fluid and sent
to
microbiology. The parietal pleural surfaces were inflamed and
there were multiple loculations and fibrinous debris scattered
through the chest. The lung was freed up of adhesion that had
attached to the diaphragm. Per the operative report, in the very
posterior recess of the costophrenic sulcus, there was some
fibrinous debris and presumably this is where the
subdiaphragmatic pigtail traversed the pleural space. A
posteriorapical chest tube and a basilar chest tube were placed
and put to wall suction. Patient was extubated and transferred
back to the surgical intensive care unit. She has two chest
tubes (apical and basilar), abdominal pigtail drain and an
abdominal wound vac.
On [**2-3**], she tranferred to the general surgical floor and both
chest tubes were placed to waterseal. Basilar chest tube was
removed on [**2-4**]. Follow up CXR revealed no pneumothorax. Patient
did develop hypotension with tachycardia soon after. EKG
revealed atrial fibrillation. She was placed on telemetry,
bolused for low blood pressure and IV lopressor pushed. Patient
immediately converted to sinus. Remained stable and
asymptomatic.
On [**2-5**], iv Nafcillin was switched to Dicloxacillin and
Fluconazole continued. She continued to have frequent CXRs
showing small improvements. Chest tube drainage decreased. On
[**2-11**], an abd/chest CT was done to evaluate peri-pancreas
collection and left pleural effusion. This revealed a small left
anterior pneumothorax with moderate left pleural effusion,
containing foci of air, and enhancing
visceral and parietal pleura. A tiny residual fluid collection
was adjacent to the pancreatic tail, smaller in size compared to
prior study. There was a focal area of colonic wall thickening
in the region of the hepatic flexure. A small amount of ascites
was noted. The peri-pancreas abscess pigtail catheter was
removed. Interventional radiology placed a a pigtail in the
pleural space and attached this to a JP drain. Pleural fluid was
negative for growth. This was later changed to a pneumostat
drain when the other chest tube was removed. CXR on [**2-13**] showed
improvement.
PT had been consulted early on during this admission and
recommended rehab. [**Hospital1 **] in [**Location (un) 701**] accepted her. She was to
be transferred to [**Hospital1 **] with a f/u in Dr.[**Name (NI) 2347**] office
on [**2-18**].
At time of discharge, vital signs were stable, she was
tolerating a regular diet. Blodd sugars were well controlled.
She was ambulating with a walker with supervision.
Of note, the L central line was removed on [**2-13**]. The tip was
sent for culture due to some discharge at the insertion site.
Results were pending.
Medications on Admission:
asa 81mg qd, colace 100mg [**Hospital1 **], ferrous sulfate 325 , lasix 80mg
qd, Lantus 33 units HS, lisinopril 10mg qd, lopressor 12.5mg
[**Hospital1 **], protonix 40mg qd, simvastatin 20mg qd, coumadin 6mg qd
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
3. Furosemide 40 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).
4. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID (2
times a day).
5. Morphine 15 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4H (every 4
hours) as needed: immediate release tab.
Disp:*40 Tablet(s)* Refills:*0*
6. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical TID
(3 times a day).
7. Fluconazole 200 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q24H (every
24 hours): continue -stop date to be determined by Dr. [**Last Name (STitle) **]
once all drains are removed.
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1) ml
Injection TID (3 times a day).
10. Dicloxacillin 500 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO Q6H
(every 6 hours): stop date to be determined by Dr. [**Last Name (STitle) **] once
all drains removed.
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
[**Last Name (STitle) **]: Two (2) Tab Sust.Rel. Particle/Crystal PO BID (2 times a
day).
12. Loperamide 2 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO QID (4 times
a day) as needed: max dose 16mg/day.
13. Insulin Glargine 100 unit/mL Solution [**Last Name (STitle) **]: Twenty Eight (28)
units Subcutaneous at bedtime.
14. Insulin Lispro 100 unit/mL Solution [**Last Name (STitle) **]: follow sliding
scale units Subcutaneous four times a day.
Discharge Disposition:
Home with Service
Discharge Diagnosis:
peripancreatic abscess growing MSSA
abdominal wall abscess
DM
Discharge Condition:
good
Discharge Instructions:
Please call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, worsening abdominal pain, if drain insertion
site or vac site becomes red/bleeds or has foul/discolored
drainage. Please call if drainage stops from pigtail drain or
wound vac.
Vac change every 72 hours by visiting nurse
Do not continue with coumadin. This has been stopped.
Followup Instructions:
Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**]
Date/Time:[**2149-2-18**] 11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2149-2-26**] 9:40
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2149-4-9**] 1:00
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2149-4-9**] 2:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2149-2-14**]
|
[
"250.50",
"041.11",
"567.22",
"997.4",
"250.60",
"578.9",
"E878.6",
"510.9",
"278.01",
"511.9",
"998.59",
"571.5",
"584.9",
"276.51",
"362.01",
"995.92",
"272.4",
"357.2",
"V85.4",
"250.40",
"583.81",
"038.9",
"571.8",
"427.31",
"998.2",
"682.2",
"512.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"54.91",
"38.93",
"34.91",
"34.06",
"34.52",
"33.22",
"86.04"
] |
icd9pcs
|
[
[
[]
]
] |
10157, 10176
|
2440, 8123
|
291, 387
|
10282, 10289
|
1851, 2417
|
10720, 11394
|
1522, 1649
|
8384, 10134
|
10197, 10261
|
8149, 8361
|
10313, 10697
|
1664, 1832
|
226, 253
|
415, 827
|
849, 1112
|
1128, 1506
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,813
| 133,202
|
33545
|
Discharge summary
|
report
|
Admission Date: [**2153-2-8**] Discharge Date: [**2153-2-23**]
Date of Birth: [**2088-11-28**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Epigastric Pain, N/V
Major Surgical or Invasive Procedure:
Intubation
RIJ Central Line
NJ Tube
Right Great Toe (MTP) Joint Aspiration
History of Present Illness:
The patient is a 64 y.o. male with history of alcohol abuse who
presented to the ED on [**2-8**] with a 1 day history of epigastric
pain consistent with pancreatitis. He presented with acute onset
of [**7-15**] sharp pain across his epigastrium that radiated to his
back after eating a bagel on the day prior to admission. The
pain was worse with inspiration. He also complained of
nasuea/vomiting and diarrhea, and was unable to tolerate POs.
His wife reported that he had hematemesis at home. He had never
had a pain like this before. His last alcoholic drink was the
day of admission ([**2-8**]).
.
In the ED, his vitals were temp 98.2, bp 140/83, HR 124, RR 18,
and SaO2 98% on RA. Given the patient's history of alcohol
abuse, he was given Ativan 2 mg IV x8. He was also given
Morphine 2 mg IV x1 and 4 mg IV x1, and Zofran 4 mg IV x1. Labs
were significant for WBC 12.5 with 91% neutrophils, Cr 2.3, AST
405/ALT 243/alk phos 173/T bili 4.4, amylase 1073/lipase 5586,
lactate 4.1. Liver/Gallbladder Ultrasound showed increased
echogenicity of the liver indicating fatty infiltration, and no
evidence of gallbladder wall edema or thickening, but the
gallbladder was not completely decompressed. CT abdomen/pelvis
showed no evidence for hepatitc mass or pancreatitis on the
noncontrast study, likely new bibasilar aspiration worse on the
right, diffuse fatty liver, and spondylotlisthesis with
bilateral pars defects at L5. The patient became obtunded and
was started on 7 L IVF NS, Levofloxacin 500 mg IV x1, Flagyl 500
mg IV x1, and Clincamycin 600 mg IV x1. He was intubated for
airway protection, but CXR showed that the ETT was at the level
of the carina. The ETT was pulled back, but the patient desatted
to the 60x-70s and his bp dropped to 83/53. Gastric contents
were being suctioned, and there was concern that the ETT was in
the esophagus. CT head showed no acute intracranial process. He
was thus urgently reintubated by anesthesia and started on
Levophed gtt with bp up to 101/68 before being admitted to the
MICU.
.
In the MICU, he was initially made NPO, and given IVF for his
pancreatitis, hypotension, and ARF (likely prerenal). Blood
cultures showed [**3-9**] [**Last Name (LF) 77756**], [**First Name3 (LF) **] he was started on Zosyn. This
speciated to an E. coli bactermia, and his antibiotic was
changed to Ciprofloxacin. He developed diarrhea in the MICU, so
C. diff was checked and was negative x2. He briefly was placed
on tube feeds via an NJT. On initial attempts to extubate,
patient did not have a cuff-leak and was treated with Decadron.
Patient was successfully extubated on [**2-11**] and had a speech and
swallow evaluation which recommended PO nectar thick liquids and
soft solid consistencies. Patient's abdominal pain has resolved,
and pancreatic enzymes trended down. He was continued on CIWA
scale for alcohol withdrawal and required Valium prn.
.
He currently denies abdominal pain, fevers/chills,
tremulousness, SOB, cough, and difficulty swallowing. He is
tolerating PO. His last BM was 2 days ago. He reports that he is
interested in an outpatient EtOH treatment program.
Past Medical History:
Hypertension
Glaucoma
EtOH abuse
Social History:
Patient reports drinking approximately 4 glasses of rum and coke
every night, starting around 6 PM. He started drinking alcohol
at the age of 17. He answered "No" to all screening questions of
CAGE. He reports a former history of tobacco use, having stopped
9 years ago. He previously smoked 1ppd. He denies any illicit
drug use. He is a veteran marine and served in the [**Country 3992**] War.
He retired 6 months ago. Since he retired, he has become
disinterested in things and has been drinking with increased
frequency. He lives at home with his second wife. [**Name (NI) **] has 16
grandchildren.
Family History:
Mother had DM and died of an MI at age 79. Father died of lung
cancer (occupational exposure - worked in a factory) at age 79.
Brother has DM.
Physical Exam:
MICU Admission Physical Exam:
Tm 100.4 Tc 98.4 HR 72-86 BP 124/79
AC 500 X 24 FiO2 0.50 PEEP 5.0 O2 sat 100%
GEN: intubated and sedated
HEENT: MM dry, OP clear
HEART: slightly tachy, S1S2, no gmr
LUNGS: CTA anteriorly, no RRW
ABD: mild tenderness to palpation in the epigastric region
(patient winced slightly)
EXT: no cce/ wwp
.
Medicine Floor Admission Physical Exam:
T: 97.4 BP: 136/80 P: 68 RR: 20 SaO2 100% on 1L, wt 191.3 lbs,
FSBG 97, CIWA 0
Gen: Awake, alert, NAD
HEENT: NC/AT; PERRLA, EOMI; OP clear with poor dentition, MMM,
no submandibular, anterior cervical, or supraclavicular LAD.
CV: Regular rate, Nl S1, S2, no murmurs/rubs/gallops
Resp: Lungs CTA bilaterally, no no wheezes, rhonchi, rales.
Abd: + BS, Soft, NT, ND abdomen, no HSM, no rebound or guarding
Ext: No lower extremity edema, extremities warm and well
perfused. No asterixis.
Pertinent Results:
LABS:
Admission:
WBC 12.5, Hct 36.6, MCV 104, plt 243
Diff: 91% neutrophils, 5% lymphs, 4% monos, 0.1% eos
PT 10.8, PTT 19.3, INR 0.9
Na 135, K 3.4, Cl 96, HCO3 21, BUN 31, Cr 2.3, Glucose 227
Ca 9.4, Mg 1.5, Phos 2.9
ALT 243, AST 405, LDH 415, alk phos 173, T bili 4.4
amylase 1073, lipase 5586
Tot protein 8.4, albumin 4.8, globulin 3.6
CK 209, 164, 140. CK-MB 2, 3, 3
Trop T <0.01, <0.01, 0.02
Ammonia 27
HbsAg, HBsAB, HBcAb, HAV Ab, HCV Ab negative
Serum Tox negative for ASA, EtOH, Acetmnp, BZD, Barbitr, Tricycl
Lactate 4.1, 1.2, 0.9
ABG: 7.31/38/487 (intubated)
UA: Clear, Sp [**Last Name (un) **] 1.019, tr blood, neg nitrite, tr protein, neg
glucose, neg ketone, mod bilirub, 12 urobiln, neg leuk, mod
bacteria, 0-2 WBC, 0-2 epis
UCr 53, UNa 211, Uosm 573
Urine Tox: negative BZD, Barbitr, cocaine, amphetm, mthdone.
positive opiates
Urine Eos ([**2-21**]): negative
ESR 130, CRP 31.9
Ret Aut 2.4
Fe 24, TIBC 203, fferritin 845, TRF 156, Vit B12 476, folate 8.9
Discharge Labs:
WBC 5.7, Hct 23.4, MCV 98, plt 516
Na 140, K 4.2, Cl 108, HCO3 23, BUN 9, Cr 1.5, Glucose 82
Ca 8.5, Mg 1.8, Phos 3.5
ALT 17, AST 24, LDH 183, alk phos 51, T bili 0.4
amylase 206, lipase 351
.
MICRO:
Blood Cx ([**2-8**]): Blood Culture, Routine (Final [**2153-2-11**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
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
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Aerobic Bottle Gram Stain (Final [**2153-2-9**]): GRAM NEGATIVE
ROD(S).
Anaerobic Bottle Gram Stain (Final [**2153-2-9**]): GRAM
NEGATIVE ROD(S).
.
Blood Cx ([**2-9**] x2, [**2-10**], [**2-11**], [**2-14**], [**2-15**], [**2-16**] x2): No growth
.
Blood Cx ([**2-21**] x2): NGTD
.
Urine Cx ([**2-8**], [**2-21**]): No growth
.
Urine Cx ([**2-15**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE.
10,000-100,000 ORGANISMS/ML.
.
Urine Cx ([**2-16**], [**2-21**]): <10,000 organisms/ml
.
Stool Cx ([**2-10**], [**2-11**], [**2-13**]): C. diff negative x3
.
Joint Fluid Cx, Right 1st MTP joint ([**2-14**]): GRAM STAIN (Final
[**2153-2-14**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2153-2-17**]): NO GROWTH.
.
Chest Pustule Cx ([**2-22**]): GRAM STAIN (Final [**2153-2-22**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2153-2-24**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
FUNGAL CULTURE (Preliminary):
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
ANAEROBIC CULTURE (Final [**2153-2-26**]): NO ANAEROBES ISOLATED.
.
IMAGING:
ECG ([**2-8**]): Sinus tachycardia at a rate of 112. Diffuse
non-specific ST-T wave changes. No previous tracing available
for comparison.
.
Liver/Gallbladder Ultrasound ([**2-8**]): IMPRESSION:
1. Limited imaging of the liver shows increased echogenicity
indicating fatty infiltration. Of note, more serious forms of
liver disease including significant hepatic fibrosis/cirrhosis
cannot be excluded on this study.
2. No evidence of gallbladder wall edema or thickening; however,
the gallbladder is not completely decompressed. If there is
continued clinical concern for acute cholecystitis, a nuclear
medicine gallbladder scan may be performed.
.
CT Abdomen/Pelvis ([**2-8**]): CT ABDOMEN AND PELVIS WITHOUT IV
CONTRAST: In the lungs, there are bibasilar opacification with
air bronchograms on the right, likely representing aspiration.
The visualized portion of the heart and great vessels appears
essentially normal, although there are vascular calcifications.
In the abdomen, the spleen is normal and an incidental note is
made of a splenule. The kidneys are small and there is some
mild, non-specific perirenal fat stranding. The liver is
diffusely fatty, but there is no focal parenchymal mass
identified on this noncontrast scan. Allowing for the lack of IV
contrast, the gallbladder, adrenals, pancreas, stomach, duodenum
and small bowel appear normal. There is no free air, free fluid
or abdominal lymphadenopathy.
In the pelvis, the pelvic loops of bowel appear normal excepting
for sigmoid diverticulosis without evidence of diverticulitis. A
Foley catheter is in place and the bladder appears normal. There
are prostatic calcifications and the seminal vesicles appear
normal. No pelvic free fluid, free air or lymphadenopathy is
identified.
OSSEOUS STRUCTURES: No suspicious lytic or blastic lesions.
There is grade I anterolisthesis of L5 on S1 and associated
bilateral spondylolysis.
IMPRESSION:
1. Likely new aspiration bibasilar, worse on the right.
2. No evidence for hepatic mass or pancreatitis on this
noncontrast study.
3. Diffuse fatty liver.
4. Spondylolisthesis with bilateral pars defects at L5.
.
CT Head ([**2-8**]): There is no intracranial hemorrhage. An old right
caudate lacunar infarct is seen. There is no shift of normally
midline structures, loss of [**Doctor Last Name 352**]-white matter differentiation,
abnormality in size or contour of ventricles, or gross osseous
abnormality. Mastoid air cells are clear. There is mild
sinonasal thickening of the ethmoid air cells.
IMPRESSION: No acute intracranial process.
.
CXR Portable ([**2-8**]): IMPRESSION:
1. Non-standard position of ETT; needs to be withdrawn.
2. OG tube in standard position, although side port is at the
diaphragmatic level.
.
CXR Portable ([**2-8**]): IMPRESSION: Standard position of ET tube and
now distended stomach.
.
CXR Portable ([**2-8**]): IMPRESSION:
1. Interval insertion of a right IJ line with tip projecting
over the right atrium; this means retraction by approximately 3
to 4 cm is recommended.
2. New right upper lobe collapse.
.
CXR Portable ([**2-8**]): Right internal jugular vascular catheter has
been re-positioned, but distal tip is still slightly below the
expected junction of the superior vena cava and right atrium.
Nasogastric tube side port remains proximal to the GE junction
level and could be advanced for optimal placement. Right upper
lobe collapse has resolved in the interval, and there has been
improvement in the degree of gastric distention. Otherwise no
substantial short-interval change.
.
CXR Portable ([**2-8**]): Moderate right pleural effusion has
increased since earlier in the day following resolution of right
upper lobe collapse. The heart size is top normal, unchanged,
and there is no longer any mediastinal vascular engorgement.
Left lung is clear, and there is no left pleural effusion or any
evidence of pneumothorax.
Tip of the endotracheal tube is at the thoracic inlet, and the
cuff remains mildly over-inflated. Nasogastric tube ends in a
non-distended stomach. Tip of the right internal jugular line
projects over the superior cavoatrial junction.
.
CXR Portable ([**2-9**]): Tip of the ET tube is in standard placement,
below the thoracic inlet, approximately 5 cm above carina.
Nasogastric tube passes into the stomach and tip of a right
jugular line in the upper right atrium. Small right pleural
effusion is still present. Heart size mildly enlarged, and
mediastinal veins are still engorged. Left lung is clear. No
evidence of pneumonia or lobar collapse, and no pneumothorax is
present.
.
CXR Portable ([**2-10**]): The endotracheal tube, nasogastric tube, and
right-sided central venous catheter are in unchanged position.
There is cardiomegaly with some prominence in the mediastinum
which is stable. There is no signs for overt pulmonary edema or
focal consolidation.
.
CXR PA/Lateral ([**2-13**]): The patient was extubated in the meantime
interval with removal of the NG tube. The right internal jugular
line tip terminates at the cavoatrial junction. The
cardiomediastinal silhouette is stable.
The right lower lobe consolidation is demonstrated, overall
slightly improved since [**2153-2-10**] which might represent area
of improving pneumonia/aspiration. Minimal retrocardiac opacity
on the left is noted most likely consistent with atelectasis.
A small bilateral pleural effusion is persistent.
IMPRESSION: Right lower lobe consolidation consistent with
pneumonia/aspiration, slightly improving. Left basal
atelectasis.
.
Bilateral Foot Films ([**2-15**]): IMPRESSIONS:
No bony abnormalities or soft tissue calcification suggestive of
gout. Small bilateral plantar calcaneal spurs.
.
CXR PA/Lateral ([**2-16**]): Right lower lobe consolidation has
markedly improved with subtle heterogeneous opacities remaining
in the periphery of the right lower lung. No new or progressive
abnormalities are identified. Cardiomediastinal contours are
within normal limits. Small pleural effusions have decreased in
size.
IMPRESSION: Resolving right lower lobe consolidation and
improving small pleural effusions.
.
CT Abdomen/Pelvis ([**2-17**]): CT ABDOMEN WITH CONTRAST: Previously
noted consolidation within the right lower lobe has demonstrated
interval improvement with only a small amount of residual patchy
opacity remaining. There is a small residual right pleural
effusion and trace left effusion.
The liver, stomach, spleen, splenule, adrenal glands, kidneys
and collecting systems are unremarkable. The pancreas appears
normal in appearance without focal abnormality or ductal
dilatation. Intra-abdominal loops of small and large bowel are
normal in appearance. No free fluid or free air is identified in
the abdomen. There are several tiny lymph nodes in the
paraaortic region. Calcified and irregular atherosclerotic
plaque is detected within the descending abdominal aorta and
iliac branches without aneurysmal dilatation.
CT PELVIS WITH CONTRAST: The bladder demonstrates a small amount
of intraluminal air, consistent with recent Foley
catheterization detected on previous study. There is a small
bladder outpouching in the left lateral aspect suggesting a
diverticulum. The distal ureters, rectum, and seminal vesicles
are normal in appearance. There is a small amount of
calcification within the prostate gland, which is otherwise
unremarkable. No inguinal or iliac adenopathy is identified.
OSSEOUS STRUCTURES: There is a synovial herniation pit of the
left femoral head. No suspicious lytic or sclerotic lesions are
identified. There is grade I anterolisthesis of L5 on S1 and
associated bilateral spondylolysis.
IMPRESSION:
1. Interval improvement of bibasilar consolidations.
2. Diffuse fatty liver.
3. Spondylolisthesis with pars defects at L5.
4. Irregular calcified atherosclerotic plaque within the
abdominal aorta and iliac branches.
5. Small right pleural effusion.
6. Small outpouching of the left lateral bladder wall suggesting
a diverticulum.
.
LENIs ([**2-21**]): IMPRESSION: No evidence of DVT of bilateral lower
extremities.
Brief Hospital Course:
# Pancreatitis: The patient has a history of alcohol abuse, and
presented with a 1 day history of acute onset [**7-15**] sharp pain
across his epigastrium that radiated to his back and was
associated with nausea and vomiting. Labs on admission were
significant for WBC 12.5 with 91% neutrophils, AST 405/ALT
243/alk phos 173/T bili 4.4, amylase 1073/lipase 5586, lactate
4.1. Liver/Gallbladder Ultrasound showed increased echogenicity
of the liver indicating fatty infiltration, and no evidence of
gallbladder wall edema or thickening, but the gallbladder was
not completely decompressed. CT abdomen/pelvis showed no
evidence for hepatic mass or pancreatitis on the noncontrast
study. In the ED he received 7 L NS and was started on
Levofloxacin 500 mg IV x1, Flagyl 500 mg IV x1, and Clincamycin
600 mg IV x1. He had at least 6 [**Last Name (un) 5063**] criteria (he did not
have an ABG in 48 hours). He was intially sent to the MICU as he
had been intubated for airway protection, and started on
Levophed gtt for hypotension. Blood cultures grew [**3-9**] E. coli,
which was thought to be from translocation from the
pancreatitis. He was treated with IVF and Zosyn->Ciprofloxacin.
He was initially made NPO, briefly placed on tube feeds via an
NJT, and then started on a regular diet. His amylase and lipase
trended down, but then bumped back up on [**2-12**], likely due to his
NJT feeds being transitioned to oral food. His amylase/lipase
plateaued, and his abdominal pain ressolved. He was continued on
a regular low fat diet. He continued to spike fevers, and a
repeat CT abdomen/pelvis showed that the pancreas appeared
normal in appearance without focal abnormality or ductal
dilatation. His amylase was 206 and his lipase was 351 on
discharge.
.
# E. coli Bacteremia: Blood cultures on admission showed [**3-9**]
bottles of pansenstive E. coli, which was thought to be
secondary to translocation from the pancreatitis.
He was treated with Zosyn->Ciprofloxacin 500 mg [**Hospital1 **] for a 13 day
course (he was stopped 1 day short of a 14 day course as
Ciprofloxacin may have been contributing to a drug fever, see
below). Surveillance blood cultures showed no growth and NGTD.
.
# Fevers: Since [**2-12**], the patient would spike fevers to 101 each
evening around midnight. This was not likely due to recurrence
of E. coli bacteremia as subsequent blood cultures had shown no
growth. Repeat CT abdomen/pelvis had shown that the pancreas
appears normal in appearance without focal abnormality or ductal
dilatation. ESR was elevated to 130, and CRP was 31.9. DDx
included drug fever (Cipro and Colchicine were new), gout,
atelectasis, aspiration PNA, aspiration pneumonitis, DVT, and
endocarditis (no murmur on exam). Rheumatology was reconsulted
and determined that there were no findings suggestive of
synovitis, periarthritis, or discitis on joint exam. Dermatology
was consulted to evaluate the papules on his chest and
determined that he has several follicularly based papules and
pustules which appear to be consistent with folliculitis, and
this does not appear to be a disseminated fungal infection as he
is well appearing, immunocompetent, with negative blood
cultures. Pustule culture showed rare growth of Staph coag
negative and no fungus isolated. The repeat CT abdomen pelvis
did show a small residual right pleural effusion and trace left
effusion, but the team did not decide to tap it given it would
likely be low yield. LENIs were negative for DVT bilaterally.
ID was consulted for the persistent fever, and determined that
it was most likely a drug fever, but urine eos were negative.
Ciprofloxacin was discontinued after a 13 day course. The team
decided not to continue thiamine, folate, MVI, and FeSO4 upon
discharge, as these new medications may be contributing to his
drug fever. They can be added back on as an outpatient when his
fevers ressolve.
.
# Gout: On [**2-14**], the patient developed right great toe pain. He
reported that he intermittently gets this pain in his right
great toe, but denies arthritis in his ankles, knees, or elbows.
He has no foot hardware in place. He has a history of alcohol
abuse putting him at risk for gout. He did have an E. coli
bacteremia on admission putting him as risk for a septic joint,
but had subsequent negative surveillance blood cultures. His
right first MTP was erythematous and swollen on exam. The joint
was tapped by Rheumatology, and found to have 2 cc
serosanguenous turbid fluid, with intra- and extra-cellular
needle shaped crystals, which were negatively birefringent
consistent with monosodium urate. Gram stain showed 1+ PMNs but
no microorganisms, and joint culture showed no growth. Plain
film of his bilateral feet showed no bony abnormalities or soft
tissue calcification suggestive of gout and small bilateral
plantar calcaneal spurs. He was started on Colchicine 0.6 daily
for 1 week, then every other day until Rheumatology follow up.
His HCTZ was discontinued, and he was encouraged to abstain from
EtOH abuse. The patient had another gout flare on the evening
prior to discharge (and spiked a low grade temp to 100.5), so
rheumatology was notified and will call him in a few days to see
how he is doing. He will follow up with Rheumatology in 4
weeks, and will likely need to start Allopurinol at that time.
.
# Alcohol Abuse/Withdrawal: The patient has a history of
drinking approximately 4 glasses of rum and coke every night. In
the MICU, he was maintained on Versed while intubated, and then
on Valium per CIWA scale. During this hospitalization, he was
started on Thiamine, Folate, and MVI. The patient was discharged
home, and will follow up with an outpatient alcohol treatment
program at the VA. He is interested in an inpatient EtOH
program, but did not want to attend the one at the VA since it
is unsupervised at night. The patient was not discharged on
thiamine, folate, and MVI, as these new medications may have
been contributing to his fevers. They can be added back on later
as an outpatient.
.
# Respiratory Failure/Aspiration PNA: The patient was initially
intubated for airway protection after receiving Ativan in the
ED. CT abdomen/pelvis on admission showed likely new aspiration
bibasilar, worse on the right. Subsequent CXRs in the MICU did
not show any infiltrates. On initial attempts to extubate,
patient did not have a cuff-leak and was treated with Decadron.
Patient was successfully extubated on [**2-11**] and had a speech and
swallow evaluation which recommended PO nectar thick liquids and
soft solid consistencies. Repeat evaluation indicated the
patient could have a regular diet with thin liquids. Repeat CXR
PA/Lateral on [**2-13**] showed right lower lobe consolidation
consistent with pneumonia slightly improving, and left basal
atelectasis.
.
# Thrombocytosis: His platelet count was 243 on admission and
trended up to 617 on [**2-21**]. This may be a reactive thrombocytosis
in response to an infection or even his iron deficiency. He may
also have had a delayed reactive increase in platelets in
response to the Zosyn or Cipro. His platelets did not decrease
in response to 1 L NS. His platelets were 516 on discharge, and
should continue to be followed as an outpatient.
.
# Anemia: The patient's Hct was 41.3 on admission, which
initially dropped to 32.1 in the setting of fluid resuscitation.
NG lavage in the MICU was guaiac negative. His MCV was 103-106
which suggests macrocytosis in the setting of alcohol use. His
Hct plateaued at 23-27. His stool was guaiac negative. Fe
studies showed: Fe 24, TIBC 203 (transferrin sat 11.8%),
ferritin 845, TRF 156. Vit B12 476, folate 8.2. Hemolysis labs
showed: LDH 175, T bili 0.8, retic 2.4%, hapto 164. He was
started on thiamine, folate, and FeSO4, but he was not
discharged on these medications as they may have been
contributing to his drug fevers. These medications can be added
back as an outpatient once his fevers ressolve. His Hct was 23.4
on discharge. He was scheduled for an outpatient colonoscopy and
EGD.
.
# Transaminitis: ALT 243/AST 405 on admission, which is most
likely secondary to alcohol abuse. CT abdomen/pelvis showed
diffuse fatty liver. HAV Ab, HBsAg, HBcAg, HGcAb, and HCV Ab
negative.
.
# ARF: His Cr was 2.3 on admission, and has trended down to
1.5-1.7. It is unclear what his baseline Cr is, and his ARF on
admission was thought to be prerenal from third-spacing in the
setting of acute pancreatitis. Urine Lytes: FeNa 4.27%, UOsm
573. He was fluid resuscitated in the ED and MICU, with
improvement in Cr to 1.5 on discharge. His renal function should
be monitored closely, especially now that he is on Colchicine.
.
# Diarrhea: The patient developed diarrhea in the MICU, and C.
diff was negative x3. He was started on Pancrease tid with meals
as there may be a component of malabsorption with his
pancreatitis, but he was not discharged on this medication. His
subsequent diarrhea was thought to be a side effect of
Colchicine.
.
# Hypertension: His HCTZ was discontinued in the setting of
gout. His Lisinopril was increased to 30 mg daily. He was
started on Toprol XL 100 mg daily.
.
# Glaucoma: He was continued on Cosopt and Lumigan eye drops.
Medications on Admission:
Medications on Admission:
Lisinopril-HCTZ 20mg-12.5mg daily
Cosopt 2% - 0.5% eye gtts
Lumigan 0.03% eye gtts
.
Allergies/Adverse Reactions:
Codeine ("feels loopy")
Discharge Medications:
1. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Cosopt Ophthalmic
3. Lumigan Ophthalmic
4. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
5. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 weeks: Take from [**Date range (1) 77757**].
Disp:*7 Tablet(s)* Refills:*0*
6. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO every other
day for 18 days: Take every other day from [**Date range (1) 77758**] (when you
follow up with rheumatology).
Disp:*9 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
PRIMARY:
Pancreatitis
E. coli bacteremia
Respiratory Failure
Gout
Alcohol Withdrawal
Transaminitis
Acute Renal Failure
Diarrhea
Anemia
.
SECONDARY:
Hypertension
Glaucoma
Discharge Condition:
Stable, no abdominal pain
Discharge Instructions:
1. If you develop increased abdominal pain, nausea/vomiting,
diarrhea, inability to tolerate food or fluids, fever >101.5,
increased cough, shortness of breath, chest pain, or any other
symptoms that concern you, call your primary care physician or
return to the ED.
2. Take all medications as prescribed.
3. Attend all follow up appointments.
4. Your Lisinopril-Hydrochlorothiazide combination pill was
discontinued during this hospitalization, as Hydrochlorothiazide
can contribute to gout. Now you should take Lisinopril 30 mg
daily.
5. You were started on Toprol XL 100 mg daily for your blood
pressure.
6. You were started on Colchicine 0.6 mg daily to complete a 1
week course for gout ([**Date range (1) 77757**]). After that you should take
Colchicine 0.6 mg every other day until you follow up with
Rheumatology on [**3-19**].
7. You should stop drinking alcohol, as this is contributing to
your pancreatitis, gout, and other medical problems.
Followup Instructions:
You have a follow up EGD (upper endoscopy) and colonoscopy (to
evaluate your anemia) on [**2153-3-1**] at 11:30 with Dr. [**Last Name (STitle) **]
([**Telephone/Fax (1) 463**]) in Gastroenterology in the [**Hospital Ward Name 1950**] Building, [**Location (un) 3202**]. They will be contacting you with more information.
.
You have a follow up appointment with your primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] ([**Telephone/Fax (1) 30837**]) on [**2153-3-2**] at 11:15.
.
You have a follow up appointment with Dr. [**Last Name (STitle) 12434**] in Rheumatology
([**Telephone/Fax (1) 2226**]) on [**2153-3-19**] at 9:00 at [**Last Name (NamePattern1) **], [**Hospital Unit Name 3269**], [**Hospital Unit Name **].
|
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[]
]
] |
[
"96.04",
"81.91",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
26735, 26793
|
16663, 25839
|
289, 366
|
27007, 27035
|
5240, 6217
|
28036, 28791
|
4204, 4348
|
26054, 26712
|
26814, 26986
|
25891, 26031
|
27059, 28013
|
6233, 8235
|
4735, 5221
|
8271, 16640
|
229, 251
|
394, 3512
|
3534, 3569
|
3585, 4188
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,873
| 125,351
|
2305
|
Discharge summary
|
report
|
Admission Date: [**2173-12-22**] Discharge Date: [**2173-12-28**]
Date of Birth: [**2108-5-17**] Sex: F
Service: MEDICINE
Allergies:
Dyazide / Prozac / Nsaids / Inderal / Cefazolin
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
hemodialysis
History of Present Illness:
65 yo F with ESRD s/p renal transplant back on HD, DM type II,
CAD, diastolic CHF, and HTN who presents with acute SOB. Pt went
to usual HD session on Monday and has been adhering to low Na
diet and taking all meds. Was drinking cup of tea yesterday
night when acutely felt SOB and had her daughter call EMS. Pt
denies fevers, + chills but has these at baseline. No cough,
wheezing, CP, HA, neck stiffness, dysuria, diarrhea, or
abdominal pain. Upon EMS arrival, pt reportedly in respiratory
distress with bilateral crackles in lung fields, placed on CPAP
with improvement in tachypnea.
In the ED, T 103.2, BP 244/70, HR 86, RR 29, O2 sat 100% on NRB.
CXR showed moderate pulmonary edema, EKG with no new ischemic
changes, UA negative, lactate 2.6. She was given vancomycin 1 gm
IV X 1, levaquin 750 mg IV X 1, ceftriaxone 1 g IV X 1, tylenol
1 gm X 1, lasix 40 IV X 2 then 80 mg IV x1 with 180 cc urine
output, [**First Name3 (LF) **] 325 mg, captopril 6.25 mg X 1, and started on a
nitro gtt which was turned off once SBPs were < 140. CPAP was
reattempted to due tachypnea to 40s, but pt was unable to
tolerate and was placed back on a NRB. She was seen by
nephrology who recommended HD once pt was admitted. As the pt
remained on a NRB, she was admitted to the [**Hospital Unit Name 153**] for further
care. Prior to transfer, pt was given 10 units reg insulin, 1
amp D50, and 1 amp CaGluc for K 6.8.
.
Currently, the pt feels her breathing is much better but not
back at baseline. ROS is otherwise notable for occasional mid to
lower back pain, chronic
Past Medical History:
-esrd s/p cadaveric renal transplant in [**2168**] back on HD at
[**Location (un) 4265**] [**Location (un) **] M-W-F. (continues on prednisone)
-post transplant course c/b c.dif infection, polyoma virus
infection
-DM II with retinopathy, neuropathy, neuropathy
-Hyperlipidemia
-s/p mult cva's (recently [**2173-8-23**])
-CHF [**12-25**] diastolic function-last echo [**2-26**]. mild [**Last Name (un) 6879**]
-CAD s/p cath [**2-26**]-LAD 50% stenosed
-s/p hyst
-s/p cataract extraction
-PNA treated at [**Hospital3 2568**] in [**11-28**]
-hypertension
-s/p thrombectomy LUE graft
-hyperparathyroidism
-L2 compression fracture
-depression
-anemia
Social History:
Lives with daughter. Retired nurses aid. No tobacco or EtOH use.
Walks with cane for balance. Born in [**Country **], used to be a
nurse's aid. HD at [**Location (un) **] [**Location (un) **] M/W/F.
Family History:
Father w/ DM and mother w/ HTN
Physical Exam:
98.1, 120/70, 64, 20, 96%RA
Gen - NAD, speaking in full sentences without SOB
HEENT - sclera anicteric, MMM, OP clear
Neck - supple
CV - RRR, nl s1/s2, I/VI diastolic murmur over RUSB, II/VI
holosystolic murmur over apex
Lungs - CTA B/L
Abd - Soft, NT, moderately obese, normoactive BS, no TTP over
graft
Ext - no LE edema, WWP
Neuro - AAO X 3, moves all 4 extremities purposefully, Ambulated
well with assistance with PT
Pertinent Results:
[**2173-12-27**] 10:07AM BLOOD WBC-7.1 RBC-3.56* Hgb-9.9* Hct-33.1*
MCV-93 MCH-27.8 MCHC-29.9* RDW-14.9 Plt Ct-318
[**2173-12-27**] 10:07AM BLOOD Glucose-126* UreaN-48* Creat-7.5* Na-134
K-3.9 Cl-96 HCO3-24 AnGap-18
[**2173-12-26**] 07:40AM BLOOD Glucose-97 UreaN-41* Creat-7.1*# Na-136
K-4.2 Cl-97 HCO3-24 AnGap-19
[**2173-12-25**] 10:45AM BLOOD Glucose-184* UreaN-27* Creat-5.2*# Na-137
K-5.1 Cl-97 HCO3-22 AnGap-23*
[**2173-12-23**] 04:40AM BLOOD CK(CPK)-89
[**2173-12-23**] 04:40AM BLOOD CK-MB-3 cTropnT-0.18*
[**2173-12-22**] 02:44PM BLOOD CK-MB-4 cTropnT-0.20*
[**2173-12-22**] 11:20AM BLOOD CK-MB-4 cTropnT-0.20*
[**2173-12-22**] 04:15AM BLOOD CK-MB-3 cTropnT-0.08*
[**2173-12-27**] 10:07AM BLOOD Calcium-8.5 Phos-5.0* Mg-2.1
[**2173-12-26**] 07:40AM BLOOD Calcium-8.8 Phos-4.5 Mg-2.2
[**2173-12-24**] 08:23AM BLOOD Vanco-28.5*
[**2173-12-22**] 07:03PM BLOOD Vanco-9.4*
[**2173-12-27**] 10:07AM BLOOD FK506-PND
[**2173-12-26**] 07:40AM BLOOD FK506-3.3*
[**2173-12-24**] 08:23AM BLOOD FK506-1.7*
[**2173-12-23**] 04:40AM BLOOD FK506-1.7*
[**2173-12-22**] 04:24AM BLOOD Lactate-2.6*
[**2173-12-22**] 4:15 am BLOOD CULTURE
**FINAL REPORT [**2173-12-25**]**
Blood Culture, Routine (Final [**2173-12-25**]):
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
Please contact the Microbiology Laboratory ([**5-/2472**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
SULFA X TRIMETH sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN-------------<=0.25 S
PENICILLIN------------ =>0.5 R
TRIMETHOPRIM/SULFA---- =>16 R
[**2173-12-26**] 7:15 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT [**2173-12-26**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2173-12-26**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
ECHO [**2173-12-24**]: Conclusions
The left atrium is dilated. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is a moderate resting left ventricular outflow
tract obstruction. The gradient increased with the Valsalva
manuever. Right ventricular chamber size and free wall motion
are normal. There are three aortic valve leaflets. The aortic
valve leaflets are moderately thickened. No masses or
vegetations are seen on the aortic valve. There is a minimally
increased gradient consistent with minimal aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. No mass or vegetation is seen on the mitral valve.
Mild (1+) mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. The pulmonary artery systolic pressure could
not be determined. There is no pericardial effusion. IMPRESSION:
No vegetations or abscess seen. Moderate symmetric LVH with
moderate resting LVOT gradient that increased with Valsalva.
Mild aortic stenosis, at least mild mitral regurgitation.
Compared with the prior study (images reviewed) of [**2173-9-21**],
the degree of LVOT gradient has increased. The other findings
are similar.
CHEST PORT. LINE PLACEMENT [**2173-12-24**] 7:40 PM
FINDINGS: The PICC line tip is at the brachiocephalic/SVC
junction. This finding was discussed with the PICC nurse caring
for the patient on the evening of [**12-24**]. Heart continues
to be severely enlarged. There is no pneumothorax. There is no
new infiltrate.
ECG Study Date of [**2173-12-23**] 10:41:22 AM
Sinus rhythm. Borderline right axis deviation. Minor right
ventricular
conduction delay. Prolonged QTc interval with diffuse
non-diagnostic
repolarization abnormalities. Compared to the previous tracing
of [**2173-12-22**] no major change.
US EXTREMITY NONVASCULAR LEFT [**2173-12-23**] 1:58 PM
FINDINGS: Son[**Name (NI) 493**] evaluation of the patient's AV graft in
the left forearm demonstrates some wall-to-wall flow, with no
evidence of thrombosis. There is no edema of the surrounding
tissues and no fluid collection identified.
IMPRESSION: Patent AV fistula, with no surrounding fluid
collection or edema.
CHEST (PORTABLE AP) [**2173-12-22**] 3:55 AM
AP PORTABLE CHEST: Moderate cardiomegaly and the mediastinal
contours are unchanged. Redemonstrated is severe thoracic
dextroscoliosis. The pulmonary vasculature is less well defined
compared to prior studies consistent with moderate interstitial
edema. There is no definite focal consolidation or pleural
effusion. IMPRESSION: Moderate interstitial edema.
Brief Hospital Course:
1. MSSA Bacteremia/Fever
- Initially Placed vancomycin and levaquin upon arrival to [**Hospital Unit Name 153**]
which was tapered down to vancomycin once blood cultures on
admission returned back with GPC in pairs and clusters,
subsequently coag + staph sensitive to penicillins, and
nafcillin was added
- Prior to discharge the renal team reduced the antibiotics back
to vancomycin given difficulty in home administration of a QID
antibiotic via IV
- Vancomycin to be given with HD total of 4 weeks
(1/30-08-3/1/08)
- No source of infection identified, and the renal team
currently plans to treat through the graft. If surveillance
cultures become positive after antibiotics, then graft removal
will be required
- Echo without vegetation
2. ESRD on HD, Failed Renal Tranplant
- Dialysis Schedule M, W, Fr
- Fluid intially removed to resolve flash pulmonary edema, with
good resolution
- Tacrolimus dose was reduced to 0.5mg Q24 based on Renal Team's
reccomendation
3. Symptomatic Hyperkalemia
- On admission
- Treated with insulin, D50, ca gluc in ED. Did receive ACE-I in
ED. No signs of hyperkalemia on initial EKG done in ED. Repeat K
upon arrival to [**Hospital Unit Name 153**] 5.0.
- Subsequently normal values throughout stay
4. Type 2 Diabetes Controlled
- Continued home NPH regimen and HISS.
- Has had several mornings of mildly low FS on the morning AC
check
- PM NPH was reduced to 4 units
- Continue morning FS checks
5. Chronic Diastolic CHF
- In setting of LVH on EKG, 2+ AR, 1+ MR
- ACE-I increased to 10 mg daily
- continued on beta-blockade.
- echo repeated as above
6. CAD native Vessle
- No signs of ischemia on admission EKG, cardiac enzymes
- Continued [**Hospital Unit Name **], statin, beta-blocker
- ACE-I increased as above.
7. Hypercholesterolemia
- Continued statin.
8. Anemia of Chronic Kidney Disease
- Stable
Medications on Admission:
(per med sheet, verified with pt)
Aspirin 81 mg daily
Metoprolol 25 mg [**Hospital1 **]
Atorvastatin 40 mg daily
Bactrim qMWF
Paroxetine 10 mg daily
Lisinopril 5 mg daily
Gabapentin 100 mg qHD
Prednisone 9 mg daily
Pantoprazole 40 mg daily
Nephrocaps 1 cap daily
Cinacalcet 30 mg daily
Tacrolimus 0.5 mg q12h
NPH 36 units qam
NPH 5 units qpm
HISS
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Atorvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD (each
hemodialysis).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
syringe Injection TID (3 times a day).
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
12. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO Q M,W,F ().
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Prednisone 1 mg Tablet Sig: Nine (9) Tablet PO DAILY
(Daily).
15. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO Q 24H
(Every 24 Hours).
17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
18. Simethicone 80 mg Tablet, Chewable Sig: [**11-24**] Tablet,
Chewables PO QID (4 times a day) as needed.
19. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous HD PROTOCOL (HD Protochol): GIVEN WITH
HEMODYALYSIS.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Bactremia with MSSA
ESRD on HD
Acute on Chronic Diastolic CHF
Type 2 Diabetes Controlled
CAD
Anemia of Chronic Kidney Disease
Discharge Condition:
Good
Discharge Instructions:
Return to the hospital with fevers/chills, nausea/vomitting,
pain at the dialysis site.
You will be getting antibiotics at dialysis, so it is very
important that you get dialysis on schedule
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD Phone:[**Telephone/Fax (1) 2386**]
Date/Time:[**2174-2-2**] 8:20
Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2174-2-15**] 9:30
Provider: [**Name10 (NameIs) 4338**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2174-4-12**] 8:20
|
[
"583.81",
"285.21",
"585.6",
"790.7",
"311",
"428.0",
"041.11",
"250.50",
"E878.0",
"250.40",
"276.7",
"362.01",
"E849.9",
"357.2",
"250.60",
"414.01",
"272.4",
"996.81",
"403.91",
"428.33",
"787.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
12379, 12449
|
8382, 10232
|
318, 332
|
12618, 12624
|
3310, 8359
|
12864, 13251
|
2820, 2852
|
10630, 12356
|
12470, 12597
|
10258, 10607
|
12648, 12841
|
2867, 3291
|
271, 280
|
360, 1919
|
1941, 2588
|
2604, 2804
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,115
| 103,736
|
21963
|
Discharge summary
|
report
|
Admission Date: [**2165-4-23**] Discharge Date: [**2165-4-28**]
Date of Birth: [**2094-7-13**] Sex: M
Service: MEDICINE
Allergies:
Amiodarone
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Transfer from [**Hospital3 **] for VT ablation
Major Surgical or Invasive Procedure:
EP study
VT ablation
Aortic catheterization with abdominal aortogram
and pelvic runoff, right common iliac artery stent, right
external iliac artery stent followed by groin closure with
Perclose.
History of Present Illness:
Patient is a 70 y/o with a history of CAD, CHF, prostate CA,
hyperlipidemia, DM, atrial fibrillation who presented to [**Hospital1 **] on [**2165-4-21**] after feeling dizzy and not himself after
dinner. His friends reported that he also looked very pale, and
activated EMS. He said he has felt like this in the past, but
usually after pacer firing. He was waiting in the ED at Sturdy
at rest, and his pacer fired. He was admitted and taking up to a
room. at around 1am as he stood up from lying down. This
discharges were for ventricular tachycardia. According to the
discharge summary, he had approx 5 runs of VT while on telemetry
and his ICD fired once.
denied CP, dyspnea, nausea or diaphoresis; pt did feel his
"typical funny" palpatations and "a bit dizzy" as per prior
events that trigger his ICD.
pt was recently discharged from [**Hospital3 **] for treatment of
RAF following 7 recorded ICD discharges on [**4-12**]; dofetilide was
added to a regimen of digoxin and increased toprol with
subsequent conversion to sinus rhythm. Pt was discharged home on
dofetilide 250 mg, and had been well controlled until [**4-17**]
episode.
Patient has had 4 difference pacers placed since [**2159**]. The first
was replaced for infection 2 weeks after placement. The second
and third were removed for abnormal firing.
[**2164-4-19**]: Upgrade of an ICD to a [**Company 1543**] Concerto biventricular
ICD, Successful ablation of the AV junction with resultant
complete heart block
[**2162-1-19**]: VT and flutter ablation
Past Medical History:
Known AAA
PVD
CHF
Prostate CA
CAD s/p PCI with angioplasty
s/o pacer placement x4
GERd
Hyperlipidemia
HTN
Sciatica Hyperthyroidism
Atrial Fibrillation
Diabetes mellitus II
Social History:
- quit smoking in [**2158**], 10 pack here smoking history,
occassional ETOH use, no other drug use. Never married. Lives in
monastery.
Family History:
- Brother died of MI age 46, sister died of MI age 59, also had
thyroid problems
Physical Exam:
VS T 97.2 BP 116/80 P 77 o2 sat 98%.
Gen: NAD. Oriented x3
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple, 8cm JVP
CV: irregular, occassional s3
Chest: CTA b/l
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
[**2165-4-24**] ART DUP EXT LOW/BILAT C
IMPRESSION: Peak systolic velocities do not show evidence of
significant
proximal femoral artery stenosis on either side.
A more comprehensive assessment may be obtained with pulse
volume recordings and segmental blood pressure measurements, if
clinically indicated.
[**2165-4-24**] Carotid dopplers
IMPRESSION:
1. There is 40-59% stenosis within the right internal carotid
artery.
2. There is 70-79% stenosis within the left internal carotid
artery.
[**2165-4-24**] US aorta and branches
IMPRESSION: Fusiform abdominal aortic aneurysm measuring up to 4
cm in
greatest dimension.
[**2165-4-25**] ECHO
Left ventricular wall thicknesses are normal. The left
ventricular cavity is dilated. No masses or thrombi are seen in
the left ventricle. Overall left ventricular systolic function
is severely depressed (LVEF= 20 %). with focal hypokinesis of
the apical free wall. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened.
[**2165-4-26**] ECHO
The left atrium is mildly dilated. There is severe regional left
ventricular systolic dysfunction with akinesis of the anterior
wall, anterior septum, inferolateral wall, and apex. There is
mild hypokinesis of the remaining segments. Quantitative
(biplane) LVEF = 22%. No masses or thrombi are seen in the left
ventricle. Transmitral Doppler and tissue velocity imaging are
consistent with Grade II (moderate) LV diastolic dysfunction.
The right ventricular cavity is mildly dilated with mild global
free wall hypokinesis. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: Severe regional left ventricular systolic
dysfunction, c/w multivessel CAD. Mild mitral regurgitation. No
pericardial effusion.
[**2165-4-27**] CT abd/pelvis with contrast
IMPRESSION:
1. No evidence of retroperitoneal hematoma.
2. Aneurysmal dilatation of the infrarenal aorta measuring up to
3.4 cm in
greatest axial dimension.
3. Right iliac stent.
Brief Hospital Course:
Patient is a 70 y/o with hx of CAD, CHF, VT with pacer placement
and multiple ablations here for VT and pacer firing, transferred
here for EP study and ablation
.
Ventricular Tachycardia: The patient presented to [**Hospital 8125**] hospital
after feeling lightheaded and will. There, he had 5 episodes of
ventricular tachycardia on tele, and his ICD fired once while in
the waiting room. The patient had been on digoxin and
transferred on amiodarone gtt. He had had multiple ablations in
the past and on admission had a dual chamber ICD. He has had
thyroid and liver abnormalites from amiodarone in the past, and
so the amiodarone was discontinued on admission, but he recieved
800mg PO x2 prior to procedure. On [**2165-4-25**] he had a VT ablation.
He had ablation of inducible ventricular tachycardia (RBBB
superior axis CL 400. He had mechanical bump termination of the
tachycardia in apical septum which caused noninducibility. The
ablation was guided b the site of termination and pacemapping.
Nonspecific endpoint on noninducibility given noninducibility
prior to ablations. His device was reprogrammed. Prior to the
procedure he was on heparin until INR. Post procedure he was on
heparin bridge to coumadin.
During the procedure he was noticed to have a cold leg. He was
transferred to the CCU:
CCU COURSE:
The patient was admitted to the CCU following a VT ablation when
it was noted that his right leg was cool and mottled. His right
common iliac artery was dissected. Vascuar surgery consult was
called. This was repaired with stent. His pulses returned. He
was transfered to the CCU for monitoring, and did well. His feet
remained warm and well perfused. There was no recurrence of VT.
He was trasnfered back to the [**Hospital1 1516**] service in good condition,
continued on heprain, aspirin, and plavix as well as coumadin.
His INR on transfer was 1.7.
- Also of note, he was had a pre and post ablation ECHO. He was
monitored on telemetry throughout the admission and did not have
recurrance ventricular tachycardia. He was continue metoprolol
50mg [**Hospital1 **], digoxin. LFTs WNL, checking baseline while on
amiodarone. TSH: 3.8. He also had ultrasounds of carotids,
femoral arteries and AAA for history of AAA, carotid bruit.
.
Atrial fibrillation: on coumadin, beta blocker, digoxin. He was
on heparin after procedure as bridge back to coumadin.
.
CAD: s/p MI, and PCI.
- continue plavix, metoprolol, aspirin, atorvastatin 80mg
.
Chronic Systolic Heart Failure: EF 20% in [**2160**].
- continue metoprolol 50mg, Lisinopril 10mg, lasix 40mg daily,
digoxin .125 mcg daily.
.
HTN: currently normotensive. continue metoprolol and lisinopril.
.
Diabetes Mellitus type II: continue insulin 70/30 10units qAM
and insulin sliding scale while here
.
Chronic kidney disease: baseline 1.5-1.8 this admission and
last, currently at baseline
- renally dose meds.
.
GERD: continue ranitadine.
Medications on Admission:
Lipitor 80mg daily
Aspirin 81mg daily
Plavix 7mg daily
Lisinopril 10mg daily
Metoprolol 50mg [**Hospital1 **]
Digoxin 0.125 daily
Ranitadine 150mg [**Hospital1 **]
Flomax 0.4 HS
Coumadin 2-3mg nightly
Insulin 70/30 10units qAM
Lasix 40mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
8. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge
Sig: Ten (10) units Subcutaneous qAM.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Ventricular Tachycardia
Common Iliac Artery Dissection
CAD
HTN
atrial fibrillation
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital after feeling lightheaded. You
intially went to another hospital and your pacer fired 2 times.
You had an ablation and developed a complication of dissection
of one of the arteries that supplies your leg. You had a
vascular procedure and the surgeons placed stents in that
artery. Your pacer did not fire while you were here.
Please have your coumadin level (INR) checked on Tuesday.
Please call your doctor if you have lightheadedness, if your
pacer fires, chest pain or any other concerning symptoms.
Followup Instructions:
Please f/u with Dr. [**Last Name (STitle) 3407**], the Vascular surgeon in 1 month for
an ultrasound of your leg and abdomen. PLease call [**Telephone/Fax (1) 1721**].
Please f/u with your cardiologist in 1 week.
Please have your coumadin level (INR) checked on Tuesday.
Completed by:[**2165-5-24**]
|
[
"427.1",
"403.90",
"440.20",
"585.9",
"426.0",
"427.31",
"428.22",
"250.00",
"428.0",
"997.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.41",
"37.34",
"00.46",
"39.90",
"00.51",
"39.50",
"88.42"
] |
icd9pcs
|
[
[
[]
]
] |
9369, 9375
|
5359, 8271
|
317, 515
|
9510, 9519
|
2976, 5336
|
10106, 10411
|
2433, 2516
|
8566, 9346
|
9396, 9489
|
8297, 8543
|
9543, 10083
|
2531, 2957
|
231, 279
|
543, 2067
|
2089, 2263
|
2279, 2417
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,823
| 151,548
|
27124+57524
|
Discharge summary
|
report+addendum
|
Admission Date: [**2169-6-22**] Discharge Date: [**2169-6-27**]
Date of Birth: [**2090-8-13**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Epidural blood mid thoracic to L3
Major Surgical or Invasive Procedure:
T8-L3 Laminectomies and evacuation of epidural hematoma
History of Present Illness:
Mr [**Name13 (STitle) 66598**] is a 78yo R-handed man with HTN, hyperlipidemia,
Afibb (on coumadin), CHF recent cardiac cath showed: three
vessel
coronary artery disease, moderately depressed systolic
dysfunction, moderately severe elevation of left heart filling
pressure who presents to the ED after 5 days of
back pain, since 2 days accompanied by bilateral leg weakness.
He reports 5 days ago developing shoulder pain which worsened
through the day. He went to [**Hospital **] Hospital on [**6-18**] he was sent
home with pain medications and reports barely being able to walk
into the house. On [**6-19**] his pain now radiated to his back and he
spent most of the day in the bed. On [**6-20**] His pain further
decended down hips and he was able to walk but fell once and was
unable to walk after that and notice he was leaking urine from
his penis. He fell again on [**6-21**] and was brought to the ER by
ambulance.
Past Medical History:
1. Hypertension.
2. Hypercholesterolemia.
3. Coronary artery disease and an MI in [**2141**] recent cath [**2-23**]:
Three vessel coronary artery disease, moderately depressed
systolic dysfunction, moderately severe elevation of left heart
filling pressure.
4. No history of CVA.
5. Chronic back pain.
6. AFib, on Coumadin. No pacemaker.
Social History:
Smoked from age 18-22. Patient is married with three children.
He is
originally from [**Country 2559**], moving to the US in [**2109**]. + [**1-21**] classes
of wine per day.
Family History:
Family History: No family history of premature CAD
Physical Exam:
PE: VS 98.6 142/81 HR 96 R 21 O2 sat 97%
GEN: NAD, in bed
HEENT: mucous membranes moist
NECK: full range neck movements; no
tenderness
LUNGS: Clear to auscultation bilaterally
HEART: [**Last Name (un) 3526**] [**Last Name (un) 3526**], normal S1 and S2, no murmurs, gallops and rubs.
ABDOMEN: normal bowel sounds, bladder palpable
EXTREMITIES: chronic skin changes due to vessel disease; bruit
L-femoral artery
SPINE: mildly tender in lower in lumbar sacral area no erthyema
Neuro: Awake, alert and orientated X3, follows commands
[**Last Name (un) 1425**],
in no distress
PERRLA, EOMs full, face symmetric, no drift.
Motor:
B T IP Q AT [**Last Name (un) 938**] G
R 5 5 3 5 3 4- [**11-21**]
L 5 5 3 5 4- 5 5-
SENSORY SYSTEM: Sensation intact to light touch, pin prick,
temperature (cold), vibration, and proprioception in upper
extremities. Proprioception absent in R-foot, fine on the Left;
PP decreased on the L compared to the R, but able to feel; LT
decreased on the R compared to the L.
Decreased sensation in anal region.
REFLEXES:
B T Br Pa Pl
Right 2 2 2 0 0
Left 2 2 2 0 0
Toes: mute bilaterally.
Anal tone: slight anal tone no change with valsalva
Pertinent Results:
[**2169-6-21**] 02:25PM URINE RBC-[**1-22**]* WBC-0-2 BACTERIA-RARE
YEAST-NONE EPI-0
[**2169-6-21**] 02:25PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2169-6-21**] 02:25PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2169-6-21**] 02:25PM PT-34.2* PTT-34.5 INR(PT)-3.7*
[**2169-6-21**] 02:25PM PLT COUNT-225
[**2169-6-21**] 02:25PM NEUTS-83.3* LYMPHS-11.5* MONOS-3.8 EOS-0.8
BASOS-0.6
[**2169-6-21**] 02:25PM WBC-12.8*# RBC-3.85* HGB-12.4* HCT-35.3*
MCV-92 MCH-32.3* MCHC-35.2* RDW-13.6
[**2169-6-21**] 02:25PM CALCIUM-9.0 PHOSPHATE-3.0 MAGNESIUM-2.5
Brief Hospital Course:
Mr [**Name13 (STitle) 66598**] is a 78yo R-handed man with HTN, hyperlipidemia,
Afib (on coumadin), CHF recent cardiac cath showed: three vessel
coronary artery disease, moderately depressed systolic
dysfunction, moderately severe elevation of left heart filling
pressure who presents to the ED after 5 days of back pain, last
2
days accompanied by bilateral leg weakness with mid thoracic to
L3 epidural hematoma collection.
He was given Proplex and admitted to the ICU for Q1 neurologic
monitoring. He was taken early am of [**6-22**] and had T8-L3
Laminectomies. Post operatively he had much improved motor
strength in his lower extremeties with ability to lift both legs
of the bed and good distal motor strenght also. On POD#1 he was
monitored overnight in the SICU for neurologic checks and
monitoring of CHF. His goal INR was I.4 or less and required
additional FFP and vitamin K.
ON POD#1 his strenght conditioned to improve with close to full
strenght in left leg and 4+ on the right. His hemovac drain was
DC'd. He was transferred to the surgical.
His hospital course was complicated by melanotic stools, for
which GI was consulted. Hct remained stable and INR was <1.4.
Vitals remained stable but the patient refused the recommended
EGD. He will be scheduled for outpatient GI for reconsideration.
Hospital course was also c/b 5 beats of NSVT on [**6-25**]. He should
f/u with cardiology re: ? AICD.
He is discharged home with staples to come out in two weeks. He
remains incontinent of stool and urine and will require a leg
bag.
Medications on Admission:
1. Lasix.
2. Lisinopril.
3. Coumadin.
4. Lipitor.
Discharge Medications:
1. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
Highgate Manor
Discharge Diagnosis:
Epidural Hematoma
Discharge Condition:
Neurologically stable
Discharge Instructions:
Keep incision clean and dry, watch for any redness, drainage,
bleeding, swelling, temperature >101.5 call Dr[**Name (NI) 4674**]
office.
Do not lift greater than 10 lbs
No driving on pain medication
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 739**] on [**7-13**] at 10:45am, [**Last Name (NamePattern1) **], [**Hospital Unit Name **] for staple removal
Provider: [**First Name11 (Name Pattern1) 20**] [**Last Name (NamePattern4) 21383**], MD Phone:[**Telephone/Fax (1) 1954**]
Date/Time:[**2169-7-26**] 2:00 at [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 470**]
Follow-up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**7-10**] at 3:30pm at
[**Location (un) 32097**] ([**Telephone/Fax (1) 2394**]) - please have PCP refer
you.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2169-6-27**] Name: [**Known lastname 11587**],[**Known firstname 3061**] Unit No: [**Numeric Identifier 11588**]
Admission Date: [**2169-6-22**] Discharge Date: [**2169-6-27**]
Date of Birth: [**2090-8-13**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1698**]
Addendum:
PT has changed their recommendations and the patient will go
instead to rehab first.
Discharge Disposition:
Extended Care
Facility:
Highgate Manor
[**Name6 (MD) **] [**Name8 (MD) 1041**] MD [**MD Number(2) 1709**]
Completed by:[**2169-6-27**]
|
[
"412",
"578.1",
"401.9",
"344.1",
"447.0",
"414.01",
"336.1",
"427.31",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"99.04",
"03.09",
"39.53"
] |
icd9pcs
|
[
[
[]
]
] |
8214, 8380
|
3874, 5431
|
353, 411
|
6723, 6747
|
3196, 3851
|
6994, 8191
|
1958, 1994
|
5533, 6597
|
6682, 6702
|
5457, 5510
|
6771, 6971
|
2009, 3177
|
280, 315
|
439, 1371
|
1393, 1733
|
1749, 1926
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,704
| 193,105
|
28381
|
Discharge summary
|
report
|
Admission Date: [**2182-7-11**] Discharge Date: [**2182-7-16**]
Date of Birth: [**2118-10-20**] Sex: F
Service: NEUROSURGERY
Allergies:
Percocet / Morphine Sulfate
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
C5-T2 POSTERIOR FUSION
History of Present Illness:
63F w/ met renal cell cell cancer has persistent cervical and
thoracic spine pain due to hardware failure.
Past Medical History:
ONCOLOGIC HISTORY:
Her oncologic history began in [**2179-1-27**] when a right kidney
mass was suspected on angiography (status post superficial
femoral angioplasty and stenting). In [**2179-6-29**], she underwent
abdominal/pelvic CT which revealed a right kidney mass. Chest CT
in [**2179-7-30**] revealed 2 small pulmonary nodules
suspicious for metastatic disease. She underwent left lower lobe
wedge resection in [**2179-8-29**] with pathology revealing
renal cell carcinoma of clear cell type. She underwent
laparoscopic right radical nephrectomy on [**2179-10-4**] with
pathology revealing renal cell carcinoma, clear cell type,
[**Last Name (un) 9951**] grade [**1-2**] with extension into the renal vein. She was
followed on observation with stable pulmonary nodules until
[**2181-2-27**] when progression was noted. She was planned for
high-dose IL-2 therapy with stress echo showing anterior
ischemia. She underwent cardiac catheterization with a 90-95%
stenosis of the proximal LAD noted. She had a balloon
angioplasty and stenting of the LAD. She recovered well without
cardiac issues and passed follow-
up stress test to meet eligibility for the high-dose IL-2 select
trial. She is status post one cycle of high-dose IL-2. She had a
CT scan done of the torso on [**2181-8-27**] and this showed interval
slight increase in the size of her multiple pulmonary nodules.
There also was slight interval increase in the size of the left
hilar node. The decision was made to stop IL-2 at that point.
PAST MEDICAL HISTORY:
- Diabetes
- Hyperlipidemia
- Hypertension
- Peripheral vascular disease, s/p R superficial femoral artery
stenting x 2
- CAD, cardiac catheterization revealing a 95-99% proximal
stenosis of the LAD; s/p PCI stenting in [**2181-3-29**]
Social History:
She continues to live in [**Hospital1 392**] and will occasionally help out
at her relatives' Chinese restaurant answering phones
does not drink or smoke
Family History:
non-contributory
Physical Exam:
General nad
Mental/Psychological a/o
Airway Mallampati [Class II]
Mouth Opening [Marginal (2-3 cm)]
Thyromental Distance [<6 cm]
Hyomental Distance [>3 cm]
Dental Other (some R molars missing)
Head/Neck Range of Motion Limited
Heart rrr no M or bruits
Lungs Clear to Auscultation
Extremities no cce
neuro: a nad 0 x3
motor decreased R UE
Pertinent Results:
[**2182-7-11**] 02:07PM GLUCOSE-163* UREA N-17 SODIUM-137
POTASSIUM-4.7 CHLORIDE-107 TOTAL CO2-24 ANION GAP-11
[**2182-7-11**] 02:07PM CALCIUM-8.0* PHOSPHATE-4.0# MAGNESIUM-2.0
[**2182-7-11**] 02:07PM WBC-1.9* RBC-3.94* HGB-10.7*# HCT-33.0*
MCV-84 MCH-27.1 MCHC-32.4 RDW-16.6*
[**2182-7-11**] 02:07PM NEUTS-61.5 BANDS-0 LYMPHS-33.7 MONOS-3.5
EOS-1.1 BASOS-0.3
[**2182-7-11**] 02:07PM HYPOCHROM-OCCASIONAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL
OVALOCYT-OCCASIONAL TARGET-OCCASIONAL
[**2182-7-11**] 02:07PM PLT COUNT-124*
[**2182-7-11**] 02:07PM PT-11.7 PTT-28.3 INR(PT)-1.0
[**2182-7-2**]
Sinus rhythm. Normal ECG. Since the previous tracing of [**2181-12-20**]
limb lead
QRS voltage has improved, but there may be no significant
change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
80 166 74 354/389 58 29 31
[**6-24**] Chest CT
IMPRESSION:
1. Stable size to minimally decreased size of target lesions in
the left
upper, right lower, and right middle lobes. However, increasing
size of the pulmonary nodule along the lateral aspect of the
left major fissure.
2. New probable pleural-based metastasis to the right of the
upper thoracic spine.
3. Increased size of lytic lesion within the anterior and left
L2 vertebra
consistent with metastatic disease.
thoracic xrays [**7-13**]
Patient is status post corpectomy at T6. The lesion seen in T2
on the previous MRI is not well appreciated on today's study.
The patient is
status post posterior stabilization hardware spanning C5-T10.
There are no
signs for hardware-related complications. Surgical skin staples
are seen
within the lower cervical spine. There is a right IJ central
venous catheter with distal tip in the mid SVC.
CT thoracic [**7-15**]:
FINDINGS: In the interim from the CT torso dated [**2182-6-24**]
the patient
has had T2 corpectomy. A significant portion of the cement at T2
has
retropulsed into the spinal canal causing significant narrowing,
and likely cord compression. There are two lateral mass screws
in each C6 and C7 as well as two pedicle screws at T1 with two
posterior longitudinal paraspinal rods. The hardware appears
well secured without evidence of loosening. The prior fixation
involving two pedicle screws at T9 and T10 as well as spinous
process hooks at T3 and T4 appear stable. The patient is status
post T6 corpectomy with intervertebral fixation. There is
lucency surrounding this fixation anteriorly and superiorly
suggesting it may not be fused to T5. A previously noted lytic
lesion at L2 appears slightly increased in size measuring 9 mm
(3:94).
There are bilateral pleural effusions. There are several
bilateral pulmonary nodules (2:25, 52). The patient is status
post right nephrectomy. A fat-containing liver lesion (2:79) is
stable. There are multiple aortic calcifications.
IMPRESSION:
1. Large amount of cement retropulsed into spinal canal at T2
causing
significant spinal canal stenosis and likely cord compression.
2. Lucency surrounding interbody fixation at T6 suggests
potential lack of
fusion with T5.
3. Pedicle screws appear stable.
4. Known metastatic disease as described above with interval
increase in L2 lytic lesion.
Brief Hospital Course:
Pt was admitted to the hospital electively and taken to the OR
where under general anesthesia she underwent posterior
cervical/thoracic fusion. She tolerated this well, was
extubated and transferred to PACU. In the PACU she had
hypertension requiring ongoing medication and to best manage
this she was monitored in the TICU overnight.She was
hemodynamically stable and transferred to the floor. Her neuro
exam remained stable with some weakness in right UE as pre-op
though this improved during her stay and she was full strength
by [**7-15**]. She had JP drain and output was monitored and was
removed [**7-13**]. Dressing was dry. Voiding trial failed on 3
attempts over 3 days. She will remain with foley upon discharge
and if unable to pass voiding trial at rehab, should follow up
with urology. She was started on aspirin post op day #1 and
plavix to restart [**7-17**].
PT/OT consults were called and she was evaluated and it was
recommended that she would need rehab placement. She received a
bed offef on [**7-16**] and was transfered.
Medications on Admission:
plavix 75'(dc'd pre-op), keppra 500''; glipizide 10',
pioglitazone 30', zocor 80', asa81'(dc'd pre-op), calcium/D,
telmisartan 20, omega 3, ranitidine, tylenol [**Telephone/Fax (1) 1999**] q6; (not
taking gabapentin 300tid and dilaudid);prochlorperazine 10,
fentanyl patch 50
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): SLIDING SCALE COVERAGE
.
7. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
11. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
13. Methocarbamol 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
14. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
16. Potassium & Sodium Phosphates 280-160-250 mg Powder in
Packet Sig: Two (2) Powder in Packet PO ONCE (Once) for 1 doses.
17. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
19. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain.
20. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): START ON [**2182-7-17**].
21. Prochlorperazine Edisylate 5 mg/mL Solution Sig: Ten (10) mg
Injection Q6H (every 6 hours) as needed for nausea.
22. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: Three
(3) ML Intravenous Q8H (every 8 hours) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
Country [**Hospital 731**] Rehabilitation & Nursing Center - [**Location (un) 5028**]
Discharge Diagnosis:
renal cell carcinoma metastatic to spine
urinary retention
Discharge Condition:
Neurologically stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR SPINE CASES
?????? Do not smoke
?????? Keep wound clean / No tub baths or pools until seen in
follow up/ take daily showers
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting for two weeks.
?????? Limit your use of stairs to 2-3 times per day
?????? Have your incision checked 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, Ibuprofen etc. for 3 months. Your aspirin has
been resumed, you may restart plavix 1 week after surgery.
?????? Increase your intake of fluids and fiber as pain
medicine (narcotics) can cause constipation
?????? 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, drainage
?????? Fever greater than or equal to 101?????? F
?????? Any change in your bowel or bladder habits
Followup Instructions:
PLEASE HAVE YOUR SUTURES/STAPLES REMOVED AT REHAB ON [**2182-7-25**]
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS.
YOU WILL NEED XRAYS PRIOR TO YOUR APPOINTMENT
If you are still unable to void at rehab, please call and make
appt to follow up in [**Hospital 159**] Clinic - [**Telephone/Fax (1) 164**]
THE FOLLOWING APPOINTMENTS ARE LISTED TO SERVE AS A REMINDER AND
ARE LISTED IN OUR SYSTEM
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2182-7-29**]
1:15
Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2182-7-29**]
3:00
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2182-12-3**] 10:00
IF YOU CANNOT ATTEND THESE APPOINTMENTS PLEASE CALL THE CLINIC
IN ADVANCE TO LET THEM KNOW.
Completed by:[**2182-7-16**]
|
[
"V10.52",
"401.9",
"197.0",
"V45.82",
"414.01",
"198.89",
"250.00",
"E878.1",
"198.4",
"996.49",
"443.9",
"272.4",
"733.13",
"198.5",
"198.3",
"788.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.63",
"77.79",
"03.53",
"80.99",
"81.03"
] |
icd9pcs
|
[
[
[]
]
] |
9464, 9576
|
6048, 7099
|
303, 328
|
9679, 9703
|
2831, 6025
|
11141, 12099
|
2439, 2458
|
7425, 9441
|
9597, 9658
|
7125, 7402
|
9727, 11118
|
2473, 2812
|
254, 265
|
356, 464
|
2014, 2252
|
2268, 2423
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,405
| 110,137
|
38507+58223
|
Discharge summary
|
report+addendum
|
Admission Date: [**2154-6-15**] Discharge Date: [**2154-7-1**]
Date of Birth: [**2087-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Increased lethargy/Nausea
Major Surgical or Invasive Procedure:
[**2064-6-18**] closed left thoracostomy
[**2154-6-20**] pericardial window
History of Present Illness:
This 67 year old black female is well known to the cardiac
surgery service as she is s/p mitral valve repair(26mm Ring),
coronary artery bypass x2(LIMA-LAD,SVG-OM1)on [**2154-5-25**] with
Dr.[**Last Name (STitle) 914**]. She presents to the ED today from [**Hospital1 **] in [**Hospital1 8**] with increasing lethargy and nausea.
Upon ED workup she was found to have a supratherapeutic INR of
10.6. The CXR revealed a large left effusion, she had acute
renal insufficiency with a creatinine of 4.2(baseline of 1.4)
and electrolyte disturbance including hyperkalemia. She was
admitted to the intensive care unit.
Past Medical History:
s/p mitral valve repair(26mm Ring),coronary artery bypass
x2(LIMA-LAD,SVG-OM1)on [**2154-5-25**]
insulin dependent diabetes mellitus
hypertension
depression
hypercholesterolemia
chronic osteomyelitis of feet
coronary artery disease
mitral regurgitation
s/p multiple foot operations/resections
diabetic retinopathy
diabetic neuropathy
Social History:
Lives at home. No alcohol, tobacco, illicit drugs
Family History:
noncontributory
Physical Exam:
admission:
Pulse: 53 Resp: 19 O2 sat: 97%
B/P Right: 122/75 Left:
Height: Weight:
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI []
Neck: Supple [x] Full ROM []
Chest: (R)crackles/(L)very diminished
sternal incision: Open pin hole mid sternotomy. Scant amount of
serous drainage. Stable. No [**Doctor Last Name **]/click
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [**11-24**]+pitting LE
edema
Neuro: Grossly intact
Pulses: DP 2+
Femoral Right: Left:
DP Right: Left:
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Carotid Bruit Right: Left:
Pertinent Results:
[**2154-6-16**] ECHO
Left ventricular wall thicknesses and cavity size are normal.
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The mitral valve
leaflets are moderately thickened. There is a moderate sized
pericardial effusion, which is likely cirumferrential although
subcostal images are markedly suboptimal. There are no
echocardiographic signs of tamponade.
IMPRESSION: Probably normal biventricular function with moderate
pericardial effusion (? circumferrential) and no
echocardiographic signs of tamponade.
[**2154-6-16**] Abdominal Ultrasound
1. Left pleural effusion.
2. Pulsatile flow within the portal vein, which is patent with
hepatopetal
flow. This may represent hepatic congestion due to congestive
heart failure. Correlate clinically.
3. No evidence of hydronephrosis or renal calculi to explain
renal failure.
[**2154-6-15**] 02:30PM BLOOD WBC-9.1 RBC-3.19* Hgb-8.8* Hct-27.4*
MCV-86 MCH-27.6 MCHC-32.0 RDW-19.0* Plt Ct-215
[**2154-7-1**] 05:04AM BLOOD WBC-9.3 RBC-3.25* Hgb-8.7* Hct-27.8*
MCV-86 MCH-26.8* MCHC-31.3 RDW-19.3* Plt Ct-330#
[**2154-7-1**] 05:04AM BLOOD PT-21.8* INR(PT)-2.0*
[**2154-6-30**] 06:15AM BLOOD PT-23.0* INR(PT)-2.2*
[**2154-6-29**] 04:30AM BLOOD PT-23.1* INR(PT)-2.2*
[**2154-6-27**] 05:09AM BLOOD PT-20.8* PTT-40.5* INR(PT)-1.9*
[**2154-6-26**] 04:51AM BLOOD PT-20.1* INR(PT)-1.9*
[**2154-6-25**] 05:26AM BLOOD PT-19.2* PTT-38.6* INR(PT)-1.8*
[**2154-7-1**] 05:04AM BLOOD Glucose-105* UreaN-37* Creat-1.3* Na-129*
K-5.0 Cl-95* HCO3-27 AnGap-12
[**2154-6-27**] 05:09AM BLOOD Glucose-115* UreaN-37* Creat-1.1 Na-135
K-4.6 Cl-99 HCO3-29 AnGap-12
[**2154-6-15**] 02:30PM BLOOD Glucose-138* UreaN-92* Creat-4.2*#
Na-127* K-6.0* Cl-93* HCO3-18* AnGap-22*
Brief Hospital Course:
Mrs. [**Known lastname 85671**] was admitted to the [**Hospital1 18**] on [**2154-6-15**] for further
management of her supratherapeutic INR, acute renal insufficency
and pleural effusion. Her hyperkalemia was treated with
dextrose, insulin and Kayexalate. FFP and Vitamin K were given
for her elevated INR. An echocardiogram was performed which
showed normal biventricular function with a moderate
pericardial effusion with no clear echocardiographic signs of
tamponade. The renal service was consulted for assistance with
her renal failure.
Dopamine was started for renal perfusion. She was pancultured
for fever. A chest tube was attempted however failed given her
habitus. Thoracentesis was thus performed which drained 1500cc
of fluid. the effusion quickly recurred and a left chest tube
was ultimately placed on [**6-19**]. The PICC line present on
admission was removed and cultured and a new central line
placed. Vancomycin was started and will continue until [**6-22**].
On [**6-20**], given the total clinical setting it was decided to
proceed with pericardial drainage in the Operating Room. 500cc
of fluid was removed with a prompt improvment of cardiac output
measured via the PA catheter in place.
The drains were removed when appropriate and anticoagulation was
resumed for her chronic atrial fibrillation. She was continued
on antibiotics for her osteomyelitis at the direction of the
Infectious Disease service. She developed c. difficile colitis
and was teeated with oral Flagyl and vancomycin.
She remained afebrile and was ready for return to
rehabilitation. The Infectious Disease service will follow her
for the osteomyelitis and labs have been ordered to be sent to
them. She still requires revascularization of ther lower
extremeties.
STOP [**7-1**]
Medications on Admission:
Paroxetine 20(1),Senna 8.6 (2 prn) Docusate Sodium 100
(2),Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every four
(4)hours,Simvastatin 20(1)Calcium Acetate
667(3),Acetaminophen 325 (4 prn), Aspirin 81(1), Ranitidine HCl
150(2),13. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig:
One (1) Tablet PO BID (2 times a day),Metoprolol Tartrate 25 (3)
Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush,Coumadin
2.5 mg Tablet Sig: as ordered Tablet PO once a day: INR goal
2-2.5,Amiodarone 200 mg Tablet Sig: as below Tablet PO twice a
day: two tablets (400mg) [**Hospital1 **] for 2 weeks, then one (200mg)twice
daily for two weeks, then one daily,Furosemide 20(2)glargine 86
units SQ q am.
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/temp\.
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
6. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Sodium Chloride 0.9 % 0.9 % Syringe Sig: Five (5) ML
Injection PRN (as needed) as needed for line flush.
13. Insulin Regular Human 100 unit/mL (3 mL) Insulin Pen Sig: as
directed ac/hs Subcutaneous ac &hs: 120-160:2units SQ
161-200:4units SQ
201-260:6units SQ
261-300:8units SQ.
14. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
15. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
16. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).
17. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gm
Intravenous Q 24H (Every 24 Hours).
18. Cefepime 2 gram Recon Soln Sig: Two (2) gm Injection Q8H
(every 8 hours).
19. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO three
times a day.
20. Outpatient Lab Work
CBC w/diff,LFTs,BUN,creatinine,trough vanco level weekly and fax
to [**Hospital 18**] [**Hospital **] Clinic ([**Telephone/Fax (1) 1419**])
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
s/p mitral valve repair(26mm Ring), coronary artery bypass
x2(LIMA-LAD,SVG-OM1)on [**2154-5-25**]
insulin dependent diabetes mellitus
pericardial effusion
acute renal failure
hypertension
depression
hypercholesterolemia
chronic feet infections
coronary artery disease
mitral regurgitation
s/p multiple foot operations/resections
bilat foot ulcers
diabetic retinopathy
diabetic neuropathy
peripheral vascular disease
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with oral medications
Incisions:
Sternal - healing well, no erythema or drainage
Feet-wet to dry dressings daily to open sites.
Edema 1+ [**Name Prefix (Prefixes) **]-[**Last Name (Prefixes) **]
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage
2) Please NO lotions, cream, powder, or ointments to incisions
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart
4) No driving for approximately one month until follow up with
surgeon
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
*Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] 09/07/10/ at 1:15 ([**Telephone/Fax (1) 170**])
Please call to schedule appointments with your:
Primary Care Dr. [**First Name (STitle) **] L.[**First Name (STitle) 18376**] in [**11-24**] weeks ([**Telephone/Fax (1) 3530**])
Cardiologist Dr. [**Last Name (STitle) **] in [**11-24**] weeks
Vascular surgery as previously scheduled
Infectious Disease-Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 457**]) on [**7-26**] at
10am
Weekly labs(CBCw/diff,BUN,creatinine,LFTs,trough Vanco level)
and Fax results to [**Hospital **] Clinic at [**Telephone/Fax (1) 1419**].
**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 atrial fibrillation
Goal INR 2-2.5
First draw m-W-Fr for two weeks then as directed.
Results to rehab MD
Completed by:[**2154-7-1**] Name: [**Known lastname 13582**],[**Doctor First Name 1911**] Unit No: [**Numeric Identifier 13583**]
Admission Date: [**2154-6-15**] Discharge Date: [**2154-7-1**]
Date of Birth: [**2087-2-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1543**]
Addendum:
Coumadin daily as directed, 1mg tablets,INR 2-2.5 goal for
atrial fibrillation
Chief Complaint:
see summary
Major Surgical or Invasive Procedure:
[**2064-6-18**] closed left thoracostomy
[**2154-6-20**] pericardial window
History of Present Illness:
see summary
Past Medical History:
s/p mitral valve repair(26mm Ring),coronary artery bypass
x2(LIMA-LAD,SVG-OM1)on [**2154-5-25**]
insulin dependent diabetes mellitus
hypertension
depression
hypercholesterolemia
chronic osteomyelitis of feet
coronary artery disease
mitral regurgitation
s/p multiple foot operations/resections
diabetic retinopathy
diabetic neuropathy
Social History:
Lives at home. No alcohol, tobacco, illicit drugs
Family History:
noncontributory
Physical Exam:
see summary
Pertinent Results:
see summary
Brief Hospital Course:
see summary
Medications on Admission:
see summary
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/temp\.
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
6. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Sodium Chloride 0.9 % 0.9 % Syringe Sig: Five (5) ML
Injection PRN (as needed) as needed for line flush.
13. Insulin Regular Human 100 unit/mL (3 mL) Insulin Pen Sig: as
directed ac/hs Subcutaneous ac &hs: 120-160:2units SQ
161-200:4units SQ
201-260:6units SQ
261-300:8units SQ.
14. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
15. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
16. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).
17. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gm
Intravenous Q 24H (Every 24 Hours).
18. Cefepime 2 gram Recon Soln Sig: Two (2) gm Injection Q8H
(every 8 hours).
19. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO three
times a day.
20. Outpatient Lab Work
CBC w/diff,LFTs,BUN,creatinine,trough vanco level weekly and fax
to [**Hospital 8**] [**Hospital **] Clinic ([**Telephone/Fax (1) 1021**])
21. Coumadin 1 mg Tablet Sig: as ordered Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2215**] Northeast - [**Hospital1 1947**]
Discharge Diagnosis:
s/p mitral valve repair(26mm Ring), coronary artery bypass
x2(LIMA-LAD,SVG-OM1)on [**2154-5-25**]
insulin dependent diabetes mellitus
pericardial effusion
acute renal failure
hypertension
depression
hypercholesterolemia
chronic feet infections
coronary artery disease
mitral regurgitation
s/p multiple foot operations/resections
bilat foot ulcers
diabetic retinopathy
diabetic neuropathy
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with oral medications
Incisions:
Sternal - healing well, no erythema or drainage
Feet-wet to dry dressings daily to open sites.
Edema 1+ [**Name Prefix (Prefixes) **]-[**Last Name (Prefixes) **]
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage
2) Please NO lotions, cream, powder, or ointments to incisions
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart
4) No driving for approximately one month until follow up with
surgeon
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 1477**]
*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) 1477**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] 09/07/10/ at 1:15 ([**Telephone/Fax (1) 1477**])
Please call to schedule appointments with your:
Primary Care Dr. [**First Name (STitle) **] L.[**First Name (STitle) 13584**] in [**11-24**] weeks ([**Telephone/Fax (1) 691**])
Cardiologist Dr. [**Last Name (STitle) 13585**] in [**11-24**] weeks
Vascular surgery as previously scheduled
Infectious Disease-Dr. [**Last Name (STitle) 13586**] ([**Telephone/Fax (1) 496**]) on [**7-26**] at
10am
Weekly labs(CBCw/diff,BUN,creatinine,LFTs,trough Vanco level)
and Fax results to [**Hospital **] Clinic at [**Telephone/Fax (1) 1021**].
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 1477**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication atrial fibrillation
Goal INR 2-2.5
First draw m-W-Fr for two weeks then as directed.
Results to rehab MD
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2154-7-1**]
|
[
"272.0",
"414.00",
"999.31",
"V45.81",
"276.7",
"423.9",
"995.92",
"250.60",
"511.9",
"357.2",
"038.40",
"362.01",
"008.45",
"401.9",
"250.50",
"997.62",
"584.9",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"34.04",
"37.12",
"96.71",
"34.91",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
14601, 14681
|
12542, 12555
|
11880, 11959
|
15113, 15399
|
12506, 12519
|
16256, 17400
|
12442, 12459
|
12617, 14578
|
14702, 15092
|
12581, 12594
|
15423, 16233
|
12474, 12487
|
11829, 11842
|
11987, 12000
|
12022, 12357
|
12373, 12426
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,084
| 132,705
|
25147
|
Discharge summary
|
report
|
Admission Date: [**2158-3-1**] Discharge Date: [**2158-3-7**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
hypotension, altered mental status
Major Surgical or Invasive Procedure:
ERCP, and biliary stent placement by IR
History of Present Illness:
Ms. [**Known lastname 63057**] is an 82 year old woman with pancreatic Ca, gastric
outlet obstruction and questionable biliary obstruction, s/p
plastic stent in CBD placed by GI several months ago. She was
transferred from [**Hospital3 **] for ERCP today with bacteremia and
septic picture.
She had ERCP today - GI could not cannulate ampula due to mass,
placed duodenal stent. IR wants to confirm biliary obstruction
+ assess the anatomy before potential PTC tomorrow. She is
admitted to the [**Hospital Unit Name 153**] for hypotension and altered mental status.
.
Patient was admitted to [**Hospital6 33**] from a nursing home
on [**2158-2-26**] with intractable nausea and vomiting and coffee
ground emesis.
She was to have ERCP as above today to look at possible
dudodenal obstruction with potential palliative stenting.
.
During the procedure GI doctors made aware by physicians at
[**Hospital3 **] that patient had blood cultures growing GNR's.
.
On seeing the patient, she is unable to provide much history.
She has received about 2 liters of normal saline for blood
pressure in 80's to 90's. Throughout ERCP blood pressure had
been in this range.
Past Medical History:
1. Metastatic pancreatic carcinoma diagnosed in [**Month (only) **] of
[**2156**]-CT scan at [**Hospital3 **] done weeks ago showed mets to liver,
lungs, and obstruction of portal, splenic veins
2. GI bleeding--recent, [**2-16**] at [**Hospital3 **], EGD revealed
erosive esophagitis and dudoenal inflammation raising concern
for duodenal outlet obstruction.
3. diabetes mellitus
4. formerly hypertension
5. Orthostatic hypotension
Social History:
Resides in skilled nursing facility. No smoking, occasional
alcohol, no drug use.
Family History:
non-contributory
Physical Exam:
Admission:
VS: Temp: 98 BP: 90 /55 HR:80 RR:16 98%2l ncO2sat
general: pleasant, comfortable but delirious
HEENT: PERLLA, EOMI, scleral icterus, no sinus tenderness,
MMdry, op without lesions, no supraclavicular or cervical
lymphadenopathy, no jvd, no carotid bruits
lungs: crackles at bases
heart: RR, S1 and S2 wnl
abdomen: distended, hypoactive b/s, soft, nt
extremities: 2+edema, non-tender
skin/nails: jaundiced
neuro: AAOx3. Cn II-XII intact.
rectal:deferred
Pertinent Results:
[**2158-3-1**] 02:25PM BLOOD WBC-22.8* RBC-3.08* Hgb-8.7* Hct-26.3*
MCV-85 MCH-28.3 MCHC-33.2 RDW-15.1 Plt Ct-64*
[**2158-3-1**] 09:46PM BLOOD WBC-25.0* RBC-3.48* Hgb-9.3* Hct-28.8*
MCV-83 MCH-26.7* MCHC-32.2 RDW-15.0 Plt Ct-62*
[**2158-3-2**] 06:18AM BLOOD WBC-26.6* RBC-3.70* Hgb-9.9* Hct-31.0*
MCV-84 MCH-26.8* MCHC-32.0 RDW-15.0 Plt Ct-71*
[**2158-3-3**] 04:14AM BLOOD WBC-15.8* RBC-3.14* Hgb-8.6* Hct-26.6*
MCV-85 MCH-27.5 MCHC-32.5 RDW-15.4 Plt Ct-57*
[**2158-3-1**] 02:25PM BLOOD PT-21.0* PTT-48.4* INR(PT)-2.0*
[**2158-3-1**] 09:46PM BLOOD PT-21.3* PTT-42.8* INR(PT)-2.1*
[**2158-3-2**] 06:18AM BLOOD PT-21.6* PTT-34.9 INR(PT)-2.1*
[**2158-3-2**] 05:47PM BLOOD PT-14.6* PTT-27.5 INR(PT)-1.3*
[**2158-3-3**] 04:14AM BLOOD PT-15.8* PTT-29.1 INR(PT)-1.4*
[**2158-3-1**] 02:25PM BLOOD Glucose-150* UreaN-20 Creat-0.9 Na-133
K-2.9* Cl-102 HCO3-16* AnGap-18
[**2158-3-1**] 09:46PM BLOOD Glucose-161* UreaN-25* Creat-0.9 Na-146*
K-3.4 Cl-113* HCO3-19* AnGap-17
[**2158-3-2**] 06:18AM BLOOD Glucose-130* UreaN-28* Creat-0.9 Na-131*
K->10.0 Cl-126* HCO3-17*
[**2158-3-2**] 09:32AM BLOOD Glucose-140* UreaN-31* Creat-1.0 Na-142
K-3.8 Cl-111* HCO3-17* AnGap-18
[**2158-3-2**] 05:34PM BLOOD Glucose-121* UreaN-33* Creat-1.0 Na-143
K-3.3 Cl-113* HCO3-18* AnGap-15
[**2158-3-3**] 04:14AM BLOOD Glucose-118* UreaN-33* Creat-0.9 Na-141
K-3.5 Cl-114* HCO3-19* AnGap-12
[**2158-3-1**] 02:25PM BLOOD ALT-67* AST-99* LD(LDH)-307* AlkPhos-242*
Amylase-114* TotBili-3.2* DirBili-2.8* IndBili-0.4
[**2158-3-1**] 09:46PM BLOOD ALT-96* AST-136* LD(LDH)-328*
AlkPhos-250* TotBili-3.5*
[**2158-3-2**] 06:18AM BLOOD ALT-89* AST-110* TotBili-2.4*
[**2158-3-1**] 09:46PM BLOOD Albumin-2.0* Calcium-7.2* Phos-3.4
Mg-1.1*
[**2158-3-2**] 06:18AM BLOOD Calcium-7.1* Phos-3.2 Mg-2.3
[**2158-3-2**] 09:32AM BLOOD Calcium-7.6* Phos-3.2 Mg-2.3
[**2158-3-2**] 05:34PM BLOOD Calcium-7.8* Phos-3.2 Mg-2.3
[**2158-3-3**] 04:14AM BLOOD Calcium-7.7* Phos-2.2* Mg-2.2
[**2158-3-1**] 09:46PM BLOOD Cortsol-40.8*
[**2158-3-1**] 10:36PM BLOOD Cortsol-58.9*
[**2158-3-1**] 11:40PM BLOOD Cortsol-75.1*
[**2158-3-1**] 05:25PM BLOOD Type-ART pO2-70* pCO2-29* pH-7.42
calHCO3-19* Base XS--3
[**2158-3-1**] CXR: 1. Right IJ terminates in the lower SVC. No
pneumothorax.
2. Small right pleural effusion and bibasilar atelectasis.
3. Multiple small nodular opacities in both lungs, suspicious
for metastasis. CT may be helpful for further evaluation.
.
[**2158-3-1**] CT abd/pelvis: 1. Extrahepatic biliary ductal dilation
measuring 9 mm in diameter. Pneumobilia.
2. Large pancreatic mass with hepatic, splenic, and likely
osseous metastases. Common bile duct and duodenal stent.
.
[**2158-3-1**] ERCP: Three spot fluoroscopic images were obtained
without a radiologist present. The initial scout image
demonstrates a plastic biliary stent overlying the right upper
quadrant as well as surgical clips at the level of the cystic
duct and gallbladder. A guide wire is seen within the duodenum.
The final image demonstrates an enteral Wallstent traversing the
duodenum with proximal end within the antrum.
.
[**2158-3-2**] PTBD: 1. Percutaneous cholangiogram demonstrated mildly
distended intrahepatic biliary ducts and severely distended
proximal common bile duct with a large filling defect occupying
most of the common bile duct and extending to the ampulla. The
in situ plastic stent previously placed by gastroenterology was
demonstrated within the filling defect in the common bile duct.
A plastic stent was partially obstructed.
2. 10 mm by 94 mm Wallstent was placed across the narrow common
bile duct extending from the bifurcation of the common bile duct
to the duodenum. Post deployment balloon dilatation of the stent
with mm balloon catheter was performed.
3. An external internal biliary drain was left in place
extending from the peripheral branch of the right intrahepatic
biliary duct into the duodenum. The biliary drain was capped for
internal drainage.
.
EKG: no acute changes
Brief Hospital Course:
# Pancreatic cancer: Ms. [**Known lastname 63057**] has extensive metastatic
pancreatic cancer ith gastric outlet obstruction, duodenal
obstruction and possible biliary obstruction. She is now s/p
stent placement by IR, with drain in place. It drained to her GI
tract. The IR team felt that at some point in the coming weeks,
her internal stents will become blocked from her disease so they
left the external drain in-place. It can remained plugged until
she develops itching or any signs that the stents are clogged.
She should have LFT's checked twice a week and if starting to
rise, her drain should be unplugged.
# Hypotension: This was likely secondary to cholangitis/sepsis:
with rising LFTs's, tbili, and she has a known biliary
obstruction from pancreatic cancer. Her blood cultures from the
OSH grew pan-sensitive E Coli. She was initially treated with
Zosyn, and admitted to the [**Hospital Unit Name 153**] after hypotension in the ERCP
suite. During that procedure, one stent was placed, but was not
sufficient to remove the obstruction. Overnight she was treated
with IV fluids for hypotension after a central line was placed.
She was also briefly on levophed to maintain a MAP > 55. THe
following day she had a second stent placement, by IR, and has
an external/internal drain in place, draining into the GI tract.
After the cultures returned as pan-sensitive E Coli, she was
switched from Zosyn to Levaquin, started [**2158-3-2**]. Surveillance
blood cultures were drawn [**3-1**], [**3-2**], and [**3-3**], and are all
NGTD. Her LFTs were followed, and are trending down. She will
complete a 14 day course of the levoquin. The day of discharge
([**2158-3-7**]) was day #[**6-16**].
# Afib: Intially during her stay Ms. [**Known lastname 63057**] was going in and out
of Afib. She has no known h/o Afib. However, her EKGs showed
irregular rhythm at times, and appeared to have P waves at times
as well. She cannot be anticoagulated given recent GIB. She was
started a low dose beta blocker for HR control
# Recent GI bleeding: Ms [**Known lastname 63057**] had recent GIB at OSH, which now
appears to be stabilized. We maintained a type and screen,
treated her with IV ppi, and followed Q12hr hct. She had a
hematocrit drop following her procedure fomr 31 to 27, but then
stabalized. She is being discharged with a hct of 33.
# Diabetes: She was on an insulin sliding scale.
# coaulopathy: secondary to sepsis vs. liver failure vs. dic.
DIC labs negative. Followed INR, gave FFP for her IR procedure.
# Code:DNR/DNI--had extensive discussions with [**Doctor First Name 553**] and [**Doctor First Name 2147**]
as well as sister [**Name (NI) **]. They serve as next of [**Doctor First Name **] and health
care proxies.
# Communication: [**Doctor First Name **] [**Telephone/Fax (1) 63058**] is sister, [**Name (NI) **].
Medications on Admission:
1. midodrine
2. lipitor
3. protonix
4. glyburide
5. reglan
6. potassium
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehabilitation & Nursing Center - [**Location (un) **]
Discharge Diagnosis:
Cholangitis
Sepsis
Discharge Condition:
Fair
Discharge Instructions:
--Please take all medications as prescribed. You need to finish
a course of antibiotices for the infection you had.
--Please return to the hospital for any increasing abdominal
pain, fevers, or chills.
--If the patient develops itching or has rising LFT's this would
likely indicate that the internal stents in her biliary tract
are blocked and her external drain should be unplugged.
Followup Instructions:
--Please see you primary care doctor (Dr. [**Last Name (STitle) 39408**] within the
next 2-4 weeks.
|
[
"038.42",
"427.31",
"576.2",
"197.8",
"250.00",
"576.1",
"198.5",
"995.91",
"157.8",
"197.7",
"537.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.98",
"87.54",
"99.07",
"46.85"
] |
icd9pcs
|
[
[
[]
]
] |
9566, 9663
|
6597, 9443
|
294, 335
|
9725, 9732
|
2626, 6574
|
10166, 10269
|
2094, 2112
|
9684, 9704
|
9469, 9543
|
9756, 10143
|
2127, 2607
|
220, 256
|
363, 1524
|
1546, 1979
|
1995, 2078
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,474
| 187,624
|
7627
|
Discharge summary
|
report
|
Admission Date: [**2103-7-12**] Discharge Date: [**2103-7-25**]
Date of Birth: [**2028-9-1**] Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
74 year old female with h/o restrictive lung disease due to
severe kyphosis (on 3L home O2 NC), chronic osteomyelitis, and A
fib s/p pacer who presents from rehab with worsening SOB. Ms.
[**Known lastname **] was recently d/c'd from [**Hospital1 18**] one day PTA at which time
she was treated for pneumonia with Levofloxacin for a LLL
pneumonia. In addition, she was seen by the pulmonary service
who concluded that part of her dyspnea was [**1-3**] extremely weak
respiratory muscles. At pulmonary's recommendation, she was
started on BiPAP for rest overnight. Her hospitalization was
also complicated by delerium which resolved prior to discharge.
She was sent to rehab on discharge.
.
On the day of admission at rehab, she noted the onset of SOB and
fatigue. She reports cough without sputum, but denies F/C, or
chest pain. She also complained of diffuse back and left side
pain. Per daughter's report, her O2 sat was in the 70's and SBP
in 60's, so she was sent to the ER for further evaluation.
.
In the ER, vitals were T = 100.2, HR = 115, BP = 68/37, RR = 31,
and O2 sat = 84% RA --> 100% NRB. CXR showed persistent LLL
opacity. WBC count was 16 and lactate 3.1. Sepsis protocol
initiated and right IJ placed. She was given total 4 L NS for
hypotension. Levophed was started for persistently low BP
despite IVF. She was transferred to the MICU for further
evaluation and management.
Past Medical History:
1. Severe restrictive lung disease due to osteoporotic kyphosis
on 3L O2 nasal cannula at home
2. Chronic osteomyelitis
3. Atrial fibrillation s/p pacemaker, (recently taken off
coumadin, BB, digoxin since last admission)
4. Osteoporosis
5. Anxiety
6. Chronic pain
7. Urinary frequency & incontinence
8. Macular degeneration
9. Depression on celexa and mertazapine
10. Hepatitis C from blood transfusion in [**2067**]
Social History:
Prior to recent discharge to rehab, Mrs. [**Known lastname **] was living at
home with her husband and daughter. She has minimal tobacco &
alcohol history.
Family History:
Mrs.[**Doctor Last Name 27811**] family history is noncontributory
Physical Exam:
T = 100.2, HR = 115, BP = 68/37, RR = 31, and O2 sat = 84% RA
--> 100% NRB
GEN: fragile, elderly, thin woman w/severe kyphosis; NAD
HEENT: MMM, anicteric, OP clear
NECK: supple, JVP not elevated, no LAD
CHEST: +severe kyphosis; +decreased BS at bases; otherwise CTA
bilat; no wheezes, rales, or rhonchi
CV: +irreg irreg; not tachy at time of exam; normal S1S2; no
murmurs appreciated
ABD: NABS; soft; no masses palpated; NT, ND
GU: +foley w/dark red/[**Location (un) 2452**] urine
EXT: 2+ peripheral LE edema; +deep ulcerated lesion on L tibial
area
Pertinent Results:
EKG: A fib @ 110; T wave flattening in V3-6; TWI I, L
Multiple Bld Cx c No growth
R IJ Catheter tip growing [**Female First Name (un) **] albicans
BAL no growth
[**2103-7-12**] 04:35AM URINE RBC-21-50* WBC-[**5-11**]* BACTERIA-MOD
YEAST-NONE EPI-<1
[**2103-7-12**] 03:58AM HGB-9.1* calcHCT-27 O2 SAT-81
[**2103-7-12**] 11:00PM PLT COUNT-97*
[**2103-7-12**] 11:00PM PT-26.2* PTT-69.1* INR(PT)-4.5
[**2103-7-12**] 11:00PM FDP-10-40
[**2103-7-12**] 11:00PM FIBRINOGE-208
[**2103-7-12**] 01:50PM CORTISOL-135.6*
[**2103-7-12**] 01:25PM CORTISOL-130.9*
[**2103-7-12**] 12:00PM CORTISOL-96.2*
[**2103-7-12**] 03:24AM LACTATE-3.1*
Brief Hospital Course:
1) Hypoxic Resp Failure likely [**1-3**] to sepsis/LLL pneumonia
initially and then later a iatrogenic PTX. Pt became tachypneic
c O2 sats in high 80s and required intubation. On the ventilator
maintained on AC for one week c multiple attempts made to
transition to lower tidal volumes and RR to allow increased CO2
to 40 to help reverse an existing respiratory alkalosis. Pt then
transitioned to PS, which she tolerated c several episodes of
tachypnea as well as [**Last Name (un) 6055**]-[**Doctor Last Name **] type breathing attributed to
CNS process. While on AC, pt's respiratory failure also
exacerbated by iatrogenic ptx induced during attempted placement
of a L IJ line by interventional pulmonology. This required
placement of a ptx drain to replace. However, the ptx drain
failed to correct the ptx and therefore a chest tube was placed.
The chest tube lead to the development of a significant amount
of subcutaneous air and had to be repositioned After
repositioning it continued to be unable to correct the ptx and
therefore it was replaced. Persistence of the ptx motivated a CT
to be ordered to determine if the pt had a restrictive process
that was limiting the ability of her lung to re-expand. CT
showed loculated ptx. Pt's continued ventilator reliance
discussed with family, and they elected for trial of extubation
despite poor prognosis. Following extubation pt expired several
hours later on [**2103-7-25**].
2. Sepsis: Pt hypotensive throughout stay. Initially, presumed
[**1-3**] pna that was inadequately treated c Levaquin on [**Hospital Ward Name 516**]
1 day prior to admission. However, pt afebrile, WBC trending
down, and LLL opacity appears slightly improved on CXR. HypoT
improved c MAPs largely >65 and sBPs>100 on only vasopressin and
fluid boluses. Source of sepsis still unknown. PNA most likely
given pt treated for this PTA. Alternative source also being
considered such as osteomyelitis (although being covered
chronically c rifampin and doxy), pacemaker, or abscess.
However, pt never hemodynamically stable enough to allow for
extensive imaging work-up. Pt's IJ from the ER was resited to
ensure it was not the source. This line became dislodged and a L
SCV was placed with IR guidance. Cultures of urine, stool, blood
and from BAL revealed no obvious source. Pt initially treated
with ceftriaxone/vancomycin and later switched to
meropenem/vacno to allow for incd pseudomonal and ESBL coverage
given pt worsened in hospital x 2 weeks. Pt received a full 14
day course of vanc and 10d course of meropenem. She was covered
for possible osteomyelitis with doxycycline and rifampin. A BAL
was perofmed.
3. Hypotension: Presumed [**1-3**] sepsis although pt's extremities
cool and clammy. Initially required multiple fluid boluses and
levophed and vasopressin to maintain MAPs>65. Unlikely
cardiogenic given normal EF and good MvO2. Partially [**1-3**] pt's
low baseline BP of 90/50s. Pt's BP improved c MAP>65 able to
wean off levophed and just give standing boluses. CVPs in teens.
Pt coninuted to third space a significant amount of fluid and
weeped serous fluid from her skin. Despite this pt continue to
be given bolues to maintain her MAPs, b/c merely increasing
pressors did not benefit her s sufficient IV volume. She was
temporarily given neosynephrine but this was also weaned when
her MAPs remained elevated s it. Multiple times her pressors
were weaned only to be restarted for persistent hypotension.
4. [**Name (NI) 27812**] Pt tachyc to 120s intermitently. Likely [**1-3**] pt
discomfort as weaning down sedation for vent weaning. Afib
better controlled on digoxin maintenance dose. Tachycardia
resolved with increased sedation.
5. Anemia- baseline Hct in mid-30's, over past 3 days steadily
dropped from 38 (after 2U for low Hct of 25) to 39.8. Possible
GI bleed but stools Guiac negative. Alternatively, Hct drop may
have partially been a result of hemodilution as pt has received
large amount of IVF. This is less likely given that all IVF have
been third spaced. Hct drop may also be [**1-3**] iatrogenic puncture
of carotid during L SCV placement two days ago. Bilirubin
elevated suggesting hemolysis but primarily direct
hyperbilirubinemia. Difficult to interpret other hemolysis labs
in setting of transfusions. Heme onc consulted and unable to
determine etiology of anemia and thrombocytopenia. Pt had to
receive another 2U of blood and FFP on [**2103-7-16**].
6. Thrombocytopenia- Platelets increased to 180s, up from 30s.
Seen by Heme/Onc and believed to be due to pt's Hep C. However,
this does not explain pt's acute drop in platelets, which is
most likely [**1-3**] infection or HIT. HIT less likely given HIT Ab-
x2. Now s/p 2U FFP on [**2103-7-15**]. Pt's HIT Ab negative x 2,
anti-platelet Ab negative.
.
.
7. Lymphocytes in pleural fluid- no evid of lymphoma on
electrophoresis. [**Name (NI) **] unclear of this significance of this
finding..
.
8) A FIB: prior to last hospitalization, patient was on Digoxin,
atenolol, and coumadin; however, these were not continued.
Currently tachycardic in Afib. Not likely [**1-3**] volume depletion
as elevated CVPs and MvO2 in 70s. Therefore was restarted on
digoxin c loading and then maintenance dose. Her anticoagulation
was held [**1-3**] her unstable Hct.
.
9) OSTEOMYELITIS: appeared stable, pt contd on doxy/rifampin
throughout her stay.
.
10) Cyanotic Extremities- Likely due to hypoperfusion [**1-3**] low
volume status, poor perfusion of RUE from RIJ and possible
thrombosis. US of RUE showed no occlusive clots. Edema may have
caused hypoperfusion although distal pulses present. [**Month (only) 116**] also
have been [**1-3**] heme deposition in tissues.
.
11) ACUTE ON CRI: patient had normal renal function in [**Month (only) 958**]
[**2102**]. since then progressively worse, with new baseline
1.2-1.3. In ICU Cr fell with incd perfusion c aggressive IVF
.
12) DEPRESSION: Pt contd on Celexa and Remeron.
.
Medications on Admission:
Rifampin
doxycycline
Coumadin
Digoxin
Atenolol
Discharge Medications:
Pt expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory Failure
Sepsis
Anemia
Thrombocytopenia
Discharge Condition:
Pt expired
Discharge Instructions:
Pt expired
Followup Instructions:
Pt expired
|
[
"486",
"733.00",
"427.31",
"518.89",
"518.84",
"599.0",
"V45.01",
"730.16",
"038.9",
"512.1",
"584.9",
"284.8",
"707.03",
"737.41",
"995.92",
"V58.61",
"070.70"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"00.17",
"38.93",
"99.04",
"33.24",
"96.04",
"96.6",
"93.90",
"34.04",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
9750, 9759
|
3675, 9618
|
286, 291
|
9854, 9866
|
3008, 3652
|
9925, 9938
|
2354, 2422
|
9715, 9727
|
9780, 9833
|
9644, 9692
|
9890, 9902
|
2437, 2989
|
227, 248
|
319, 1724
|
1746, 2165
|
2181, 2338
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,171
| 179,338
|
22728
|
Discharge summary
|
report
|
Admission Date: [**2155-7-10**] Discharge Date: [**2155-7-16**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Falls
Major Surgical or Invasive Procedure:
PPM placement [**7-11**]
History of Present Illness:
89 YO M with recent ETOH abuse, HTN, likely vascular dementia
and episodes of arm and leg shaking with decreased
responsiveness over the past 1.5 years presenting after several
similar episodes within the past several days. Per his family,
he had 3 episodes on [**7-5**] and 6th and 1-2 episodes of the
7th. He has had no episodes since that time. The patient's
daughter and wife describe his past episodes as: eyes are
dilated, he flails his arms out and he taps either foot, he is
intermittently responsive throughout the episode. At other times
he will cling to his chair, with his eyes dilated, and when his
wife or daughter asks him what the matter is, he says "nothing."
His family also notes that he is getting increasingly confused,
falling about 3 times within the past month (without fractures).
He denies any symptoms during the episodes and actually does not
remember them at all. He does endorse one fall.
.
Upon presentation to the ED, his VS were initially notable for
bradycardia to the 50s which dropped down to 30s with a stable
BP and without symptoms. His labs were notable for hyponatremia
to 129 and a negative trop. Multiple EKGs reportedly looked like
AFLUT with variable slow conduction. EP and cards were called
due to c/f complete HB. Per the ED resident's report, EP and
cards did not think the EKGs were c/f CHB. Exam was otherwise
notable for confusion, orientation times [**2-1**] which his family
reported was at his baseline. His neuro exam was reportedly
non-focal. Given his mental status and episodes of syncope,
neurology was also called and felt these episodes were unlikely
to be seizures. A CT head was done and showed small vessel
disease which neurology felt was c/w with his poor mental
status. Since the patient is on atenolol at home, he was given
Ca gluconate although without effect. He was also given aspirin.
Atropine was pulled but not given. Per report, his Bps remained
stable. Vs prior to tx : 97.3 50 152/82 16 100% on 2L.
.
Upon arrival to the floor, he reports feeling well. He states
that he stopped drinking 5-6 months ago because his wife stopped
buying alcohol and not because he wasn't feeling well. He
reports feeling himself and has no complaints.
.
Review of sytems:
Unable to reliably provide but specifically denies chest pain,
shortness of breath, palpitations.
Past Medical History:
Severe arthritis particularly involving his feet. He has had
bilateral bunionectomies, has hammertoes, has had a total knee
replacement on his right and he had a previous hip fracture.
HTN
Alcohol dependence
BPH with urinary obstructive symptoms
Elevated PSA
Hearing loss
Falls largely associated with alcohol use
Dementia
Chronic constipation
snores at night ?OSA(not formally diagnosed)
b/l cataract surgeries
Social History:
Both [**Doctor Last Name **] (patient's wife) and the patient are originally
from [**Country 4754**]. They have 4 adult children. He is a non-smoker. He
has drunk 7 beers and several shots of whisky all of his adult
life, apart from the past 10 days. He worked as a custodian in a
school. He does not use recreational drugs
Family History:
Not known, his mother lived until she was aged 106, and the
patient's wife stated that she had her "marbles" until she died.
Physical Exam:
Vitals: 97.7 165/79 60 20 100RA
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
Neuro: alert and oriented to self, hospital, and year. poor
memory.
On discharge:
Pacemaker in place, slightly bruised and tender, but no
drainage, edema.
Pertinent Results:
[**2155-7-10**] 09:30AM BLOOD WBC-8.6 RBC-4.79 Hgb-14.5 Hct-42.1 MCV-88
MCH-30.2 MCHC-34.4 RDW-13.1 Plt Ct-373
[**2155-7-10**] 09:30AM BLOOD Neuts-65.4 Lymphs-23.5 Monos-5.4 Eos-5.3*
Baso-0.5
[**2155-7-10**] 09:30AM BLOOD PT-12.3 PTT-24.8 INR(PT)-1.0
[**2155-7-10**] 09:30AM BLOOD Glucose-107* UreaN-9 Creat-0.9 Na-129*
K-4.0 Cl-93* HCO3-30 AnGap-10
[**2155-7-10**] 09:30AM BLOOD ALT-13 AST-20 AlkPhos-68 TotBili-0.5
[**2155-7-10**] 09:30AM BLOOD cTropnT-<0.01
[**2155-7-10**] 09:30AM BLOOD Albumin-3.9 Calcium-8.4 Phos-3.5 Mg-2.1
[**2155-7-10**] 09:30AM BLOOD VitB12-466 Folate-9.1
[**2155-7-11**] 03:12AM BLOOD Osmolal-265*
[**2155-7-10**] 05:58PM BLOOD Ammonia-30
[**2155-7-10**] 09:30AM BLOOD TSH-1.9
[**2155-7-14**] 06:25AM BLOOD CRP-30.5*
[**2155-7-14**] 06:25AM BLOOD Vanco-20.3*
[**2155-7-16**] 06:20AM BLOOD WBC-7.4 RBC-3.63* Hgb-11.2* Hct-32.4*
MCV-89 MCH-30.8 MCHC-34.5 RDW-13.8 Plt Ct-308
[**2155-7-16**] 06:20AM BLOOD Glucose-157* UreaN-14 Creat-1.1 Na-133
K-4.3 Cl-95* HCO3-26 AnGap-16
[**2155-7-16**] 06:20AM BLOOD Calcium-7.9* Phos-4.2 Mg-2.1
CT head:
1. No acute intracranial hemorrhage.
2. Small vessel ischemic disease and bilateral basal ganglia
lacunes.
3. Ethmoid sinus disease and fluid in the bilateral mastoid air
cells, with
extension of fluid in the left middle ear cavity. Findings may
represent an
ongoing inflammatory process, but clinical correlation is
recommended.
4. Gas in the cavernous sinus and the subcutaneous tissues,
likely venous and
secondary to injection/IV placement.
5. Enlarged ventricles disproportionate to the degree of sulcal
atrophy,
possibly due to central atrophy, but NPH is not excluded.
CXR: Trace right pleural effusion.
CXR: Pacemaker tip in right ventricle
TEE attempted and unsuccessful.
Panorex - read pending
Brief Hospital Course:
89 year old man with a history of high alcohol intake until 10
days prior, HTN, and several months of episodes of altered
mental status and falls now presenting s/p fall with
bradycardia and pauses.
# Bradycardia with history of atrial fibrillation and 5 second
pauses. Patient was thought to be asymptomatic, but on
observation in the ICU he was more confused during these
episodes. EP was consulted and pacemaker was placed on [**2155-7-11**].
He was also started on ASA 325mg of atrial fibrillation.
Coumadin was not started due to recent falls and ETOH abuse.
Several hours after pacemaker was placed blood cultures drawn on
admission returned positive. Blood cultures were obtained to
complete workup for altered mental status though infection was
not the leading diagnosis. Pt was started on vancomycin on
[**2155-7-11**] after cultures returned positive. ID team was consulted
who recommended TEE to rule out endocarditis. TEE was attempted
but unsuccessful. He had a panorex on [**7-16**] and was evaluated by
dentistry who did not feel he had an acute infection. At time
of discharge plan was to continue nafcillin for 4 weeks, and 2
weeks of levoquin and rifampin orally. Midline should be pulled
upon completion of nafcillin course. Weekly
CBC/diff/electrolytes and LFTs should be checked and faxed to [**Hospital **]
clinic. Pt has follow up with device clinic and [**Hospital **] clinic as
noted below.
.
# Altered mental status. Likely [**3-4**] vascular dementia with
possible contribution of hyponatremia and alcohol dependence. At
risk for Wernicke's. He was given thiamine, MVI, folic acid. He
did not score on CIWA during hospital stay. Blood cultures drawn
to complete infectious workup and after 48 hrs grew three
bottles of coag negative staphylococcus. Neurology consulted
and B12, folate, and TSH, along with cardiac enzymes, CBC, chem
7, LFTs, ammonia returned within normal limits.
#During his hospitalization pt was noted to have poor dentition.
He will require follow up with the [**Hospital 9786**] clinic at rehab for
complete exam, cleaning and plan to extract mobile teeth which
include 1,16, 32, and fractured 9.
# Hyponatremia. Urine lytes suggested SIADH possibly secondary
to multiple strokes, history of ETOH abuse, or reset osmostat.
Sodium corrected with fluid restriction. Pt should maintain on
a 1500cc fluid restriction.
# Shaking episodes at home. The etiology of this remains
unclear. It may be related to pauses or episodes of profound
bradycardia vs seizures. neuro did not feel EEG would be high
yield. After pacer was placed, he had no further episodes during
his hospitalization.
# Falls. [**Month (only) 116**] be related to posterior column demyelinization vs
ETOH abuse vs bradycardia. Pt was evaluated by PT who felt he
was incredibly unsteady on his feet and would not be able to use
a walker without placing excess weight on his left arm
(pacemaker site). He was discharged to rehab.
# Code: Full (discussed with wife)
Rehab to do:
[ ] Continue antibiotics as directed
[ ] Pull midline upon completion of Nafcillin course
[ ] f/u with device clinic and ID
[ ] daily physical therapy
[ ] evaluation by [**Hospital 9786**] clinic for tooth extraction once stable
[ ] 1500 cc fluid restriction
Medications on Admission:
Ketoconazole 2 % Topical Cream use at least once a day between
buttocks once a day
Atenolol 50 mg Tab 1 Tablet(s) by mouth once a day
Colace 100 mg Cap 2 Capsule(s) by mouth once a day
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day): for constipation
.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
to prevent stroke caused by irregular heart rate.
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily):
(vitamin).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
(vitamin).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for pain.
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) grams
Intravenous Q6H (every 6 hours): day 1= [**7-11**], last day [**8-9**].
4 week course.
9. Rifampin 300 mg Capsule Sig: Two (2) Capsule PO Q24H (every
24 hours): First day [**8-10**]. Last day is [**8-24**]. Two [**Doctor Last Name **]
course following completion of 4 week course of nafcillin. .
10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours): First day [**8-10**]. Last day is [**8-24**]. Two
[**Doctor Last Name **] course following completion of 4 week course of nafcillin. .
11. Outpatient Lab Work
Please draw weekly CBC with differential, Basic Metabolic Panel
including BUN and Cr, and liver function tests. Please fax to
[**Telephone/Fax (1) 1419**] to the Infectious disease nurses.
All questions regarding outpatient antibiotics should be
directed to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**] or to
on [**Name8 (MD) 138**] MD in when clinic is closed.
12. Pull midline
Please pull midline upon completion of Nafcillin course.
13. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
primary:
symptomatic bradycardia
coagulase negative staph infection
hypertension
atrial fibrillation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. [**Known lastname 5395**] - you were admitted for recent falls. You were
found to have a very slow heart rate requiring a pacemaker.
Pacemaker was placed. It was later discovered that you have had
a blood stream infection that requires aggressive treatment. We
tried to figure out where the infection came from but this was
unclear.
.
Also during your hospitalization a dentist evaluated your teeth.
You should be evaluated at [**Hospital 100**] Rehab by the dentist and
likely will need extraction of several teeth.
.
You have a number of new medications. Please stop taking
Atenolol. A number of medications were started. Please see
attached list.
Followup Instructions:
Please make the following appointment:
Department: CARDIAC SERVICES
When: FRIDAY [**2155-7-18**] at 10:30 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
Department: INFECTIOUS DISEASE
When: TUESDAY [**2155-8-5**] at 10:50 AM [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
You may follow up with Dr. [**Last Name (STitle) 11616**] when you finish your rehab
stay.
Completed by:[**2155-7-17**]
|
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icd9cm
|
[
[
[]
]
] |
[
"37.82",
"37.71"
] |
icd9pcs
|
[
[
[]
]
] |
11339, 11405
|
6074, 9347
|
267, 293
|
11550, 11550
|
4271, 5332
|
12420, 13066
|
3448, 3576
|
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|
11426, 11529
|
9373, 9560
|
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|
3591, 4164
|
4178, 4252
|
222, 229
|
2552, 2652
|
321, 2534
|
5341, 6051
|
11565, 11711
|
2674, 3088
|
3104, 3432
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,041
| 177,677
|
12884
|
Discharge summary
|
report
|
Admission Date: [**2101-11-1**] Discharge Date: [**2101-11-8**]
Date of Birth: [**2022-7-3**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 79-year-old gentleman
with known aortic stenosis who has a four-month history of
worsening lightheadedness, fatigue and shortness of breath.
Echocardiogram showed aortic valve area of 1.1 cm squared
with a transvalvular gradient of 29 mm mercury, ejection
fraction of 77 percent. Cardiac catheterization showed a
left ventricular and diastolic pressure of 19, a capillary
wedge pressure of 15, 30 percent proximal LAD stenosis and 50
percent osteal PDA stenosis. The patient was referred to Dr.
[**First Name (STitle) **] [**Last Name (Prefixes) **] for aortic valve replacement.
PAST MEDICAL HISTORY:
1. Status post retinal hemorrhage of the left eye [**2100**].
2. Status post transient ischemic attack of the left eye
[**2099**].
3. Rheumatic heart disease.
4. Status post bilateral knee replacement.
5. Status post appendectomy.
6. Status post bilateral cataract surgery.
7. Hypercholesterolemia.
8. Hard of hearing.
PREOPERATIVE MEDICATIONS:
1. Allopurinol 300 mg once a day.
2. Welchol 625 mg tablets, 3 tablets twice a day.
3. Aspirin 325 mg p.o. once a day.
ALLERGIES: No known drug allergies.
PREOPERATIVE PHYSICAL EXAMINATION: Significant for pupils
that were unequal with his right pupil greater than his left.
HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] on [**2101-11-1**] for aortic valve
replacement with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **], with a 23 mm
pericardial aortic valve. The patient tolerated the
procedure well and was transferred to the Intensive Care Unit
in stable condition on Neo-Synephrine and amiodarone infusion
which was started in the Operating Room for irritable rhythm
post bypass. The patient was weaned and extubated from
mechanical ventilation on his first postoperative evening.
The patient's chest tubes were removed on postoperative day
no. 1. He was transferred from the Intensive Care Unit to
the regular part of the hospital. He was started on Lasix
and low dose Lopressor. His pacing wires were removed
without incident. He began working with physical therapy.
The evening of postoperative day no. 2, the patient developed
atrial fibrillation. He was rebolused with amiodarone. On
postoperative day no. 3, the patient was started on heparin
infusion for anticoagulation as well as Coumadin therapy. On
postoperative day no. 3, the patient was noted to have an
elevated creatinine. Lasix was held and the creatinine
drifted back down to approximately 1.4 and 1.5 by
postoperative day no. 6. The patient's allopurinol was also
discontinued. By postoperative no. 7, his creatinine
stabilized and was restarted on Lasix. The patient continued
to be anticoagulated reaching an INR of 2.0. The patient
converted to sinus rhythm on the evening of postoperative day
no. 6 and he was able to ambulate 500 feet and climb one
flight of stairs without requiring oxygen and remaining
hemodynamically stable. By postoperative day no. 7 he was
cleared for discharge to home.
CONDITION ON DISCHARGE: TMAX 98.9 degrees, pulse 59 and
sinus rhythm, blood pressure 123/58, respiratory rate 16,
room air oxygen saturation 98 percent. Neurologically, he is
awake, alert, oriented times three. Heart: Regular rate and
rhythm without rub or murmur. Respiratory: Breath sounds
are clear bilaterally. Abdomen soft, nontender and
nondistended. Positive bowel sounds, tolerating a regular
diet. The sternal incision is clean, dry and intact. The
sternum is stable. There is no erythema or drainage.
LABORATORY DATA: White blood cell count 10.8, hematocrit
28.6, platelet count 255, sodium 136, potassium 4.6, chloride
102, bicarbonate 26, BUN 28, creatinine 1.6, glucose 101.
DISCHARGE DIAGNOSIS:
1. Aortic stenosis.
2. Aortic valve replacement.
3. Postoperative atrial fibrillation.
4. Postoperative elevated creatinine.
DISPOSITION: To be discharged to home in stable condition.
DISCHARGE MEDICATIONS:
1. Colace 100 mg p.o. twice a day.
2. Zantac 150 mg p.o. twice a day.
3. Tylenol with codeine 1-2 tablets p.o. q.4h. p.r.n.
4. Lopressor 25 mg p.o. twice a day.
5. Amiodarone 200 mg p.o. once a day.
6. Aspirin 81 mg p.o. once a day.
7. Coumadin. The patient is to take 2 1/2 mg on [**11-8**]
and [**11-9**], and he is to have a PT and INR checked and
the results called to Dr.[**Name (NI) 39613**] office and further
Coumadin dosing and INR checks per Dr.[**Name (NI) 39613**] office.
8. Lasix 20 mg p.o. once a day times 7 days.
9. Welchol 625 mg tablets, 3 tablets p.o. twice a day.
The patient is to follow-up with his primary care physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 656**], in one to two weeks, and to follow-up with Dr.[**Name (NI) 39614**] office by phone on Thursday, [**2101-11-10**] for
INR results and Coumadin dosing, and to follow-up with Dr.
[**Last Name (STitle) 1295**] in the office in one to two weeks and he is to
follow-up with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] in three to four weeks.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern4) 8524**]
MEDQUIST36
D: [**2101-11-9**] 18:26:10
T: [**2101-11-9**] 22:33:34
Job#: [**Job Number **]
|
[
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"V43.65",
"395.0",
"794.4",
"274.9",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.61",
"89.64",
"38.93",
"35.21",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
4092, 5424
|
3881, 4069
|
1429, 3158
|
1129, 1302
|
1325, 1411
|
164, 757
|
779, 1103
|
3183, 3860
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,744
| 185,141
|
41067
|
Discharge summary
|
report
|
Admission Date: [**2120-1-24**] Discharge Date: [**2120-1-30**]
Date of Birth: [**2067-9-5**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
cardiac arrest
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
52 yo M with reported hx of Cardiomyopathy (EF 35%, etiology
unspecified), morbid obesity, HTN, HLD, and Sleep Apnea who
presents after cardiac arrest in the community. The patient was
found down by a snow plower who had seen the patient brushing
the snow off his car 10 minutes earlier. EMS was called and
arrived approximately 15 minutes later. No compressions were
started at that time. Patient was found to be in Ventricular
Fibrillation. Compressions were started, and the patient was
intubated. He was shocked three times and given Epinephrine 1mg
x 3, Atropine x 3, and Lidocaine 100 mg once with return of
sinus tachycardia. He was taken to [**Hospital3 1443**] where he
was found to be in a wide complex tachycardia at 120, BP 80/50,
agonal, and was placed on a lidocaine drip. A right femoral line
was placed. He was transferred to [**Hospital1 18**] for cardiac evaluation.
.
At [**Hospital1 18**] initial vitals revealed HR 113, BP 116/ 51, Intubated.
Patient was taken to the cath lab where he was found to have
normal coronary arteries.
.
In the CCU, the patient was intubated, sedated. Initial vitals:
113, 133/80, Sat 100% on CMV 500, 26, 5. Artic Sun cooling
protocol for neuroprotection was initiated. It was difficult to
get the patient cooled, which was concerning for an underlying
infection.
.
Unable to perform review of systems
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. OTHER PAST MEDICAL HISTORY:
Diabetes
Obstructive Sleep Apena
Atrial Fibrillation
Depression
Back Pain
Gout
Obesity
Hyperlipidemia
Cardiomyopathy NOS
HTN
Social History:
On [**Social Security Number 89547**]Social Security Disability. Lives in subsidized housing.
Smoker, Social Drinker. (from records)
Family History:
Family history is sgnificant for cardiovascular disease. (from
records)
Physical Exam:
Admission PHYSICAL EXAMINATION:
VS: BP= 130/80 HR=108 RR=26 O2 sat= 100% - Fi02 100%
GENERAL: intubated, paralyzed, morbidly obese man
HEENT: NC, sclera anicteric, pupils dilated, not reactive
NECK: unable to appreciated JVP given body habitus
CARDIAC: difficult to auscultate over lung sounds
LUNGS: diffuse coarse rhochorous inspirations
ABDOMEN: enlarged, + BS over lower abdomen, + cooling pads in
place
EXTREMITIES: no edema, +SCDs, DP & PT pulses 1+ bilaterally
.
NEURO ExAM [**2120-1-29**]
VS: T: 98.2 P: 100 BP: 113/67 RR: 22 SaO2: 99% intubated
General: Lying in bed, not arousible to voice or noxious stimuli
MS: No arousal to voice or noxious stimuli. Not following
commands.
CN: Pupils 4->2mm bilaterally. Slight skew deviation, with
right
eye elevated a few mm compared to the left. Small lateral
movements noted with oculocephalics. Negative corneals,
negative
gag.
Motor/Sensory: Very slight extensor movements noted in bilateral
upper extremities in response to pinch bilaterally. No response
to painful stimuli in bilateral lower extremities.
Reflexes: 2+ and symmetric throughout
Pertinent Results:
PERTINENT LABS:
[**2120-1-24**] 06:00PM BLOOD WBC-16.0* RBC-4.21* Hgb-14.1 Hct-39.3*
MCV-93 MCH-33.5* MCHC-36.0* RDW-14.4 Plt Ct-301
[**2120-1-24**] 06:00PM BLOOD Neuts-88.9* Lymphs-5.7* Monos-4.6 Eos-0.5
Baso-0.3
[**2120-1-24**] 06:00PM BLOOD PT-23.4* PTT-25.8 INR(PT)-2.2*
[**2120-1-25**] 02:03AM BLOOD Fibrino-648*
[**2120-1-24**] 06:00PM BLOOD Glucose-216* UreaN-20 Creat-1.3* Na-134
K-4.8 Cl-103 HCO3-15* AnGap-21*
[**2120-1-24**] 10:34PM BLOOD ALT-109* AST-130* CK(CPK)-655* AlkPhos-78
TotBili-0.5
[**2120-1-24**] 10:34PM BLOOD CK-MB-26* MB Indx-4.0 cTropnT-0.57*
[**2120-1-24**] 06:00PM BLOOD CK-MB-15* MB Indx-3.8 cTropnT-0.33*
[**2120-1-30**] 04:41AM BLOOD Lipase-27 GGT-58
[**2120-1-24**] 10:34PM BLOOD Calcium-8.2* Phos-5.1* Mg-1.8
[**2120-1-28**] 05:07AM BLOOD calTIBC-204* Hapto-224* Ferritn-1250*
TRF-157*
[**2120-1-25**] 06:07PM BLOOD D-Dimer-3857*
[**2120-1-24**] 06:00PM BLOOD %HbA1c-6.1* eAG-128*
[**2120-1-24**] 06:00PM BLOOD Type-ART O2 Flow-15 pO2-465* pCO2-35
pH-7.31* calTCO2-18* Base XS--7 -ASSIST/CON Intubat-NOT INTUBA
Comment-INTUBATED
[**2120-1-24**] 06:00PM BLOOD Glucose-210* Lactate-2.8* K-4.7
[**2120-1-27**] 08:56PM BLOOD Lactate-3.5*
.
.
STUDIES:
CARDIAC CATH [**2120-1-24**]:
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
no angiographically apparent obstructive coronary disease. The
LMCA,
LAD, Lcx and RCA all had no angiographically apparent disease.
2. Limited hemodynamics revealed normal filling pressure with
LVEDP of
8mmHg. There was normotension of 116/63 mmHg. There was no
transaortic
valve gradient on careful pullback from LV to aorta.
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Normal diastolic function.
3. Systemic normotension.
.
TTE [**2120-1-25**]:
Conclusions
The right atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Overall left ventricular systolic function is normal
(LVEF 65%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. The mitral valve leaflets are elongated.
Mitral valve prolapse cannot be excluded. An eccentric,
posteriorly directed jet of Moderate (2+) mitral regurgitation
is seen. There is no pericardial effusion.
.
Chest Xray [**2120-1-24**]
IMPRESSION: Moderate cardiomegaly without evidence of pulmonary
edema,
adequate placement of the endotracheal tube.
.
Chest Xray [**2120-1-30**]
FINDINGS: In comparison with the study of [**1-29**], monitoring and
support devices remain in place. There is again substantial
enlargement of the cardiac silhouette with evidence of increased
pulmonary venous pressure. Retrocardiac and left lower lung
opacification suggests volume loss and possible pleural
effusion.
.
Liver Ultrasound [**2120-1-30**]
1. Equivocally increased liver echogenicity, which may be
technical, though alternatively may suggest a mild degree of
fatty infiltration.
2. Likely segment III hemangioma.
3. No biliary duct dilation. Patent hepatic vasculature.
4. Sludge is seen within the gallbladder.
.
MICRO:
URINE CX [**2120-1-25**]: NO GROWTH
.
BLOOD CX [**2120-1-25**]: PENDING
BLOOD CX [**2120-1-26**]: PENDING
.
[**2120-1-27**] 1:50 pm SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2120-1-27**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Preliminary):
Further incubation required to determine the presence or
absence of
commensal respiratory flora.
STAPH AUREUS COAG +. MODERATE GROWTH.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
FUNGAL CULTURE (Preliminary):
.
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
.
.
URINE CULTURE (Final [**2120-1-29**]):
PROBABLE ENTEROCOCCUS. ~6OOO/ML.
.
Brief Hospital Course:
HOSPITAL COURSE
52 yo M with reported hx of cardiomyopathy s/p Ventricular
Fibrillation cardiac arrest in the community, transferred to our
facility, found to have no hemodynamically significant coronary
disease, preserved ejection fraction, who underwent cooling
protocol for neuroprotection. Neurological evaluation revealed
only minimal neurogical brainstem function. Family member
decided to withdraw life sustaining measures and pursue comfort
measures as goals of care. Organ Donation was contact[**Name (NI) **] and
arrangements were made for organ donation. The case was
accepted by the Medical Examiner.
.
ACTIVE ISSUES
# Ventricular Fibrillation Cardiac Arrest: Unclear etiology.
Occurred in the community setting, and patient was resuscitated
by EMS (estimated time to perfusion 20-25 minutes). He was
intubated in the field and initially brought to [**Hospital3 19345**], then transferred to [**Hospital1 18**] where he immediately went
for cardiac catheterization, which revealed no significant
coronary artery disease. He was admitted to the Cardiac
Intensive Care Unit and started on the Artic Sun Therapuetic
Cooling Protocol for neuroprotection (detailed below). He was
monitored on telemetry and remained in sinus rhythm. An
echocardiogram obtained the day after admission revealed mild
left ventricular hypertrophy and preserved ejection fraction.
The etiology behind his ventricular fibrillation remained
unclear.
.
# Therapuetic Cooling for Neuroprotection after Cardiac Arrest:
The interval between arrest and initiation of cooling was 5
hours. However, the patient was difficult to cool to optimal
temperature of 33 degrees, which was concerning for underlying
infection. During his cardiac catheterization he showed no signs
of meaningful interaction. He was sedated and paralyzed. His
labs were closely monitored for the expected hypokalemia and
hyperglycemia during cooling and hyperkalemia and hypoglycemia
during rewarming. He was started on insulin sliding scale for
tight glucose control. He received continuous video EEG, which
revealed seizure activity consistent with status epilepticus.
Neurology was consulted and provided recommendations regarding
anti-epileptic agents and dosing. He was started on three
different antiepileptics (phenytoin, valproic acid, and
levetiracetam) in attempt to control his seizure activity. Once
warmed, he did demonstrate preserved brainstem function
evidenced by preserved respiratory drive and pupillary reaction.
Off of sedation he remained non-responsive to stimuli.
Neurological evaluation revealed exam notable only for reactive
pupils, intact reflexes, and very slight extensor posturing of
his upper extremities in response to painful stimuli. While the
patient was still exhibiting some signs of brainstem activity,
these were all poor prognostic signs for a meaningful recovery.
Given his poor prognosis, his only living family member and
health care proxy decided to withdraw life sustaining care and
focus on comfort measures.
.
# Hypoxic Respiratory Failure: The patient was initially
intubated by EMS secondary to his neurological insult after
cardiac arrest. He was started on Fentanyl and Midazolam for
sedation. We monitored his arterial blood gases and attempted to
wean his FiO2 to prevent free radial formation; however, the
patient began to demonstrate decreased PaO2 requiring higher
PEEP and FiO2 to remain adequate. This was most likely secondary
to a Ventilator Associated Pneumonia, as his PaO2 improved with
aggressive suctioning of thick green secretions that grew
methicillin-resistant staph aureus in culture. He was initially
started on broad antibiotics, which were tapered to Vancomycin
(cefepime and flagyl discontinued) once the speciation data
returned.
.
# Hypotension: The patient had a brief period of hypotension
requiring transient use of pressure support with norepinephrine.
This was likely secondary to hypovolemia, and improved with
fluid boluses.
.
# Coagulopathy: The patient was on coumadin for atrial
fibrillation as an outpatient. He presented with a
supratherapuetic INR, which increased during the cooling
process, but then trended down with vitamin K. Labwork was
negative for DIC. He showed no evidence of active bleeding.
.
# Acute Kidney Injury: Likely pre-renal in etiology as improved
with IV hydration. Enterococcus grew in urine ~6000 units.
Vancomycin for positive sputum culture continued.
.
# Reported History of Cardiomyopathy: The patient presented with
a history of cardiomyopathy, and on an outpatient regimen of
digoxin, toprol, lisinopril, aldactone, aspirin, and lasix. He
was found to have clean coronaries during cardiac
catheterization and preserved ejection fraction without
significant valvular abnormalities on echocardiogram. His
outpatient medications were held during this admission.
.
# Atrial fibrillation: He remained in sinus rhythm. We held his
anticoagulation and rate control agents.
.
# HTN: We held his antihypertensives which were started HD 5
after warming as patient became hypertensive.
.
# HLD: We held his statin.
.
# Goals of Care: After discussion with his Health Care Proxy
(his only living relative, his sister [**Doctor First Name **] it was decided
that goals of care would be switched from providing life
sustaining care to pursuing aggressive comfort measures. His
code status was changed to Do Not Resucitate/Do Not Intubate.
The patient was evaluated for organ donation following the
Health Care Proxy's wishes. He was terminally extubated in the
operating room. The case was accepted by the Medical Examiner.
Medications on Admission:
Furosemide 40 mg q am
Lisinopril 40mg Daily
Digitek 0.25mg Daily
Allopurinol [**Age over 90 **]m g Daily
Vicodin 5-500 mg Tabs 1-2 tabs po BID prn severe pain
Econazole Nitrate 1% twice daily
Colchicine 0.6mg one tab PO BIC x 5-7 days prn gout flare
Medrol dose pak
Coumadin 7.5mg mondays, 5 days
Aldactone 25mg Daily
Pravastatin 40mg Daily
Nispan 500mg one tab PO QHS
Toprol 50mg once daily
Discharge Medications:
not applicable
Discharge Disposition:
Expired
Discharge Diagnosis:
Ventricular Fibrillation arrest with anoxic brain injury
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"272.4",
"570",
"327.23",
"425.4",
"790.92",
"785.59",
"427.31",
"780.39",
"584.9",
"V85.41",
"401.9",
"276.52",
"274.9",
"348.1",
"997.31",
"518.81",
"250.00",
"507.0",
"278.01",
"E879.8",
"427.5",
"427.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.72",
"38.93",
"96.6",
"89.19",
"88.56",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
13798, 13807
|
7729, 13317
|
318, 343
|
13907, 13916
|
3348, 3348
|
13972, 13982
|
2137, 2210
|
13759, 13775
|
13828, 13886
|
13343, 13736
|
4987, 6966
|
13940, 13949
|
2225, 2235
|
7256, 7706
|
7007, 7226
|
2257, 3329
|
264, 280
|
371, 1724
|
3364, 4970
|
1843, 1970
|
1986, 2121
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,011
| 167,813
|
24719
|
Discharge summary
|
report
|
Admission Date: [**2176-10-3**] Discharge Date: [**2176-11-8**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Ampullary Mass
Major Surgical or Invasive Procedure:
1. Pylorus preserving pancreaticoduodenectomy.
2. Open cholecystectomy.
3. Staging laparoscopy.
History of Present Illness:
Mrs. [**Known lastname 19407**] is an 81-year-old woman who lost
weight, got jaundiced, felt bad, apparently fell and was
admitted
through [**Hospital6 54196**] back in [**2176-8-9**] for
evaluation. She was profoundly jaundiced, and an ERCP was
necessary to stent a distal biliary stricture in the
periampullary area. Apparently, her bilirubin got up in the
range of 12 mg per deciliter. She had a 35-pound weight loss
over the past 2 months. Her periampullary mass was biopsied,
negative. Her jaundice has since fully resolved.
A CT scan later showed a 6-7 mm mass at the pancreatic head
adjacent to the
CBD (1.8 mm).
Past Medical History:
Her past surgical history is significant for total abdominal
hysterectomy and an appendectomy remotely. From a medical
standpoint, she has diet-controlled diabetes, which has gotten a
lot better since she has lost weight. She has mild hypertension
and she had uterine cancer, prompting the hysterectomy eight
years ago.
Social History:
She stopped smoking over 40 years ago and does not
drink alcohol.
Physical Exam:
On exam she is non-distressed, alert and
oriented. She is not jaundiced. Her neck
is supple with a midline trachea, and no jugular venous
distention or lymphadenopathy. Her chest is clear on
auscultation. Breast exam was not performed. Her cardiac rate
and rhythm is normal. Her abdomen shows lower, old, well-healed
incisions. The upper abdomen is without incisions. Otherwise,
the belly has no masses or hepatosplenomegaly. Rectal exam is
guaiac negative, and there are no masses. She has no hernias.
Pelvic exam was deferred. Her extremities are normal with full
range of motion and symmetrical pulses though she does have 1+
pitting edema bilaterally at the ankles.
Brief Hospital Course:
Patient Expired POD 36
The patient was admitted for surgery-day-admission. The patient
tolerated the surgery and was admitted to the surgical intensive
care unit and had a complicated stay. She had acute MI
(NSTEMI), alterned mental status, pneumonia with acute
respiratoy failure, new onset of Afib, and became septic.
Several consult teams became involved in her care including
Cardiology, Pulmonology, and Infectious Disease. Multiple
procedures where done inorder to maximize her recovery,
including tracheostomy, central line placements, chest tubes,
and VATS. She was placed on antibiotics such as Vancomycin,
Levofloxacin, Flagyl, Zosyn, Meropenum, and Ambisone. She was
transfused several times with pRBC's. All efforts were made to
resusitate the patient. However, the patients WBC remained
elevated in the 20,000's (although seldomly febrile) and she
required pressors to maintain the BP. She continued to
detiorate and expired on POD 36.
Discharge Disposition:
Expired
Discharge Diagnosis:
Death
Discharge Condition:
Death
Discharge Instructions:
non-applicable
Followup Instructions:
none
Completed by:[**2177-1-17**]
|
[
"427.31",
"250.00",
"412",
"156.2",
"V10.42",
"486",
"584.5",
"783.21",
"518.5",
"428.0",
"574.10",
"995.92",
"038.9",
"410.71",
"401.9",
"577.1",
"511.9",
"576.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"52.7",
"38.91",
"00.11",
"89.64",
"99.04",
"99.07",
"99.15",
"31.1",
"34.04",
"33.24",
"99.62",
"34.91",
"96.04",
"96.72",
"96.6",
"51.22",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
3151, 3160
|
2169, 3128
|
275, 376
|
3209, 3216
|
3279, 3314
|
3181, 3188
|
3240, 3256
|
1474, 2146
|
221, 237
|
404, 1027
|
1049, 1374
|
1390, 1459
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,760
| 148,425
|
47731
|
Discharge summary
|
report
|
Admission Date: [**2123-3-9**] Discharge Date: [**2123-3-12**]
Date of Birth: [**2077-9-24**] Sex: F
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: Patient is a 45-year-old woman
with a longstanding history of headaches since her teens with
a pulling feeling of her scalp x2 years with no numbness,
tingling, or weakness. She is preoped for a craniotomy,
clipping of a posterior communicating artery aneurysm. On
physical exam, she denies hypertension or CAD.
PAST MEDICAL HISTORY: She has a negative past medical
history. She had cesarean section x2 and angio on
[**2123-3-2**].
PHYSICAL EXAM: She is a petite woman in no acute distress.
Heart: Regular rate and rhythm, S1, S2. Lungs are clear to
auscultation. Abdomen is soft, nontender, and nondistended.
Extremities: No edema, warm, and dry. Mental status:
Anxious, but had a bad experience with angio in the past.
She is nonicteric. Pupils are equal, round, and reactive to
light, no lymphadenopathy, no thyromegaly. Neck is supple.
She was admitted status post a clipping of a posterior
communicating artery aneurysm. There were no intraoperative
complications. Postoperatively, she was monitored in the
Surgical ICU. She was awake and alert. Her strength was [**3-15**]
in grasp, IPs, ATs, and gastrocs were [**4-14**] bilaterally.
Pupils: The right was 1 mm, the left was 4 mm, both were
reactive. The left is postsurgical. She was able to follow
commands x4.
Remained neurologically stable overnight on [**2123-3-10**]. She
was awake, alert, and oriented times two. Pupils were 2 down
to 1.5 bilaterally. Face was symmetric. She had no drift.
Her strength was [**4-14**]. She was weaned off Neo-Synephrine to
keep her blood pressure over 100 and her blood pressure
remained stable after coming off Neo-Synephrine. She was
then transferred to the regular floor.
She was seen by Physical Therapy and Occupational Therapy,
and found to be safe for discharge to home. She went on
[**2123-3-11**] for angiogram to check placement of a clip. It
showed good evidence of clip of the aneurysm with no
residual. Her groin site post procedure was clean, dry, and
intact. Her pedal pulses were present and intact. Her vital
signs remained stable throughout her hospital stay.
She was discharged to home on [**2123-3-12**] in stable condition
with followup with Dr. [**Last Name (STitle) 1132**] in [**12-11**] weeks for staple removal.
CONDITION ON DISCHARGE: Stable.
MEDICATIONS ON DISCHARGE:
1. Colace 100 mg p.o. b.i.d.
2. Pantoprazole 40 mg q.24h.
3. Percocet 1-2 tablets p.o. q.4h. prn for headache.
CONDITION ON DISCHARGE: Stable.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2123-3-12**] 10:57
T: [**2123-3-15**] 09:32
JOB#: [**Job Number 100786**]
|
[
"458.29",
"305.1",
"437.3",
"782.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"39.51"
] |
icd9pcs
|
[
[
[]
]
] |
2500, 2612
|
622, 828
|
168, 483
|
843, 2440
|
506, 606
|
2637, 2901
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,390
| 151,554
|
53813
|
Discharge summary
|
report
|
Admission Date: [**2129-6-7**] Discharge Date: [**2129-6-19**]
Date of Birth: [**2057-1-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Mild dyspnea on exertion
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting x4 (left internal mammary artery
grafted to the left anterior descending artery/ Saphenous vein
grafted to diagnal/ramus/right coronary artery- [**2129-6-7**]
History of Present Illness:
72 year old male who had some mild complaints of dyspnea on
exertion. Denies chest pain, palpitations or dizziness. Had a
cardiac cath done several years
ago which revealed moderate LAD and RCA disease. Has been
medically managed and then underwent a stress test which was
positive for ischemia. Therefore, had a cardiac cath which
revealed severe three vessel coronary artery diseease and was
referred for surgical intervention
Past Medical History:
Coronary artery disease s/p CABG
Post operative atrial fibrillation
Secondary:
Hypertension
Hyperlipidemia
Hypothyroidism
Borderline Diabetes Mellitus
Possible skin cancer left cheek
tremors or several years
Social History:
Lives with: Wife
Occupation: Retired
Cigarettes: Smoked yes [X] last cigarette ? Hx: 1.5ppd x
40+ yrs
Other Tobacco use: Denies
ETOH: < 1 drink/week [] [**2-15**] drinks/week [] >8 drinks/week [X] 3
scotch/night
Illicit drug use: Denies
Family History:
non-contributory
Physical Exam:
Pulse: 54 Resp: 18 O2 sat: 98%
B/P Right: - Left: 128/79
Height: 70" Weight: 232"
General: Well-developed obese male in no acute distress
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X] Exopthalamus
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 [] _____
Varicosities: Bilat varicosities, large on right leg
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: faint Left: 2+
Carotid Bruit Right: - Left: -
Pertinent Results:
Intra-op TEE [**2129-6-7**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Conclusions
PRE-CPB:
The left atrium is markedly dilated. No atrial septal defect is
seen by 2D or color Doppler.
The left ventricular cavity is moderately dilated. Overall left
ventricular systolic function is mildly depressed. Estimated
LVEF= 45%. The right ventricular cavity is mildly dilated with
borderline normal free wall function.
The descending thoracic aorta is mildly dilated. There are
complex (>4mm) atheroma in the descending thoracic aorta. No
thoracic aortic dissection is seen.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis. There are
filamentous strands on the aortic leaflets consistent with
Lambl's excresences (normal variant). Trace eccentric aortic
regurgitation is seen from the commissure between the left and
the non-coronary cusps.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
POST-CPB:
After initial separation from bypass, the patient is on a low
dose norepinephrine infusion. Images from 15 minutes after
separation shows improved biventricular function, estimated
LVEF=50%. The RV systolic function appears normal. MR remains
mild. Other valvular function are unchanged. The CO is
calculated to be 5.8L/min.
Upon closure of sternum, the patient requires more than the
normal escalation of vasopressors and does not respond to fluid
bolus. Reinspection of echo images at this time shows new
notable LV inferior wall hypokinesis as well as RV free wall
hypokinesis. Surgeon immediately notified. Over the next 10
minutes, the RV free wall becomes severely hypokinetic, with
sparing of the basal segment. The LV inferior and inferoseptal
segments also appears severely hypokinetic. The sternum is
reopened and vein graft to RCA is messaged with near immediately
improvement in the RV free wall and LV inferior wall
contractility on echo images. When the sternum is closed again
30 minutes later, the same wall motion abnormalities are again
noted. Surgeons aware and believe this not to be due to graft
kinking. Low dose epinephrine started with mild improvement of
RV free wall and LV inferior wall contractility. Final chest
closed estimated LVEF=40%.
There is no evidence of aortic dissection.
CXR [**2129-6-12**]
FINDINGS: The right IJ line tip is in the distal SVC.
Mediastinal clips and sternal wires are unchanged. There
continues to be moderate cardiomegaly. There is improved
aeration in the left lower lobe with some residual volume
loss/effusion. There is also probable small right effusion.
Overall, the appearance of the lungs is improved compared to the
study from the prior day.
.
[**2129-6-17**] 04:46AM BLOOD WBC-10.0 RBC-2.86* Hgb-9.7* Hct-28.6*
MCV-100* MCH-34.0* MCHC-34.0 RDW-14.0 Plt Ct-399
[**2129-6-16**] 05:09AM BLOOD WBC-9.8 RBC-2.96* Hgb-9.5* Hct-29.2*
MCV-99* MCH-32.1* MCHC-32.5 RDW-14.2 Plt Ct-327
[**2129-6-19**] 06:35AM BLOOD PT-18.5* INR(PT)-1.7*
[**2129-6-18**] 06:09AM BLOOD PT-17.0* INR(PT)-1.6*
[**2129-6-17**] 04:46AM BLOOD PT-13.8* INR(PT)-1.3*
[**2129-6-16**] 05:09AM BLOOD PT-13.0* INR(PT)-1.2*
[**2129-6-15**] 12:31AM BLOOD PT-22.7* INR(PT)-2.2*
[**2129-6-14**] 04:00PM BLOOD PT-57.2* INR(PT)-5.7*
[**2129-6-14**] 08:30AM BLOOD PT-47.0* INR(PT)-4.6*
[**2129-6-13**] 05:20PM BLOOD PT-55.1* INR(PT)-5.5*
[**2129-6-13**] 09:15AM BLOOD PT-44.4* INR(PT)-4.4*
[**2129-6-13**] 04:50AM BLOOD PT-39.6* INR(PT)-3.9*
[**2129-6-12**] 03:54AM BLOOD PT-16.9* INR(PT)-1.6*
[**2129-6-19**] 06:35AM BLOOD Na-139 K-4.5 Cl-103
[**2129-6-17**] 04:46AM BLOOD Glucose-93 UreaN-17 Creat-1.3* Na-145
K-4.7 Cl-107 HCO3-28 AnGap-15
Brief Hospital Course:
Same day admission and was brought to the operating room and
underwent Coronary artery bypass graft surgery. See operative
report for further details. He tolerated the procedure well and
was transferred to the CVICU for invasive monitoring. He was
weaned from sedation, awoke neurologically intact and was
extubated that evening. He was progressively weaned off pressors
and inotropes. On post operative day one he was started on
betablockers and diuretics. He continued to do well and was
transferred to the post operative floor. Earlier the morning of
post operative day two he went into rapid atrial fibrillation,
was treated with beta-blockers and additionally amiodarone which
he converted back to sinus rhythm after multiple hours. Chest
tubes were removed on post operative day three and epicardial
wires on post operative day four. Physical therapy worked with
him on strength and mobility. He continued with burst of atrial
fibrillation, lopressor was titrated and he continued on oral
amiodarone. Coumadin was initiated due to ongoing episodes of
atrial fibrillation. He was noted for sternal drainage placed on
antibiotics. On post operative day seven he had
supratherapuetic INR and received vitamin K and fresh frozen
plasma, and additionally had echocardiogram which ruled out
pericardial effusion. He remained in the hospital due to
ongoing episodes of atrial fibrillation. Rate control was
achieved and the patient was discharged home on POD 12. His PCP
will manage INR/Coumadin dosing.
Medications on Admission:
Atenolol 50mg daily
Nifedical XL 30mg daily
Lasix 40mg daily
Lipitor 40mg daily
Levothyroxine 125mg daiy
Aspirin 81mg daily
KCl 10meq daily
Folic acid daily
Discharge Medications:
1. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain, fever.
6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
8. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
9. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO once a day.
Disp:*30 Tablet Extended Release(s)* Refills:*2*
11. Outpatient Lab Work
Labs: PT/INR for Coumadin ?????? indication AFib
Goal INR 2-2.5
First draw [**2129-6-20**]
Results to Dr. [**Last Name (STitle) **] [**0-0-**] fax [**Telephone/Fax (1) 110441**], attn:
[**Doctor First Name **]
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Coronary artery disease s/p CABG
Post operative atrial fibrillation
Secondary:
Hypertension
Hyperlipidemia
Hypothyroidism
Borderline Diabetes Mellitus
Possible skin cancer left cheek
tremors or several years
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema +1 bilateral lower extremities
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:
Appointments already scheduled
Cardiac Surgeon Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Thrusday [**2129-7-6**] 1:45
Cardiologist: Dr.[**Last Name (STitle) 4922**] [**2129-6-30**] at 1:15p
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] [**0-0-**] in [**4-15**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication AFib
Goal INR 2-2.5
First draw [**2129-6-20**]
Results to Dr. [**Last Name (STitle) **] [**0-0-**] fax [**Telephone/Fax (1) 110441**], attn:
[**Doctor First Name **]
Completed by:[**2129-6-19**]
|
[
"414.01",
"511.9",
"E878.2",
"440.0",
"411.1",
"454.9",
"244.9",
"427.31",
"790.29",
"997.1",
"272.4",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.13",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
9038, 9121
|
5953, 7469
|
335, 528
|
9374, 9617
|
2268, 5930
|
10541, 11273
|
1490, 1508
|
7677, 9015
|
9142, 9353
|
7495, 7654
|
9641, 10518
|
1523, 2249
|
270, 297
|
556, 986
|
1008, 1219
|
1235, 1474
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,021
| 165,181
|
39570
|
Discharge summary
|
report
|
Admission Date: [**2120-8-12**] Discharge Date: [**2120-8-27**]
Date of Birth: [**2063-11-1**] Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
[**8-12**]:
1. Osteotomy L3-L4.
2. Partial vertebrectomy of L4 and 5.
3. Fusion L3-S1.
4. Anterior spacers x 3.
5. Anterior instrumentation.
6. Autograft bone morphogenic protein and allograft.
[**8-13**]:
1. Osteotomy of L2-3, as well as L1-2, and vertebral at L1.
2. Vertebrectomy of L1.
3. Fusion of T12 to L3.
4. Anterior cages x2.
5. Autograft bone morphogenic protein and allograft.
[**8-14**]:
1. Ultrasound-guided vascular access of the right common
femoral vein.
2. Inferior vena cava catheter placement.
3. Inferior vena cava imaging.
4. Inferior vena cava filter insertion of a Cook Celect
inferior vena cava filter.
[**8-18**]:
1. T4 to S1 fusion.
2. Revision laminectomies from L2-S1, S2.
3. Osteotomy L1.
4. Multiple thoracic laminotomies.
5. Instrumentation T4-S1, S2.
6. Autograft.
7. Epidural catheter placement.
8. VAC dressing application.
History of Present Illness:
Ms. [**Known lastname **] has a long history of back paini due to scoliosis. She
now presents for surgical intervention.
Past Medical History:
PMHx:
HTN
hypercholesterolemia
scoliosis
benign thyroid nodules
failed back surgery syndrome
PSHx:
[**2111**], [**2114**] lumbar spine surgery
breast reduction
Social History:
Lives: with family
Occupation: disabled
Smoking history: current smoker
Alcohol: denies
Family History:
N/C
Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2120-8-12**] and taken to the Operating Room for L3-S1 interbody
fusion through an anterior approach. Please refer to the
dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
given per standard protocol. Initial postop pain was controlled
with a PCA. On HD#2 she returned to the operating room for a
scheduled T12-L3 fusion with L1 corpectomy as part of a staged
2-part procedure. Please refer to the dictated operative note
for further details. The second surgery was also without
complication and the patient was transferred to the PACU in a
stable condition. Postoperative HCT was stable. Prior to going
to the OR for the scheduled third stage she was noticed to have
a severly swollen left thigh. She was administered [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
ultrasound which confirmed a large femoral vein DVT. She was
taken to the OR for a filter placement by vascular surgery. She
was transfered to the ICU after this procedure and started on IV
heparin.
Her third surgery would be delayed three days while her fitness
for surgery was evaluated. She went back to the OR for her
T3-S1 posterior fusion. The procedure went as scheduled and she
was transfered back to the SICU for observation. The patient
was transitioned to oral pain medication when tolerating PO
diet. Foley was removed on POD#4 from the third procedure. She
developed a urinary tract infection and was placed on Bactrim
DS. She was fitted with a TLSO brace for ambulation. Physical
therapy was consulted for mobilization OOB to ambulate. Hospital
course was otherwise unremarkable. On the day of discharge the
patient was afebrile with stable vital signs, comfortable on
oral pain control and tolerating a regular diet. She will
continue coumadin for 6 months.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Amlodipine 10 mg PO DAILY
2. Gabapentin 800 mg PO HS
3. Simvastatin 20 mg PO DAILY
4. Ascorbic Acid 500 mg PO BID
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Ascorbic Acid 500 mg PO BID
3. Simvastatin 20 mg PO DAILY
4. Bisacodyl 10 mg PR HS:PRN constipation
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. HYDROmorphone (Dilaudid) 2-4 mg PO Q3H:PRN pain
7. Morphine SR (MS Contin) 30 mg PO Q12H
8. Gabapentin 600 mg PO TID
9. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 1 Weeks
10. Warfarin 2 mg PO ONCE Duration: 1 Doses
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Scoliosis
L1 compression fracture
Femoral vein DVT
Acute post-op blood loss anemia
Urinary tract infection
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: Three part
thoracolumbar fusion.
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a brace. This brace is to be worn
when you are walking. You may take it off when sitting in a
chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually 2-3 days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
As tolerated
TLSO for ambulation; may be out of bed to chair without.
Treatments Frequency:
Please continue to change the dressings daily
Followup Instructions:
With Dr. [**Last Name (STitle) 363**] in 10 days. Call [**Telephone/Fax (1) **] for an
appointment.
With Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**] in 3 weeks. Call [**Telephone/Fax (1) 1393**] for an
appointment.
Completed by:[**2120-8-27**]
|
[
"721.3",
"737.39",
"997.2",
"272.0",
"V13.51",
"241.1",
"E878.1",
"997.5",
"453.41",
"305.1",
"998.2",
"599.0",
"401.9",
"285.1",
"349.31",
"E870.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.51",
"38.7",
"96.6",
"81.64",
"81.62",
"88.51",
"84.52",
"81.05",
"39.32",
"03.90",
"81.07",
"81.04",
"80.99",
"81.63",
"81.06",
"03.59"
] |
icd9pcs
|
[
[
[]
]
] |
4933, 5003
|
2192, 4237
|
318, 1191
|
5153, 5160
|
7276, 7555
|
1648, 1653
|
4502, 4910
|
5024, 5132
|
4263, 4479
|
5185, 5264
|
1668, 2169
|
7114, 7184
|
7206, 7253
|
5300, 5493
|
269, 280
|
5529, 5984
|
5996, 7096
|
1219, 1342
|
1364, 1526
|
1542, 1632
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,083
| 148,413
|
20604
|
Discharge summary
|
report
|
Admission Date: [**2181-3-4**] Discharge Date: [**2181-3-27**]
Date of Birth: [**2114-2-24**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 13561**]
Chief Complaint:
Unresponsiveness, transferred with combativeness
Major Surgical or Invasive Procedure:
Intubation at OSH/Extubation at [**Hospital1 18**]
PEG placement
PICC placement
History of Present Illness:
The pt is a 67 year-old man who was transferred from [**Location (un) **].
Per report he was found unresponsive by his wife this morning
"drooling". EMS found him combative and his FS was 101. Per his
wife's description she heard him making "grunting sounds" and
found him sitting in a chair, slumped to the R with eyes closed
and "stiff all over" with extended fingers. His lip was also
forward but no facial droop or eye deviation noted. He also
seemed "ashen". This episode lasted about 10 minutes and he was
then fighting EMS as they were putting him into the ambulance.
He was taken to the OSH where he was persistently combative.
From their notes he was initially tachycardic in the 130's and
BP of 106/72 with a temp of 97.5 PR. [**Name6 (MD) **] the RN notes he was
"agitated, awake, combative, non-verbal, pale, diaphoretic and
BP elevated. He was give 2mg of ativan x 2 and 5mg of haldol x 2
without effect and then he was intubated. His max BP was 194/87,
however after intubation and sedation with versed he was
hypotensive in the 80/50's briefly. In one of the notes it also
reports that he had a facial droop but the side was not
documented and he was unresponsive after which he became
agitated, combative and non-cooperative.
His exam there was "non-focal" and his screening labs showed a
sodium of 129, Cl 94 and a HCO3 of 16 (anion gap of 19). His
Glucose was 182 and his LFTs were normal. CBC was unremarkable.
His Cr was 1.3 and his serum ASA, tylenol and EtOH were
negative. It was positive for bensozs however this was drawn
after the ativan was given. A repeat chemistry was done (however
per the recorded timing on the forms they were drawn at the same
time). This showed a Na of 137. His Troponin was < 0.03 and the
CK was 180. An LP was obtained which showed 0 WBC in tubes 1 and
4 and 27 RBC in tube 1, but 0 in tube 4. CSF Glucose, protein
and gram stain were not recorded and it is not documented if HSV
was sent off. His UA was negative. I contact[**Name (NI) **] [**Name (NI) **] for his
CSF 77 gluc, 52 protein. They stated that the gram stain was
not.
Past Medical History:
- early onset dementia (wife has been told he has AD or vascular
dementia)
- high-degree AV block with a permanent pacemaker
- hyperlipidemia
- "mini stroke" in the past w/ baseline [**1-19**] word sentences for
fluency
- recurrent episodes of syncope for last 8 yrs, resolved w/
pacer
- prior reported EEG which was abnormal and MRI brain with
frontal atrophy
- EtOHism, quit 14 years ago
Social History:
History of EtOHism, quit 14 years ago. He lives at home with
wife, can feed himself, needs help with bathing, speaks in [**1-19**]
word phrases.
Family History:
no hx of strokes, seizures or dementia
Physical Exam:
exam on admission off propofol x 20 min
Vitals: T: 98.7 P: 66 R: 16 BP: 127/70 SaO2: 100% on ET
General: intubated, off sedation
HEENT: NC/AT, no scleral icterus noted, ET in place
Neck: Supple, no carotid bruits appreciated.
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 edema. bilateral ankle contracture
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: unresponsive to verbal or tactile stimuli but
does withdraw all extremities (no localization to pain)
CN
I: not tested
II,III: no blink to threat, pupils 1mm->0.5mm bilaterally,
unable to visualize fundi
III,IV,V: no oculocephalic, no ptosis. No nystagmus
V: + corneals & nasal tickle bilaterally
VII: face symmetric w/ ET in place
VIII: UA
IX,X: + gag
[**Doctor First Name 81**]: UA
XII: UA
Motor: Normal bulk, slightly increased tone throughout.
Symmetric withdrawal throughout but not brisk
Reflex: No clonus
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 1--------- 0 0 up
R 1--------- 0 0 up
-Sensory: as above
Pertinent Results:
LABS:
[**2181-3-4**] 01:28PM BLOOD WBC-9.6 RBC-4.08* Hgb-13.9* Hct-40.0
MCV-98 MCH-34.0* MCHC-34.7 RDW-13.1 Plt Ct-171
[**2181-3-23**] 05:58AM BLOOD WBC-8.7 RBC-4.05* Hgb-13.5* Hct-38.8*
MCV-96 MCH-33.4* MCHC-34.9 RDW-13.1 Plt Ct-494*
[**2181-3-4**] 01:28PM BLOOD Neuts-85.2* Lymphs-8.9* Monos-4.8 Eos-0.9
Baso-0.2
[**2181-3-19**] 06:10AM BLOOD Neuts-84.3* Lymphs-7.4* Monos-6.7 Eos-1.4
Baso-0.3
[**2181-3-4**] 01:28PM BLOOD PT-13.6* PTT-26.0 INR(PT)-1.2*
[**2181-3-4**] 01:28PM BLOOD Glucose-103 UreaN-10 Creat-0.9 Na-142
K-3.8 Cl-109* HCO3-25 AnGap-12
[**2181-3-23**] 02:56PM BLOOD Na-129*
[**2181-3-4**] 01:28PM BLOOD ALT-19 AST-24 CK(CPK)-493* AlkPhos-83
TotBili-0.7
[**2181-3-5**] 02:16AM BLOOD CK(CPK)-555*
[**2181-3-17**] 07:50AM BLOOD CK(CPK)-114
[**2181-3-4**] 01:28PM BLOOD CK-MB-3
[**2181-3-4**] 01:28PM BLOOD cTropnT-0.03*
[**2181-3-5**] 02:16AM BLOOD CK-MB-3 cTropnT-<0.01
[**2181-3-17**] 07:50AM BLOOD CK-MB-2 cTropnT-<0.01
[**2181-3-4**] 01:28PM BLOOD Lipase-42
[**2181-3-4**] 01:28PM BLOOD Albumin-3.9 Calcium-7.8* Phos-2.0* Mg-2.2
[**2181-3-23**] 05:58AM BLOOD Calcium-8.4 Phos-2.7 Mg-2.4
[**2181-3-20**] 05:45AM BLOOD Osmolal-267*
[**2181-3-22**] 05:55AM BLOOD Osmolal-280
[**2181-3-23**] 05:58AM BLOOD Osmolal-269*
[**2181-3-5**] 02:16AM BLOOD TSH-0.46
[**2181-3-20**] 05:45AM BLOOD Cortsol-32.1*
[**2181-3-4**] 01:28PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
[**2181-3-4**] 01:33PM BLOOD Lactate-1.6
[**2181-3-4**] 01:28PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
[**2181-3-4**] 01:28PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2181-3-20**] 06:08AM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.023
[**2181-3-20**] 06:08AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-8* pH-7.5 Leuks-NEG
[**2181-3-20**] 06:08AM URINE RBC-26* WBC-0 Bacteri-NONE Yeast-MOD
Epi-0
[**2181-3-14**] 05:10PM URINE Hours-RANDOM Creat-76 Na-130
[**2181-3-18**] 06:27PM URINE Hours-RANDOM UreaN-285 Creat-49 Na-164
[**2181-3-21**] 04:26PM URINE Hours-RANDOM Creat-110 Na-67
[**2181-3-14**] 05:10PM URINE Osmolal-533
[**2181-3-18**] 06:27PM URINE Osmolal-490
[**2181-3-20**] 04:14PM URINE Osmolal-699
[**2181-3-21**] 04:26PM URINE Osmolal-631
MICRO:
Blood Cx ([**3-4**] x2): No growth
Urine Cx ([**3-4**]): No growth
Urine Cx ([**3-6**]): No growth
Urine Cx ([**3-16**]): No growth
Blood Cx ([**3-16**] x2):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL
SENSITIVITIES.
COAG NEG STAPH does NOT require contact
precautions,regardless
of resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
SPECIMEN WILL BE HELD IN MICRO UNTIL FORM IS RECEIVED.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SECOND MORPHOLOGY.
FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
CLINDAMYCIN-----------<=0.25 S <=0.25 S
ERYTHROMYCIN----------<=0.25 S <=0.25 S
GENTAMICIN------------ <=0.5 S <=0.5 S
LEVOFLOXACIN---------- 4 R 4 R
OXACILLIN------------- =>4 R =>4 R
RIFAMPIN-------------- <=0.5 S <=0.5 S
TETRACYCLINE---------- <=1 S <=1 S
VANCOMYCIN------------ 2 S 2 S
Blood Cx ([**3-18**] x2, [**3-19**] x2, [**3-20**] x2, [**3-21**] x2): NGTD
PEG Drainage ([**3-21**]): GRAM STAIN (Final [**2181-3-21**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
WOUND CULTURE (Final [**2181-3-23**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
IMAGING:
CXR ([**3-4**]): IMPRESSION:
1. Orogastric tube side port may be just above the GE junction
and would
benefit from advancement.
2. Mild blunting of both costophrenic angles, which may relate
to
small effusions. No focal pneumonia identified.
CTA Head/Neck ([**3-4**]): IMPRESSION:
1. No evidence of acute intracranial abnormalities.
2. Normal CTA of the head and neck.
3. Emphysema.
4. The orogastric tube is coiled in the pharynx.
EEG ([**3-5**]): IMPRESSION: This telemetry captured no pushbutton
activations. Routine sampling showed a slow and low voltage
background suggestive of a widespread encephalopathy.
Medications, metabolic disturbances, and infection are among the
most common causes. The low voltage faster patterns suggest
medication. There were no areas of prominent focal slowing, but
encephalopathy may obscure focal findings. Routine sampling, as
well as automated spike and seizure detection programs, showed
no epileptiform features or electrographic seizures.
EEG ([**3-6**]): IMPRESSION: This telemetry captured no pushbutton
activations. Routine sampling showed a very low voltage slow
background, indicative of a widespread and severe
encephalopathy. Medications, metabolic disturbances, and
infection are among the most common causes. There were no
epileptiform features on routine sampling or by automated
detection, and no electrographic seizures were recorded.
CXR ([**3-12**]): FINDINGS: In comparison with study of [**3-11**], the
patient has taken a much better inspiration. The cardiac
silhouette remains within normal limits and there is no evidence
of vascular congestion or acute pneumonia. Monitoring and
support devices remain in place.
TTE ([**3-19**]): The left atrium is normal in size. Left ventricular
wall thickness, cavity size, and global systolic function are
normal (LVEF 55-60%). Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded.
Transmitral and tissue Doppler imaging suggests normal diastolic
function, and a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The number of aortic valve leaflets cannot be
determined. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: poor technical quality due to patient's body
habitus. Left ventricular function is probably normal, a focal
wall motion abnormality cannot be fully excluded. The right
ventricle is not well seen. No pathologic valvular abnormality
seen. Pulmonary artery systolic pressure could not be
determined.
CT Head ([**3-19**]): IMPRESSION: There is no evidence of acute
intracranial abnormality. No significant changes since the prior
examination dated [**2181-3-4**]. Persistent areas of low
attenuation in the periventricular white matter, likely
consistent with chronic microvascular ischemic changes. There is
no evidence of hemorrhage, mass, mass effect, or large
territorial infarction.
CT Abd/Pelvis ([**3-21**]): IMPRESSION:
1. Satisfactory gastrostomy tube placement, with mild soft
tissue stranding and postprocedural free intraabdominal air.
2. No focal fluid collection or evidence of obstruction.
PEG Study ([**3-22**]): IMPRESSION: Gastrografin contrast flows freely
into the stomach confirming appropriate placement. No evidence
of leakage.
MOST RECENT LAB RESULTS:
[**2181-3-27**] 05:05AM
COMPLETE BLOOD COUNT
White Blood Cells 9.5 K/uL 4.0 - 11.0
Red Blood Cells 3.78* m/uL 4.6 - 6.2
Hemoglobin 13.0* g/dL 14.0 - 18.0
Hematocrit 36.1* % 40 - 52
MCV 95 fL 82 - 98
MCH 34.3* pg 27 - 32
MCHC 36.0* % 31 - 35
RDW 12.7 % 10.5 - 15.5
Neutrophils 80* % 50 - 70
Bands 1 % 0 - 5
Lymphocytes 7* % 18 - 42
Monocytes 9 % 2 - 11
Eosinophils 3 % 0 - 4
Basophils 0 % 0 - 2
Atypical Lymphocytes 0 % 0 - 0
Metamyelocytes 0 % 0 - 0
Myelocytes 0 % 0 - 0
RED CELL MORPHOLOGY
Hypochromia NORMAL
Anisocytosis NORMAL
Poikilocytosis NORMAL
Macrocytes NORMAL
Microcytes NORMAL
Polychromasia NORMAL
BASIC COAGULATION (PT, PTT, PLT, INR)
Platelet Smear NORMAL
Platelet Count 402 K/uL 150 - 440
[**2181-3-27**] 05:05AM
RENAL & GLUCOSE
Glucose 105 mg/dL 70 - 105
Urea Nitrogen 13 mg/dL 6 - 20
Creatinine 0.7 mg/dL 0.5 - 1.2
Sodium 134 mEq/L 133 - 145
Potassium 4.8 mEq/L 3.3 - 5.1
Chloride 96 mEq/L 96 - 108
Bicarbonate 32 mEq/L 22 - 32
Anion Gap 11 mEq/L 8 - 20
ENZYMES & BILIRUBIN
Alanine Aminotransferase (ALT) 90* IU/L 0 - 40
Asparate Aminotransferase (AST) 39 IU/L 0 - 40
Alkaline Phosphatase 147* IU/L 39 - 117
Bilirubin, Total 0.5 mg/dL 0 - 1.5
CHEMISTRY
Albumin 3.4 g/dL 3.4 - 4.8
Calcium, Total 9.1 mg/dL 8.4 - 10.2
Phosphate 2.7 mg/dL 2.7 - 4.5
Magnesium 2.4 mg/dL 1.6 - 2.6
Brief Hospital Course:
1. Episode of unresponsiveness-seizure vs. syncope. The patient
is a 67 year-old man with a history of early onset dementia,
high grade AV block s/p PPM, and HLD who presented with an
episode of unresponsiveness associated with an "ashen"
appearance, and subsequent combativeness at an OSH requiring
Ativan, Haldol, and intubation. An LP at the OSH showed 0 WBC in
tubes 1 and 4 and 27 RBC in tube 1, but 0 in tube 4, 77 glucose,
52 protein, and HSV reportedly negative. He was initially on
Acyclovir, but this was discontinued when the HSV came back
negative. He was transferred to the [**Hospital1 18**] NeuroICU, where he was
subsequently extubated. Serum and urine tox were positive only
for BZD. EEG showed widespread encephalopathy, but no
epileptiform features or electrographic seizures. CTA head/neck
was normal and showed no acute intracranial abnormalities. He
was started on Dilantin and Lamictal for the presumed seizure
(with the goal of titrating off Dilantin once the Lamictal was
therapeutic). He was transferred to the Neurology Floor.
His mental status continued to wax and wane while on the floor.
Cardiology interrogated his [**Company 1543**] PPM on [**3-19**] which showed no
abnormal rhythm or rate since [**11-25**] to explain his episode of
unresponsiveness. TTE showed LVEF 55-60% and no pathologic
valvular abnormality. His altered mental status was thought to
be due to his bacteremia and hyponatremia (see below), but also
due to the antiepileptic drugs which had been started.
Therefore, both the Dilantin and Lamictal were discontinued. He
was given Seroquel as needed for agitation. The patient was
scheduled to follow up with his outpatient neurologist.
[**2181-3-27**] Last physical exam at discharge: patient was awake,
responsive not following commands properly, however he was able
to say isolated words. Not oriented. Moving all four extermities
antigravity.
2. Staph coagulase negative bacteremia. The patient had blood
cultures on admission ([**3-4**]) which showed no growth x2. The
patient had a PEG placed by surgery on [**3-16**], and had a low grade
fever to 100.2 associated with tachycardia and tachypnea when he
returned to the floor. Blood cultures were drawn ([**3-16**]) which
showed Staph coagulase negative x2. He was started on Vancomycin
IV bid to complete a 2 week course last day on [**2181-4-1**].
VANCOMYCIN LAST TWO DOSES SHOULD BE ON [**2181-4-1**].
There was concern that brown drainage was leaking around the PEG
site on [**3-21**]. Culture of the drainage showed 4+ GNRs and 3+ GPCs
in pairs and chains. CT abdomen/pelvis showed no focal fluid
collection or evidence of obstruction. PEG study showed no
evidence of leakage.
3. Hyponatremia/SIADH. His Na on admission was 142. On [**3-11**], his
sodium decreased to 132, and subsequently ranged 126-132. His
sodium began to trend down around the same time Lamictal was
started, so drug effect was thought to be the cause of his
hyponatremia. Urine osms were concentrated (490-699) even though
sodium and serum osm were low, so SIADH was thought to be the
cause of his hyponatremia. Medicine was consulted to help manage
the hyponatremia, and Lamictal was discontinued. Renal was also
consulted who recommended adding salt tabs and starting Lasix
PO. These improved his Na to 132, so were subsequently
discontinued.
4. Early onset dementia. He was continued on his home doses of
Aricept and Namenda.
5. High degree AV block s/p PPM. Cardiology interrogated the
patient's pacemaker on [**3-19**], which did not show any abnormal
rhythm or rate.
6. Hyperlipidemia.
Medications on Admission:
- aspirin 81mg PO daily
- Namenda 10mg [**Hospital1 **]
- Aricept 10mg qhs
- Vitamin B12 daily
- Folic Acid daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Namenda 10 mg Tablet Sig: One (1) Tablet PO twice a day.
3. Aricept 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
4. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Therapeutic Multivitamin Liquid Sig: One (1) Tablet PO
DAILY (Daily). Tablet(s)
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QHS (once a day
(at bedtime)) as needed for agitation.
9. Vancomycin 500 mg Recon Soln Sig: Three (3) Recon Soln
Intravenous Q 12H (Every 12 Hours): 1500mg [**Hospital1 **] until [**2181-4-1**].
10. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
PRIMARY:
Episode of unresponsiveness: seizure vs. syncope
Staph coagulase negative bacteremia
Hyponatremia/SIADH
SECONDARY:
Early onset dementia
High degree AV block s/p PPM
Hyperlipidemia
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital with an episode of
unresponsiveness, followed by combativeness at an outside
hospital. You were intubated at the outside hospital and
transferred to [**Hospital1 18**] for further evaluation. It was initially
thought that this episode was a seizure, and you were started on
anti-seizure medications. However, it was later determined that
these anti-seizure medications may be contributing to your
altered mental status and causing your low sodium level, so they
were discontinued. Subsequent EEG were negative for seizures or
epileptiform features. You had a PEG tube placed to help with
your nutritional input. After that was placed you developed
bacteremia which is being treated with antibiotics.
The following changes were made to your medications: You were
prescribed Vancomycin IV twice daily (until [**4-1**] for a two week
course). You were started on a Multivitamin and Thiamine daily.
You were started on Seroquel as needed for agitation.
Patient will require bladder training: clamp and unclamp foley
every 4 hours round the clock for three days then discontinue
foley and monitor urine output, bladder scan if necessary and
straight cath every 8 hours until able to void. Of note, family
reports patient typically needs to be standing in order to
urinate on his own.
If you develop unresponsiveness, weakness or numbness,
difficulty swallowing, decreased vision or blurry vision,
headache, fevers/chills, or any other symptoms that concern you,
call your PCP or return to the ED.
Followup Instructions:
You will need to follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 19186**] ([**Telephone/Fax (1) 55082**]) in the next 1-2 weeks.
You have a follow up appointment with Dr. [**First Name4 (NamePattern1) 450**] [**Last Name (NamePattern1) **] in
Neurology ([**Telephone/Fax (1) 55083**]) on [**2181-4-25**] at 3:00 in [**University/College **].
|
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17,497
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28095
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Discharge summary
|
report
|
Admission Date: [**2129-12-9**] Discharge Date: [**2129-12-21**]
Date of Birth: [**2081-5-10**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Fevers and hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 48 year old female recently discharged from
[**Hospital1 18**] after prolonged hospitalization (early [**Month (only) 462**] until the
end of [**Month (only) 359**]) for chronic interstitial lung disease
complicated by pneumonia, hemoptysis, hypotension, atrial
fibrillation. During that hospitalization the patient underwent
a bronchoscopy x2, BAL was PCP negative, but grew out highly
resistant Klebsiella. Cytology was initially negative for
malignancy, second sample showed atypical cells, likely
reactive. The pt also had extensive w/u with [**Doctor First Name **], ANCA,
Anti-Gbm, mycoplasm, Legionella, and influenza labs- all of
which were negative. Most recent CT scan of the chest showed no
evidence of pulmonary embolism in the main pulmonary artery,
right pulmonary artery, and left pulmonary artery. There was
slight improvement of the left apex and anterior aspect of the
right and left lower lobes in terms of ground-glass opacities,
but worsening/progression of opacities at the bases, extensive
mediastinal/hilar lymphadenopathy was unchanged. The patient
was eventually trached on [**11-5**] and successfully weaned to trach
mask. She was treated with two courses of Vanc and Meropenem, 8
days and 14 days respectively. She was discharged to rehab
after being successfully weaned to a trach mask.
.
She returned to the ED this evening after experiencing desats to
the 60's and a fever to 100.1. In addition, she reportedly
coughed up some reddish-brown sputum. She was treated with
combivent nebs x3 and Solumedrol at rehab. In the ED she was
tachycardic, temp of 99.0 and tachypneic w/ RR in 30's. Initial
ABG showed 7.38/40/45/25, likely venous sample. The patient
received 2 liters NS, nebs, and was ordered for a dose of
Meropenem. A CXR was done, and the patient was admitted to the
ICU.
.
On arrival to the unit, the patient was lethargic but arousable.
She denied chest pain or abdominal pain. Further ROS unable to
be assessed.
Past Medical History:
Chronic interstitial lung disease/pulmonary fibrosis
Paroxysmal atrial fibrillation (on coumadin) and ablation (/06)
Atherosclerotic cardiovascular disease
HTN
Hyperlipidemia
Obesity
Uncontrolled blood sugars (prednisone-induced)
Social History:
She has a history of tobacco abuse but currently does not smoke.
No EtOH or drug abuse
Family History:
Significant for mother dying of heart disease at age 47 after MI
at age 43.
Physical Exam:
PE: vitals: tm 99/ tc 97.8/ bp 143/44/ hr 90/ rr 30/ 90% o2 sat
GEN: obese, lethargic, arousable, diaphoretic
HEENT: atraumatic, anicteric, mmm, dobhoff tube in place
CV: tachy, soft 2/6 systolic murmur, faint pulses distally
LUNGS: decreased at bases, rhonchi throughout, tachypneic
ABDOMEN: soft, nt, nd, nabs
EXT: warm, diaphoretic, no rashes, trace [**Location (un) **]
NEURO: lethargic but arousable, responds to tactile/ verbal
stimulation. Moves all extremities spontaneously. No focal
deficits
Pertinent Results:
Labs on Admission:
Blood:
ABG:
[**2129-12-9**] 07:21PM TYPE-ART RATES-20/32 TIDAL VOL-600 PEEP-10
O2-100 PO2-45* PCO2-40 PH-7.38 TOTAL CO2-25 BASE XS-0 AADO2-649
REQ O2-100 -ASSIST/CON INTUBATED-INTUBATED
.
Blood:
[**2129-12-9**] 07:45PM WBC-27.6*# RBC-3.38* HGB-9.9* HCT-29.3*
MCV-87 MCH-29.2 MCHC-33.6 RDW-19.3*
[**2129-12-9**] 07:45PM NEUTS-92* BANDS-2 LYMPHS-5* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2129-12-9**] 07:45PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL
SPHEROCYT-1+
[**2129-12-9**] 07:45PM PT-11.3 INR(PT)-1.0
[**2129-12-9**] 08:01PM LACTATE-3.9*
[**2129-12-9**] 07:45PM CK(CPK)-52
[**2129-12-9**] 07:45PM GLUCOSE-420* UREA N-10 CREAT-0.6 SODIUM-135
POTASSIUM-6.5* CHLORIDE-98 TOTAL CO2-22 ANION GAP-22*
.
Urine:
[**2129-12-9**] 08:10PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2129-12-9**] 08:10PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2129-12-9**] 08:10PM URINE RBC-0-2 WBC-0 BACTERIA-FEW YEAST-FEW
EPI-0-2
Other Results:
[**2129-12-17**] 05:55AM BLOOD TSH-18*
[**2129-12-17**] 06:56AM BLOOD Free T4-1.3
[**2129-12-17**] 06:56AM BLOOD Cortsol-25.3*
[**2129-12-13**] 04:25AM BLOOD Digoxin-0.7*
Imaging:
CXR ([**2129-12-9**]) The tracheostomy, left side of central line, and
feeding tube are unchanged in position. There has been interval
increase in the pulmonary vascular markings consistent with
pulmonary edema. There are more confluent opacities seen within
the bases. The cardiac silhouette and mediastinum are within
normal limits.
.
CTA ([**2129-12-9**])
1. No pulmonary embolism.
2. Stable enlarged mediastinal and hilar lymphadenopathy.
3. There has been interval increase in the ground-glass opacity
seen bilaterally, within the lower lobes predominantly but also
within the upper lobes. These are geographic in nature, and
appear in dependent positions. Given the interval increase,
diagnostic considerations include pulmonary edema, alveolar
hemorrhage, infection or aspiration, superimposed upon the
patient's known underlying chronic interstitial lung disease.
.
Sinus CT ([**2128-12-10**]) No evidence of sinusitis.
Microbiology:
URINE CULTURE (Final [**2129-12-11**]): YEAST. 10,000-100,000
ORGANISMS/ML.
.
SPUTUM ([**2129-12-10**]) GRAM STAIN >25 PMNs and <10 epithelial
cells/100X field. 1+ BUDDING YEAST WITH PSEUDOHYPHAE.
RESPIRATORY CULTURE: OROPHARYNGEAL FLORA ABSENT. YEAST.
SPARSE GROWTH. LEGIONELLA CULTURE: NO LEGIONELLA ISOLATED.
.
VIRAL CULTURE ([**2129-12-11**]) VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS
NO VIRUS ISOLATED.
.
STOOL ([**2129-12-12**]) CLOSTRIDIUM DIFFICILE TOXIN ASSAY FECES
NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Brief Hospital Course:
A/P: 48 yo female with respiratory failure requiring trach
secondary to chronic interstitial lung disease complicated by
pneumonia, also with a-fib, CAD, and HTN, recently discharged to
rehab who returns to [**Hospital1 18**] for hypoxia and fevers.
.
# Hypoxic respiratory failure: The patient presented after being
observed to have desturations down to the 60s at her rehab
facility. A number of etiologies were considered for her
worsening respiratory status including infection, pulmonary
edema, mucous plugging, pulmonary embolism or exacerbation of
her underlying lung disease. CT angiogram was negative for
pulmonary embolus but showed increased ground glass opacities
bilaterally in dependent regions consistent with either
pulmonary edema, infection or aspiration. Given her severe
underlying lung disease and the potential for exacerbation she
was started on high dose steroids which were tapered quickly.
On presentation she was taking meropenem for a resistent
klebsiella pneumonia and vancomycin was added to broaden her
antibiotic coverage. The meropenem was discontinued on hospital
day two and she completed a 7 day course of vancomycin. It was
ultimately thought a majority of her symptoms were secondary to
volume overload and she was aggressively diuresed with lasix.
Because of her worsening respiratory status it was necessary to
reinitiate mechanical ventilation. From her previous
hospitalization it was known that the patient tends to require
high levels of PEEP to maintain her oxygenation. Throughout the
remainder of her hospitalization her PEEP was slowly weaned with
plans to continue to wean from the ventilator at a skilled
nursing facility upon discharge.
.
# Fevers - On presentation the patient was febrile to 100.1 with
hypoxia, tachycardia, tachypnea and increased sputum production.
She also was found to have leukocytosis with a left shift. At
no time was she hemodynamically unstable. It was thought that
the source of her fevers was likely due to recurrent pulmonary
infection. Other considerations included bacteremia secondary
to a line infection, sinusitis given her dobhoff tube,
c-difficile or urinary tract infection. Blood, urine, sputum
cultures were sent. Blood cultures were all negative and both
sputum and urine cultures grew only yeast. Stool was negative
for c.difficile. CT of the sinuses was negative for sinusitis.
CXR showed evidence of increased pulmonary edema. On admission
the patient was already on miropenem for prolonged treatment of
resisistent Klebsiella pneumonia from her previous
hospitalization. She was continued on miropenem and vancomycin
was added for broader antibiotic coverage. She also was started
on high dose steroids. She did not experience any fevers after
her initial day of presentation and her WBC count trended
downwards. The miropenem was discontinued on hospital day two
and she completed a 7 day course of vancomycin.
.
# Congestive Heart Failure: Cardiac enzymes on presentation
showed no evidence of cardiac ischemia. Given her recent
echocardiogram during her last hospitalization which revealed
regional systolic LV dysfunction she was continued on her ace
inhibitor for afterload reduction. Given evidence of volume
overload on exam and on chest xray she was aggressively diuresed
during this hospitalization with subsequent improvement in her
respiratory status.
.
# Atrial Fibrillation: The patient has a history of atrial
fibrillation but during the majority of this hospitalization she
was found to be in normal sinus rhythm. She was continued on
her outpatient doses of diltiazem and digoxin for rate control.
.
# Hypothyroidism - The patient was continued on her outpatient
dose of levothyroxine. Repeat TSH was 18 on [**2129-12-17**] but TFTs
were within normal limits. No changes were made to her
outpatient regimen.
.
# Anemia- The patient's baseline hematocrit during last
admission ranged from 23-27. On presentation at this admission
her hematocrit was 29 which was thought to represent
hemoconcentration. At no time did she require transfusion. Her
hematocrit was monitored throughout this admission and remained
stable.
.
# Diabetes: During the patient's previous hospitalization her
blood sugars were difficult to control. With the initiation of
high dose steroids the patient required managment with an
insulin drip. She was then transitioned to NPH insulin with an
insulin sliding scale with good control of her blood sugars.
.
# FEN: The patient was contined on Dobhoff tube feedings
throughout her hospitalization.
.
# Access: Right sided PICC line.
.
# Prophylaxis: SC Heparin, pneumoboots, PPI, calcium, vitamin D
and oral bisphosphonate for bone health, bactrim given chronic
steroid use.
.
# Code: Full
Medications on Admission:
1. Acetaminophen 325 mg
2. Trimethoprim-Sulfamethoxazole 160-800 mg
3. Miconazole Nitrate 2 % Powder
4. Ipratropium Bromide
5. Albuterol Sulfate 0.083 %
6. Albuterol 90 mcg/Actuation Aerosol
7. Ipratropium Bromide 17 mcg/Actuation Aerosol
8. Diphenhydramine HCl 25 mg Capsule
9. Diltiazem HCl 90 mg
10. Digoxin 250 mcg
11. Escitalopram 10 mg
12. Levothyroxine 75 mcg
13. Senna 8.6 mg
14. Aspirin 325 mg
15. Lactulose
16. Cholecalciferol (Vitamin D3) 400 unit
[**Unit Number **]. Captopril 12.5 mg Tablet
18. Zolpidem 5 mg
19. Docusate Sodium
20. Lansoprazole 30 mg
21. Fluticasone 110 mcg/Actuation Aerosol [**Unit Number **]: Four (4) Puff
Inhalation [**Hospital1 **] (2 times a day).
22. Prednisone 10 mg Tablet [**Hospital1 **]: Three (3) Tablet PO DAILY
(Daily): 23. Insulin
24. FOSAMAX 70 mg Tablet [**Hospital1 **]
25. Meropenem
26. Zoledronic Acid
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [**Hospital1 **]: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
2. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical TID
(3 times a day).
3. Digoxin 250 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
4. Escitalopram 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
5. Levothyroxine 75 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. Fluticasone 110 mcg/Actuation Aerosol [**Last Name (STitle) **]: Four (4) Puff
Inhalation [**Hospital1 **] (2 times a day).
8. Alendronate 70 mg Tablet [**Hospital1 **]: One (1) Tablet PO QSUN (every
Sunday).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Hospital1 **]: Two (2)
Tablet PO DAILY (Daily).
10. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
11. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
12. Docusate Sodium 150 mg/15 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day) as needed.
13. Senna 8.8 mg/5 mL Syrup [**Hospital1 **]: Five (5) ML PO BID (2 times a
day) as needed.
14. Calcium Carbonate 500 mg Tablet, Chewable [**Hospital1 **]: One (1)
Tablet, Chewable PO TID (3 times a day).
15. Trazodone 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
16. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Six (6)
Puff Inhalation Q4H (every 4 hours).
17. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: Six (6) Puff
Inhalation Q4H (every 4 hours).
18. Prednisone 5 mg Tablet [**Hospital1 **]: Three (3) Tablet PO DAILY
(Daily).
19. Furosemide 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
20. Captopril 12.5 mg Tablet [**Hospital1 **]: 0.5 Tablet PO TID (3 times a
day).
21. Ventilator Settings
Current settings are CPAP&PS [**11-15**] @FiO2 0.50. Please wean the
PEEP down by 1/day as tolerated by the patient in order to
maintain O2 sats >90%.
22. Insulin NPH Human Recomb 100 unit/mL Suspension [**Month/Year (2) **]: One (1)
80 Subcutaneous twice a day.
Disp:*1 1* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Non-specific interstitial pneumonitis
Pneumonia
Discharge Condition:
Stable, on ventilator
Discharge Instructions:
You will be continued on your current medications at rehab.
They will gradually try to decrease the amount of support you
get from the ventilator, in an effort to see if you can
eventually come off completely in the long-term future.
Followup Instructions:
Patient should follow up with her primary care physician [**Name Initial (PRE) 176**]
3 weeks of discharge.
|
[
"515",
"507.0",
"276.1",
"250.02",
"518.84",
"276.8",
"285.9",
"427.31",
"V44.0",
"278.01",
"999.9",
"428.0",
"244.9",
"458.9",
"255.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
14091, 14170
|
6140, 10888
|
335, 341
|
14262, 14286
|
3353, 3358
|
14569, 14680
|
2736, 2813
|
11794, 14068
|
14191, 14241
|
10914, 11771
|
14310, 14546
|
2828, 3334
|
277, 297
|
369, 2360
|
3372, 6117
|
2382, 2614
|
2630, 2720
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,134
| 111,870
|
25117
|
Discharge summary
|
report
|
Admission Date: [**2114-11-26**] Discharge Date: [**2114-11-29**]
Date of Birth: [**2046-9-23**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 45**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
68y/o F w/ CCU admit for tailored medical management of CP
attributed to thoracic aneurysm w/clot
.
CAD, MI, PCI and stent [**64**], dyslipidemia, PVD s/p
AAA repair '[**11**] c/b hemiplegia, CVAs x 2 c/b hemiparesis '[**99**],
cerebral aneurysms s/p clips '[**11**], awoke this AM w/L breast pain,
took SL NTG with no relief, took all AM meds, called EMS,
recieved NTG spray en rounte w/benefit. Upon arrival in ED was
pain free w/BP 92/41 HR 73. CT performed with concern for new
thoracic dissection, compressing the L PA, LLL collapse, b/l
effusions, pt referred to [**Hospital1 18**] ED.
.
Upon arrival, pt was seen by CT [**Doctor First Name **], review of CT by [**Hospital1 18**]
radiology attending revealed no dissection but intramural
thrombus in the descending aorta with aneurysmal dilatation. Pt
declined surgical intervention. ED stay complicated by BP
elevations to 140s/80s w/sinus tachycardia and SOB/chest
pressure, no sig ECG changes, this resolved with IV NTG,
morphine, lasix 40mg IV, and approx 1L urine output.
.
ROS: no PND/orthopnea, no edema, palpitations, syncope or
presyncope, denies sick contacts, felt [**Name2 (NI) **] prior to this AM, no
f/c/n/v/anorexia until ED arrival, no abd pain, mild
constipation, incontinent of stool and urine.
Past Medical History:
CAD, recent pneumonia admission [**11-14**], h/o MI, PCI [**11-14**] for
NSTEMI and LCX stent placed, PCI [**Hospital1 2025**] '[**06**], dyslipidemia, h/o
tobacco, PVD s/p thoracoabdominal aneurysm repair at [**Hospital1 2025**] Dr.
[**Last Name (STitle) 62999**] c/b CVA and b/l LE paralysis, known new thoracoabdominal
aneurysm, cerebral aneurysms LUE paresis s/p clips, HTN, anemia,
DVT, established preference for comfort care and DNR/DNI status
Social History:
no tobacco, quit 3y ago, 40PY, no etoh or illicits, lives
w/husband, w/c bound, son and dtr in law live in same building
Family History:
noncontributory
Physical Exam:
Vitals:97. BP: 96/42 HR:86 RR:16 O2sat:99% 5L NC
GEN:thin, frail, fatigued appearing woman
HEENT: NC, nl lids, conjunctiva pink, injected, anicteric,
PEERL, 3mm->2mm, dry mucosa, poor dentition, op clear, mmm,
thyroid nl, nt, no masses appreciated, trach scar
CV: carotids w/nl upstroke and amplitude, no bruits, no JVP
elevation, PMI diffuse, quiet s1/s2, 2/6 systolic m, no r, +S3,
?pleural rub, no abdominal bruits, palpable pulsation, radial
and dp pulses 1+ b/l, cool hands, clammy, thigh edema b/l,
+varicosities, cap refill <3 sec
RESP: no accessory mm use, I:E = 1:2, crackles [**2-4**] way up, no
wheezes
ABD: scaphoid, s/nt/nd/nabs, no organomegaly appreciated
MUSC: gait not assesed, no clubbing or cyanosis, poor mm tone
NEURO: CN 2-12 grossly intact
PSYCH: nl affect, no anxiety or agitation, good judgement and
insight, A&Ox3, recent and remote memory grossly intact
Pertinent Results:
ECG: 15:45 sinus 80s, reg, LAD, QII, III, F, TWI in III, V1,
biphasic in V2, compared to early in day at OSH Ts are less
biphasic across precordium, 22:19 w/sinus tach at 120s, LAD, no
sig ST/TW changes
.
CXR: LLL opacification, cephalization
Admission Labs: CK 64, trop 0.57 at 3pm, CK 69 and trop 0.70 at
2330, WBC 16.8, nl diff, hct 34.6, plt 471, Na 140, K 5.3, CL
109, bicarb 17, BUN 27, Cr 1.0, gluc 111
[**2114-11-26**] 11:30PM ALT(SGPT)-7 AST(SGOT)-14 LD(LDH)-253*
CK(CPK)-69 ALK PHOS-116 TOT BILI-0.4
[**2114-11-26**] 11:30PM LIPASE-28
[**2114-11-26**] 11:30PM CK-MB-NotDone cTropnT-0.70*
[**2114-11-26**] 11:30PM ALBUMIN-3.7
[**2114-11-26**] 03:05PM GLUCOSE-111* UREA N-27* CREAT-1.0 SODIUM-140
POTASSIUM-5.3* CHLORIDE-109* TOTAL CO2-17* ANION GAP-19
[**2114-11-26**] 03:05PM CK(CPK)-64
[**2114-11-26**] 03:05PM CK-MB-NotDone cTropnT-0.57*
[**2114-11-26**] 03:05PM WBC-16.8* RBC-3.55* HGB-11.5* HCT-34.6*
MCV-98 MCH-32.3* MCHC-33.1 RDW-13.6
[**2114-11-26**] 03:05PM NEUTS-86.8* LYMPHS-9.0* MONOS-2.5 EOS-1.3
BASOS-0.4
[**2114-11-26**] 03:05PM HYPOCHROM-1+ MACROCYT-1+
[**2114-11-26**] 03:05PM PLT COUNT-471*
[**2114-11-26**] 03:05PM PT-14.6* PTT-29.8 INR(PT)-1.4
[**2114-11-28**] 06:50AM BLOOD WBC-21.3* RBC-3.32* Hgb-10.7* Hct-32.5*
MCV-98 MCH-32.4* MCHC-33.1 RDW-14.1 Plt Ct-486*
[**2114-11-26**] 03:05PM BLOOD Neuts-86.8* Lymphs-9.0* Monos-2.5 Eos-1.3
Baso-0.4
[**2114-11-28**] 06:50AM BLOOD Plt Ct-486*
[**2114-11-28**] 06:50AM BLOOD Glucose-147* UreaN-40* Creat-1.9* Na-145
K-5.4* Cl-112* HCO3-16* AnGap-22*
[**2114-11-27**] 08:11PM BLOOD CK(CPK)-48
[**2114-11-27**] 08:11PM BLOOD CK-MB-NotDone cTropnT-1.16*
[**2114-11-27**] 01:00PM BLOOD CK-MB-NotDone cTropnT-0.96*
[**2114-11-27**] 05:00AM BLOOD CK-MB-7 cTropnT-0.84*
[**2114-11-28**] 06:50AM BLOOD Calcium-8.5 Phos-5.2* Mg-2.0
[**2114-11-27**] 05:00AM BLOOD Triglyc-139 HDL-39 CHOL/HD-4.4
LDLcalc-104
[**2114-11-27**] 08:11PM BLOOD Cortsol-48.5*
Brief Hospital Course:
The presenting complaint of chest pain/SOB was thought to be
presumably due to demand ischemia +/- aortic dilation and clot
formation, however her symptoms improved upon admission, but
continued to occur intermittently. Patient was continued on her
aspirin and plavix, but demonstrated labile blood pressure and
heart rate variation. Her blood pressure was initially elevated
in ED, then trended down and patient became hypotensive,
particularly after narcotic administration for pain relief. In
regards to her elevated troponin, it was thought to be secondary
to her recent MI and stent placement. Patient made it clear
that she did not want any further intervention, including
further studies or imaging. Given her chronic renal
insufficiency, it was also a concern that catheterization would
further damage her kidneys, resulting in hemodialysis, which the
patient refused as well. A palliative care consult was obtained
and it was determined, after extensive discussion with the
patient and all involved physicians, that the patient wished to
be DNR/DNI with comfort measures only. The patient and her
family expressed wishes to be discharged home with hospice
care/VNA. The patient was continued on all of her medications,
continued on oxygen, and given morphine for pain control, with
Anzemet to help control nausea. In addition, the patient was
prescribed a seven day course of levofloxacin for infiltrates
seen on CXR, thought to be likely partially treated pneumonia,
which may also be contributing to the patient's dyspnea. The
patient was arranged to receive home nursing assistance, home
oxygen, and all necessary medications. In addition, her primary
care physician was [**Name (NI) 653**] to be informed of the plan, and of
note, she stated that the aneurysm found on CT was known, not
new, and that discussions had already been initiated with the
patient regarding comfort care/end of life issues. The patient
was kept comfortable until discharge.
Medications on Admission:
Meds: asa 325, lisinopril 20, zoloft 50, prevacid 30, neurontin
100mg [**Hospital1 **], labetolol 100mg [**Hospital1 **], levofloxacin 500mg since [**11-14**]
.
NKDA
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4-6H (every 4 to 6 hours) as needed.
11. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours) for 5 days.
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
13. Morphine Concentrate 20 mg/mL Solution Sig: 5-10mg mg/ml PO
Q1-2H () as needed for air hunger, pain.
14. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) patch
Transdermal ONCE (once): to dry/lessen secretions .
15. Senna 8.6 mg Capsule Sig: Two (2) Tablet PO HS (at bedtime).
16. Hyoscyamine 0.15 mg Tablet Sig: One (1) Tablet PO every [**5-9**]
hours as needed for cough: please give to lessen secretions if
pt does not want scopalamine patch.
17. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety: please give PO or IV.
18. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
19. Dolasetron Mesylate 12.5-50 mg IV Q8H:PRN nausea
20. Ceftriaxone 1 gm IV Q24H Duration: 5 Days
21. Azithromycin 500 mg IV ONCE Duration: 1 Doses
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
thoracoabdominal aneurysm with clot
chest pain
acute renal failure
chronic renal insufficiency
hypoxia
anemia
hypotension
bradycardia
CAD
myocardial infarction
dyslipidemia
lower extremity paralysis
Discharge Condition:
BP low but stable, on oxygen tent for hypoxia, comfort measures
enacted
Discharge Instructions:
Please take all medications as advised. Call your primary care
physician with any questions or for any need needs.
Followup Instructions:
See you PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] as needed [**Telephone/Fax (1) 12597**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**]
|
[
"V45.82",
"584.9",
"585.9",
"486",
"441.2",
"276.2",
"414.01",
"401.9",
"285.9",
"410.72",
"438.20"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9209, 9292
|
5167, 7144
|
326, 332
|
9535, 9609
|
3201, 3445
|
9772, 10011
|
2261, 2278
|
7361, 9186
|
9313, 9514
|
7170, 7338
|
9633, 9749
|
2293, 3182
|
276, 288
|
360, 1632
|
3461, 5144
|
1654, 2106
|
2122, 2245
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,943
| 171,237
|
46764
|
Discharge summary
|
report
|
Admission Date: [**2109-8-7**] Discharge Date: [**2109-8-8**]
Date of Birth: [**2027-5-26**] Sex: F
Service: MEDICINE
Allergies:
Sulfonamides
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Found unresponsive
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. [**Known lastname **] was an 81 year old F with hx of CAD s/p MI and VF
arrest with subsequent ICD placement, CHF, OSA, hypertension,
bipolar disorder, dementia, s/p right colectomy and ileostomy,
mucous fistula of the transverse colon brought to ED from NH
after being found unresponsive. She was found lying in bed with
unresponsive to sternal rub. O2 sat 66% on NRB. Brought to
[**Hospital1 18**].
.
In ER, VS T98.8, HR 89, BP 83/52, RR 11, O2 sat 90% on CPAP.
Patient was placed on CPAP for ventilation with improved O2 sats
to 90s. CXR with RLL PNA vs atelectasis. She was given
Levofloxacin and Flagyl for +UA, ?PNA as well as foul output
from fistula. WBC count 13, lactate 1.3. Plan was to give
ethacrynic acid for diuresis, reportedly rales on exam, but was
not given due to low BP. Code status was confirmed with legal
guardian and patient is DNR/DNI and no pressors.
.
On arrival to the floor the patient was on BiPAP with settings
of [**8-30**]. She continued to be unresponsive. ABG done on arrival
was 7.15/79/259.
Past Medical History:
Reported history of CHF (unclear if systolic vs diastolic - last
echo [**2106**] with EF 55%)
s/p MI [**2096**] complicated by vfib arrest, AICD placement
bipolar disorder s/p ECT
depression
hypercholesteremia
sleep apnea
B 12 deficiency
HTN
open cholecystectomy [**2099**]
s/p right colectomy and ileostomy, mucous fistula of the
transverse colon secondary to volvulus with right cecal necrosis
Social History:
lived at [**Hospital3 2558**]
Family History:
depression in mother
Physical Exam:
VS T 95.0, BP 112/50, HR 81, R 14, O2 sat 99% on BiPap with FiO2
80%, PEEP 5, PS 5.
Gen: Acute respiratory distress using accessory muscles.
Unresponsive.
HEENT: PERRL, EOMI, MM dry
Neck: no carotid bruits, supple, no JVD, no LAD
CV: RRR, normal s1 s2, no m/g/r
Chest: Wheezing throughout, most anteriorly. No rales or
rhonchi.
Abd: Ostomy in RLQ, stoma adjacent to ostomy bag with drainage
of purulent discharge; hypoactive BS, palpable mass in
left upper quadrant measuring about 8cm in diameter;
nondistended
Ext: trace edema bilaterally, 2+ DP - well perfused.
Neuro: Unresponsive. Pupils reactive.
Pertinent Results:
Admission Labs:
[**2109-8-7**] 12:00PM BLOOD WBC-13.1* RBC-3.81* Hgb-13.2 Hct-40.9
MCV-107*# MCH-34.7* MCHC-32.3 RDW-13.2 Plt Ct-276
[**2109-8-7**] 12:00PM BLOOD Neuts-67.7 Lymphs-24.8 Monos-5.0 Eos-2.1
Baso-0.4
[**2109-8-7**] 12:00PM BLOOD Glucose-196* UreaN-32* Creat-1.2* Na-143
K-4.5 Cl-105 HCO3-27 AnGap-16
[**2109-8-7**] 12:00PM BLOOD ALT-19 AST-28 LD(LDH)-213 CK(CPK)-592*
AlkPhos-44 Amylase-116* TotBili-0.2
[**2109-8-7**] 12:00PM BLOOD CK-MB-8 cTropnT-0.02*
[**2109-8-7**] 05:16PM BLOOD Type-ART Rates-/14 PEEP-5 FiO2-80
pO2-259* pCO2-79* pH-7.15* calTCO2-29 Base XS--3 AADO2-244 REQ
O2-47 Intubat-NOT INTUBA Comment-BIPAP
[**2109-8-7**] 06:59PM BLOOD Type-ART pO2-104 pCO2-87* pH-7.13*
calTCO2-31* Base XS--2 Intubat-NOT INTUBA
[**2109-8-7**] 12:09PM BLOOD Lactate-1.3
Brief Hospital Course:
Ms. [**Known lastname **] was an 81F with hx of dementia, bipolar d/o, CAD s/p
MI/VF arrest presents after being found unresponsive at nursing
home. Patient was hypoxic, transiently hypotensive who presented
with ARF and worsening respiratory acidosis on BiPAP.
.
Respiratory Acidosis: Result of hypercarbia. Unclear
precipitating factor (UTI vs PNA vs cardiac vs sedation).
Initial ABG 7.15/79/259. Initially increased pressure support to
12, repeat ABG was 7.13/87/104. Had discussion with patient's
legal guardian who felt that the patient's wishes would be for
comfort measures. She was made comfortable with morphine and
cool mist for comfort. Bipap was removed and patient expired on
[**2109-8-8**].
Medications on Admission:
Aspirin 81mg daily
Folic acid 1mg tablet daily
Omeprazole 20mg daily
Therems mineral tabs
Depakote 125mg cap [**Hospital1 **]
Lamictal 50mg [**Hospital1 **]
Namenda 10mg [**Hospital1 **]
Mirtazapine 45mg qhs
Trazodone 50mg qhs
Zyprexa 7.5mg qhs
Tylenol PRN
Discharge Medications:
None.
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired.
Discharge Condition:
Expired.
Discharge Instructions:
Expired.
Followup Instructions:
None.
|
[
"266.2",
"E937.9",
"401.9",
"327.23",
"296.80",
"584.9",
"412",
"294.8",
"780.09",
"486",
"V66.7",
"V45.02",
"518.81",
"272.4",
"424.1",
"458.9",
"428.0",
"599.0",
"557.9",
"V44.2",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
4356, 4365
|
3309, 4018
|
290, 297
|
4417, 4427
|
2506, 2506
|
4484, 4492
|
1845, 1867
|
4326, 4333
|
4386, 4396
|
4044, 4303
|
4451, 4461
|
1882, 2487
|
232, 252
|
325, 1360
|
2522, 3286
|
1382, 1781
|
1797, 1829
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,483
| 106,630
|
51998
|
Discharge summary
|
report
|
Admission Date: [**2167-4-30**] Discharge Date: [**2167-5-4**]
Service: MEDICINE
Allergies:
Codeine / Vasotec / Cortisporin / Ciloxan / Atenolol
Attending:[**First Name3 (LF) 9853**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
extubation (intubation occurred at OSH)
History of Present Illness:
85 yo F w/recent dx from [**Hospital Unit Name 196**] after cath last month, hx CHF,
PVD, DM, HTN, initially presented to [**Hospital3 **] for SOB.
At [**Name (NI) **], pt acutely decompensated requiring
intubation. Labs were sig for Hct 26 and BNP of 1600. UA there
was positive for leuk est, WBCs, Bacteria. She was given
Ceftriaxone and 60mg of IV lasix.
On transfer to [**Hospital1 18**], pt afebrile 97.3, HR 71, BP 133/59, RR 20,
satting 100% intubated. She had diffuse rhonchi on exam. She was
transfused 1U pRBCs for Hct 24. Other significant labs include
tropT 0.14 with flat CK. Was given vancomycin and Zosyn for
asymmetric infiltrate on CXR. No additional lasix or IVF given.
.
Unable to obtain ROS.
Past Medical History:
1. CAD, status post cardiac catheterization in [**2167-3-15**]
with bare metal stenting and PTCA of an ostial 90% RCA lesion,
complicated by dissection and pseudoaneurysm .
2. Peripheral [**Year (4 digits) 1106**] disease with lower extremity c/b
neuropathy
3. Insulin-dependent diabetes mellitus.
4. Hypertension.
5. Hyperlipidemia.
6. Asthma.
7. GERD.
8. Osteoarthritis.
9. Recent contrast-induced nephropathy after cardiac
catheterization with a peak creatinine of 4.4 requiring
transient
renal replacement therapy.
10. CRI baseline 1.1 - 1.2
11. Hyperparathyroidism
12. B12 deficiency anemia
13. Appendectomy
14. Bladder suspension
15. Right meniscectomy in [**2161-1-11**]
16. Excision of benign breast mass times two
Social History:
The patient currently lives in [**Location 107641**] with her [**Age over 90 **] year old
Husband. She has 1 son who lives in [**Name (NI) 701**]. At baseline she
walks with a cane, she is otherwise independent in all ADl
although looking to get an aid to help clean soon.
Tobacco: None
ETOH: None
Illicits: None
Family History:
Non-Contributory
Physical Exam:
VITAL SIGNS:
T= 95.9 BP= 128/58 HR= 57 RR= 15 O2= 100%
.
.
PHYSICAL EXAM
GENERAL: Intubated sedated
HEENT: ETT in place
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP=
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: sedated
Pertinent Results:
[**2167-4-30**] 09:00PM BLOOD WBC-6.8 RBC-UNABLE TO Hgb-7.5* Hct-24.0*
MCV-UNABLE TO MCH-UNABLE REP MCHC-32.6 RDW-UNABLE TO Plt
Ct-267
[**2167-4-30**] 09:00PM BLOOD Neuts-84.7* Bands-0 Lymphs-8.7* Monos-5.3
Eos-1.0 Baso-0.3
[**2167-5-1**] 02:55AM BLOOD PT-12.9 PTT-24.4 INR(PT)-1.1
[**2167-4-30**] 09:00PM BLOOD Glucose-344* UreaN-50* Creat-1.4* Na-136
K-5.0 Cl-103 HCO3-23 AnGap-15
[**2167-4-30**] 09:00PM BLOOD ALT-43* AST-38 CK(CPK)-131 AlkPhos-164*
Amylase-36
[**2167-4-30**] 09:00PM BLOOD CK-MB-8 proBNP-[**Numeric Identifier 107642**]*
[**2167-4-30**] 09:00PM BLOOD cTropnT-0.14*
[**2167-5-1**] 02:55AM BLOOD CK-MB-8 cTropnT-0.12*
[**2167-5-1**] 02:55AM BLOOD Calcium-7.9* Phos-3.4 Mg-3.0*
[**2167-4-30**] 09:00PM BLOOD TSH-3.0
[**2167-5-1**] 02:19AM BLOOD Lactate-1.3
.
Studies CXR [**4-30**]:
FINDINGS: Previously, the bilateral perihilar opacities have
been decreasing, there is worsening opacity predominantly in
bilateral hila on the current study. There are profoundly low
lung volumes. The distribution favors superimposed acute
pulmonary edema. There may be residual opacity from underlying
infection. There are likely small bilateral pleural effusions
and significant left lower lobe atelectasis. Consistent with the
given history, an endotracheal tube is present. The distal tip
is on the order of 2 cm from the carina which is satisfactory in
placement. The nasogastric tube is in place with the side hole
in the region of the gastroesophageal junction. No pneumothorax
is noted. There is atheromatous disease of the aorta. The
cardiac silhouette size is difficult to assess but is likely
stable. There is a rounded density projecting over the left
medial hemithorax, presumably extrinsic to the patient.
.
IMPRESSION: Overall, there is likely superimposed acute
pulmonary edema,
moderate-to-severe in nature, both interstitial and alveolar
which represents a worsening since the prior study. More
confluent opacities noted in the background may be the residual
of prior infection or recurrent aspiration or pneumonia. Repeat
radiography following appropriate diuresis recommended to assess
for underlying infection. Small bilateral pleural effusions are
also evident. Please advance nasogastric tube 5-10 cm.
.
TTE [**5-1**]:
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild to
moderate regional left ventricular systolic dysfunction with
near akinesis of the distal half of the anterior septum and
hypokinesis of the distal half of the anterior wall and apex
(mid-LAD distribution). The remaining segments contract normally
(LVEF = 40 %). No masses or thrombi are seen in the left
ventricle. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets are mildly thickened.
There is a minimally increased gradient consistent with minimal
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is an
anterior space which most likely represents a fat pad.
Compared with the prior study (images reviewed) of [**2167-4-11**],
the severity of mitral regurgitation is reduced and the
estimated pulmonary artery systolic pressure is higher. Minimal
aortic stenosis is now suggested. Left ventricular systolic
function is similar.
.
RLE US [**5-1**]:
IMPRESSION: No evidence of DVT in the right lower extremity
Brief Hospital Course:
85 yo F with h/o Diabetes, cardiac disease, presents with acute
shortness of breath to OSH, requiring intubation for respiratory
distress.
.
#. Respiratory distress: Differential included CHF, infection,
PE. Primary etiology was felt to be most likely CHF rather than
infection given significantly elevated BNP >23,000 and fluid
overload on CXR. Asymmetry had been present on prior recent CXR,
and diffuse congestion is noteably new. Based on recent
discharge summary and follow up cardiology appointments, it
appeared that the patient was no longer taking her lasix at
home. She received 60mg IV lasix at [**Hospital3 **]. She was
placed on lasix gtt and diuresed well overnight >2,5L. She was
quickly weaned off the vent and extubated without complication
on [**5-1**]. There was initial concern for concurrent PNA (had
received course of azithro on recent hospitalization for ?
atypical PNA). She was noted to have a rising WBC count as well
as hypothermia which was concerning for possible early sepsis
and she was started on vanc/cefipime for possible HAP. She had
received vanc/zosyn and the OSH. After extubation the patient's
CXR was significantly improved and she did not have significant
cough, sputum or SOB and there was low suspicion for a pulmonary
infection and therefore vanc/cefepime was stopped. The lasix gtt
was discontinued after extubation and she was restarted on PO
lasix of 40 mg [**Hospital1 **] once on the medical [**Hospital1 **]. She had repeat TTE
performed which showed stable EF of 40%.
.
# Leukocytosis: Patient's WBC was normal on admission, however
rose to 8.7 the day after. She was also hypothermic and
therefore there was concern for an infectious process. There
was some concern for HAP as above and therefore vanc/cefipime
was started. She then had low grade temp of 100. UA was
negative here, however reports from OSH showed dirty UA.
Culture at OSH grew >100,000 cfu of lactose-fermenter. Per OMR
she has a h/o pan-sensitive Klebsiella UTI. Given preliminary
culture reports she was started on cipro PO empirically for UTI.
Given UTI was more likely source of infection her vanc/cefepime
was discontinued. Her WBC normalized and she will complete a
total of 7 days of ciprofloxacin orally.
# NSTEMI - Trop T peaked at 0.14 on admission which was stable
from OSH in setting of normal renal function. She had recent
RCA stents placed last admission. Her CK and MB remained flat.
EKG was without significant changes. Her troponin leak was felt
to be demand in the setting of CHF exacerbation. She was
continued on medical management with ASA and statin. When she
was extubated her home amlodipine, metoprolol and valsartan were
restarted. TTE was repeated and showed stable EF.
# Chronic Renal insufficiency - Cr was 1.4 on admission which
was improved from recent hospitalization. Cr peaked at 4.4
during the hospital stay due to contrast exposure and required
temporary CVVH. Cr remained stable, however bumped slightly to
1.5 after diuresis and then remained stable. Medications were
renally dosed.
#. Anemia - within pt's baseline of known anemia of chronic
disease
#. Hypertension - not active issue, continue home meds
(amlodipine, BB, valsartan)
#. Diabetes: Sugars were initially elevated on admission to
300s-400s. Thought to be due to not taking home meds vs
infection. She was placed on Humalog sliding scale and her BS
quickly corrected.
# Lt ankle pain - on [**5-3**] she developed severe acute lt ankle
pain without known trauma. Examination of the ankle was
unrevealing. This was felt to possibly represent an acute gouty
attack given her aggressive diuresis - plain films showed no
fracture, uric acid was slightly elevated. Given her recent
acute on chronic renal fialure, NSAIDs and colchicine were
avoided, and her pain was treated with Percocet.
Medications on Admission:
Pre recent d/c summary:
1. Acetaminophen 325 mg PO Q6H as needed.
2. Aspirin 325 mg Daily
3. Amlodipine 5 mg daily
4. Multivitamin daily
5. Cyanocobalamin 100 mcg daily
6. Atorvastatin 80 mg daily
7. Clopidogrel 75 mg daily
8. Metoprolol Tartrate 25 mg [**Hospital1 **]
9. Lidoderm Topical
10. Nitroglycerin Sublingual
11. Pentoxifylline 400 mg Tablet three times a day: with meals
(pt. reports stopping this
12. Calcium 600 with Vitamin D3 600 mg(1,500mg) -200 unit [**Hospital1 **]
13. Omega-3 Fatty Acids 1,000 mg Capsule once a day
14. Valsartan 80 mg daily
15. Glimepiride 4mg daily
16. Insulin Aspart SS
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Calcium 600 + D(3) 600 mg(1,500mg) -200 unit Tablet Sig: One
(1) Tablet PO twice a day.
10. Omega-3 Fatty Acids 1,000 mg Capsule Sig: One (1) Capsule PO
once a day.
11. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous ASDIR (AS DIRECTED).
17. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 days.
18. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for sob/wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Primary: acute on chronic systolic heart failure
Secondary: coronary artery disease, diabetes mellitus Type 2,
hypertension, asthma, GERD, osteoarthritis, chronic renal
insufficiency
Discharge Condition:
good, stable, O2 sats in high 90s on 1.5L NC
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2000mL
You were evaluated for respiratory distress due to congestive
heart failure. You improved with diuresis, but because of left
foot pain likely due to gout, you will benefit from rehab.
If you have worsening shortness of breath, chest pain,
lightheadedness, fevers, chills, or any other concerning
symptoms, have the doctors at the facility evaluate you.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2167-5-11**]
12:10
|
[
"493.90",
"428.23",
"585.9",
"599.0",
"428.0",
"414.01",
"410.71",
"357.2",
"403.90",
"443.9",
"285.21",
"272.4",
"274.9",
"518.81",
"V45.82",
"250.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
12121, 12206
|
6176, 10015
|
280, 322
|
12433, 12480
|
2649, 6153
|
13009, 13133
|
2160, 2178
|
10676, 12098
|
12227, 12412
|
10041, 10653
|
12504, 12986
|
2193, 2630
|
220, 242
|
350, 1065
|
1087, 1813
|
1829, 2144
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,692
| 119,206
|
51765
|
Discharge summary
|
report
|
Admission Date: [**2173-6-15**] Discharge Date: [**2173-6-19**]
Date of Birth: [**2123-11-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
LLQ pain
Major Surgical or Invasive Procedure:
Cystoscopy with ureteral stent placement
History of Present Illness:
49yoM with h/o diabetes, HTN, CHF (EF 10-15%), p/w acute onset
LLQ pain, N/V x 4-5d, worsening today. Denies fevers, chills,
dysuria, hematuria, change in bowel habits, ever having similar
prior episodes.
.
In the ED, initial VS were: 99.2 109 131/87 18 100. Appeared
well. Left abdominal pain, initially concerning for
diverticulitis. Breathing comfortably. Labs were sig for BUN/Cr
39/2.1 (baseline 1.2), lactate 3.3, WBC 12.3 74%N, Hct 40.9 (MCV
69). UA pending.
Patient was given Morphine 4mg x2, Tylenol 1gm, Cipro 400mg IV,
Zofran 2mg. IVF: 1L IVF.
CT scan showed "7 x 11 mm stone at the left UPJ with associated
hydronephrosis. multiple additional small nonobstructing calculi
are noted in the kidneys bilaterally. bowel unremarkable. s/p
CCY.
7 mm left lower lobe nodule, rec [**3-27**] mo f/up if at high or low
risk,
respectively."
Pt was seen by urology, given risk of infection pt planned for
ureteral stent placement vs lithotripsy tomorrow.
Vitals on transfer were 98.6, 102, 129/92, 99% RA.
Past Medical History:
DM type 2,
CHF with EF 10-15% (cardiomyopathy of unknown cause, recent
echo)
HTN
HL
Erectile Dysfunction
hearing loss
s/p CCY
Social History:
Works as patient transport supervisor at [**Hospital1 2177**]. Denies etoh,
tobacco, IVDU.
Family History:
No family history of kidney stones.
Physical Exam:
Vitals: T: 98.6 BP: 137/93 P: 100 R: 18 O2: 100%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, tender to palpation to left abd, non-distended,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly
Back: +CVA on left
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A+Ox3, answers questions and follows directions
appropriately
Pertinent Results:
Admission labs:
[**2173-6-15**] 12:55PM WBC-12.3* RBC-5.99 HGB-13.4* HCT-40.9 MCV-68*
MCH-22.4* MCHC-32.8 RDW-14.6
[**2173-6-15**] 12:55PM NEUTS-74.4* LYMPHS-18.5 MONOS-5.9 EOS-0.7
BASOS-0.5
[**2173-6-15**] 12:55PM PLT COUNT-204
[**2173-6-15**] 12:55PM ALT(SGPT)-22 AST(SGOT)-24 ALK PHOS-65 TOT
BILI-0.8
[**2173-6-15**] 12:55PM LIPASE-38
[**2173-6-15**] 12:55PM GLUCOSE-125* UREA N-39* CREAT-2.1* SODIUM-136
POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-23 ANION GAP-20
[**2173-6-15**] 01:03PM LACTATE-3.3*
[**2173-6-15**] 07:40PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2173-6-15**] 07:40PM URINE BLOOD-SM NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-7.0
LEUK-NEG
[**2173-6-15**] 07:40PM URINE RBC-[**3-26**]* WBC-0-2 BACTERIA-RARE
YEAST-NONE EPI-0-2
[**2173-6-15**] 05:06PM URINE HOURS-RANDOM UREA N-687 CREAT-79
SODIUM-115
.
[**2173-6-15**] CT abdomen and pelvis: IMPRESSION:
1. 7 x 11 mm obstructing stone in the left proximal ureter, just
distal to
the UPJ with mild hydronephrosis.
2. Multiple small non-obstructing stones in both kidneys.
3. Status post cholecystectomy. Unremarkable appearance of the
small and
large bowel, without evidence for obstruction or bowel wall
thickening.
4. 7-mm pulmonary nodule at the left lower lobe; recommend three
or six-month imaging followup if the patient is at high or low
risk for intrathoracic malignancy, respectively.
.
[**2173-6-16**] Echocardiogram:
IMPRESSION: Symmetric left ventricular hypertrophy with normal
regional with mild global hypokinesis. Right ventricular free
wall hypertrophy. In the absence of a history of systemic
hypertension, an infiltrative process (e.g., amyloid,
[**Location (un) 4223**]-Fabry's) or hypertrophic cardiomyopathy should be
considered.
If clinically indicated, a cardiac MRI ([**Telephone/Fax (1) 9559**]) may be
useful to discriminate among these etiologies.
.
Blood cultures: NGTD
Brief Hospital Course:
49 yo M with diabetes, HTN, CHF, presents with worsening left
abdominal pain, found to have obstructive kidney stone.
.
# Pyelonephritis/Obstructing nephrolithiasis: Patient admitted
with 5 days of LLQ pain, nausea and vomiting with a large
obstructing stone and left-sided hydronephrosis on CT scan. He
was started on IV ciprofloxacin 400mg [**Hospital1 **] in case of infection,
tamsulosin to aid with relaxation of the ureter and IV morphine
for pain control. He appeared euvolemic and well-compensated in
terms of his heart failure, so he was hydrated with normal
saline to prevent further stones from obstructing. He was taken
[**2173-6-16**] by urology for ureteral stent placement to relieve the
pressure on the kidney.
.
ICU COURSE: Pt underwent cystoscopy and ureteral stent placement
on [**6-16**] w/ post-procedure course complicated by purulent
drainage s/p stenting and subsequent fevers to 102.6, relative
hypotension to 107/60, and tachycardia to 110s. He received 1 L
LR and 900 mcg phenylephrine during the procedure. Ampicillin
and gentamicin had been administered prior to the procedure.
Given concern for developing sepsis and reported history of
significant cardiomyopathy with LVEF 10-15%, pt was transferred
to ICU for further hemodynamic monitoring. Upon arrival to ICU
pt was 92% on 5L NC which quickly improved and pt was soon able
to sat in mid-90s on RA, making the most likley diagnosis
post-procedure atelectasis. Aspiration events, complications of
intubation, PTX and PE were all considered in the differential
but based on imaging and rapid improvement of pts system, most
likely cause was atelectasis. Pt improved and was transferred
back to general medical service on [**6-17**], put on empiric Zosyn.
.
Patient continued to improve and cultures remained negative.
Given lack of past culture data, he was changed to Augmentin at
the advice of urology. He must complete a 14 day course total
of antibiotic therapy. He must follow up with urology in 10
days for definitive management of his nephrolithiasis. Flomax
to be continued at discharge
.
# Chronic systolic CHF: new diagnosis in [**3-/2172**] per patient with
EF of [**11-5**]% at that time. s/p biopsy and cath at the [**Hospital1 756**],
all negative per pt. Very well compensated on admission, lying
flat comfortably with no edema, JVP not elevated even after 1L
in ED. His Lasix was held on admission, as the elevated Cr and
lactate were thought to be in part dehydration. Repeat echo was
done, showing an EF of 45% with global mild hypokinesis. In the
absence of a history of systemic hypertension, an infiltrative
process (e.g., amyloid, [**Location (un) 4223**]-Fabry's) or hypertrophic
cardiomyopathy should be considered. A prior cardiac biopsy at
[**Hospital1 112**] was reportedly nondiagnostic. If clinically indicated, a
cardiac MRI may be useful to discriminate among these
etiologies. His ACE-I was held given his ARF. Lasix restarted
at discharge
.
# Acute renal failure: Cr up to 2.1 from baseline 1.2-1.4,
likely a combination of pre-renal from dehydration and
post-renal from unilateral obstruction. Improved with hydration
and relief of the obstruction. His ACE-I and lasix were held
initially, but his creatinine returned to baseline by discharge,
so these were resumed.
.
# Type 2 Diabetes mellitus: Continued on home lantus. Metformin
held given CT scan and ARF and covered with a humalog SS.
Metformin held at discharge pending resolution of his ARF.
.
# Pulmonary nodule: CTA abd/pelvis showed a 7-mm pulmonary
nodule at the left lower lobe. Recommended for three or
six-month imaging followup if the patient is at high or low risk
for intrathoracic malignancy, respectively.
Medications on Admission:
Cialis 10mg prn
Lantus 24U hs
Carvedilol 12.4 [**Hospital1 **]
Metformin 500mg [**Hospital1 **]
Simvastatin 20mg hs
Lisinopril 10mg daily
Aspirin 81mg daily
Furosemide 40mg daily
Omeprazole 20mg daily
Discharge Medications:
1. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
6. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. Lantus 100 unit/mL Solution Sig: Twenty Four (24) units
Subcutaneous at bedtime.
Discharge Disposition:
Home
Discharge Diagnosis:
Pyelonephritis with sepsis
Obstructing nephrolithiasis
Acute renal failure
Chronic systolic CHF
Type 2 diabetes mellitus, controlled
Hyperlipidemia
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 caused by an obstructing
kidney stone. This was relieved by our urologists through
cystoscopy. You were also found to have an infection as well,
requiring a stay in the ICU. With supportive care you
recovered. You will be discharged to complete a course of oral
antibiotics. Additionally, you will need to follow up with our
urologists for further management of your kidney stones: call
Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] Tuesday to confirm your appointment at: ([**Telephone/Fax (1) 14702**].
.
Incidentally found was a lung nodule, for which you will need a
repeat CT scan in 6 months.
.
Medication changes:
1. Augmentin 500mg three times per day for 14 days total,
through [**2173-6-29**] (added)
2. Tamsulosin 0.4 mg daily STARTED
Followup Instructions:
Please follow up with Urology and Dr. [**Last Name (STitle) **]. Please call ([**Telephone/Fax (1) 14702**] to follow up within 10 days
.
Please follow up with your PCP as soon as possible
|
[
"518.89",
"272.4",
"591",
"995.91",
"250.02",
"E878.1",
"425.4",
"584.9",
"389.9",
"590.10",
"428.22",
"038.9",
"428.0",
"592.0",
"592.1",
"997.39",
"401.9",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"59.8",
"87.74"
] |
icd9pcs
|
[
[
[]
]
] |
9074, 9080
|
4326, 8038
|
325, 368
|
9272, 9272
|
2361, 2361
|
10246, 10439
|
1677, 1714
|
8289, 9051
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9101, 9251
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8064, 8266
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9423, 10077
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1729, 2342
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10097, 10223
|
277, 287
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396, 1403
|
2377, 4303
|
9287, 9399
|
1425, 1552
|
1568, 1661
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,091
| 160,349
|
52034
|
Discharge summary
|
report
|
Admission Date: [**2177-3-26**] Discharge Date: [**2177-4-1**]
Service: MEDICINE
Allergies:
Ibuprofen / Penicillins / Shellfish
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
CVVH
History of Present Illness:
[**Age over 90 **] yo M with end-stage renal disease on HD, CHF (EF 40%), CAD
and hypothyroidism who presents with fluid overload, EKG changes
and cardiac enzyme elevations concerning for ischemia
transferred to the ICU for urgent dialysis.
.
By report of the patient, his sons and on review of his medical
records, the patient had progressive shortness of breath for
many months. This became abruptly worse approximately 24 hours
prior to admission. The patient had profound orthopnea and was
forced to sit on the edge of his bed with rapid breathing. His
sons asked the patient to go to the hospital but he refused. His
shortness of breath symptoms worsened and by morning the patient
agreed to come to the hospital. He denies at any point
developing chest pain. He notes baseline nausea unchanged and
worsening dyspnea on exertion at 12 steps and 2 pillow
orthopnea. He describes unchanged peripheral edema and denies
weight gain.
.
The patient initially presented to [**Hospital3 1196**]
where he was felt to be volume overloaded with possible anterior
ST elevation on EKG and positive cardiac enzymes. He received
aspirin 81mg x 4, clopidogrel 600mg, lasix 100mg IV, nitropaste
1 inch subsequently changed to a nitroglycerin drip and then
discontinued and a heparin gtt. On admission to the [**Hospital1 18**] floor
the patient was hemodynamically stable but in persistent
respiratory distress, tachypneic to 24-30 saturating well on 3L
oxygen by NC. He was evaluated by the renal consult service who
recommended transfer to the ICU for semi-urgent CVVHD for fluid
removal.
.
Of note, the patient was has difficulty with fluid removal at HD
due to hypotension. As a result he had chronic accumulation of
fluid. In addition, his outpatient cardiologist was not able to
institute a comprehensive cardiac regimen (including
beta-blocker).
.
Review of systems: Denies fevers, cough, weight loss,
nightsweats, melena, hematochezia, rash, arthralgias, myalgias,
claudication
Past Medical History:
- CAD, likely prior silent MI with apical hypokinesis on echo
- End-stage renal disease on HD with tunnelled line in place,
failed AV fistulas, usual schedule MWF.
- Hypothyroidism
- Systolic CHF, EF 40%
- MR [**First Name (Titles) **] [**Last Name (Titles) **]
- Pulmonary Hypertension
Social History:
No tobacco, alcohol, or illicit drugs.
Family History:
NC
Physical Exam:
VS:97.8 78-83 127-144/51-70 24-30 97-100% 3L
Gen: Elderly gentleman in some respiratory distress.
HEENT: PERRL. Pink, moist oral mucosa without lesions.
CV: MR murmur heard at the apex.
Pulm: Tachypneic. Crackles halfway up the lung fields
bilaterally.
Abd: Soft, nontender. No masses or organomegaly.
Ext: Trace bilateral lower extremity edema. Referred murmur vs.
bruit bilaterally in the groin. 2+ femoral pulses.
Neuro: A&Ox3.
Integumentary: No rashes or lesions.
Pertinent Results:
[**2177-3-27**] 02:04AM BLOOD WBC-4.0 RBC-3.79* Hgb-11.4* Hct-33.7*
MCV-89 MCH-30.0 MCHC-33.8 RDW-13.9 Plt Ct-138*
[**2177-3-27**] 11:05PM BLOOD Neuts-87.6* Bands-0 Lymphs-9.0* Monos-2.8
Eos-0.5 Baso-0.2
[**2177-3-27**] 11:05PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2177-3-29**] 07:49AM BLOOD PT-14.3* PTT-82.7* INR(PT)-1.2*
[**2177-3-27**] 02:04AM BLOOD Glucose-97 UreaN-63* Creat-9.1*# Na-137
K-5.8* Cl-95* HCO3-27 AnGap-21*
[**2177-3-29**] 01:47AM BLOOD Glucose-104 UreaN-42* Creat-5.0*# Na-133
K-4.5 Cl-92* HCO3-22 AnGap-24*
[**2177-3-31**] 03:15AM BLOOD Glucose-90 UreaN-29* Creat-3.1* Na-132*
K-4.1 Cl-95* HCO3-26 AnGap-15
[**2177-3-29**] 07:49AM BLOOD ALT-48* AST-114* LD(LDH)-352*
CK(CPK)-1159* AlkPhos-93 TotBili-0.4
[**2177-3-30**] 04:40AM BLOOD ALT-42* AST-67* LD(LDH)-276* AlkPhos-87
TotBili-0.3
[**2177-3-28**] 07:53AM BLOOD CK-MB-25* MB Indx-1.4 cTropnT-1.97*
[**2177-3-29**] 07:49AM BLOOD CK-MB-23* MB Indx-2.0 cTropnT-2.70*
[**2177-3-30**] 04:40AM BLOOD Calcium-9.8 Phos-2.9 Mg-1.8
[**2177-3-27**] 02:04AM BLOOD TSH-1.3
[**2177-3-30**] 04:12PM BLOOD Type-[**Last Name (un) **] Temp-37.8 pH-7.38
[**2177-3-28**] 11:17AM BLOOD Lactate-2.0
[**2177-3-30**] 04:12PM BLOOD freeCa-1.23
CXR [**3-26**]:
AP single view of the chest has been obtained with patient in
sitting semi-erect position. Bilateral pleural effusions
obliterate the diaphragmatic contours and obscure the lower
portions of the heart silhouette. Significant cardiac
enlargement is most likely present. One can identify a
semi-circular calcification within the heart shadow indicative
of mitral ring calcium deposits. The thoracic aorta shows
extensive wall calcifications in the area of the arch, but the
aorta is not significantly widened. The pulmonary vasculature
demonstrates an upper zone redistribution pattern and there is
perivascular haze on the bases consistent with marked
congestion. Evidence of discrete local parenchymal infiltrates
cannot be identified; however, the possibility of infectious
processes in the bases concealed by the congestive pattern and
the pleural effusions is possible. The presence of a left
internal jugular approach double lumen catheter is recognized
seen to terminate in the lower SVC just at the junction with the
right atrium. In the right apical area, the metallic structures
of a stent, presumably in the right subclavian vein are
identified. There is no pneumothorax.
Comparison is made with the next previous available chest
examination of [**2176-4-12**]. Cardiac enlargement and pulmonary
congestive pattern with pleural effusions existed already at
that time, but these findings have moderately increased. The
wide caliber tube on the left side (probably dialysis line) did
not exist at that time.
IMPRESSION: Progression of left-sided CHF with bilateral pleural
effusions in elderly gentleman. No new pneumonia identified
which however, cannot be completely excluded.
Brief Hospital Course:
The patient was admitted for urgent CVVH given his obvious
clinical volume overload causing dyspnea and relative hypoxia.
Previously, the dialysis team had been unable to remove enough
fluid intermittently without causing significant hypotension.
The patient was begun on CVVH by the renal team with an emergent
need for levophed to be run concurently through his return
dialysis line to support his blood pressure, even during a more
gentle CVVH. In addition, he had cardiac enzyme elevations and a
newly dropped EF from 40% to 20% on this admission, likely
secondary to demand ischemia due to his volume overload. He was
initially begun on integrillin and a heparin drip to treat
possible occlusive thrombotic heart disease. His oxygenation
improved but he was unable to be weened from his vasopressor
medications while on CVVH. In discussion with the patient and
his family, it was made clear that the patient wanted to return
to his previous quality of life, only requiring intermittent HD.
However, it was also clear that it was very unlikely he would be
able to return to this state. In discussion with the patient and
his family, it was decided to make the patient comfort measures
only. All non-comfort medications were stopped including CVVH
and levophed and the patient was made comfortable using
intermittent morphine by IV. The patient expired peacefully
surrounded by family approximately 24 hours after
discontinuation of pressors and CVVH.
Medications on Admission:
Levothyroxine 175mcg daily
Sevelamer 2400mg TID
Imdur 30mg daily
Renal cap daily
Discharge Medications:
none, expired
Discharge Disposition:
Expired
Discharge Diagnosis:
End stage renal disease on hemodialysis
Acute on chronic systolic heart failure
Discharge Condition:
Expired
Discharge Instructions:
None, expired
Followup Instructions:
Expired
|
[
"785.51",
"424.0",
"585.6",
"412",
"403.91",
"410.71",
"V45.1",
"244.9",
"428.0",
"785.52",
"416.8",
"995.92",
"414.01",
"038.9",
"397.0",
"428.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
7773, 7782
|
6147, 7603
|
261, 267
|
7905, 7914
|
3162, 6124
|
7976, 7986
|
2654, 2658
|
7735, 7750
|
7803, 7884
|
7629, 7712
|
7938, 7953
|
2673, 3143
|
2157, 2270
|
202, 223
|
295, 2138
|
2292, 2581
|
2597, 2638
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,020
| 119,316
|
26053
|
Discharge summary
|
report
|
Admission Date: [**2135-10-27**] Discharge Date: [**2135-10-28**]
Date of Birth: [**2083-10-3**] Sex: F
Service: MEDICINE
Allergies:
Darvocet-N 50 / Sumatriptan / Penicillins / Midrin / Ketorolac
Attending:[**First Name3 (LF) 5438**]
Chief Complaint:
Clonazepam, Seroquel, Trazodone, Keflex
Major Surgical or Invasive Procedure:
Intubated [**10-27**] AM, extubated [**10-27**] AM
History of Present Illness:
52yo F with bipolar and depresion presents with overdose. She
was found somnolent and was intubated on the field for
unresponsiveness. Per EMS and ED notes, patient was reportedly
found with empty pill bottles from klonopin, trazodone, and
keflex. Patient now recalls only taking "about 12" seroquel
tablets, nothing more. She does not remember anything more
after taking them until she awoke in the hospital. She has
history of suicide attempts in the past. She was last
hospitalized in [**2119**] for a suicide attempt. She has been
followed by psychiatrists in the past, but has not seen one
since [**2135-4-3**].
.
IN ED, her vital signs were T98.5 P72 BP92/56 R 14 O2100%. She
was given activated charcoal. SHe was also apparently paralyzed
for transport to the ED per verbal report. ALthough her
paralytics were stopped, there was no spontaneous movement. CT
head was negative for blood. She was guiac negative. EKG showed
prolonged QT. Urine tox was positive for benzo and methadone.
Past Medical History:
PMH:
hypertension
hard of hearing
history of suicide attempts
anxiety
bipolar disorder
depression
currently under outpatient psychiatry treatment
Social History:
Social history:
Rare alcohol, experimented with cocaine and heroin in the past,
narcotic seeker by report, lives with son and daughter.
Family History:
Noncontributory.
Physical Exam:
PE:
P72 BP 108/49
Gen- intubated, sedated
HEENT- pinpoint pupils b/l, nonreactive pupils, mmm, neck supple
CV- rrr, no r/m/g
resp- CTAB
abdomen- soft, NT/ND
ext- no edema, equivocal plantar reflexes
Pertinent Results:
[**2135-10-27**] 04:32AM GLUCOSE-116* UREA N-13 CREAT-0.7 SODIUM-140
POTASSIUM-4.6 CHLORIDE-110* TOTAL CO2-21* ANION GAP-14
[**2135-10-27**] 04:32AM WBC-8.4 RBC-3.63* HGB-11.0* HCT-32.0* MCV-88
MCH-30.4 MCHC-34.5 RDW-14.0
[**2135-10-27**] 04:32AM PLT COUNT-172
[**2135-10-27**] 01:50AM URINE HOURS-RANDOM
[**2135-10-27**] 01:50AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-POS
[**2135-10-27**] 01:50AM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.016
[**2135-10-27**] 01:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2135-10-27**] 01:50AM URINE RBC-0 WBC-0 BACTERIA-FEW YEAST-NONE
EPI-0
[**2135-10-27**] 01:50AM URINE AMORPH-MOD
[**2135-10-27**] 01:12AM TYPE-ART TEMP-36.9 RATES-/14 TIDAL VOL-600
O2-50 PO2-197* PCO2-37 PH-7.37 TOTAL CO2-22 BASE XS--3
-ASSIST/CON INTUBATED-INTUBATED
[**2135-10-27**] 01:12AM LACTATE-3.9*
[**2135-10-27**] 01:12AM freeCa-1.21
[**2135-10-27**] 12:49AM K+-3.8
[**2135-10-27**] 12:45AM GLUCOSE-118* UREA N-17 CREAT-0.8 SODIUM-139
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-22 ANION GAP-18
[**2135-10-27**] 12:45AM CALCIUM-9.6 PHOSPHATE-4.9* MAGNESIUM-1.9
[**2135-10-27**] 12:45AM MAGNESIUM-1.9
[**2135-10-27**] 12:45AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2135-10-27**] 12:45AM WBC-10.7 RBC-4.06* HGB-12.4 HCT-34.7* MCV-85
MCH-30.6 MCHC-35.9* RDW-14.0
[**2135-10-27**] 12:45AM NEUTS-77.3* LYMPHS-17.2* MONOS-4.3 EOS-1.0
BASOS-0.3
[**2135-10-27**] 12:45AM PLT COUNT-226
Brief Hospital Course:
A/P:
52yo F with hypertension and prior suicide attempts found
unresposive, believe to have overdosed on Clonazepam, Trazodone,
Seroquel.
.
# Clonazepam, Trazodone OD:
CT Head was performed to assess for midline shift due to edema
or fluid shifts, and was found to be negative. Concern for
Trazodone OD (t1/2 = 7 hrs) was in EKG changes, seizures,
respiratory distress. Treatment was supportive. Concern for
Clonazepam OD (t1/2 = 30-40 hrs) was somnolence, confusion,
coma, diminished reflexes. Treatment included monitoring of
respiration, pulse and blood pressure, general supportive
measures. Intravenous fluids were administered to euvolemia,
and patient was intubated for airway protection. Dialysis is of
no known value in these drug ODs. Patient was intubated on
[**10-27**] AM on admission, and extubated on [**10-27**] AM without
weaning. After extubation, vital signs were completely stable,
O2 saturation was 100% on room air, patient was communicating
clearly and asking questions, and was eating a regular diet and
drinking fluids without problems swallowing or choking.
.
Another concern was methadone which was found in urine tox
screen. Patient stated that she did not know how she could have
taken methadone since she does not usually take methadone. She
has not been prescribed methadone either for heroin addiction or
for pain control. [**Name (NI) **] brother stated "she will take
anything she can get her hands on". Patient denies taking
methadone.
.
Another concern was seroquel, of which patient states she took
12 tablets. Supportive treatment was given.
.
Psych consult assessed patient on [**10-28**], and recommended
inpatient psych hospitalization. Patient was agitated from
[**10-27**] to [**10-28**], stating that she wanted to leave repeatedly, and
that she needed to make her daughter's court date [**10-28**] at 9 am.
Plan was to call code purple if patient attempted to leave.
Patient needs 1:1 sitter on floor. Patient is medically cleared
to go directly from [**Hospital Unit Name 153**] to psych unit.
.
## Respiratory failure [**1-5**] obtundation from overdose:
Patient was intubated [**10-27**] AM, extubated [**10-27**] AM without
weaning. Mental status was wnl immediately after extubation,
vital signs stable, 100% O2 saturation on room air.
.
## HTN:
Patient was taken off Toprol 100 QD upon admission, and placed
back on Toprol on [**10-27**].
Medications on Admission:
Medication list:
seroquel 400mg hs
klonopin 1mg TID
prozac 40mg daily
toprol 100mg daily
.
Allergy:
darvocet, dichlorophenazone, imitrex, isometheptene, ketorolac,
midrin, penicillin, propoxyphene, sumatriptan
Discharge Medications:
1. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
2. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
none
Discharge Diagnosis:
Trazodone, Clonazepam, Methadone overdose; presumed Seroquel
overdose per patient
Discharge Condition:
Good, vital signs stable, satting 100% room air, eating regular
diet, drinking fluids well, communicating and mentating clearly
Discharge Instructions:
1. Please take all medications as prescribed.
Followup Instructions:
Please follow up with your primary care physician and your
psychiatrist within the next week.
Completed by:[**2135-10-28**]
|
[
"780.09",
"311",
"969.3",
"518.81",
"965.02",
"969.0",
"E950.0",
"E950.3",
"296.80",
"401.9",
"969.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
6544, 6575
|
3641, 6051
|
365, 417
|
6701, 6831
|
2033, 3618
|
6926, 7052
|
1781, 1799
|
6311, 6521
|
6596, 6680
|
6077, 6288
|
6855, 6903
|
1814, 2014
|
286, 327
|
445, 1442
|
1464, 1611
|
1643, 1765
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,628
| 189,711
|
30634
|
Discharge summary
|
report
|
Admission Date: [**2154-9-8**] Discharge Date: [**2154-9-10**]
Date of Birth: [**2128-7-28**] Sex: F
Service: MEDICINE
Allergies:
Vistaril
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Alcohol Intoxication
Major Surgical or Invasive Procedure:
none
History of Present Illness:
26 yoF w/ a h/o EtOH abuse, hepatitis (HCV, EtOH), chronic
pancreatitis, multiple admissions for EtOH intoxication and
pancreatitis, brought to [**Hospital1 18**] after being found by friends to
be sleepy and intoxicated. Patient notes that she had only 3
shots of tequila yesterday. She denies any other drugs. She
notes that she has been extremely upset whenever she is not
drinking because she is reminded that her children were taken
from her by DSS. She states this is because there was concern
that her husband was hitting her. However, she strongly denies
this.
.
Of note, recent admission [**2154-9-6**] for abdominal pain, alcohol
intoxication, and suicidal ideation. She reported RLQ/flank pain
radiating to back, blood in stools, and vomiting. In the ED,
pelvic exam showed cervical motion tenderness and she was given
ceftriaxone and azithromycin for presumed PID. A CT abdomen
showed a distended gallbladder with wall thickening as well as
diffuse colonic wall thickening. She also had a RUQ US that
showed similar findings, concerning for cholecystitis. She was
started on flagyl and Surgery was consulted who felt her exam,
lack of fever, and normal WBC count were not consistent with
cholecystitis and attributed gallbladder abnormalities to liver
disease and anorexia/malnutrition. She was admitted to medicine
for further evaluation. However, upon arriving to the floor,
patient requested to leave AMA. Psychiatry was consulted and
patient deemed to have capacity. She was given presciptions for
cipro and flagyl to be taken for 14 days for empiric treatment
of cholecystitis vs. colitis.
.
In ED, T 98.8, BP 113/40, HR 96, RR14, O2 93% RA. Serum EtOH
375 but other tox negative. Initial lactate of 4. Amylase and
lipase elevated (amylase not above typical levels but lipase
elevated from prior), LFTs within typical range, INR elevated
but at baseline. Patient complained of RUQ pain and an
ultrasound was performed which showed persistent changes c/w
prior u/s. Surgery was consulted who again felt that these
changes were most likely secondary to cirrhosis and anorexia.
While in the ED, her BPs dropped to the SBPs of 80s-90s and she
received 5 L of NS. Patient received 3 grams of Unasyn. Of
note, patient's SBPs have been in the 90s-100s during all of her
previous hospitalizations. However, due to hypotension, patient
was admitted to the ICU for closer monitoring.
.
Upon arrival to the floor, patient continues to complain of
RUQ/R flank pain. She notes that she has had this [**6-20**] pain
constantly since she "fell" at home on Friday and hit her side
on her bed frame. She denies any change in this pain with deep
breaths, with po intake, or with position. She also reports
feeling "out of her own head", not realizing what she is saying
when she is saying it. Also notes feeling like "she can't hold
her hands still". She otherwise complains of being sore all over
and anxious. She denies any recent fevers, chills, nightsweats,
sick contacts, cough, urinary complaints, nausea, vomiting,
diarrhea. She has felt thirsty and has had decreased UOP since
Friday but also has not eaten since Friday because of concern
for her children.
Past Medical History:
EtOH abuse (admissions in [**5-/2154**] and [**6-/2154**] for
intoxication/chronic pancreatitis); sought inpatient detox on
[**7-11**] but left facility early because of "nerves")
Alcoholic hepatitis
Anxiety
Tremor
Chronic pancreatitis
Social History:
Has two young children who she reports were taken by DSS the
night of presentation to the ER. Lives at home with husband,
chart with history of physical abuse by him, patient denies.
Long history of EtOH abuse, was clean for 1.5 years while
pregnant with her son, relapsed without known precipitant,
reports 8 beers per day. Denies tobacco, denies other drugs.
Family History:
Both parents with DM2. Father with alcoholism and on
hemodialysis.
Physical Exam:
T: 96.0 BP: 90/51 HR: 72 RR: 14 O2 100% RA
Gen: anxious, smells of alcohol, mildly tremulous
HEENT: Ecchymoses surrounding L eye. No conjunctival pallor.
MMM. OP clear.
NECK: Supple, No LAD, No JVD.
CV: RRR. nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**]
LUNGS: CTAB, good BS BL, No W/R/C
ABD: NABS. Soft. TTP in R flank. No RUQ tenderness. Negative
[**Doctor Last Name 515**] sign. No epigastric tenderness.
EXT: WWP, NO CCE. 2+ DP pulses BL
SKIN: Multiple ecchymoses over UEs and LEs. LUE with ecchymoses
in shape of fingers
NEURO: A&Ox3. CN 2-12 intact. Moving all extremities.
Pertinent Results:
[**2154-9-8**] 06:41PM LACTATE-3.3*
[**2154-9-8**] 04:07PM LACTATE-3.4* K+-3.7
[**2154-9-8**] 03:55PM GLUCOSE-70 UREA N-5* CREAT-0.5 SODIUM-145
POTASSIUM-3.4 CHLORIDE-110* TOTAL CO2-24 ANION GAP-14
[**2154-9-8**] 03:55PM WBC-4.7 RBC-2.65* HGB-9.7* HCT-29.3* MCV-111*
MCH-36.6* MCHC-33.1 RDW-18.8*
[**2154-9-8**] 03:55PM NEUTS-56.0 BANDS-0 LYMPHS-40.3 MONOS-2.8
EOS-0.3 BASOS-0.7
[**2154-9-8**] 03:55PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-2+
MACROCYT-2+ MICROCYT-1+ POLYCHROM-NORMAL TARGET-1+ ENVELOP-2+
[**2154-9-8**] 03:55PM PLT COUNT-179
[**2154-9-8**] 01:23PM COMMENTS-GREEN TOP
[**2154-9-8**] 01:23PM LACTATE-4.0*
[**2154-9-8**] 12:40PM URINE HOURS-RANDOM
[**2154-9-8**] 12:40PM URINE HOURS-RANDOM
[**2154-9-8**] 12:40PM URINE GR HOLD-HOLD
[**2154-9-8**] 12:40PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2154-9-8**] 12:40PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.003
[**2154-9-8**] 12:40PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2154-9-8**] 12:40PM URINE RBC-0 WBC-0 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2154-9-8**] 12:15PM GLUCOSE-67* UREA N-5* CREAT-0.6 SODIUM-143
POTASSIUM-3.5 CHLORIDE-106 TOTAL CO2-22 ANION GAP-19
[**2154-9-8**] 12:15PM ALT(SGPT)-108* AST(SGOT)-348* LD(LDH)-595*
ALK PHOS-122* AMYLASE-238* TOT BILI-3.6* DIR BILI-2.3* INDIR
BIL-1.3
[**2154-9-8**] 12:15PM LIPASE-64*
[**2154-9-8**] 12:15PM ALBUMIN-2.7*
[**2154-9-8**] 12:15PM ASA-NEG ETHANOL-375* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2154-9-8**] 12:15PM WBC-4.8 RBC-2.86* HGB-10.5* HCT-30.2*
MCV-106* MCH-36.6* MCHC-34.7 RDW-19.0*
[**2154-9-8**] 12:15PM NEUTS-64.0 LYMPHS-32.1 MONOS-3.6 EOS-0.1
BASOS-0.3
[**2154-9-8**] 12:15PM PLT COUNT-207
[**2154-9-8**] 12:15PM PT-16.5* PTT-37.1* INR(PT)-1.5*
Brief Hospital Course:
Pt admitted for EtoH intoxication, sent to MICU for hypotension
and question of acute on chronic pancreatitis. Pt responded
appropriately to fluid resuscitation and her hypotension
resolved to her baseline blood pressures within the first 24
hours of her admission. She required repeated doses of diazepam
for mild hand tremors and "feeling anxious" but did not actively
display frank withdrawal symptoms from alcohol. Her pancreatic
enzymes remained elevated consistent with chronic pancreatitis,
but the patient had resolved abdominal pain, a non-elevated
white blood cell count, and no fever. On the morning of [**9-10**]
the patient had no further complaints of her abdominal pain, had
a normal mental status, was ambulating, and tolerating a regular
diet. She did complain of occasional diarrhea, possibly after
ingestion of dairy products. The patient was seen by social
work while she was here, and in discussion with the MICU team
was put under "section 35" restrictions which require her to
appear in court for evaluation for possible mandatory referral
for inpatient alcohol treatment. The patient was in stable
condition on the morning of [**9-10**] awaiting discharge and
transport to her court appointment. However, prior to arrival
of escort to her court appointment, the patient left the
hospital against medical advice. The legal office was aware of
the patient leaving against medical advice.
Medications on Admission:
Ativan and Librium prn "shakes" per patient
Cipro and Flagyl prescribed [**9-6**] during recent admission
Discharge Medications:
Continue home medications as previously prescribed:
Ativan and Librium prn "shakes" per patient
Cipro and Flagyl prescribed [**9-6**] during recent admission
Discharge Disposition:
Home
Discharge Diagnosis:
1. Alcohol intoxication and abuse
2. Chronic Pancreatitis
3. Hepatitis C
Discharge Condition:
stable
Discharge Instructions:
You are being discharged from the hospital. You are required to
attend court as discussed with the social worker and ICU team.
Please attend your court appointment today- you may be arrested
if you do not.
Followup Instructions:
We strongly recommend that you are admitted to an inpatient
alcohol rehab facility. You may be required to enter such a
facility as ordered in a court of law. Please also call your
regular doctor to arrange follow-up for your other medical
problems including pancreatitis and hepatitis.
|
[
"458.0",
"305.01",
"577.1",
"070.54"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8497, 8503
|
6741, 8158
|
287, 294
|
8620, 8629
|
4849, 6718
|
8884, 9176
|
4152, 4221
|
8315, 8474
|
8524, 8599
|
8184, 8292
|
8653, 8861
|
4236, 4830
|
227, 249
|
322, 3498
|
3520, 3757
|
3773, 4136
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,963
| 125,476
|
2088
|
Discharge summary
|
report
|
Admission Date: [**2123-10-4**] Discharge Date: [**2123-11-1**]
Date of Birth: [**2060-9-23**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Morphine / Preservative / Amoxicillin / Ciprofloxacin
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
ascites and LE edema
Major Surgical or Invasive Procedure:
[**2123-10-5**] MV repair/TV repair/ right atrial thrombectomy with RAA
ligation (28 mm [**Company 1543**] CG Future Mitral ring/ 34 mm CE MC3
tricuspid ring)
History of Present Illness:
62 yo female initially seen in early [**Month (only) 216**] for evaluation of
MR/TR in the setting of LE edema and ascites. Echo in [**2123-6-25**]
revealed 4+ MR, 3+ TR, 1+ AI, and dilated main PA and RA.
Referred to Dr. [**Last Name (STitle) 1290**] for surgery. This was delayed pending
preoperative workup as well as the pt's concerns regarding
probable need for blood transfusions.Preop workup complete
during an admission in late [**Month (only) 216**] that included cath, PICC
placement for IV access,as well as treatment for a UTI. Her INR
did not ever completely normalize given continuing hepatic
issues. PICC was removed prior to this admission. Returns now
for surgery.
Past Medical History:
NIDDM
chronic AFib
ascites
prolactinoma
childhood polio
hypothyroidism (Hashimoto's thyroiditis)
sleep apnea
CHF
pulm. HTN
left breast CA/mastectomy
peripheral neuropathy
left shoulder fx
left foot fx
PSH: right partial thyroidectomy
right breast lumpectomy
TAH/BSO
Social History:
4 drinks per week
Family History:
Noncontributory
Physical Exam:
NAD
56.7 kg 65" 95.5 T 98% RA sat. 73 A fib 110/70 RR 22
alert and oriented x3
MAE [**5-29**] BUE, [**4-29**] BLE
old abd scar healed
EOMI PERRLA
neck supple, with full ROM, no carotid bruits
CTAB posteriorly
Irregular 2/6 systolic murmur
abd soft, NT, distended, + BS, ascites
extrems warm, well-perfused
1+ bil. DP/PT/radials
2+ bil. fems
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 5269**] [**Last Name (NamePattern1) **] [**Hospital1 18**] [**Numeric Identifier 11319**]TTE (Complete)
Done [**2123-10-4**] at 5:04:26 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Last Name (Prefixes) 413**], [**First Name3 (LF) 412**]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2060-9-23**]
Age (years): 63 F Hgt (in): 65
BP (mm Hg): 92/60 Wgt (lb): 116
HR (bpm): 78 BSA (m2): 1.57 m2
Indication: Left ventricular function. Preoperative assessment.
Valvular heart disease.
ICD-9 Codes: V43.3, 424.1, 424.0, 424.2
Test Information
Date/Time: [**2123-10-4**] at 17:04 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) 4082**], MD
Test Type: TTE (Complete) Son[**Name (NI) 930**]: [**First Name11 (Name Pattern1) 11320**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], RDCS
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Adequate
Tape #: 2007W037-0:00 Machine: Vivid [**8-1**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.3 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.1 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *6.5 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: 3.6 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 60% >= 55%
Aorta - Sinus Level: 2.8 cm <= 3.6 cm
Aorta - Ascending: 2.6 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.5 m/sec <= 2.0 m/sec
Aortic Valve - Pressure Half Time: 424 ms
Mitral Valve - E Wave: 1.0 m/sec
TR Gradient (+ RA = PASP): 14 mm Hg <= 25 mm Hg
Pulmonic Valve - Peak Velocity: 0.7 m/sec <= 1.5 m/sec
Findings
This study was compared to the prior study of [**2123-9-23**].
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Normal
IVC diameter (1.5-2.5cm) with <50% decrease during respiration
(estimated RAP 11-15mmHg).
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). [Intrinsic LV
systolic function likely depressed given the severity of
valvular regurgitation.]
RIGHT VENTRICLE: Moderately dilated RV cavity. Normal RV
systolic function. [Intrinsic RV systolic function likely more
depressed given the severity of TR]. Abnormal diastolic septal
motion/position consistent with RV volume overload.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Eccentric
MR jet. Moderate (2+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Tricuspid leaflets do not fully coapt. Severe [4+] TR. Normal PA
systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: The rhythm appears to be atrial fibrillation.
Ascites.
Conclusions
The left and right atrium are moderately dilated. The estimated
right atrial pressure is 11-15mmHg.There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF >55%) [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of mitral regurgitation.] Right ventricular chamber
size is moderately increased with normal free wall motion.
[Intrinsic right ventricular systolic function is likely more
depressed given the severity of tricuspid regurgitation.] There
is abnormal diastolic septal motion/position consistent with
right ventricular volume overload. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. An eccentric, anteriorly directed jet of
moderate (2+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened and fail to fully coapt. Severe
[4+] tricuspid regurgitation is seen. The estimated pulmonary
artery systolic pressure is high normal. There is a
trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2123-9-23**],
the findings are similar (TR was also severe on the prior
study).
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting
physician
RADIOLOGY Preliminary Report
CHEST (PORTABLE AP) [**2123-10-23**] 7:25 AM
CHEST (PORTABLE AP)
Reason: placement of dophoff tube confirmation
[**Hospital 93**] MEDICAL CONDITION:
63 year old woman s/p MV repair/TV repair now s/p tracheostomy
REASON FOR THIS EXAMINATION:
placement of dophoff tube confirmation
HISTORY: Dobbhoff tube placement.
Single portable radiograph of the chest demonstrates no change
in the support lines when compared with [**2123-10-21**]. Right-sided
pleural effusion persists and is unchanged. There may be slight
interval improvement in the previously seen left-sided pleural
effusion. Bibasilar atelectasis persists. No pneumothorax is
identified. Trachea is midline. Cardiomediastinal contours are
unchanged.
IMPRESSION:
Slight interval improvement in left-sided pleural effusion,
otherwise no change.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6892**]
?????? [**2119**]
Brief Hospital Course:
Admitted [**10-4**] and underwent surgery on [**10-5**] with Dr. [**Last Name (STitle) 1290**].
Please refer to the operative note for details. Transferred to
the CVICU on epinephrine, propofol and nitroglycerin drips.
Epinephrine weaned off due to VTach. Extubated that night, but
reintubated the following afternoon for increasing acidosis and
mental status changes. Renal consult also done for decreasing
urine output.Echo also done with no significant findings. EP
service also consulted for her chronic Afib management.
Extubated again on the morning of [**10-9**], but reintubated again a
few hours later for resp. failure.
She was noted to have ventilator associated pneumonia on [**10-11**].
She was treated with vancomycin, levofloxacin, and meropenem.
She was followed by the Renal service for continued renal
failure. On [**10-14**], she was noted to be positive for Clostridium
difficile toxin in her stool, and she was treated with Flagyl.
At this point, she was on Vancomycin and Flagyl. She was unable
to wean from the ventilator and underwent a tracheostomy on
[**2123-10-21**].
Throughout her course, he bilirubin counts had risen steadily.
She was initiated on hemodialysis. She was maintained
supportively, but with no signs of improvement. She was
unresponsive to painful stimuli, and an EEG demonstrated
encephalopathy. She was given lactulose and rifaximin with th
eintent of clearing any hepatic encephalopathy.
She was evaluated by the renal service, hepatology service and
the transplant surgery service. All felt that her condition was
critical and likely irreversible. Her family was [**Name (NI) 653**], and
met with social work, hepatology, and the on-call intensivist.
The decision was made to change her code status to Comfort
Measures.
A fentayl drip was initiated and her pressors were withdrawn
at 6:45 PM, [**11-1**]. Her blood pressure declined, and her heart
rhythm degenerated to ventricular tachycardia, fibrillation, and
then asystole. She was pronounced at 7:54 PM, [**2123-11-1**]. The
family requested tha a post-mortem be performed.
Medications on Admission:
Liothyronine 400 mcg daily
JANUVIA 50 mg daily
Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr twice
daily
Bumetanide 4 mg twice daily
Spironolactone 25 mg twice daily
Vicodin 5-500 mg One Tablet PO every 6-8 hours as needed for
pain.
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiac failure
Discharge Condition:
Deceased
Discharge Instructions:
none
Followup Instructions:
None
|
[
"518.5",
"427.31",
"286.9",
"997.3",
"V10.3",
"997.5",
"008.45",
"584.5",
"250.00",
"458.29",
"486",
"401.9",
"424.0",
"397.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"37.99",
"31.1",
"39.61",
"96.71",
"35.12",
"37.33",
"96.6",
"39.95",
"35.14"
] |
icd9pcs
|
[
[
[]
]
] |
10144, 10153
|
7721, 9819
|
341, 502
|
10213, 10224
|
1961, 6873
|
10277, 10285
|
1555, 1572
|
10115, 10121
|
6910, 6973
|
10174, 10192
|
9845, 10092
|
10248, 10254
|
1587, 1942
|
281, 303
|
7002, 7698
|
530, 1213
|
1235, 1503
|
1519, 1539
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,059
| 132,157
|
18909
|
Discharge summary
|
report
|
Admission Date: [**2111-8-16**] Discharge Date: [**2111-8-22**]
Service: [**First Name9 (NamePattern2) **] [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: The patient is an 87-year-old
woman with a history of diabetes, hypertension, and a high
cholesterol with a history of previous tobacco smoking who
had a recent history of left humeral fracture who presented
to an outside hospital with substernal chest discomfort and
nausea from home. She was found to have EKG changes
consistent with myocardial ischemia and was transferred to
the [**Hospital6 256**] for further
evaluation. She was found to have a non-Q wave myocardial
infarction and was admitted to the Cardiology service, where
further workup was performed.
PHYSICAL EXAMINATION: The patient is a pleasant, elderly
woman who had extensive ecchymosis of the left upper
extremity. She had some decreased breath sounds at the right
base consistent with question of consolidation on her x-ray.
She had regular cardiac rhythm. Pulses were diminished in
both lower extremities with an absent right femoral pulse and
a weak left femoral pulse. EKG showed diffuse S-T
depressions with 1 mm S-T elevation in AVR.
HOSPITAL COURSE: The patient underwent cardiac cath on
[**2111-8-18**] which showed 80% stenosis of the left main
coronary artery and occluded right coronary artery and
diffuse disease of the other vessels. The patient had poor
ventricular dysfunction with an ejection fraction of 25 to
30% on echo. However, at that cardiac cath her right iliac
artery was found to be occluded so a balloon pump could not
be placed.
Post procedure the patient also had some coffee ground emesis
and was also found to have an elevated white blood cell count
of 20,000 and a question of a left lower lobe infiltrate as
well as white blood cells on her urinalysis. She was felt to
be a high risk operative candidate, but given her good
functional status and her diffuse coronary vascular disease,
it was felt that operation was really her only option.
On [**2111-8-19**] she underwent coronary artery bypass times
three with left internal mammary artery graft to a proximal
diag. and saphenous vein graft to obtuse marginal and right
coronary artery. Postoperatively the patient remained on
Dobutamine for inotropy and was generally stable postop day
zero.
Around 4 a.m. on postoperative day number one she developed
unstable dysrhythmias with both supraventricular narrow
complex dysrhythmias as well as a brief run of ventricular
tachycardia. She was defibrillated and afterward remained
hemodynamically stable. She was started on an Amiodarone
drip.
On postoperative day number two she was substantially more
stable with no real further rhythm problems. She was
extubated on the afternoon of postoperative day number two
and was progressing in her post CABG recovery.
On the morning of postoperative day number three the patient,
however, took a turn for the worse. She was in some
respiratory distress and her cardiac numbers began to
deteriorate with a reduced cardiac index. Her Dobutamine was
increased and started on epinephrine. Cardiac echo was
obtained at the bedside which did not show any focal
dyskinetic myocardial segments. She was then taken for a
cardiac cath for diagnostic purposes and to possibly
revascularize her percutaneously in the event that her bypass
grafts were down.
At Angio she indeed was found to have occluded saphenous vein
grafts times two. Revascularization of the obtuse marginal
was attempted, but the circumflex could not be traversed.
Patient during this intervention became progressively more
hypotensive and eventually developed electromechanical
dissociation. Resuscitation was attempted, unfortunately,
without success, and the patient expired in the Cardiac Cath
Lab.
DISCHARGE CONDITION: Death.
DISCHARGE STATUS: As above.
DISCHARGE DIAGNOSES:
1. Hypertension.
2. Diabetes.
3. Hypercholesterolemia.
4. Status post humeral fracture.
5. Status post coronary artery bypass graft times three on
[**2111-8-19**] with diffuse coronary artery disease.
6. Postoperative dysrhythmias.
7. Occlusion of saphenous vein grafts with death on cardiac
catheterization.
DISCHARGE MEDICATIONS: Not applicable.
DISCHARGE INSTRUCTIONS: Not applicable.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern4) 51711**]
MEDQUIST36
D: [**2111-8-24**] 10:52
T: [**2111-8-25**] 12:53
JOB#: [**Job Number 51712**]
|
[
"785.51",
"427.1",
"414.01",
"996.72",
"E878.2",
"486",
"410.71",
"428.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"88.53",
"88.56",
"88.55",
"99.20",
"37.23",
"37.22",
"36.12",
"38.93",
"88.52"
] |
icd9pcs
|
[
[
[]
]
] |
3825, 3863
|
3884, 4201
|
4225, 4242
|
1204, 3803
|
4267, 4562
|
758, 1186
|
168, 735
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,175
| 150,649
|
41095
|
Discharge summary
|
report
|
Admission Date: [**2196-5-8**] Discharge Date: [**2196-5-17**]
Date of Birth: [**2161-11-27**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Motorcycle crash
Major Surgical or Invasive Procedure:
[**2196-5-8**] IRRIGATION AND DEBRIDEMENT RIGHT FEMUR/ WOUND; EXTERNAL
FIXATION RIGHT FEMUR; VAC DRESSING APPLICATION [**Doctor Last Name 5322**]
[**2196-5-10**] 1. ORIF RIGHT HIP WITH T.FN NAIL. 2. ORIF RIGHT FEMUR
WITH [**Last Name (un) 101**] PLATE 3. I AND D RIGHT POSTERIOR WOUND RIGHT LEG.
4.APPLICATION OF WOUND VAC RIGHT THIGH. 5. REMOVAL EX-FIXATOR
RIGHT LEG. [**Location (un) **]
[**2196-5-13**] 1. I AND D RIGHT LEG. APPLICATION OF WOUND VAC SPONGE
History of Present Illness:
38yo M who was involved in a MCC vs. Auto at ~25MPH. The patient
was a helmeted motorcyclist who was reportedly stationary when
he was hit by a car. There was no loss of consciousness. He had
an obvious open femur fracture. His vital signs were stable in
the field. He received a total of 400 mcg of fentanyl and 1 mg
of Ativan. He also received antibiotics in the field. he was
transported to [**Hospital1 18**] for further care. He is complaining of
right leg pain. He denies neck or back pain or abdominal or
chest pain.
Past Medical History:
- h/o obesity s/p gastric bypass (514lbs --> 200lbs)
- Dumping syndrome w/ any sugar (per family)
- concusion 2 months ago after fall onto back of head leading to
anosmia and the loss of sense of taste. Has had HAs since, for
which he is taking oxycodone
.
PSH:
- Gastric bypass
- Mastopexy
- Paniculectomy
- Appendectomy
- UHR
Family History:
noncontributory
Physical Exam:
Upon presentation to [**Hospital1 18**]:
Constitutional: Collar and backboard, obvious right femur
deformity
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Neck is in a collar, nontender
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender
Pelvic: Pelvis is stable
Extr/Back: Right lower extremity he does have positive PT
pulses. He has an obvious severe deformity of the right mid
femur shaft. There is a large laceration just above the
popliteal fossa approximately 15 cm long. There is no
obvious bone protruding. Back is nontender all showing
pulses are normal.
Neuro: Speech fluent, awake alert and oriented nonfocal.
Pertinent Results:
CT CHEST/ABD/PELVIS/LE [**5-8**]: *Final Read* 1. Extensively
comminuted right intertrochanteric and distal femoral fractures,
with over one shaft-width lateral displacement at the distal
fracture site, and extensive soft tissue irregularity and
hemorrhage.2. Multiple nondisplaced right rib fractures, as
above. No pneumothorax noted. This was called to Dr. [**First Name (STitle) 3449**]
[**Name (STitle) 3450**] on [**2196-5-8**] at 6:00 p.m. 3. No evidence of visceral or
vascular injury.
CTA LOWER/EXT [**5-8**]: *Final Read* 1. Extensively comminuted right
intertrochanteric and distal femoral fractures, with over one
shaft-width lateral displacement at the distal fracture site,
and extensive soft tissue irregularity and hemorrhage. 2.
Multiple nondisplaced right rib fractures, as above. No
pneumothorax noted. 3. No evidence of visceral or vascular
injury.
CT HEAD [**5-8**]: *Final Read* No ICH, no fx
CT CSPINE [**5-8**]: *Final Read* No fx
CXR [**5-10**]: widening at AC joint concerning for separation
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt
Ct
[**2196-5-17**] 05:40 6.6 2.99* 9.3* 28.0* 94 31.1 33.2 15.5 475*
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2196-5-17**] 05:40 90 13 0.5 136 4.5 102 27 12
Brief Hospital Course:
The patient was seen in the trauma bay and stabilized per ATLS
protocol. His injuries were found to be limited to his rib
fractures and RLE injuries. He did lose a significant volume of
blood during his resuscitation and in the field. The patient was
taken from the trauma bay to the operating room for external
fixation. Because of a large soft tissue defect, he could not be
definitively managed initially. He was taken from the operating
room to the TSICU intubated and sedated, with significant
bleeding from his wound VAC. This appeared to be diffuse in
nature with no acute arterial or large venous bleeding, so it
was managed expectantly with products. The following day the
patient returned to the operating room for definitive management
of his fractures as above. This was performed without
complication and the patient was extubated in the TSICU
following the procedure. His diet was advanced and he
transferred to the floor for further management.
Upon transfer to the floor his course was as follows:
He was noted with significant pain control issues requiring PCA
Dilaudid with IV and oral narcotics for breakthrough pain. He
was eventually weaned off of the PCA and given an oral pain
regimen. This regimen required several adjustments during his
stay. Currently his pain is controlled with po Dilaudid with IV
form being used for VAC dressing changes. His initial VAC change
was done in the operating room by Orthopedics. He has required
multiple blood transfusions over the course of his stay due to
acute blood loss volume. His most recent HCT was 28 on [**5-17**]. He
is receiving Heparin subcutaneously for DVT prophylaxis.
He was also seen by orthopedics for his right shoulder
dislocation and was ordered for a sling to be worn. He will
require follow up of this along with his other orthopedic
injuries in clinic as an outpatient.
He was evaluated by Physical and Occupational therapy and is
being recommended for rehab after his acute hospital stay.
Medications on Admission:
oxycodone PRN pain
Discharge Medications:
1. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
6. alprazolam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety.
7. docosanol 10 % Cream Sig: One (1) APPL Topical twice a day as
needed for cold sore.
8. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO TID (3 times a day).
9. hydromorphone 2 mg Tablet Sig: 2-4 Tablets PO Q3H (every 3
hours) as needed for pain.
10. senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **] [**Hospital1 **]
Discharge Diagnosis:
s/p Motorcycle crash
Injuries:
Right intertrochanter fracture
Right distal femur fracture
Right [**2-14**] rib fractures
Right shoulder dislocation
Acute blood loss anemia
Discharge Condition:
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
You were admitted to the hospital after a motorcycle crash where
you sustained multiple rib fractures and fractures of your right
leg. Your leg fractures required several operations and
placement of a special device called a VAC dressing. The VAC is
used to help with wound healing and is changed every 3 days.
You are being recommended for rehab stay after discharge from
the hospital to help with building your strength and endurance
following your trauma.
Followup Instructions:
Follow up in 2 weeks in [**Hospital 5498**] clinic, call [**Telephone/Fax (1) 1228**]
for an appointment.
Follow up in [**Hospital 2536**] clinic in 2 weeks, call [**Telephone/Fax (1) 600**] for an
appointment. You will need an end expiratory single view chest
xray for this appointment.
Completed by:[**2196-5-18**]
|
[
"807.09",
"831.00",
"821.23",
"V45.86",
"890.2",
"821.11",
"820.22",
"E812.2",
"V85.36",
"458.9",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"78.15",
"78.17",
"79.65",
"83.45",
"78.65",
"78.19",
"79.35",
"93.44"
] |
icd9pcs
|
[
[
[]
]
] |
6834, 6894
|
3826, 5805
|
320, 782
|
7110, 7225
|
2519, 3803
|
7770, 8090
|
1704, 1721
|
5874, 6811
|
6915, 7089
|
5831, 5851
|
7286, 7747
|
1736, 2500
|
264, 282
|
810, 1336
|
7240, 7262
|
1358, 1688
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,446
| 178,856
|
35306
|
Discharge summary
|
report
|
Admission Date: [**2158-1-5**] Discharge Date: [**2158-1-9**]
Date of Birth: [**2081-9-1**] Sex: F
Service: MEDICINE
Allergies:
Vicodin
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
[**Known firstname **] [**Known lastname 80517**] is a 76 yo female with PMH of major depressive
disorder, afib on coumadin, CAD s/p stent (details unclear),
right ICA 60-70% stenosis, CVA in [**8-24**], aphasic at baseline,
DM, DNR/DNI presenting to [**Hospital1 18**] emergency department from
nursing home with resp distress. This AM, she was noted to have
sudden onset hypoxia, 78% on 3L NC. It appears that she is on 3L
O2 at baseline. She received neb and her O2 increased to 86% on
4L NC. At that time, HR was 119 and BP 170/100. Tube feeds were
stopped. EMS was called. Per EMS, she was 70% on RA which
improved to 90's on O2. Upon presentation, to the ED, she was
tachypneic, rhonchorous with upper airway noise. Given a ?
history of CHF, she was given lasix and nitro with no
improvement. A CXR in the ED showed LLL pna, so IVF was started
for repletion and her lasix was stopped.
.
Vitals in the ED showed T 101.2, BP154/81, tachycardic at 126,
and breathing 32/min. Her lactate was 2.8, her WBC 36, and she
was bipap dependent. She received a dose of vanc, levo, and
ceftriaxone for pna.
.
Of note, she was recently admitted to [**Hospital **] Healthcare Center
from [**Hospital1 2177**] after massive CVA. Admitted to [**Hospital1 2177**] from [**12-18**], with
CVA secondary to afib. Hypoxic event. G-tube placed.
Past Medical History:
? CHF
Massive CVA at [**Hospital1 2177**] related to afib
DM2
HTN
Afib on coumadin, last INR 1.12 (yesterday)
h/o MVA [**8-24**]
CAD
Hypothyroidism
Psychosis
h/o homelessness
Social History:
Lives in [**Hospital **] Healthcare Center. Friend [**Name (NI) **] [**Name (NI) 56494**] is
HCP. Previously homeless. Has 2 daughters, whereabouts unknown.
Family History:
noncontributory
Physical Exam:
vitals:96.1 128/88 84 20 95%RA
gen: NAD, awake and alert, aphasic
heent: NCAT
pulm: difficult exam [**12-19**] to vocalization, coarse breath sounds
no w/r/r
cv: s1s2, irregular, no m/r/g
abd: soft, NTND, +BS, no rebound or gaurding, +PEG in place
extr: no c/c/e
neuro: does not communicate effectively but makes eye contact.
Follows simple commands. Does not wiggle right toes or squeeze
with right hand. Moves left arm and leg. No spontaneous movement
of right arm/leg.
Pertinent Results:
[**2158-1-5**] 08:58AM PT-16.2* PTT-26.1 INR(PT)-1.4*
[**2158-1-5**] 08:58AM PLT SMR-HIGH PLT COUNT-590*
[**2158-1-5**] 08:58AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+
[**2158-1-5**] 08:58AM NEUTS-84* BANDS-8* LYMPHS-5* MONOS-1* EOS-0
BASOS-1 ATYPS-1* METAS-0 MYELOS-0
[**2158-1-5**] 08:58AM WBC-36.4* RBC-4.85 HGB-15.1 HCT-45.6 MCV-94
MCH-31.2 MCHC-33.1 RDW-14.8
[**2158-1-5**] 08:58AM GLUCOSE-215* LACTATE-2.8* NA+-133* K+-5.4*
CL--88* TCO2-28
[**2158-1-5**] 08:58AM COMMENTS-GREEN TOP
[**2158-1-5**] 08:58AM CK-MB-NotDone proBNP-1686*
[**2158-1-5**] 08:58AM cTropnT-0.01
[**2158-1-5**] 08:58AM CK(CPK)-50
[**2158-1-5**] 08:58AM estGFR-Using this
[**2158-1-5**] 08:58AM GLUCOSE-235* UREA N-27* CREAT-0.8 SODIUM-129*
POTASSIUM-5.9* CHLORIDE-90* TOTAL CO2-29 ANION GAP-16
[**2158-1-5**] 09:09AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2158-1-5**] 09:09AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2158-1-5**] 11:18AM PT-16.7* PTT-25.8 INR(PT)-1.5*
[**2158-1-5**] 11:21AM PLT COUNT-575*
[**2158-1-5**] 11:21AM WBC-40.0* RBC-4.46 HGB-13.9 HCT-42.3 MCV-95
MCH-31.1 MCHC-32.7 RDW-14.5
[**2158-1-5**] 11:21AM ALBUMIN-4.0 CALCIUM-10.5* PHOSPHATE-5.1*
MAGNESIUM-1.8
[**2158-1-5**] 11:21AM GLUCOSE-201* UREA N-28* CREAT-0.8 SODIUM-133
POTASSIUM-5.3* CHLORIDE-93* TOTAL CO2-29 ANION GAP-16
[**2158-1-6**] 03:36AM BLOOD WBC-42.3* RBC-4.03* Hgb-12.5 Hct-37.8
MCV-94 MCH-31.1 MCHC-33.2 RDW-14.5 Plt Ct-530*
[**2158-1-9**] 05:10AM BLOOD WBC-12.2* RBC-3.69* Hgb-11.2* Hct-34.3*
MCV-93 MCH-30.3 MCHC-32.6 RDW-14.5 Plt Ct-637*
[**2158-1-9**] 05:10AM BLOOD PT-21.3* PTT-30.7 INR(PT)-2.0*
[**2158-1-9**] 05:10AM BLOOD Glucose-150* UreaN-12 Creat-0.4 Na-136
K-4.1 Cl-98 HCO3-31 AnGap-11
[**2158-1-8**] 06:00AM BLOOD ALT-15 AST-15 LD(LDH)-182 AlkPhos-107
Amylase-28 TotBili-0.8
[**2158-1-5**] 08:58AM BLOOD CK(CPK)-50
[**2158-1-8**] 06:00AM BLOOD Lipase-27
[**2158-1-5**] 08:58AM BLOOD cTropnT-0.01
[**2158-1-9**] 05:10AM BLOOD Calcium-8.8 Phos-2.7 Mg-2.1
[**2158-1-6**] 03:36AM BLOOD TSH-0.45
[**2158-1-6**] 07:23PM BLOOD Vanco-15.1
[**2158-1-5**] 08:58AM BLOOD Glucose-215* Lactate-2.8* Na-133* K-5.4*
Cl-88* calHCO3-28
Micro:
Urine [**1-5**], [**1-5**]: no growth
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2158-1-5**]):
Negative for Influenza A viral antigen.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2158-1-5**]):
NEGATIVE FOR INFLUENZA B VIRAL ANTIGEN.
Legionella Urinary Antigen (Final [**2158-1-6**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
Blood Cx: NGTD
CXR [**1-5**]
FINDINGS: A single AP upright view of the chest was obtained.
The cardiac
silhouette is normal in size. There is atherosclerotic disease
of the aorta.
The right lung is clear. There is focal airspace disease noted
at the left
lung base. No pleural effusions are identified. There is no
pneumothorax.
Multiple surgical clips are noted around the epigastrium and the
right upper
quadrant. The bones are diffusely demineralized. A J-tube is
noted in the
upper abdomen.
IMPRESSION:
Left basilar airspace disease likely representing pneumonia
versus
atelectasis. The former is favored.
Brief Hospital Course:
In summary, Ms. [**Known lastname 80517**] is a 76 yo with history of stroke
(aphasic at baseline), diabetes who presents in respiratory
distress, requiring BIPAP and ICU stay secondary to LLL pna.
.
Pneumonia. Ms. [**Known lastname 80517**] initially presented with sudden onset
hypoxia, 78% on 3L NC the day of admission; pt is on 3L O2 at
baseline. A CXR showed LLL pna and she was started on
Vancomycin, zosyn, levaquin an Flagyl. She was febrile to
101.2 in the ED. She was briefly on BIPAP. Her WBC was
initially elevated to 36 but improved with antibiotics. She was
afebrile throughout the rest of her hospital stay and her
antibiotics were narrowed to vancomycin and zosyn and she will
complete a 7 day course to be completed on [**1-13**]. A PICC was
placed for IV antibiotics. Her culture data remained negative
including legionella and influenza. Her WBC count trended down
with antibiotics and was 12.2 on discharge. She continues to be
DNR/DNI.
.
A. fib. Patient is on coumadin for secondary prevention of
stroke in A. fib. She had a recent stroke at [**Hospital1 2177**] this month
believed to be embolic from afib. Her INR was subtherapeutic on
admission. She was continued on coumadin 4mg and her became the
therapeutic. Her INR on discahrge was INR 2.0 and her coumadin
was dosed at 5mg. Her metoprolol and dilt her held initially
due to her infection. She was restarted on metoprolol 12.5mg
TID for rate control. Her metoprolol should be titrated up prn.
.
History of CVA at [**Hospital1 2177**] related to afib. Patient is aphasic at
baseline and unable to move her right side. She remains awake
and alert.
.
DM2: Pt is currently on TF and was placed on a sliding scale
insulin with finger sticks. Her sugars remained stable and her
fingersticks were disocntinued.
.
HTN: Her antihypertensives were held due to her infection. Once
stablized she was restarted on metoprolol 12.5 TID and
lisinopril
.
CAD: Patient is not on aspirin or ACE-I. Metoprolol was held
initially, but was resumed after she clinically improved from
her pneumonia.
.
Hypothyroidism. She was continued on levothyroxine.
.
Psychosis. She was continued on seroquel.
.
FEN. Patient was at goal for tube feeds and continued on these
during hospital stay.
.
DNR/DNI.
.
HCP [**Name (NI) **] [**Name (NI) 56494**] (family friend) [**Telephone/Fax (1) 80518**].
.
Medications on Admission:
levothyroxine 125mcg qday
seroquel 75mg TID
diltiazem 15mg QID
metoprolol succinate 25 QID (?)
prevacid 30mg qday
coumadin 5mg qday
scopalamine 1.5 td q 72 hrs
miralax
magnesium oxide 400mg qday
levsin 0.125 q 4hrs prn secretions
Discharge Medications:
1. Quetiapine 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
2. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
3. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual QID (4 times a day) as needed for
airway secretions.
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
5. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
11. Saline Flush 0.9 % Syringe Sig: One (1) Injection once a
day: for each port of PICC line.
12. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
13. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
Sig: One (1) 4.5g Intravenous Q8H (every 8 hours) for 4 days:
Last dose [**2158-1-13**].
14. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous Q 12H (Every 12 Hours) for 4 days: Last dose
[**2158-1-13**].
15. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare-[**Location (un) 86**]
Discharge Diagnosis:
Pneumonia
.
Type 2 Diabetes
Atrial fibrillation
Coronary artery disease
History of CVA
Discharge Condition:
Fair. She is not requiring supplemental oxygen. SHe remains
aphasic.
Discharge Instructions:
You were admitted for pneumonia. You were given antibiotics and
your symptoms improved. You will need to continue intravenous
antibiotics until [**2158-1-13**].
.
Please follow up with your primary care physician if you develop
shortness of breath, rapid breathing, fevers/chills, cough,
sputum production or any other concerning symptoms.
Followup Instructions:
You should follow up with your primary care physician 1-2 weeks.
|
[
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"507.0",
"V44.4",
"790.92",
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"401.9",
"275.42",
"238.71",
"428.0",
"414.01",
"296.24",
"433.10",
"438.11",
"276.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
10028, 10104
|
5860, 8232
|
284, 305
|
10235, 10307
|
2577, 5837
|
10697, 10766
|
2052, 2069
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10125, 10214
|
8258, 8490
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10331, 10674
|
2084, 2558
|
225, 246
|
333, 1663
|
1685, 1862
|
1878, 2036
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,758
| 143,423
|
55102
|
Discharge summary
|
report
|
Admission Date: [**2171-5-24**] Discharge Date: [**2171-5-31**]
Date of Birth: [**2099-5-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Exertional Chest Discomfort
Major Surgical or Invasive Procedure:
[**2171-5-27**] Coronary artery bypass graft times four (LIMA to LAD,
RSVG to Diagonal, RSVG to OM, RSVG to PDA), aortic valve
replacement with 23mm [**Last Name (un) 3843**]-[**Doctor Last Name **] valve.
History of Present Illness:
71 year old male with a prior CAD history who for the past month
has noted exertional chest discomfort. He complains of angina in
the center of his chest and shortness of breath after walking up
on incline or walking up one flight of stairs. The pain will
dissipate after stopping activity and resting for one minute.
This discomfort has been occurring for the past 4-5 weeks. He
was referred for a cardiac catheterization and is now being
referred to cardiac surgery for revascularization.
Past Medical History:
Coronary artery disease s/p Inferior Myocardial Infarction
[**7-/2163**] s/p stent of RCA
Keratosis
Hypertension
Osteoarthritis
Colon polyp
Hyperlipidemia
Dupuytren's contracture knuckle
s/p Tonsillectomy
Social History:
Works in genetics research at [**Hospital3 1810**] of [**Location (un) 86**].
Lives with his wife. [**Name (NI) **] three children (middle son w/muscular
dystrophy) and four grandchildren.
-Tobacco history: Never smoked; No smokeless tabacco
-ETOH: 1-2 beers/month
-Illicit drugs: Denies
Family History:
?????? Father had [**Name2 (NI) **] placed at 75
?????? Brother died at 60 with arrythmia
?????? Sister s/p MI with stent at age early 50s
?????? Mother had HTN
Physical Exam:
Pulse:59 Resp:16 O2 sat:96/RA
B/P Right:95/60 Left:108/62
Height: 6' Weight: 220 lbs
General: NAD, A+OX3
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur [] grade ______
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [] Edema [] _____
Varicosities: None []
Neuro: Grossly intact [X]
Pulses:
Femoral Right: Palp Left: Palp
DP Right: Palp Left: Palp
PT [**Name (NI) 167**]: Palp Left: Palp
Radial Right: Palp Left: Palp
Carotid Bruit: None heard
Pertinent Results:
[**2171-5-24**] CARDIAC CATH: 1. Selective coronary angiography in this
right dominant system demonstrated moderate left main and severe
3 vessel coronary artery disease. There was diffuse, heavy
calcification of the coronary arteries. The LMCA had a 40-50%
lesion in its mid segment. The LAD had a 95% proximal lesion
with TIMI 2 distal flow and a 40% lesion in its mid segment.
The LCX had an 80% lesion in the OM1 and a 60% lesion in the
OM2. The RCA had a 70% lesion in its proximal segment, a 70%
lesion in its distal segment, and a 70% lesion in the PDA. 2.
Limited resting hemodynamics revealed normal a systemic arterial
blood pressure with a central aortic blood pressure of 115/66
mmHg. The LVEDP was normal at 10 mmHg. There was no gradient
across the aortic valve with careful pullback.
FINAL DIAGNOSIS:
1. Moderate left main and severe 3 vessel coronary artery
disease.
2. Normal systemic arterial blood pressure.
3. Normal LVEDP.
4. Recomend CABG.
.
[**2171-5-24**] Carotid U/S: CAROTID SERIES: No significant carotid
artery stenosis (less than 40% bilaterally).
.
Brief Hospital Course:
Mr. [**Known lastname **] [**Last Name (Titles) 1834**] a cardiac cath on [**2171-5-24**] which revealed
severe three vessel coronary artery disease. Following cath he
was admitted for surgery and [**Date Range 1834**] a pre-operative work-up.
On [**5-27**] he was brought to the operating room where he [**Month/Day (2) 1834**] a
coronary artery bypass graft times four (LIMA-LAD; SVG to
PDA,OM1, OM2) and aortic valve replacement. Please see the
operative report for surgical details. Following surgery he was
transferred to the cardiovascular intensive care unit for
invasive monitoring in stable condition. He briefly required
neosynepherine for blod pressure support which was readily
weaned off. Later that day he was weaned from sedation, awoke
neurologically intact and extubated. He was started on low dose
lopressor and lasix. Chest tubes and temporary pacing wires were
removed per protocol. He was evaluated by physical therapy for
strength and conditioning and cleared for discharge to home on
post-operative day four. All appropriate instructions and
appointments were advised.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver[**Name (NI) 2287**].
1. Metoprolol Succinate XL 50 mg PO DAILY
2. Aspirin EC 81 mg PO DAILY
3. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY Hold
for SBP <100 or HR < 60
4. Nitroglycerin SL 0.4 mg SL PRN Chest Pain
5. Pravastatin 60 mg PO DAILY
6. Lisinopril 20 mg PO DAILY
Hold for SBP < 100 or HR < 60
7. Multivitamins 1 TAB PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Fish Oil (Omega 3) 1200 mg PO DAILY
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Fish Oil (Omega 3) 1200 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Pravastatin 60 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Metoprolol Tartrate 12.5 mg PO TID
Hold for HR < 55 or SBP < 90 and call medical provider.
[**Last Name (NamePattern4) 9641**] *metoprolol tartrate 25 mg 0.5 (One half) Tablet(s) by mouth
three times daily Disp #*90 Tablet Refills:*2
7. Acetaminophen 650 mg PO Q4H:PRN pain or temp >38.4
8. Docusate Sodium 100 mg PO BID
9. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
RX *Dilaudid 2 mg [**11-26**] Tablet(s) by mouth every three hours Disp
#*40 Tablet Refills:*0
10. Furosemide 20 mg PO DAILY Duration: 14 Days
RX *furosemide 20 mg one Tablet(s) by mouth daily Disp #*14
Tablet Refills:*2
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 4
9LIMA-LAD, SVG to PDA, OM1, OM@
Past medical history:
Inferior Myocardial Infarction [**7-/2163**] s/p stent of RCA
Keratosis
Hypertension
Osteoarthritis
Colon polyp
Hyperlipidemia
Dupuytren's contracture knuckle
s/p Tonsillectomy
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 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**]
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) **] [**2171-7-3**] at 1PM
Cardiologist: Dr. [**First Name (STitle) **] [**Name (STitle) 33746**] [**2171-6-11**] at 9:10 AM [**Location (un) 2274**]
[**Location (un) **]
Wound check at cardiac surgery office [**Hospital Ward Name **] 2A [**2171-6-6**] at
10:15AM
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 3510**] in [**2-28**] weeks [**Telephone/Fax (1) 11962**]
**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:[**2171-5-31**]
|
[
"413.9",
"414.01",
"401.9",
"V45.82",
"412",
"272.4",
"V17.3",
"V85.25",
"278.00",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"36.13",
"37.22",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
6003, 6052
|
3548, 4642
|
306, 514
|
6387, 6627
|
2441, 3243
|
7550, 8279
|
1584, 1746
|
5222, 5980
|
6073, 6166
|
4668, 5199
|
3260, 3525
|
6651, 7527
|
1761, 2422
|
239, 268
|
542, 1034
|
6188, 6366
|
1278, 1568
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,552
| 120,254
|
4281
|
Discharge summary
|
report
|
Admission Date: [**2100-7-5**] Discharge Date: [**2100-7-8**]
Date of Birth: [**2028-5-27**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 832**]
Chief Complaint:
Pre-syncope, anemia
Major Surgical or Invasive Procedure:
Endoscopy with 2 clips placed
History of Present Illness:
72 yo M with metastatic prostate CA on q3 month chemotherapy,
prior colon CA, CKD 3, HTN, chronic anemia and prior upper GI
bleed admitted after pre-syncope at his primary care doctor's
office, found to have acute on chronic anemia.
.
The patient reports that he walked up 1 flight of stairs at home
around 8 or 9AM and developed diaphoresis and marked dizziness.
On direct questioning he notes that he may have had similar
symptoms yesterday or even over the past several days. His wife
was with him and noted his sweating. He sat and then got up and
walked down the stairs and noted similar symptoms. He also
endorsed intermittent epigastric discomfort over the prior day
and black stool this AM. He notes that the black stool may have
started 1 or more days ago.
.
The patient attempted to go to his primary care doctor's office.
In the office he developed diaphoresis and pre-syncope. Vitals
in the [**Hospital 2287**] clinic: 97.6 80 113/67 18 95% RA. Hct was 17 down
from a baseline of high 20's to low 30's. He received 1L NS. He
was transferred to the ER.
.
On presentation to the ER, 99.1 76-77 118-132/68-74 18. He
received 80mg IV protonix x1. He was noted to be guaiac positive
in the ER.
.
Status of 3 chronic conditions:
- Metastatic prostate CA -> on q3month chemotherapy.
- HTN -> Controlled on meds.
- Colon CA -> S/p therapy, no known active disease.
.
ROS: All other systems were reviewed and are negative.
Past Medical History:
Prostate cancer
Colon cancer
CKD3
HTN
Nephrolithiasis
Alcohol abuse
Impotence
Social History:
Denies tobacco use. Rare, social EtOH use. Lives with his wife
at home.
Family History:
Positive for father with diabetes. No family history of GI
disorders.
Physical Exam:
PE: 97.2 82 134/75 18 100% RA
Gen: Comfortable, NAD.
Eyes: PERRLA. Anicteric sclera.
ENT: Normal appearance of ears and nose. Clear oropharynx.
Neck: No masses or asymmetry. No thyromegaly.
CV: RRR. Normal S1 and S2. No M/R/G.
Pulm: CTA bilaterally. Regular effort.
Abd: Soft, nontender, no masses or organomegaly.
Skin: No rashes, ulcers or lesions. Normal turgor and temp.
Psych: Appropriate mood and affect. Intact judgement and
insight.
Pertinent Results:
Labs from [**Hospital 2287**] clinic:
Na 139, K 4.6, Cl 108, Bicarb 23, BUN 42, Cr 1.6, glucose 103,
WBC 9.9, Hct 17.1, platelets 226
.
EKG: Sinus at 72. Normal axis and intervals. Flattened T's in I,
aVL and V6. No acute changes. T wave flattening is more
pronounced in I and V6 compared ot prior study on [**2100-2-3**]. I
personally reviewed the tracings.
.
[**2100-7-5**] 12:15PM BLOOD Glucose-95 UreaN-40* Creat-1.5* Na-141
K-4.3 Cl-107 HCO3-21* AnGap-17
[**2100-7-5**] 12:15PM BLOOD WBC-9.5 RBC-2.25*# Hgb-5.6*# Hct-17.5*#
MCV-78*# MCH-24.8*# MCHC-32.0 RDW-16.5* Plt Ct-242
[**2100-7-5**] 12:15PM BLOOD Neuts-80.9* Lymphs-16.8* Monos-1.6*
Eos-0.4 Baso-0.3
[**2100-7-5**] 12:15PM BLOOD ALT-14 AST-20 LD(LDH)-107 AlkPhos-73
TotBili-0.1
[**2100-7-5**] 12:15PM BLOOD Lipase-60
[**2100-7-5**] 12:15PM BLOOD Albumin-3.8
Brief Hospital Course:
72 yo M with metastatic prostate CA on q3 month chemotherapy,
prior colon CA, CKD 3, HTN, chronic anemia and prior upper GI
bleed admitted with pre-syncope, found to have acute blood loss
anemia due to bleeding gastric ulcer.
.
The patient was admitted with episodic pre-syncope and was found
to have a Hct of 17 down from a baseline of high 20's to low
30's. This occurred in the setting of vague abdominal discomfort
and possible melanotic stools though the patient was a poor
historian. The patient was admitted to the medical floor - given
3 units of PRBC's overnight and started on a PPI [**Hospital1 **]. He
underwent EGD revealing a single pyloric ulcer with a spurting
vessel. 2 endoclips were placed during the procedure. Because of
the high-risk nature of the observed lesion, the patient was
transferred overnight to the ICU for closer monitoring. He
received a 4th unit of PRBC's and 18 hours of a PPI drip before
transitioning back to PPI [**Hospital1 **]. His Hct improved - from 17 on
admission to 29 prior to transfer out of the ICU. His
pre-syncope and orthostatic symptoms resolved. His Hct was
stable at 29 for the remainder of his hospital course. H Pylori
testing is pending and he will follow-up on the result and
initiate treatment if positive with his primary care doctor. The
patient is discharged on a PPI that he should take for a minimum
of 8 weeks. He requires outpatient repeat endoscopy in 8 weeks
to monitor for ulcer healing. The patient will have a repeat Hct
in 5 days at his primary care doctor's office.
.
Because of the patient's presenting complaints including
exertional dyspnea, diaphoresis and pre-syncope, he did have an
EKG and 2 sets of cardiac enzymes all of which were negative for
signs of ischemia. His symptoms were due to hypovolemia
associated with the acute blood loss anemia and as above the
symptoms resolved with transfusion.
.
Metastatic prostate CA, prior colon CA. The patient will
follow-up as an outpatient for ongoing care.
.
History of HTN, off of medications. He was not on any
antihypertensives during this hospitalization and had normal
blood pressure throughout his stay.
.
The patient has CKD stage 3. On admit he had some acute on
chronic renal failure but his Cr returned to its baseline with
correction of his hypovolemia.
Medications on Admission:
Goserelin (Zoladex) 10.8mg subq, last dose [**2100-4-22**]
Zoledronic acid 3mg, frequency uncertain
Multivitamin
Tadalafil (Cialis) 20mg PRN
Amlodipine 5mg Daily
Discharge Medications:
1. goserelin 10.8 mg Implant Sig: Per oncology schedule
Subcutaneous Per oncology schedule.
2. zoledronic acid 4 mg/5 mL Solution Sig: One (1) Intravenous
Per oncology schedule.
3. Outpatient Lab Work
Blood draw: CBC. To be drawn on Monday [**2100-7-12**] at your
primary care doctor's office. Please discuss the result with
your primary care doctor.
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:*5*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute blood loss anemia
GI bleed due to gastric ulcer
Metastatic prostate cancer
Prior colon cancer
Hypertension
CKD 3
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with a bleeding stomach ulcer. You were
transfused several units of blood and had clips placed at the
bleeding site. Please continue to take pantoprazole as
prescribed for a minimum of 8 weeks to reduce acid in the
stomach and allow healing at the ulcer site. In addition, you
need to return for a repeat endoscopy to monitor for healing at
the ulcer site in 8 weeks - your primary care doctor can help
you arrange for this.
Have your blood count checked on Monday at your primary care
doctor's office and discuss the results with your doctor.
Follow-up the results of H Pylori testing (testing for a
specific bacteria that can cause ulcers). This test result
should be back tomorrow and your primary care doctor can help
you get the result when you see her next. If this test is
positive, you should be treated for this infection with
additional antibiotics that your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **]e for you.
For at least 8 weeks and preferrably until you have proof of
ulcer healing on repeat endoscopy, please avoid all
anti-inflammatories like ibuprofen and naprosyn. Also avoid
aspirin and all other anti-coagulants or blood thinners during
this time.
You are due for a screening colonoscopy. Discuss this with your
primary care doctor and please arrange to have this done in the
near future.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] M.
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2261**]
When: Tuesday, [**2100-7-13**]:30Am
|
[
"V10.05",
"607.84",
"276.52",
"V10.46",
"403.90",
"584.9",
"531.00",
"585.3",
"285.1",
"553.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
6468, 6474
|
3405, 5700
|
321, 353
|
6637, 6637
|
2561, 3382
|
8174, 8416
|
2014, 2085
|
5912, 6445
|
6495, 6616
|
5726, 5889
|
6788, 8151
|
2100, 2542
|
262, 283
|
381, 1808
|
6652, 6764
|
1830, 1909
|
1925, 1998
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,980
| 165,485
|
7072
|
Discharge summary
|
report
|
Admission Date: [**2177-10-19**] Discharge Date: [**2177-10-24**]
Date of Birth: [**2100-1-9**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / NSAIDS
Attending:[**First Name3 (LF) 9824**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
EGD - [**2177-10-20**] by Drs. [**First Name (STitle) 26390**] and [**Name5 (PTitle) **]
History of Present Illness:
Mr. [**Known lastname 449**] is a 77 y.o male with h/o rectal cancer s/p resection
with colostomy and chemotx in [**2164**], afib on coumadin who
presents with black tarry colostomy output x2 days. He states
that for the past 2 weeks he has felt lightheaded, weak, and
fatigued, but otherwise in his USOH. Two days PTA he noticed
black tarry output in his ostomy bag. He has not had abdominal
pain, nausea/vomiting, or bright red blood. He notes that this
happened to him once approx 1 year ago but it resolved without
intervention. Of note, pt has taken naproxen twice daily for
arthritis pain for many years. Also has taken coumadin for afib
for over 10 years, last INR checked approx 2 weeks ago and was
therapeutic (between [**1-16**]).
.
In the ED, he was noted to be tachycardic with HR 130s, BP
128/60, RR 24, O2 sat 100% on RA. Labs were notable for Hct 17,
INR 8.7, WBC 21.9, lactate 4.5. He was transfused 2u pRBCs, 2u
FFP, and received 2.5mg IV vit K. GI was consulted and
performed NG lavage, which was negative. He was started on
pantoprazole gtt and admitted to the MICU for monitoring.
.
On arrival to the MICU, initial vitals were T 98.7, HR 108, BP
130/76, RR 19, O2 sat 99% on 2L NC. Currently he states that he
feels well overall, improved since receiving transfusions.
Denies CP/SOB, palpitations, N/V, abdominal pain.
Past Medical History:
-rectal cancer status post resection and end colostomy,
chemotherapy in [**2164**]
-macular degeneration
-remote h/o duodenal ulcer, evaluated at [**Hospital1 112**], resolved without
tx
-osteoarthritis
-atrial fibrillation
-hyperlipidemia
-[**Last Name (un) 23424**] esophagus ([**2171**])
Social History:
Non-smoker, no EtOH or IVDU. Lives with wife in [**Name (NI) 5087**].
Family History:
NC
Physical Exam:
Admission Exam:
General: Pleasant elderly male, breathing comfortably on RA, in
NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
ostomy bag in LLQ
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII grossly intact, no focal deficits
Discharge Exam:
Unchanged from admission
Pertinent Results:
Lab Results on Admission:
[**2177-10-19**] 09:15AM BLOOD WBC-21.9*# RBC-1.82*# Hgb-5.5*#
Hct-17.1*# MCV-94 MCH-30.3 MCHC-32.2 RDW-14.9 Plt Ct-294
[**2177-10-19**] 09:15AM BLOOD Neuts-88.6* Lymphs-7.8* Monos-3.4 Eos-0.2
Baso-0.1
[**2177-10-19**] 09:15AM BLOOD PT-75.9* PTT-38.5* INR(PT)-8.7*
[**2177-10-19**] 09:15AM BLOOD Glucose-192* UreaN-30* Creat-0.8 Na-138
K-3.4 Cl-103 HCO3-23 AnGap-15
[**2177-10-19**] 09:15AM BLOOD ALT-10 AST-18 AlkPhos-29* TotBili-0.5
[**2177-10-19**] 09:15AM BLOOD Lipase-9
[**2177-10-20**] 03:02AM BLOOD Calcium-7.3* Phos-2.1* Mg-1.7
[**2177-10-20**] 10:18PM BLOOD Type-ART pH-7.40 Comment-GREEN TOP
[**2177-10-19**] 09:28AM BLOOD Glucose-179* Lactate-4.5* Na-135 K-3.4
Cl-100 calHCO3-24
[**2177-10-19**] 11:43AM BLOOD Lactate-2.2*
[**2177-10-19**] 09:28AM BLOOD Hgb-6.0* calcHCT-18 O2 Sat-91
[**2177-10-20**] 10:18PM BLOOD freeCa-1.06*
STUDIES:
**FINAL REPORT [**2177-10-20**]**
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2177-10-20**]):
POSITIVE BY EIA.
(Reference Range-Negative).
IMAGING:
[**2177-10-20**] CXR: IMPRESSION: AP chest reviewed in the absence of
prior chest radiographs, read in conjunction with torso CT
showing images of the lower hemithorax performed [**2170-2-20**]:
Lungs are mildly hyperinflated and the configuration of the
chest suggests
COPD. Heart is moderately enlarged. Asbestos-related pleural
calcification
is extensive and obscures larger areas of the lungs making it
difficult to say whether any significant lung lesions are
present in addition to rounded
atelectasis that was demonstrated on the [**2169**] torso CT.
Conventional
radiographs should be obtained as first step in imaging
evaluation.
Thoracic aorta is generally large, particularly in the aortic
arch but would need a lateral view for more reliable assessment.
[**2177-10-21**] Portable upright radiograph of chest
Comparison was made with prior chest radiograph from [**2177-10-20**].
FINDINGS: Since [**2177-10-20**], there are no relevant changes
in the chest. Hyperinflated lungs suggesting COPD. Bilateral
opacities from calcified and non-calcified pleural plaques which
is appropriate in the clinical setting of asbestos exposure and
right lower lung opacity which corresponds to rounded
atelectasis (on correlation with CT abdomen dated [**2177-2-19**])
are unchanged. Mild-to-moderate heart size and prominent aortic
arch with mild atherosclerotic intimal calcifications is stable.
There are no new lung opacities of concern. No acute
intrathoracic process.
EGD [**2177-10-20**]:
Impression:
Schatzki's ring
Ulcer in the pre-pyloric
Normal mucosa in the duodenum
Otherwise normal EGD to third part of the duodenum
Recommendations: This superficial ulcer is the likely source of
the patient's bleeding. Please check hpylori IgG levels and
treat if positive.
Will need repeat EGD in 8 weeks to confirm healing given risk of
malignancy in gastric uclers.
[**10-19**] ECG: Atrial fibrillation with a moderate ventricular
response. Diffuse non-specific
ST-T wave abnormalities. Compared to the previous tracing of
[**2177-4-9**] one
ventricular premature beat is now seen.
Lab Results on Discharge:
[**2177-10-24**] 06:05AM BLOOD WBC-10.0 RBC-2.76* Hgb-8.6* Hct-25.1*
MCV-91 MCH-31.0 MCHC-34.1 RDW-15.4 Plt Ct-311
[**2177-10-21**] 03:06AM BLOOD Neuts-86.0* Lymphs-8.1* Monos-5.0 Eos-0.7
Baso-0.3
[**2177-10-23**] 06:05AM BLOOD PT-13.5* PTT-30.1 INR(PT)-1.1
[**2177-10-24**] 06:05AM BLOOD Glucose-96 UreaN-14 Creat-0.8 Na-142
K-3.7 Cl-101 HCO3-36* AnGap-9
[**2177-10-24**] 06:05AM BLOOD Calcium-8.2* Phos-3.1 Mg-2.0
Brief Hospital Course:
Primary Reason for Hospitalization:
Patient is a 77yoM with h/o rectal cancer s/p colectomy with
colostomy, afib on coumadin who presented with anemia and
melena. He was found on EGD to have a gastric ulcer and on H.
pylori testing to be infected. His coumadin was held, he was
transfused blood products for anemia, and treated with proton
pump inhibitor and antibiotics for H. pylori. He was discharged
to complete a Prevpac and remained off coumadin to re-start as
an outpatient. His Hct and hemodynamics were stable on discharge
with residual melana per ostomy but no signs of continued
bleeding.
Active Issues:
1. Bleeding Gastric Ulcer: Patient presented with large amounts
of black tarry colostomy output, Hct 17, INR 8.7. He received a
total of 6u pRBCs, 2u FFP, and 2.5mg IV Vit K. EGD was
performed and showed a pre-pyloric ulcer, not actively bleeding.
It was thought that the bleeding had stopped with correction of
his coagulopathy and was likely the source of his melena. His
Hct gradually stabilized at 26 and he remained hemodynamically
stable. H pylori Antibody test was positive and he was started
on triple therapy with Amoxicillin, Clarithromycin, and
Pantoprazole. He was discharged to complete a 14 day course of
the antibiotics and will need to continue a PPI indefinitely.
He should also avoid NSAIDs and is to discuss restarting
warfarin with his primary care physician.
2. Atrial fibrillation: Patient is anticoagulated with coumadin
for Afib and presented with INR 8.7, which likely contributed to
UGIB. It is unclear why his INR was significantly elevated, as
he has taken coumadin for 10 years and per pt his INR is
typically very stable. No recent changes in coumadin dosing or
recent medication changes. His coumadin was held throughout his
hospitalization, and he should follow up with his primary care
physician regarding when to resume anticoagulation. His rate
was controlled in 70s-90s throughout stay on his home diltiazem.
Chronic Issues:
1. Anxiety: Stable. He was continued on his home regimen of
alprazolam, clonazepam, sertraline.
2. HLD: Stable. He was continued on his home pravastatin and
aspirin 81mg (per GI, safe to continue low dose aspirin).
3. Osteoarthritis: Stable. His home naproxen was discontinued
due to his UGIB. He was continued on acetaminophen and tramadol
as needed for pain.
Transitional Issues:
-F/u with primary providers regarding when to restart
anticoagulation for afib
-Outpt f/u of asbestosis plaques seen on CXR
-Repeat EGD in 8 weeks
-Continue PPI indefinitely
-CODE: full
Medications on Admission:
Medications - Prescription
ALPRAZOLAM - 0.5 mg Tablet - 1 Tablet(s) by mouth every night;
half in morning
CLONAZEPAM - 0.5 mg Tablet - 1 po(s) by mouth twice a day as
needed for anxiety
NAPROXEN - 375 mg Tablet - one Tablet(s) by mouth twice a day
PRAVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth once a day in
the evening
SERTRALINE - 100 mg Tablet - 1 Tablet(s) by mouth once a day
TRAMADOL - 50 mg Tablet - [**12-15**] Tablet(s) by mouth every four (4)
-
six (6) hours as needed for pain
VERAPAMIL - 240 mg Cap,Ext Release Pellets 24 hr - 1 Cap,24 hr
Sust Release Pellets(s) by mouth qd for heart rate
WARFARIN - 2 mg Tablet - Take up to 2 (two) tablets by mouth
once
a day or as directed by [**Hospital3 **]
Medications - OTC
ACETAMINOPHEN - (OTC) - 500 mg Tablet - 2 Tablet(s) by mouth
twice a day ** No more than 6tablets per day **
ASPIRIN - (OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s) by mouth daily as per PCP
[**Name Initial (PRE) 26391**] - (OTC) - Dosage uncertain
Discharge Medications:
1. sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day.
2. pravastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. alprazolam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
4. alprazolam 0.5 mg Tablet Sig: 0.5 Tablet PO qam.
5. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
6. tramadol 50 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
7. verapamil 240 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
8. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO twice a
day: ** No more than 6 tablets per day **
.
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours):
start taking once you have completed the Prevpac.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
11. multivitamin Tablet Sig: One (1) Tablet PO once a day.
12. Prevpac 500-500-30 mg Combo Pack Sig: One (1) pill PO twice
a day for 14 days.
Disp:*1 pack* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: gastric ulcer secondary to H pylori infection
Secondary: 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 Mr. [**Known lastname 449**],
It was a pleasure taking part in your care. You were admitted to
the hospital because you had black, tarry ostomy output for two
days and two weeks of progressive weakness, lightheadedness, and
fatigue. You were found to have an ulcer in your stomach that is
the presumed source of the bleed. Also, your level of blood
thinner was too high leading to increased likelihood of bleeding
as well. You were admitted to the medical intensive care unit
where you received several units of blood transfusion and blood
products to reverse the blood thinners. The bleeding stopped,
and you were transferred to the medical floor where you were
given diuretics to remove the extra fluid put on in the ICU.
Once the fluid was removed your oxygen levels improved. You were
discharged home with continuting therapy for the ulcer. You may
discuss eventually re-starting the blood thinners with your PCP.
Please make the following changes to your medications:
1. STOP taking coumadin for now. You may re-start this as an
outpatient with your primary care physician.
2. STOP taking ibuprofen, or any other NSAID. You may take your
low-dose aspirin once daily.
3. START Prevpac and complete a 14-day course of two pills daily
4. START Pantoprazole 40mg by mouth twice daily once you have
completed the Prevpac
Please continue the other medications you were taking prior to
this hospitalization.
Please keep all follow-up appointments.
Followup Instructions:
Department: [**Hospital3 249**]
When: THURSDAY [**2177-10-30**] at 10:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2177-11-26**] at 1:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9864**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: WEST PROCEDURAL CENTER
When: TUESDAY [**2177-12-30**] 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
|
[
"715.90",
"530.3",
"530.89",
"285.1",
"E879.8",
"793.19",
"531.40",
"V10.06",
"276.61",
"414.01",
"041.86",
"427.31",
"E935.9",
"V58.61",
"790.92",
"300.00",
"V44.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
11172, 11178
|
6426, 7027
|
309, 399
|
11303, 11303
|
2794, 2806
|
12966, 13937
|
2193, 2197
|
10036, 11149
|
11199, 11282
|
9015, 10013
|
11486, 12437
|
2212, 2733
|
2749, 2775
|
5986, 6403
|
8802, 8989
|
12467, 12943
|
263, 271
|
7042, 8399
|
427, 1774
|
2821, 5971
|
11318, 11462
|
8415, 8781
|
1796, 2088
|
2104, 2177
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,025
| 170,853
|
280+55202
|
Discharge summary
|
report+addendum
|
Admission Date: [**2133-6-13**] Discharge Date: [**2133-6-29**]
Date of Birth: [**2064-9-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2074**]
Chief Complaint:
L sided CP, [**7-4**] "dull," no pleuritic component, no radiation
Major Surgical or Invasive Procedure:
Cardiac catheterization
Peritoneal dialysis
History of Present Illness:
68yoM with ESRD [**2-26**] PCKD on PD, Prostate Ca p/w L sided CP, [**7-4**]
"dull," no pleuritic component, no radiation. Went directly to
cath lab from ED due to new STE anteriorly, ? AIVR, hypotension,
evidence of cardiogenic shock. Found to have chronically
occluded RCA 90% pLAD lesion and add'l diffuse disease and
diseased LCx. Bare metal stent to LAD in lab.
.
Given ASA, plavix, BB, NTG; in ED bedside TTE with EF = approx
15-20%
.
Pt with acute volume o/l couple months ago treated with
increased PD per renal attg.
Past Medical History:
1. ESRD [**2-26**] PCKD on PD
2. Prostate Ca treated with neoadjuvant hormonal therapy
followed by external beam radiation therapy
3. Anemia of CD
4. PVD with LE claudication (on plavix)
5. ? GIB, guaiac + stools
Social History:
+ tobacco hx, no EtOH. Lives with his wife.
Family History:
N/C
Physical Exam:
97.3 134/98 94 17 100% 4L
PCWP 40 PAD 36 RA mean 19 CI 1.74 CO 3.38
Gen: intubated, sedated
HEENT: anicteric, MMM
NECK: JVP > 10cm
CV: RRR, no apprec m/r/g
Chest: cta anteriorly
Abd: soft, + BS
Extr: warm, [**1-26**]+ DPs
Neuro: sedated, responds to voice, easily arousable
Pertinent Results:
[**2133-6-13**] 09:06PM GLUCOSE-130* UREA N-45* CREAT-12.7*
SODIUM-135 POTASSIUM-5.4* CHLORIDE-99 TOTAL CO2-20* ANION
GAP-21*
[**2133-6-13**] 09:06PM CK(CPK)-457*
[**2133-6-13**] 09:06PM CK-MB-70* MB INDX-15.3* cTropnT-2.17*
[**2133-6-13**] 09:06PM CALCIUM-8.1* PHOSPHATE-5.9* MAGNESIUM-1.8
[**2133-6-13**] 09:06PM WBC-7.4 RBC-3.93* HGB-11.6* HCT-34.9* MCV-89
MCH-29.5 MCHC-33.2 RDW-20.5*
[**2133-6-13**] 09:06PM PLT COUNT-349
[**2133-6-13**] 09:00PM TYPE-MIX
[**2133-6-13**] 09:00PM TYPE-ART PO2-217* PCO2-34* PH-7.37 TOTAL
CO2-20* BASE XS--4
[**2133-6-13**] 09:00PM LACTATE-2.2*
[**2133-6-13**] 09:00PM O2 SAT-61
[**2133-6-13**] 09:00PM HGB-11.6* calcHCT-35 O2 SAT-97
[**2133-6-13**] 09:00PM freeCa-1.07*
[**2133-6-13**] 07:30PM TYPE-ART TIDAL VOL-700 O2-100 PO2-239*
PCO2-39 PH-7.33* TOTAL CO2-21 BASE XS--4 AADO2-442 REQ O2-75
-ASSIST/CON INTUBATED-INTUBATED
[**2133-6-13**] 06:11PM GLUCOSE-118* UREA N-46* CREAT-13.3*
SODIUM-140 POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-24 ANION GAP-22*
[**2133-6-13**] 06:11PM CK(CPK)-87
[**2133-6-13**] 06:11PM CK-MB-NotDone
[**2133-6-13**] 06:11PM cTropnT-0.24*
[**2133-6-13**] 06:11PM CALCIUM-9.3 PHOSPHATE-6.1* MAGNESIUM-1.9
[**2133-6-13**] 06:11PM WBC-6.7 RBC-4.38* HGB-12.9* HCT-39.4* MCV-90
MCH-29.5 MCHC-32.8 RDW-20.7*
[**2133-6-13**] 06:11PM NEUTS-76.5* LYMPHS-17.1* MONOS-4.4 EOS-1.7
BASOS-0.2
[**2133-6-13**] 06:11PM PLT COUNT-370
[**2133-6-13**] 06:11PM PT-12.3 PTT-22.5 INR(PT)-1.1
.
[**6-24**] labs: hct 34.2, wbc 7.7. plt 359
Na 136, K 4.1, Cl 91, HCO3 28, BUN 52, Cr 10.5 Ca 8.9 Phos 4.7
Mg 1.5
Amylase 69, lipase 49
[**6-22**]: ALT 2, AST 9, Alk phos 81, LDH 258, Tbili 0.2
Fe 38, Ferritin 123, TIBC 234
TSH 7.3, FT4 1.0
PSA 0.4
PTH 210
CKs peaked at 522(110), trop 6.86.
.
EKG#1: new Qs in v2-v4, 2mm STE v2-v4; ST depressions I, avL
.
EKG#2: ? slow VT, rate 80 (AIVR)
.
[**6-17**] CXR IMPRESSION: AP chest compared to [**6-14**] and 22:
Intraaortic balloon pump has been removed. Lung volumes remain
low with persistent atelectasis at the right base, but
insufficient abnormality in the lungs to explain respiratory
failure. Moderate cardiomegaly and a generally large and
tortuous thoracic aorta are unchanged in appearance. There is no
pulmonary edema or appreciable pleural effusion. Tip of
endotracheal tube is in standard placement at the thoracic
inlet. No pneumothorax.
.
[**6-19**] CT head IMPRESSION: No intracranial hemorrhage
.
[**6-22**] Ct Abd Pelvis IMPRESSION:
1. No evidence of intra-abdominal collection or large hematoma.
2. Small amount of fluid and air and moderate amount of air in
the abdomen likely related to the peritoneal dialysis.
3. Multicystic kidneys. Some of the cysts are complex and not
well evaluated in this non-contrast study. Some of the cysts are
increased when compared to prior study. There is a new area of
calcification in the left kidney. If indicated this cysts could
be further evaluated with ultrasound or MRI.
4. Gallstones.
5. Severe coronary artery calcifications.
.
Cath report:
COMMENTS:
1. Selective coronary angiography showed a left dominant system.
LMCA
had a 20% origin stenosis. The LAD had a 90% origin stenosis
involving
also a D1 (90%). Rest of the LAD was diffusely diseased with
60-70%
sequential lesions. LCX had mild itraluminal irregularities with
50% OM
and 60% distal LCX disease. RCA was chronically occluded
distally with
R->L and R->R collaterals.
2. Left ventriculography was deferred.
3. Aortic root aortography showed markedly dilated aortic root.
4. Hemodynamic assessment reaveled a depressed Cardiac Index
1.7-1.9
and PCWP of 35 (with large V-waves).
5. The lesion in the proximal LAD was predilated with a 2.0 X
09mm
Maverick balloon and stented with a 2.5 X 12mm Minivision stent.
The
final angiogram showed TIMI III flow with no residual stenosis,
6. Under fluoroscopic guidance, we then placed a 40cc intra
aortic
balloon pump just beyond the left subclavian origin. Successful
diastolic augmentation of blood pressure was achieved.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Severe systolic ventricular dysfunction.
3. Acute anterior myocardial infarction, managed by acute ptca
and IABP.
PTCA of vessel.
4. Successful stenting of the proximal LAD lesion with a bare
metal
stent.
5. Successful placement of a 40cc intra aortic balloon pump.
.
[**6-15**] TTE:
Conclusions:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with moderate cavity dilation and severe
global hypokinesis. The basal inferior and inferolateral walls
contract best with the more distal left ventricular segments
near akinetic. There is an apical left ventricular aneurysm. No
intraventricular thrombus is identified. Tissue velocity imaging
E/e' is elevated (>15) suggesting increased left ventricular
filling pressure (PCWP>18mmHg). Right ventricular chamber size
and free wall motion are normal. The ascending aorta is
moderately dilated. The aortic valve leaflets (3) are mildly
thickened but with good leaflet excursion and no aortic
regurgitation.
There is no aortic valve stenosis. The mitral valve leaflets are
mildly
thickened. Mild to moderate ([**1-26**]+) mitral regurgitation is seen.
There is at least mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
Compared with the findings of the prior report (images reviewed)
of [**2130-10-4**], the left ventricular findings are new and c/w
multivessel CAD. Mild-moderate mitral regurgitation and
pulmonary artery systolic hypertension are now present.
.........................................
ABDOMEN (SUPINE & ERECT) [**2133-6-24**] 6:15 PM
ABDOMEN (SUPINE & ERECT)
.
COMPARISON: CT abdomen and pelvis [**2133-6-22**] and portable
abdomen [**2133-6-22**].
.
ABDOMEN, UPRIGHT AND SUPINE: Only one of these radiographs
includes the right hemidiaphragm. There are small ovoid-shaped
collections of free intra- abdominal air layering above the
liver and stomach. Large and small bowel are of normal caliber.
There is no evidence of obstruction. Extensive stool is noted
within the right colon. A peritoneal dialysis catheter coils
over the left abdomen into the pelvis. Surrounding osseous and
soft tissue structures are unchanged.
.
IMPRESSION: Small collections of free intra-abdominal air above
the liver and stomach which is expected given presence of
peritoneal dialysis catheter.
Brief Hospital Course:
Assessment: 68yo M with ESRD on PD, prostate Ca p/w ACS and
severe 2VD presented with CP and taken to cath lab and found to
have 2VD with stent to LAD and subsequent mental status changes
that have steadily improved.
.
#. CV:
a. [**Name (NI) 2694**] Pt went directly to the cath lab on admission where
he was found to have significant 2VD, s/p bare metal stent to
proximal LAD. Patient was s/p ACS with unclear culprit lesion,
developed cardiogenic shock and was intubated in CCU for several
days. Per CT [**Doctor First Name **], was determined not to be a CABG candidate
due to poor touchdowns and severe R sided lesions. His course
was complicated by a groin bleed (see below). Continued ASA,
Plavix and high dose statin, and titrated BB to Metoprolol XL
200 mg PO DAILY. Due to known residual coronary lesions, Isordil
10mg TID was initially added for better CP control, but was
ultimately d/c'ed due to low BPs, with the addition of SL NTG
prn for chest pain. Was initially on Lisinopril 30 mg PO DAILY,
which was also ultimately decreased to 10mg PO QD due to low BP.
Beta blockade will be the most important factor in the medical
management of his CAD, and should not be decreased if at all
possible. He was discharged on Toprol XL 150 mg QD. He should
have f/u with cardiology within the next 6-8 weeks, and see his
PCP soon after discharge from rehabilitation facility.
.
b. Pump - cardiogenic shock, newly depressed EF. He had
significant volume o/l and LV dysfunction. An IABP was in place
(1:1) with hep gtt after cath. The balloon was subsequently
removed and we titrated up inotropes/pressors to MAP > 60, CI >
2
A PCWP > 40 determined that he needed aggressive diuresis which
he underwent via PD with renal service following. Several
liters of fluid were removed by PD and was maintained at
relatively even volume exchanges for several days prior to
discharge.
.
c. Rhythm- AIVR in ED, NSR since. QTc was monitored in setting
of Haldol administration, and was consistently in normal range.
.
#. ESRD on PD x several years -- volume o/l by elev PCWP on
admission, s/p fluid removal by PD for several days, now
euvolemic on exam with even volume exchanges. Renal following
and maintaining even Is/Os. He should continue with daily
peritoneal dialysis. He should follow-up with his nephrologist
Dr. [**Last Name (STitle) 1366**] on discharge from rehab facility.
.
#. Groin hematoma- Pt had rapidly expanding groin hematoma of
his right groin in setting of heparin s/p cath. He was
reintubated in setting of pain when he was uncontrollable and
thrashing in bed. Hematoma was tamponaded with a pressure
dressing and external fixture and was controlled by the
following day. He had a HCT drop in setting of bleed.
Peripheral pulses were still dopplerable (baseline) throughout.
This has now resolved, with persistent ecchymosis, but stable
HCT x 5 days.
.
#. S/p intubation- done for agitation purposes at first in the
cath lab. He was successfully weaned by HD #3 but reintubated
the next day s/p groin bleed and uncontrolled behavior,
including trying to get out of bed and resisting pressure on his
bleeding groin. He was successfully weaned a second time and as
his MS has improved, he has not required further intubation.
.
#. Acute MS changes: Pt has been agitated at times, generally in
the setting of pain, and seemed to have no clear understanding
of what was going on. He has been on several sedatives and
could have been experiencing medication effects s/p extubation.
His mental status started to clear. He passed speech and
swallow, now on regular renal/cardiac diet. CT head [**6-19**] ruled
out bleed/new process but did show old lacunar infarct.
Continued Haldol HS and PRN Haldol as needed, with input from
psychiatry service. His MS improved daily and was near baseline
at time of discharge, with minimal need for Haldol. His Haldol
was discontinued several days before discharge. His mental
status is approaching baseline, however, he still has some
difficulty performing his own peritoneal dialysis. He will need
ongoing education in this process while at rehab.
.
#. Abdominal discomfort: Developed on [**6-22**]. There were initial
concerns for peritoneal fluid infection in setting of ongoing
PD, and dialysate was pink-tinged. Pain may have been due to
hematoma from subcutaneous heparin, which was d/c'ed prior to
d/c, as patient was ambulating well CT Abdomen ruled out bleed,
or other pathology that could explain his symptoms. Peritoneal
fluid analysis from [**6-22**] showed gram positive cocci in pairs,
not yet speciated. His cell count from his peritoneal fluid was
low, with a very low number of PMNS. He received vancomycin 2 gm
IP x 1; he should have a second dose on [**2133-6-28**]. He had guaiac
negative stool on day of discomfort. LFTs were normal, as were
amylase and lipase. A plain film of the abdomen on [**6-24**]
demonstrates a small amount of intra-abdominal free air, which
is likely secondary to a PD cath that was uncapped for too long.
Repeat analysis of peritoneal fluid showed on 33 WBC, 14% PMNs.
Abdominal pain had significantly improved on day of discharge.
.
#. Guaiac + stools: Pt has documented history of this before and
during this admission, but not for last several days.
Outpatient colonoscopy should be arranged. HCT remained stable.
.
#. Prostate Ca- Not acute issue while in-house. PSA 0.4. Has f/u
appt with oncology.
Medications on Admission:
ASA 81mg daily
Flomax
[**Doctor First Name **]
Neurontin
Labetalol 400mg Daily
Iron
Norvasc 10mg Daily
CaC03
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
6. Epoetin Alfa 10,000 unit/mL Solution Sig: 8000 (8000) Units
Injection QMOWEFR (Monday -Wednesday-Friday).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
8. Lanthanum 250 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID (3 times a day).
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
12. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
13. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: 1.5 Tablet Sustained Release 24HRs PO once a day.
14. Vancomycin 1,000 mg Recon Soln Sig: Two (2) gm Intravenous
once for 1 days: please administer vancomycin 2 gm x 1
intraperitoneally on [**2133-6-28**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Myocardial infarction
Congestive heart failure
End-stage renal disease
Discharge Condition:
Stable, cardiac medication regimen optimized.
Discharge Instructions:
You had a blockage in your coronary artery with evidence of
damage to your heart; the blockage was stented. You also had a
bleed from the cateterization site, as well as some
post-operative confusion that has been improving. Your heart
medicines were optimized prior to discharge.
*
Your fluid status should be kept even with peritoneal dialysis.
*
Call your doctor or return to the emergency room if you develop
cehst pain, shortness of breath, nausea/vomting, you are unable
to continue with your peritoneal dialysis or you develop any
other symptoms that are concerning to you.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2695**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2133-8-20**] 11:00
.
You should follow with Dr. [**Last Name (STitle) 2696**] soon after being discharged
from the rehabilitation center. You can call [**Telephone/Fax (1) 2697**] for an
appointment.
.
You have an appointment with Dr. [**Last Name (STitle) **] on [**2133-7-7**] at 3pm on
the [**Location (un) 436**] of the [**Hospital Ward Name 23**] building.
.
You should also follow-up with your nephrologist Dr. [**Last Name (STitle) 1366**]
after you are discharged from your rehab program.
Name: [**Known lastname 294**],[**Known firstname **] Unit No: [**Numeric Identifier 295**]
Admission Date: [**2133-6-13**] Discharge Date: [**2133-6-29**]
Date of Birth: [**2064-9-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 296**]
Addendum:
Lanthanum dose at discharge is 750mg PO tid.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 41**] - [**Location (un) 42**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 297**] MD [**MD Number(1) 298**]
Completed by:[**2133-6-29**]
|
[
"410.11",
"414.01",
"998.12",
"428.0",
"785.51",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.98",
"00.45",
"37.23",
"36.06",
"00.40",
"37.61",
"96.04",
"96.71",
"88.56",
"00.66"
] |
icd9pcs
|
[
[
[]
]
] |
16873, 17098
|
8021, 13442
|
382, 428
|
15112, 15160
|
1613, 5624
|
15789, 16850
|
1298, 1303
|
13602, 14904
|
15018, 15091
|
13468, 13579
|
5641, 7998
|
15184, 15766
|
1318, 1594
|
276, 344
|
456, 984
|
1006, 1221
|
1237, 1282
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,098
| 133,065
|
18832
|
Discharge summary
|
report
|
Admission Date: [**2162-2-18**] Discharge Date: [**2162-3-4**]
Date of Birth: [**2116-6-18**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5644**]
Chief Complaint:
swelling in my legs
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
45-yo-woman h/o DM2, Hep C cirrhosis, primary pulm HTN, h/o IVDU
presents w/ syncope 3 days ago. She fell while walking from
bedroom to bathroom, witnessed by friend. Pt does not recall
event, but was observed falling to the floor and then found to
have urinated. She denies associated CP, dizziness, confusion,
alcohol use, tongue biting, convulsions. Presented last night
after talking to PCP, [**Name10 (NameIs) 1023**] recommended evaluation. She also c/o
persistent dyspnea despite lasix, which was recently started
during admission for massive R sided heart failure. She reports
frequent nose bleed w/ cough, no hematemesis, hematochezia, or
melena.
Past Medical History:
1. Asthma
2. Pulmonary HTN - cathed [**8-/2161**], mean PA pressure 63 mmHg.
Right- sided filling pressures severely elevated: RA mean 24
mmHg, RVEDP 24 mmHg). Left sided filling pressures mildly
elevated: PCW 20 mmHg.
3. Thrombocytopenia
4. DM2 - unknown duration, on Lispro and NPH at home.
5. RHF - cor pulmonale, ECHO [**8-16**] w/ EF 55%, global R
ventricular dilation and hypokinesis
6. Liver cirrhosis - HCV positive Ab, neg VL in [**8-/2161**], not a
transplant candidate due to cor pulmonale, no varices by EGD
[**11-16**]
Social History:
Smokes ciggaretes on occasion, last one 2 days ago. Denies any
etoh, IVDU. Lives alone with her cat.
Family History:
HTN
CAD
Breast CA
Physical Exam:
T 99.0 BP 120/60 HR 101 RR 20 O2sats 97% RA
Gen: Obese female, comfortable, NAD
HEENT: clear OP, mmm, PERRL, EOMI
Neck: supple, no LAD, no thyromegaly, JVD to the ear
Lungs: Poor inspiratory effort and difficult to hear [**3-17**]
obesity. Otherwise clear no crackles, wheezes
Heart: RRR + S1/S2 no m/r/g
Abd: obese, soft, NT, ND, +BS
Ext: 2+ pitting edema to knees B, 2+ DP's
Neuro: A&O times 3, pt appropriate, no signs of delerium, no
asterixis
Pertinent Results:
[**2162-2-17**] 08:28PM WBC-4.7 RBC-2.56* HGB-9.2* HCT-30.8* MCV-121*
MCH-36.1* MCHC-30.0* RDW-17.9*
[**2162-2-17**] 08:28PM PLT COUNT-61*
[**2162-2-17**] 08:28PM NEUTS-56.6 LYMPHS-35.6 MONOS-6.5 EOS-1.1
BASOS-0.2
[**2162-2-17**] 08:28PM GLUCOSE-100 UREA N-13 CREAT-1.3* SODIUM-132*
POTASSIUM-3.4 CHLORIDE-99 TOTAL CO2-21* ANION GAP-15
[**2162-2-17**] 08:28PM ALT(SGPT)-69* AST(SGOT)-166* CK(CPK)-700* ALK
PHOS-110 TOT BILI-6.1*
[**2162-2-17**] 08:28PM LIPASE-21
[**2162-2-17**] 08:28PM PT-18.3* PTT-37.4* INR(PT)-2.1
[**2162-2-17**] 08:28PM CK-MB-5 cTropnT-<0.01
[**2162-2-18**] 04:45AM CK-MB-4 cTropnT-<0.01
[**2162-2-18**] 04:45AM LD(LDH)-431* CK(CPK)-579*
CT Head: There is no intracranial hemorrhage, abnormal
extra-axial fluid collection, mass effect or midline shift. The
ventricles are normal, and the cisterns are patent. The
[**Doctor Last Name 352**]-white matter attenuation is normal. The visualized
paranasal sinuses and mastoid air cells are clear. No fracture
is detected.
CXR: The heart size is unchanged. The pulmonary vascularity is
within normal limits. There is no pleural effusion or
pneumothorax. The visualized osseous structures are
unremarkable.
Abd US: The liver is diffusely coarsened in echotexture
consistent with cirrhosis. There is a tiny amount of ascites.
Spleen is not enlarged at 8.6 cm. The gallbladder is
decompressed. There is no intra or extrahepatic biliary
dilatation, and the common bile duct measures 4 mm.
Liver Doppler: There is reversal of flow within the portal
vein as well as the splenic vein. Normal flow and waveforms are
identified within the left and right hepatic arteries. The IVC
as well as the hepatic veins are dilated.
Brief Hospital Course:
1. Syncope: her presenting complaint of syncope was most likely
[**3-17**] orthostatic hypotension, as supported by measurement of
orthostasis on admission and improvement in the pt's dizziness
after hydration, as below. There was no cardiac arrhythmia on
telemetry, and the pt ruled out for MI by EKG and normal cardiac
enzymes. The pt had no further dizziness or syncope during her
admission. At d/c, she is at her baseline functional status.
2. GI bleed: the pt's HCT was noted to trend down over the 1st 2
hospital days. She had guaiac positive stool, which was
concerning for slow GI bleed [**3-17**] portal gatropathy. GI was
consulted and recommended colonoscopy after stabilization of the
pt's hypotension, as the bowel prep may exacerbate dehydration
and hypotension. The pt's HCT stabilized after its initial
drop, and there was no evidence of active bleeding during the
rest of her hospital stay. At d/c, there is no evidence of
active bleeding and the pt is advised to f/u with her PCP to
arrange colonoscopy in the near future.
3. Hypotension: the pt was hypotensive on admission w/ positive
orthostasis, indicating likely intravascular volume depletion in
the setting of total body fluid overload [**3-17**] cor pulmonale. Her
cor pulmonale requires diuresis for treatment, but this was
limited during her admission by hypotension. On the 2nd
hospital day, the pt became hypotensive w/ SBP in the 80s and
required multiple small fluid boluses (250cc each) to increase
SBP to 100s. Given her tenuous fluid status, the pt was
transferred to the MICU for close monitoring and fluid
management. During her short MICU stay, her SBP remained stable
in the 100-120 range, and she was then called out to the
Medicine service for ongoing care. SBP remained stable
throughout the rest of her hospital stay. At d/c, SBP remains
stable in the 120s.
4. Cor pulmonale: she has right heart failure [**3-17**] pulm HTN, not
responsive to NO on previous cath. She was overall fluid
overloaded during her admission, but initially was
intravascularly depleted as above. CHF service was consulted
for recs, and recommended gentle diuresis for treatment of RHF,
as limited only by BP. Gentle diuresis was accomplished in the
hospital w/ lasix 40mg PO daily. She will continue lasix after
d/c, and f/u in [**Hospital 1902**] clinic.
5. UTI: pt developed delirium during her hospital stay, which
was investigated with head CT and blood/urine cx. Head CT was
normal, but UCX grew pan-sensitive enterococcus. Her UTI was
treated w/ levaquin for a 7 day course, resulting in prompt
resolution of her delirium. At d/c, there is no evidence of
active infxn and the pt is asymptomatic.
6. Anemia: workup of the pt's low presenting HCT demonstrated
low haptoglobin and elevated LDH, supporting a dx of hemolytic
anemia. She had no schistocytes on peripheral smear, but had
many target cells most likely [**3-17**] liver dz. Heme service was
consulted, and recommended Hb electrophoresis and outpt f/u in
[**Hospital **] clinic. At d/c, Hb electrophoresis is pending. The pt's
HCT is stable. She will f/u in [**Hospital **] clinic after d/c.
7. DM2: controlled w/ outpt doses of NPH and lispro insulin
during this admission.
8. Asthma: controlled w/ advair and albuterol during this
admission.
9. Code status during this admission was full code.
Medications on Admission:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) inhalation Inhalation [**Hospital1 **] (2 times a day).
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 9 days.
Disp:*9 Tablet(s)* Refills:*0*
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
Disp:*30 Tablet(s)* Refills:*2*
7. NPH insulin
Take 25 units with breakfast each morning
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) inhalation Inhalation [**Hospital1 **] (2 times a day).
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 9 days.
Disp:*9 Tablet(s)* Refills:*0*
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
Disp:*30 Tablet(s)* Refills:*2*
7. NPH insulin
Take 25 units with breakfast each morning
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Vasovagal syncope
2. Dehydration
3. Right heart failure
4. UTI
5. Cirrhosis
6. Hemolytic anemia
Secondary:
1. Asthma
2. DMII
Discharge Condition:
Stable to go home; no dysnpea with walking, peripheral edema
stable, HCT stable.
Discharge Instructions:
You are being discharged after treatment for dehydration, heart
failure, and urinary tract infection. Please take all
medications as prescribed. Present to your doctor or the ED if
you have chest pain, dizziness, fever, bleeding, or other
concerning symptoms.
Weight yourself every day. Call your doctor if you gain more
than 2 pounds in any 24 hour period.
Followup Instructions:
Follow-up with your PCP (Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 250**]) in 2 weeks.
Follow-up with Dr. [**First Name (STitle) 2031**] in heart failure clinic on [**2162-3-25**] at
2PM.
Follow-up with Dr. [**Last Name (STitle) **] in Pulmonary clinic on [**2162-3-15**] at
7:45AM, [**Hospital Ward Name 23**] Clinical Center [**Location (un) **], Rehab Services
Follow-up in [**Hospital **] clinic ([**Telephone/Fax (1) 22**]) in [**3-18**] weeks.
|
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
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] |
9008, 9014
|
3959, 7322
|
334, 342
|
9204, 9286
|
2229, 2910
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1722, 1741
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8178, 8985
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9035, 9183
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9310, 9673
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1756, 2210
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275, 296
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370, 1033
|
2919, 3936
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1055, 1588
|
1604, 1706
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,583
| 147,395
|
14704+14705+56566
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2178-6-17**] Discharge Date: [**2178-6-29**]
Date of Birth: [**2114-12-6**] Sex: M
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 63 year-old
gentleman transferred from [**Location (un) **] [**Hospital 350**] Medical
Center for surgical treatment of spinal stenosis and
posterior herniation of T2 to T3. The patient gives a one
year history of ataxia with multiple visits to a neurologist
and neurosurgeon. An MRI in [**2177-10-9**] showed a
stenosis at the T2 T3 level. Five days prior to admission
the patient developed increased leg weakness increased
urinary incontinence. He has not been able to bear weight
for 48 hours and traveled to [**Hospital3 15054**] Emergency Department with
the assistance of a walker.
PAST MEDICAL HISTORY: Non Hodgkin's lymphoma treated with
radiation in [**2145**] and [**2150**] and then surgical evacuation in
[**2175**]. Hypertension and high cholesterol.
PHYSICAL EXAMINATION: He had 3 out of 5 strength in both
right and left lower extremities. His upper extremities were
5 out of 5 in all muscle groups. He has 3+ reflexes in the
lower extremities. He has 1+ reflexes in the upper
extremities. Cranial nerves II through XII were intact. He
is awake, alert and oriented times three. His MRI showed
spinal stenosis at the T2 to T3 level with posterior
herniation of the disc.
LABORATORIES ON ADMISSION: His INR was 1.1, white count
10.5, hematocrit 44.6, sodium 141.
HOSPITAL COURSE: The patient underwent a T2 to T3
decompression laminectomy on [**2178-6-18**] without intraoperative
complications. Postoperatively, his vital signs were stable.
He was afebrile. His lower extremity strength, his IPs were
3 out of 5 on the right, quad was 3 out of 5 and his
hamstring was 3 out of 5. [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] and AT were 4- out of
5. On the left he had fairly antigravity strength in the IP,
quad and hamstring. [**Last Name (un) 2339**] was 2, [**Last Name (un) 938**] 2 and AT was 2 on the
left. He was stable neurologically. Over the weekend his
neurological status failed to improve. He had a repeat CAT
scan, which showed the need for further decompression. The
patient was seen by the Cardiology Service after having gone
into atrial fibrillation spontaneously. He was ruled out. He
did convert spontaneously back to sinus rhythm and has had no
further problems with atrial fibrillation. He was started on
a beta blocker 25 mg po b.i.d. and his Hydrochlorothiazide
was held. He had no further problems with atrial
fibrillation. Postoperatively for his second surgery, which
was done on [**2178-6-25**] he had T2 revision laminectomy, which
he had no intraoperative complications from. His vital signs
remained stable. His dressing was clean, dry and intact. He
was seen by physical therapy. He need a max assist of two
people to remain in the standing position. He will require
acute rehab prior to discharge to home.
MEDICATIONS ON DISCHARGE: Decadron 4 mg p q 8 hours,
Metoprolol 50 mg po b.i.d. hold for systolic blood pressure
of less then 100, heart rate less then 60. Lactulose 30 cc
po t.i.d., Colace 100 mg po b.i.d., Dulcolax 10 mg po pr q.d.
prn, Senna two tabs po b.i.d., Hydromorphone 2 to 8 mg po q 4
hours prn, Terazosin 10 mg po q day, Zantac 150 mg po b.i.d.,
Atorvastatin 10 mg po q day.
CONDITION ON DISCHARGE: Stable. His neurological status is
4- out of 5 strength in the lower extremities and will
require acute rehab. He will follow up with Dr. [**Last Name (STitle) 6910**]
in ten days for staple removal. He was stable at the time of
discharge with stable vital signs.
[**Name6 (MD) 6911**] [**Name8 (MD) **], MD [**MD Number(1) 6913**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2178-6-29**] 09:32
T: [**2178-6-29**] 10:00
JOB#: [**Job Number 43265**]
Admission Date: [**2178-6-17**] Discharge Date: [**2178-8-5**]
Date of Birth: [**2114-12-6**] Sex: M
Service: GENERAL S.
CHIEF COMPLAINT: Abdominal sepsis, perforated cecum, status
post right hemicolectomy, ileostomy, and mucous fistula.
HISTORY OF THE PRESENT ILLNESS: Mr. [**Known lastname **] is a 63-year-old
gentleman, who was transferred from the [**Hospital 28978**] Medical Center for surgical treatment of spinal
stenosis and posterior herniation of T2 to T3. He was
admitted to the Neurosurgery Service. He had a one-year
history of ataxia with multiple visits to the Neurologist and
Neurosurgeon. MRI in [**2177-10-9**] showed a stenosis at the
T2 to T3 level. He also had increasing leg weakness and
increased urinary incontinence prior to presentation to the
emergency department.
On the Neurosurgery Service, he underwent a T2 to T3
decompression laminectomy on [**2178-6-18**] without any
intraoperative complication. Repeat CT scan showed the need
for further decompression. He also went into atrial
fibrillation spontaneously. He was seen by the Department of
Cardiology. He converted spontaneously back to sinus rhythm
and had no further problems with atrial fibrillation. He was
started on a beta blocker 25 mg PO b.i.d. at that time. He
had a revision T2 laminectomy on [**2178-6-25**], which showed no
intraoperative complications.
The patient complained of constipation. He received daily
bowel regimens of Lactulose, Senna, and Colace. He received
magnesium citrate times two and he had a bowel movement on
[**2178-7-1**] and [**2178-7-2**]. However, no [**2178-7-2**], he was noted
to be more distended on examination. KUB was normal. Rectal
tube was placed. However, later in the day, he had increased
distention, tachycardia, and then hypotension. He was
transferred to the MICU at this time. Chest x-ray and KUB
showed free air in the abdomen. The Department of Surgery
was consulted at this time and then the patient was taken to
the operating room after resuscitation, at which time he was
found to have a cecum perforation. Free stool and fibrinous
exudate were also found in the peritoneal cavity. He
received a right hemicolectomy, ileostomy and mucous fistula
were performed.
PAST MEDICAL HISTORY:
1. Non-Hodgkin lymphoma treated with radiation in [**2145**] and
[**2150**] and then surgical evacuation in [**2175**].
2. Hypertension.
3. Hypercholesterolemia.
4. History of atrial fibrillation.
5. Rheumatoid arthritis.
6. Left carotid stenosis.
SOCIAL HISTORY: The patient has a tobacco history of 30
years.
MEDICATIONS:
1. Solu-Medrol.
2. Protonix.
3. Flagyl.
4. Heparin,
5. Imipenem.
6. Neo-Synephrine.
7. Morphine.
ALLERGIES: The patient is allergic to ATIVAN AND COZAAR.
PHYSICAL EXAMINATION: The patient was seen in the MICU by
the consultation team. Vital signs: 99.3, 120, 94/65, 29.
The patient is confused. He is awake. CARDIAC: Regular
rate and rhythm, no murmurs, rubs, or gallops. LUNGS: Lungs
were clear to auscultation bilaterally. ABDOMEN:
Impressively distended, tympanic, nontender, no bowel sounds.
EXTREMITIES: Warm. He has 1+ peripheral pulses bilaterally.
He has 2+ edema.
HOSPITAL COURSE: The patient was taken to the operating room
on [**2178-7-2**] for abdominal sepsis and perforated cecum. He
received a right hemicolectomy, ileostomy, and mucous
fistula. Please refer to the operative note for more
information. The patient was admitted to the Trauma
Intensive Care Unit postoperatively, where he was continued
with fluid resuscitation, blood products, and pressors, while
monitoring for arrhythmias. Immediately, postoperatively, he
required Levophed to keep his blood pressure up. He went
into atrial fibrillation and IV Lopressor was given, which
converted him to sinus rhythm and he was kept intubated with
NG tube in place. He was placed on Flagyl and Imipenem along
with Vancomycin and Fluconazole.
On postoperative day #1, the patient's atrial fibrillation
continued, which was treated with an Amiodarone drip. The
patient was also on Levophed drip, Ativan drip, and a
Dilaudid drip. The patient was kept intubated and sedation.
A Nutrition consultation was requested. Peritoneal fluid
from the operation showed 2+ Gram-positive rods, 2+
Gram-negative rods, and 1+ yeast. Culture grew back
enterococcus. The patient's atrial fibrillation persisted.
On postoperative day #4, cardiac output declined somewhat and
the dobutamine drip was started, which improved cardiac
output. Also, Vancomycin was stopped at that time and
Ampicillin was started, continued along with the Imipenem,
Flagyl, and Fluconazole for the patient's sepsis. TPN was
started for nutritional support.
Cardiology consultation was obtained to assess the patient's
cardiac status. Recommendations were to discontinue the
Amiodarone and Dobutamine, to rate control with beta
blockers, and to get an echocardiogram to assess left
ventricular function. He was started on Heparin for
anticoagulation.
Nutritionally, the patient was continued on TPN, however, a
post pyloric tube feed was placed, and he was started on
trophic feeds.
Over the next few days, in the ICU, the Ativan was weaned
down slowly. However, the dobutamine was needed to increase
cardiac index. The tube feeds were increased to provide
adequate nutrition for the patient. The patient was on
insulin drip to keep the sugars under control.
By postoperative day #8, the patient was stable, off
dobutamine and the Swan-Ganz catheter was discontinued. The
patient continued in atrial fibrillation, however, this was
rate controlled with IV Lopressor.
On postoperative day #10, the patient had a run of
ventricular tachycardia, about 12 beats, but there was no
drop in systolic blood pressure. He self converted. There
was no hyponatremia. He was continued with the Lopressor and
increased on the Diltiazem and not started on Amiodarone
until discussing with the Department of Cardiology.
Cardiology consultation was obtained at which point he was
started on an Amiodarone drip. They also recommended
heparin, however, heparin was not started because the patient
was so critically ill and the risk for bleeding was still
high.
Cultures came back from the blood that showed Gram-positive
cocci and all lines were changed. This then grew out Staph
coagulase negative and Pseudomonas aeruginosa. The patient's
Ampicillin was stopped at this time and Vancomycin was
started along with his Imipenem, Flagyl, and Fluconazole,
which were continued.
On postoperative day #13, the patient received
transesophageal echocardiogram, which showed no intracardiac
thrombus. It showed some trace MR, trivial AI, and trace TR,
otherwise, LV and RV systolic function were preserved.
The patient, soon, spontaneously converted back to sinus
rhythm and he was soon after changed to PO Amiodarone.
Around postoperative day #13, it was noted that there was an
ascitic fluid drainage from the wound and the wound began to
dehiscence on the abdomen. Over the next few days in the
Intensive Care Unit, the patient's wound completely dehisced
and the wound was started to be treated with wet-to-dry
dressing of normal saline soaked gauze. For this time, the
patient continued on p.r.n. Dilaudid and Ativan with
decreased mental status, however, he began to become more
awakened and coherent.
On postoperative day #15, the patient had increased
requirements of the vent secondary to tachycardia. At this
point, he was only on Vancomycin for antibiotics, as the
Imipenem, Fluconazole, and Flagyl had been given for a
two-week course.
Around postoperative day #17, the patient spontaneously
converted to atrial fibrillation SVT with vagal maneuvers
attempted and cardiology consultation obtained. The patient
was stable throughout. He was restarted on an Amiodarone
drip. He also spiked a temperature at this time. On
postoperative day #18, the pressures dropped. He was started
on Neo-Synephrine drip, Ceftazidime, and Gentamicin
empirically and he was cultured. Cultures from the sputum
showed Pseudomonas and he was switched to Amikacin.
On [**2178-7-22**], after the patient resolved from his septic
episode, the patient received tracheostomy, done by
Dr. [**Last Name (STitle) **]. The patient tolerated the procedure well, but
was continued on the vent. After sensitivities were returned
from the Pseudomonas, the patient was switched from
Vancomycin to Zosyn, Oxacillin, and Amikacin.
The patient also developed a cellulitis in his right lower
extremity. Ultrasound of the extremities were negative for
any thrombus. The patient was continued on his antibiotic
course. Also, PT/OT, and speech-swallowing consultations and
evaluations were obtained and they followed the patient
throughout his Intensive Care Unit course.
Around postoperative day #25, the patient spontaneously
converted to sinus rhythm. However, he was still on
Amiodarone and Lopressor.
Over the next few days, the patient improved fairly quickly.
By postoperative day #28, the patient improved to the point
where he was able to be transferred to the floor. The
patient was no longer needing respiratory assistance at this
time. The patient no longer needed antibiotics by
postoperative day #30. He was continued on his tube feeds.
Wound was granulating well. He was continued with the
wet-to-dry dressings b.i.d. The OT/PT and Speech Departments
were following the patient on the floor and the main issue
became rehabilitation as the patient had deconditioning from
his lengthy Intensive Care Unit stay.
By postoperative day #34, the patient was breathing on his
own with tracheostomy. Mobility was increasing, however, he
was still limited to lying in bed and moving to a chair with
assistance. He was afebrile without any antibiotics. The
wound was granulating slowly. He was cleared by the
Departments of Speech and Swallow to start PO intake slowly.
Secretions and respiratory status had improved.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient was discharged to a
rehabilitation facility.
DISCHARGE DIAGNOSES: Abdominal sepsis with cecum perforation
status post right hemicolectomy, ileostomy, mucous fistula
formation. The patient also had wound dehiscence and
pneumonia.
DISCHARGE MEDICATIONS: To follow.
FOLLOW UP PLANS: To follow.
[**Name6 (MD) 843**] [**Name8 (MD) 844**], M.D. [**MD Number(1) 845**]
Dictated By:[**Name8 (MD) 43099**]
MEDQUIST36
D: [**2178-8-5**] 12:23
T: [**2178-8-5**] 12:43
JOB#: [**Job Number 43266**]
cc:[**Last Name (STitle) 43267**] Name: [**Known lastname 7888**], [**Known firstname **] Unit No: [**Numeric Identifier 7889**]
Admission Date: [**2178-6-17**] Discharge Date: [**2178-8-7**]
Date of Birth: [**2114-12-6**] Sex: M
Service: GENERAL S.
CHIEF COMPLAINT: Abdominal sepsis, perforated cecum, status
post right hemicolectomy, ileostomy, and mucous fistula
formation. The patient also had wound dehiscence pneumonia,
and atrial fibrillation.
HISTORY OF THE PRESENT ILLNESS: Please see above.
PAST MEDICAL HISTORY: Please see above.
SOCIAL HISTORY: Please see above.
MEDICATIONS: Please see above.
ALLERGIES: Please see above.
PHYSICAL EXAMINATION: Please see above.
HOSPITAL COURSE: This is the addendum onto the previous
discharge summary. The patient remained on the floor for
another two to three days after the last discharge summary.
Over this time, the patient's respiratory status improved to
the point, where on the day of discharge, postoperative day
#36 from the exploratory laparotomy, the tracheostomy tube
was capped and the patient was breathing on his own with good
oxygen saturations. The plan for us had been that if the
patient were to stay over the weekend, we would have pulled
out the tracheostomy in the next one to two days as he was
tolerating it well. The patient was also tolerating more PO
intake of pureed nectar-thick liquids. However, the patient
was requiring assistance, because he was so deconditioned and
he could not feet himself. The patient was continuing to be
seen by the Department of Physical Therapy. Occupational
Therapy and Speech and Swallow to improve on the
deconditioning state.
CONDITION ON DISCHARGE: Stable, afebrile, vital signs were
stable. Tracheostomy tube was in placed, however, it was
capped and he was breathing well. The patient had a
post-pyloric nasogastric feeding tube, which was running with
Promote with fiber, full strength at 95 cc per hour. He also
had a capped arm PICC line. The patient had an abdominal
midline open wound, which was being packed with wet-to-dry
dressings and granulating well with minimal fibrinous
exudate. The patient's edema in his arms and legs had
decreased significantly from previous, however, still
minimally present. The patient had a Foley catheter in place
and ostomy bag on the ostomy.
DISCHARGE STATUS: The patient will be transferred to
[**Hospital3 7890**] Facility.
DISCHARGE DIAGNOSES:
1. Abdominal sepsis with cecum perforation, status post
right hemicolectomy, ileostomy, and mucous fistula formation.
2. Wound dehiscence.
3. Pneumonia.
4. Atrial fibrillation.
DISCHARGE MEDICATIONS:
1. Enoxaparin sodium 30 mg subcutaneously q.12h.
2. Tocopherol 400 IU PO q.d.
3. Paroxetine hydrochloride 220 mg PO q.d.
4. Oxybutynin 10 mg PO t.i.d.
5. Atenolol 50 mg PO q.d.
6. Glutamine 10 grams PO t.i.d.
7. Ranitidine 159 mg PO b.i.d.
8. Amiodarone HCL 400 mg PO q.d.
9. Heparin flush through the PICC line 100 units per
milliliter, 2 ml IV q.d.
10. Zolpidem tartrate 10 mg PO q.h.s.p.r.n.
11. Albuterol nebulizer solution, one nebulizer Inh q.4h.
p.r.n.
12. Darvocet 5 mg to 10 mg PO q.4h. to 6h.p.r.n.
13. Promote with fiber, full strength, 95 ml per hour to
check residuals q.4h. and hold for residuals greater than 150
and to flush the tube with water q.6h. 30 cc. The patient
was also discharged with ostomy supplies.
FOLLOW-UP PLAN: The patient is to follow up with Dr. [**Last Name (STitle) **]
in her office in two to three weeks. He is to call for an
appointment.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 3676**]
Dictated By:[**Name8 (MD) 7891**]
MEDQUIST36
D: [**2178-8-7**] 13:19
T: [**2178-8-7**] 13:48
JOB#: [**Job Number 7892**]
cc:[**Hospital1 7893**]
|
[
"038.49",
"996.62",
"785.59",
"427.31",
"567.2",
"482.1",
"722.11",
"569.83",
"998.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.23",
"46.20",
"80.51",
"99.15",
"38.93",
"31.1",
"45.73"
] |
icd9pcs
|
[
[
[]
]
] |
17000, 17182
|
17205, 18346
|
3027, 3390
|
15275, 16225
|
15238, 15257
|
14835, 15073
|
174, 784
|
1420, 1485
|
15096, 15115
|
15132, 15215
|
16250, 16979
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,985
| 117,366
|
7611
|
Discharge summary
|
report
|
Admission Date: [**2104-1-8**] Discharge Date: [**2104-1-10**]
Date of Birth: [**2026-5-18**] Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
abnormal stress test
Major Surgical or Invasive Procedure:
s/p cardiac cathterization with stent on [**2104-1-8**]
History of Present Illness:
77 year old female with DM, COPD, CAD s/p CABG [**2101**], angina and
abnormal stress test at OSH with worsening EF on [**1-3**] presents
for cardiac catheterization. Patient's cardiac history includes
a silent MI about 15 yrs ago, CP and dyspnea with MI in [**2101**],
s/p CABGx4 by Dr. [**Last Name (STitle) 5296**]. Patient was diagnosed with DM 2 days
prior to admission with blood sugar 300. Pt was admitted to OSH
last week with CHF. She was admitted again on [**1-7**] with CHF, BNP
1760, ruled out for MI. At OSH patient noted to have worsening
EF and she was admitted to [**Hospital1 18**] for cath. Patient states she
had CP at rest 5 days prior for 10 minutes and overnight that
night woke up short of breath without CP. Patient denies
orthopnea. She has had increasing lower extremity swelling in
the past 4 days and does get short of breath with activity (she
has had PFTs at [**Location (un) **] in past).
During catheterization patient had an episode of CP,
increased PCWP and hypotension when balloon was inflated, but
this resolved when balloon was deflated. A small vessel was
perforated and Echo performed but no effusion seen.
Past Medical History:
HTN
hypercholesterolemia
newly diagnosed DM
ischemic CM
silent MI [**2088**]'s
CAD s/p MI and CABG [**2101**] (LIMA-LAD; VG-diag; VG2-OMs)
known LBBB
s/p cataract surgery
osteo
right CEA
Social History:
Soc Hx: widowed, 1.5 ppd tobacco x 50 yrs.
Family History:
Non-contributory
Physical Exam:
afebrile 101 128/66 19 97%/2L n.c.
Gen: AOX3, pleasant, NAD, speaking in full sentences
HEENT: MMM, small amount dried blood on lip
Neck: supple
CV: Distant S1, S2, RRR, no murmurs appreciated
Pulm: CTA-anteriorly
Abd: Normoactive BS, soft, ND/NT
Ext: wwp, 1+ pitting edema b/l, 1+ DP b/l. Right groin without
hematoma.
Pertinent Results:
[**2104-1-8**] 05:09PM TYPE-ART PO2-85 PCO2-52* PH-7.40 TOTAL
CO2-33* BASE XS-5 INTUBATED-NOT INTUBA
[**2104-1-8**] 05:09PM O2 SAT-96
.
[**2104-1-8**] 10:24PM BLOOD CK(CPK)-75 CK-MB-3
[**2104-1-9**] 04:05AM BLOOD CK(CPK)-77 CK-MB-4
.
[**2104-1-8**] CARDIAC Catheterization
FINAL DIAGNOSIS:
1. Two vessel native coronary artery disease. Patent SVG-OM3.
Occluded
proximal SVG-D1-OM2 with patent D1-OM2 jump segment. Atretic
LIMA-LAD.
2. Mild biventricular diastolic dysfunction.
3. PCI of LAD with DES.
COMMENTS: 1. Selective coronary angiography demonstrated native
two
vessel coronary artery disease in this right dominant
circulation. The
LMCA had mild disease without flow limitation. The LAD was
heavily
calcified proximally with serial 80% and 90% stenoses in the mid
and
distal vessel. The diagonal had a jump segment of vein graft
that filled
an occluded OM. The LCX had a 50% proximal stenosis. The OM1 was
without
flow limiting disease. The OM2 and OM3 were totally occluded.
The OM2
filled via the jump segment from the diagonal. The OM3 filled
via a
patent vein graft. The RCA had mild luminal irregularities
without flow
limiting disease.
2. Graft angiography demonstrated the SVG-OM3 to be widely
patent. The
SVG-D1-OM2 was totally occluded in the proximal graft with a
patent jump
segment supplying the OM2 via the native diagonal.
3. Arterial conduit angiography demonstrated an atretic LIMA-LAD
with
minimal flow into the LAD.
4. Resting hemodynamics from right and left heart
catheterization
demonstrated elevated right and left filling pressures
(RVEDP=15mmHg,
PCWP=20mmHg, LVEDP=20mmHg). Cardiac output and index were
preserved at
4.9 L/min and 2.8 L/min/m2. Mild pulmonary arterial hypertension
was
present.
5. Left ventriculography was not performed to reduce contrast
load.
6. PCI of LAD with DES.
.
Echocardiogram [**2104-1-9**]:
EF 20%. The left atrium is elongated. Left ventricular wall
thicknesses and cavity size are normal. There is severe regional
left ventricular systolic dysfunction with relative preservation
of the basal lateral and distal lateral walls and near akinesis
of remaining segments. No masses or thrombi are seen in the left
ventricle. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. 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 no pericardial effusion.
IMPRESSION: Extensive regional left ventricular systolic
dysfunction c/w multivessel CAD or other diffuse process.
Moderate pulmonary artery systolic hypertension. Mild mitral
regurgitation. No pericardial effusion.
.
Day of discharge Labs [**2104-1-10**]:
[**2104-1-10**] 05:15AM BLOOD WBC-9.4 RBC-3.30* Hgb-10.4* Hct-30.3*
MCV-92 MCH-31.6 MCHC-34.5 RDW-13.2 Plt Ct-341
[**2104-1-10**] 05:15AM BLOOD Glucose-111* UreaN-28* Creat-1.3* Na-143
K-4.1 Cl-103 HCO3-34* AnGap-10
Brief Hospital Course:
A/P: 77 yo F with DM, COPD, CAD s/p CABG '[**01**], recent angina and
abnormal stress test at OSH w/ worsening EF on [**1-3**] presents
for cardiac catheterization.
.
1. CV:
Ischemia: s/p LAD stents. Continue ASA, Plavix,
beta-blocker, statin. Not on ACEI given history of ?renal
failure. Started Captopril, creatinine stable at 1.3 and
transitioned to lisinopril 5 on day of discharge. Creatinine to
be followed by outpatient PCP and cardiologist.
Pump: Continued lasix and titrate to goal even to 500 cc
negative. Rechecked Echo on 1/0/06, EF 20%, mod PA systolic
HTN, no pericardial effusion (results above). Started Digoxin
0.125.
Rhythm: NSR, monitor on Telemetry. Monitor EKGs.
.
2. DM: newly diagnosed and not on any medications. Will check
finger sticks and regular insulin sliding scale for now.
Patient required very little insulin, blood sugars 100-170.
Patient to follow with [**Last Name (un) **] at [**Location (un) **]. She is to follow-up
with PCP 5 days after discharge and to schedule an appointment
at the [**Last Name (un) **] in the next week. She was given a glucometer and
was instructed to test her blood sugars at least once daily and
call her PCP if blood sugars > 300.
.
3. Pulm: Patient with COPD, not currently wheezing. Continue
advair.
.
4. FEN: low salt/heart healthy/diabetic diet. Monitor
electrolytes and repleted prn.
.
5. Proph: ambulate, PT to see pt prior to discharge.
.
6. Dispo: Patient to receive VNA at home for Diabetes teaching.
She is to test blood sugars at least once daily. She has
follow-up scheduled next week with both her PCP and her
cardiologist.
Medications on Admission:
Toprol xl 200 qam, 100 qpm
Pravachol 80 po qhs
Plavix
Norvasc 10 po qday
lasix 40 po qday
ecASA 325 qday
zetia 10 po qday
Fosamax qweek
folate 1 po qday
advair [**Hospital1 **]
ambivent
?metazalone (new), ?recently started on digoxin
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 30 days.
Disp:*30 Tablet(s)* Refills:*1*
3. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO twice a day.
Disp:*120 Tablet Sustained Release 24HR(s)* Refills:*2*
4. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
10. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
coronary artery disease s/p cardiac catheterization on [**2104-1-8**]
systolic congestive heart failure
diabetes mellitus
Discharge Condition:
stable
Discharge Instructions:
Please call your physician or return to the hospital if you
experience chest pain, shortness of breath, increased leg
swelling or other concerning symptoms.
Followup Instructions:
You have a follow-up appointment scheduled with your
cardiologist, Dr. [**Last Name (STitle) 11493**] on [**1-16**] at 9:45 a.m.
You have a follow-up appointment scheduled with Dr. [**Last Name (STitle) 27772**] on
Tuesday, [**2104-1-15**] at 9:45 a.m.
Please call [**Telephone/Fax (1) 27773**] to schedule an appointment with the
[**Hospital **] clinic at [**Location (un) **] in the next week.
Completed by:[**2104-1-10**]
|
[
"428.23",
"401.9",
"250.00",
"413.9",
"414.01",
"496",
"412",
"428.0",
"V45.81",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.46",
"00.40",
"88.56",
"99.20",
"00.66",
"36.07",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
8298, 8366
|
5260, 6897
|
295, 352
|
8532, 8541
|
2209, 2486
|
8746, 9173
|
1828, 1846
|
7181, 8275
|
8387, 8511
|
6923, 7158
|
2503, 5237
|
8565, 8723
|
1861, 2190
|
235, 257
|
380, 1542
|
1564, 1752
|
1768, 1812
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,164
| 184,328
|
16724
|
Discharge summary
|
report
|
Admission Date: [**2112-3-24**] Discharge Date: [**2112-3-28**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo male with h/o CAD, AICD, CHF (EF 25%) who presents with
SOB. Unclear history, but pt states he has been feeling SOB x
3 days, with DOE but not at rst. Per his daughter-in-law he was
started on NC O2 several days ago, but unclear how much. Per
report appears he was feeling more SOB at [**Hospital3 **]
facility, so EMS was called. There was concern that his O2 tank
was empty. Pt denies fevers, chills, cough, palpitations, chest
pain, nasal congestion, sore throat or LE edema.
.
In the ER his VS were T 98.1 HR 68 BP 151/87 RR 12 O2 sat 96%
on unclear amt of O2. He had a CXR that showed bilateral pleural
effusions and evidence of moderate CHF. CT scan of the chest
also demonstrated b/l effusions and evidence of pulmonary edema.
EKG showed no acute changes. He was treated with nebulizers,
solumedrol 125 mg IV, combivent, ctx 1 gm IV, azithromycin 500
mg PO and vancomycin 1 gram IV. His BNP was found to be 9957
and he was treated with 20 of IV lasix.
.
Of note he was recently admitted to the hospital from [**Date range (1) 47316**]
for acute on chronic renal failure (Cr 3.5 up from 2.6) and his
ramipril and lasix were stopped. He was to f/u with his PCP and
appears that his NP re-started him on lasix 20 mg [**Hospital1 **] sometime
in the last two weeks, but ramipril was not re-started.
.
Upon arrival to the floor pt was breathing comfortably on a NRB.
He states his breathing is improved.
.
ROS: Denies fevers,chills, nasal congestion, ST, cough, palps,
CP, abdominal pain, N/V, LE edema. Did have diarrhea several
days ago.
Past Medical History:
-Coronary artery disease - chronic stable angina. ? CABG with
aortic valve replacement in a [**Hospital 531**] hospital, although
patient cannot remember where. ? H/o PCI as well.
-Ischemic cardiomyopathy with LVEF=25% in [**1-/2112**]
-Systolic CHF, TTE [**2112-2-11**] showed EF 25%
-AVR [**2099**] c/b re-exploration x 2 for bleeding
-AICD implanted in [**State 108**] in [**2103**] after monomorphic VT with
presyncope, generator changed [**12-18**]
-Atrial fibrillation
-Atrophic Right Kidney
-Chronic Kidney Disease
-Small, early squamous cell skin cancer of R shoulder, found in
[**2-18**]
-History of Respiratory failure requiring a 12 day intubation
(pt does not remember this)
-Hernia repair
Social History:
The patient denies tobacco use for past 30 years. Occasional
history of alcohol use. Lives in [**Hospital3 400**] in [**Location (un) **].
He uses a cane to ambulate, and reports that he walks a lot.
Family History:
There is no family history of premature coronary artery disease
or sudden death. He reports that all of his 12 siblings have
been healthy. No history of kidney disease.
Physical Exam:
VS: T: 97.5 HR: 77 BP: 156/55 RR: 21 O2 sat: 98% on NRB
Gen: Elderly male, NAD, with NRB in place
HEENT: anicteric sclera, MMM, dentures in place
Neck: supple, JVP at his jaw
Cardio: RRR, nl S1 S2, [**2-18**] harsh systolic murmur loudest at RUSB
Pulm: crackles at bases b/l L>R
Abd: soft, NT, ND, + BS
Ext: trace b/l pitting edema, 2+ DP pulses
Neuro: A&Ox3, PERRL, moves all extremities well
Pertinent Results:
CXR: [**2112-3-25**]
IMPRESSION: Persistent intrafissural pleural fluid in the right
lung, with interval increase in bilateral pleural effusions.
Slight decrease in pulmonary edema.
.
CXR: [**2112-3-24**]
IMPRESSION:
1. New rounded opacities in the right mid lung zone and diffuse
hazy opacities in the lower lung zones bilaterally concerning
for reaccumulation of pleural fluid within the fissure.
2. Large, bilateral pleural effusions.
3. Moderate congestive heart failure.
.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2112-3-28**] 05:35AM 9.1 3.73* 11.5* 34.5* 93 30.9 33.4 14.6
329
[**2112-3-24**] 09:10AM 8.9 3.61* 11.0* 33.6* 93 30.6 32.8 14.8
309
.
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3
[**2112-3-28**] 05:35AM 98 74* 3.1* 145 4.1 107 28
[**2112-3-24**] 09:10AM 135* 66* 3.0* 144 4.4 110* 22
Brief Hospital Course:
ASSESSMENT/PLAN: [**Age over 90 **] yo M with h/o CAD, AICD, CHF (EF 25%)
presented with shortness of breath from CHF exacerbation. Pt's
symptoms improved with diuresis
.
# Acute on chronic CHF exacerbation: Pt with multiple admissions
in recent months for acute exacerbations of CHF. We have been
diuresing pt with furosemide with pt's improvement for symptoms
of shortness of breath. We have increased his home regimen
furosemide from 20mg po BID to 40mg po BID. We continue pt on
carvedilol, imdur and amlodipine, however did not restart ACEI
given acute on CKD. Pt will need a low sodium diet & 1.5-2L
fluid restriction. Pt had been started on oxygen at home perhaps
by PCP, [**Name10 (NameIs) **] ambulatory O2sats were 94% on RA and pt was not
discharged on oxygen.
.
# CAD: h/o of CAD, pt ruled out for MI with negative enzymes.
Continued pt on aspirin as well as carvedilol.
.
# Afib: Well rate controlled on home regimen carvedilol which
was continued.
.
# Anemia: Hct stable from last admission. Recent baseline has
been variable from 33-40. Recent iron studies with low TIBC and
nl iron, suggesting ACD.
.
# CRI: Pt with chronic kidney disease and reportedly a right
atrophic kidney. Appears baseline Cr has been around 1.9-2.6.
Creatinine on admission 3.6, slowly trending down during
hospitalization with diuresis.
.
# Goals of care: Pt and family interested in inpatient hospice
facility and would like transition from rehab facility to an
inpatient hospice facility.
.
# Code Status: DNR/DNI confirmed with daughter-in law
Medications on Admission:
MEDICATIONS ON ADMISSION (per d/c summary [**3-4**] and pharmacy):
1. Carvedilol 25 mg [**Hospital1 **].
2. Aspirin 325 mg daily
3. Amlodipine 10 mg daily
4. Isosorbide Mononitrate 60 mg daily
5. Mirtazapine 15 mg qhs
6. Pantoprazole 40 mg daily
7. lasix 20 mg [**Hospital1 **] (per daughter in law)
Discharge Medications:
1. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once 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. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Acute on Chronic systolic heart failure
Coronary Artery Disease
h/o Atrial fibrillation
Chronic kidney disease
Discharge Condition:
stable
Discharge Instructions:
You were admitted with shortness of breath due to congestive
heart failure causing fluid in your lungs. You were treated with
lasix to get fluid off your lungs and improved.
.
We have increase your home regimen furosemide from 20mg [**Hospital1 **] to
40mg po BID. Please continue to take all other medications as
[**Hospital1 1988**].
.
Please call your doctor or return to the ER if you have chest
pain, shortness of breath, swelling in your legs, fevers, chills
or other concerning symptoms.
Followup Instructions:
Please follow-up with your primary care doctor, Dr.
[**Last Name (STitle) 1266**],[**Telephone/Fax (1) 608**] in [**12-16**] weeks.
|
[
"V10.83",
"414.8",
"587",
"584.9",
"285.21",
"428.0",
"428.23",
"427.31",
"585.9",
"V45.02",
"414.00",
"V43.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6981, 7053
|
4324, 5864
|
280, 286
|
7208, 7217
|
3450, 4301
|
7760, 7895
|
2848, 3018
|
6215, 6958
|
7074, 7187
|
5890, 6192
|
7241, 7737
|
3033, 3431
|
221, 242
|
314, 1889
|
1911, 2614
|
2630, 2832
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,081
| 187,103
|
10440
|
Discharge summary
|
report
|
Admission Date: [**2179-2-25**] Discharge Date: [**2179-2-27**]
Date of Birth: [**2102-5-31**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8487**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
76y/o M with h/o NSCLC, COPD, a fib, symptomatic bradycardia s/p
[**First Name3 (LF) 4448**] placement, h/o posterior fossa SAH in setting of
supratherapeutic INR presents with altered mental status at
rehab. Pt was recently admitted [**Date range (1) 34519**] with hypotension, COPD
exacerbation, and RUL pneumonia, thought to be postobstructive
[**2-25**] lung Ca. During that admission, he had episodes of a fib
with RVR as well. He was given a 2-week course of levo/flagyl,
which he completed on [**2179-2-24**].
.
Per wife's report, pt was confused on the AM of admission. He
had visual hallucinations and had shaking tremors. She also says
that he told her that they were "keeping him locked up." Per the
nursing home, he was noted to be more confused the night prior
to admission, and accusing them of "practicing voodoo." No
fevers per nursing home report; wife states that he had no other
complaints.
.
In the [**Name (NI) **], pt was given vancomycin 1g x1, ceftriaxone 2g x1,
solumedrol 125mg x1, albuterol/atrovent nebs. Sats on admission
to ED 93% (?RA), 97% on 2L, then 95% on 4L 7 hours later. Was
noted to be more short of breath, using accessory muscles, and
was placed on BiPAP. Sats 99%, breathing improved. Was
subsequently intubated.
Past Medical History:
Past Medical History:
1) COPD/chronic bronchitis, on chronic prednisone
- [**2161**] fev 1.0/fvc 52% no recent PFTs on file
2) AF: on coumadin [**2172**]/[**2178**]; now off given h/o small cerebellar
bleed w/supratherapeutic INR [**12-28**].
3) s/p [**Company 1543**] V/V/I [**Company 4448**] placement [**2178-12-23**] for
symptomatic bradycardia with prolonged QT leading to torsades
and VT
4) CAD - s/p CABG in [**2168**] following non-Q wave MI. LIMA to LAD,
SVG to RCA and PVA
- [**12-28**] ETT MIBI Modified [**Doctor Last Name 4001**] treadmill X 8 min,
uninterpretable EKG, no myocardial perfusion defects
5) h/o small cerebellar bleed w/supratherapeutic INR [**12-28**]
6) Ischemic cardiomyopathy: TTE [**1-29**] EF<25%, mildly dilated LA,
dilated LV, severe global LV hypokinesis, dilated RV, trivial
MR.
7) hypercholesterolemia
12) hearing loss
13) h/o ETOH abuse/dependence quit 7 yrs ago
14) iron deficiency anemia since [**9-28**]
15) NSCLC RUL: dx by transbronchial bx [**12-28**]
Social History:
Previously lived at home with wife, recently d/c'd to rehab
[**2-13**]. H/o ETOH dependence, quit drinking 7 yrs. ago, no
illicits. Former smoker quit in his 50s (40 pkyr). Retired from
work in tire warehouse in [**Location (un) 34517**], at baseline walks with
walker
Family History:
Non-contributory
Physical Exam:
VS: Tm 99.0 Tc 98.1 101/66 109 20 99% on AC 550x18/0.5/5
Gen: intubated, sedated
HEENT: small green fluid from mouth
Chest: sternotomy scar well-healed
Neck: no JVD, no LAD
Pulm: + wheezes, artifact from ventilator, no crackles noted,
breath sounds symmetric
CV: irregularly irregular, mildly tachycardic, no murmurs
appreciated
Abd: soft, NT/ND, hypoactive bowel sounds, no masses
Ext: trace pretibial edema, 2+ DP pulses
Neuro: sedated
Pertinent Results:
Imaging:
[**2-25**] head CT: hyperdensity adjacent to previously identified
calcified extra-axial lesion - may be tiny focus of hemorrhage
or calcification
.
[**2-25**] CXR: partial improvement in RUL PNA; known R hilar mass not
visualized
.
[**2-25**] CTA chest: no evidence of PE; main pulmonary A large (3.8cm
diameter) suggestive of pulm HTN; lg R hilar mass with
encasement of hilar structures including R pulm A and R main
bronchus, and smaller areas; no change in size/appearance since
[**2-10**]; in R hilum, at previous opacity area, has developed
air-filled cavity with surrounding opacity - 2.1x1.7cm; [**Month/Year (2) **] has
completely collapsed, interval progression of patchy/nodular
opacities with area of confluence anteriorly; severe
emphysematous changes; small effusion surrounding [**Month/Year (2) **] collapse
CTA CHEST W&W/O C &RECONS [**2179-2-25**] 8:55 PM
CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST
Reason: pls evaluate for PE in setting of malignancy and hypoxia
and
Field of view: 36 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
76 year old man with sob, active lung ca, chronic
postobstructive pneumonia
REASON FOR THIS EXAMINATION:
pls evaluate for PE in setting of malignancy and hypoxia and
characterization of pneumonia
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Shortness of breath and active lung cancer with
post-obstructive pneumonia. Please evaluate for PE in the
setting of malignancy and hypoxia.
COMPARISON: [**2179-2-10**].
TECHNIQUE: Contiguous axial images through the chest were
obtained without contrast. Subsequently, following the
administration of 100 cc of Optiray, contiguous axial images
through the chest were obtained during opacification of the
pulmonary artery. Coronal, sagittal, and oblique reformatted
images were obtained.
CTA OF THE CHEST: There are no filling defects within the
pulmonary arterial branches to suggest a pulmonary embolus. The
main pulmonary artery is large, measuring 3.8 cm in diameter,
suggesting pulmonary arterial hypertension. The thoracic aorta
is of normal caliber. Atherosclerotic changes of the aorta have
a similar appearance to [**2-10**]. The patient is post CABG.
CT OF THE CHEST WITH CONTRAST: Left-sided [**Month (only) 4448**] with single
lead in the right ventricle is unchanged. The patient has been
reintubated. A nasogastric tube is in place. Again noted is a
large right hilar mass with encasement of hilar structures
including the right pulmonary artery and right main bronchus in
addition to smaller airways. Size and appearance is not
significantly changed from [**2-10**]. In the right hilum at
an area of previous opacity with tiny air bubbles on the [**2-10**] study, there has developed an air-filled cavity with
surrounding opacity measuring 2.1 x 1.7 cm as seen on the
coronal images (series 688B, image 23). Since [**2-10**], the
right lower lobe has completely collapsed. There has been
significant interval progression of both patchy and nodular
opacities within the right middle lobe, with an area of relative
confluence anteriorly. Patchy and interstitial opacities within
the right upper lobe have worsened as well. Severe emphysematous
changes are again noted. In contrast to the right lung, the left
lung is relatively clear. There is a small effusion surrounding
right lower lobe collapse. Small mediastinal lymph nodes are
unchanged in the interim. No left pleural effusion or
pericardial effusion.
Within the imaged portion of the upper abdomen, the noncontrast
enhanced visualized portions of the liver, gallbladder, spleen,
right adrenal gland, and superior kidney are unremarkable. An NG
tube is seen within the stomach, with the tip oriented cephalad.
There are heavy calcifications of the splenic artery.
BONE WINDOWS: There are no suspicious osteolytic or sclerotic
lesions.
Multiplanar reformatted images were essential in delineating the
anatomy and pathology in this case (grade 3).
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Interval collapse of the right lower lobe.
3. Large right hilar mass encasing the right pulmonary artery
and the airway is relatively unchanged compared to [**2179-1-24**].
4. Soft tissue density containing air bubbles of the right hilum
has become an air-filled cavity at the right hilum with
surrounded soft tissue on today's exam.
5. Interval worsening of patchy nodular opacities of the right
upper and middle lobes, consistent with an infectious process.
Left lung remains clear.
6. Small right pleural effusion.
CT HEAD W/O CONTRAST [**2179-2-25**] 6:26 AM
CT HEAD W/O CONTRAST
Reason: eval for a bleed
[**Hospital 93**] MEDICAL CONDITION:
76 year old man with ams
REASON FOR THIS EXAMINATION:
eval for a bleed
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 76-year-old man with altered mental status.
COMPARISON: Multiple head CTs, most recent dated [**2179-2-17**].
TECHNIQUE: Noncontrast head CT.
FINDINGS: Adjacent to the previously identified right frontal
extra-axial calcified lesion that represent an osteoma or
meningioma, there is a tiny focus of hyperdensity which may
represent blood or calcification, but likely partial volume
imaging of the contiguous calcific/ossific lesion itself. There
is no mass effect, hydrocephalus, or shift of normally midline
structures. [**Doctor Last Name **]- white differentiation is preserved. Mild
mucosal thickening is noted in the ethmoid and right maxillary
sinuses. Osseous and soft tissue structures are otherwise
unremarkable.
IMPRESSION: Hyperdensity adjacent to the previously identified
calcified extra-axial lesion, which may represent a tiny focus
of hemorrhage or calcification, but likely partial volume
imaging of the calcific/osific lesion itself. Otherwise, stable
CT appearance of the brain.
[**2179-2-26**] 12:00AM COMMENTS-SPECIMEN-O
[**2179-2-25**] 10:06PM GLUCOSE-155* UREA N-29* CREAT-0.9 SODIUM-139
POTASSIUM-4.8 CHLORIDE-103 TOTAL CO2-26 ANION GAP-15
[**2179-2-25**] 10:06PM CK(CPK)-33*
[**2179-2-25**] 10:06PM CK-MB-4 cTropnT-0.05*
[**2179-2-25**] 10:06PM CALCIUM-8.3* PHOSPHATE-4.3 MAGNESIUM-1.8
[**2179-2-25**] 10:06PM WBC-16.7* RBC-3.93* HGB-10.1* HCT-31.3*
MCV-80* MCH-25.7* MCHC-32.2 RDW-17.2*
[**2179-2-25**] 10:06PM PLT COUNT-462*
[**2179-2-25**] 07:45PM TYPE-ART PO2-216* PCO2-52* PH-7.37 TOTAL
CO2-31* BASE XS-3
[**2179-2-25**] 07:45PM LACTATE-1.7
[**2179-2-25**] 05:20AM URINE HOURS-RANDOM
[**2179-2-25**] 05:20AM URINE GR HOLD-HOLD
[**2179-2-25**] 05:20AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.024
[**2179-2-25**] 05:20AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR
[**2179-2-25**] 05:20AM URINE RBC-0 WBC-[**3-28**] BACTERIA-OCC YEAST-MOD
EPI-0-2
[**2179-2-25**] 05:06AM LACTATE-1.3
[**2179-2-25**] 05:05AM PT-14.0* PTT-24.5 INR(PT)-1.2*
[**2179-2-25**] 04:55AM GLUCOSE-115* UREA N-29* CREAT-0.8 SODIUM-140
POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-28 ANION GAP-16
[**2179-2-25**] 04:55AM CALCIUM-8.7 PHOSPHATE-3.5 MAGNESIUM-1.9
[**2179-2-25**] 04:55AM WBC-16.3*# RBC-3.94* HGB-10.4* HCT-31.0*
MCV-79* MCH-26.3* MCHC-33.4 RDW-18.2*
[**2179-2-25**] 04:55AM NEUTS-86.8* BANDS-0 LYMPHS-8.5* MONOS-4.4
EOS-0.1 BASOS-0.2
[**2179-2-25**] 04:55AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL
[**2179-2-25**] 04:55AM PLT SMR-VERY HIGH PLT COUNT-633*
Brief Hospital Course:
A/P: 76y/o M with non-small cell lung cancer, COPD, recent
post-obstructive pneumonia presents with mental status changes.
.
# mental status changes - This was likely multifactorial in
etiology. Likely contribution from pneumonia (only partial
improvement on CXR, was hypoxic, low grade temp, leukocytosis,
sputum being suctioned). Also could be partially due to meds -
lorazepam, remeron had been increased to 15mg daily, steroids.
His electrolytes were within normal limits and blood urine
cultures were all negative. His mental status did not changed
during his hospital course and prior to his death.
.
# post-obstructive pneumonia - This was likely due to NSCLC.
The patient had recently completed course of levo/flagyl
without complete resolution; could also have new pneumonia not
yet seen on CXR. A CT demonstrated [**Year/Month/Day **] collapse with a RML and
RUL infection. He was initially treated with zosyn and
vancomycin, and sputum and blood cultures were negative. During
his hospital care, goals of care were better defined with pain
and palliation consult on board, the patient's goals of care
were discussed with the wife, as the patient had a progressive
lung cancer and unlikely to have good quality of life with
further treatment. Care was transitioned to comfort measures
only and his antibiotics were stopped and he was extubated.
.
# [**Year/Month/Day **] collapse - It was unclear whether due to tumor itself,
mucous plugging in setting of COPD, or infectious etiology
.
# non-small cell lung Ca -He has been followed by Dr. [**Last Name (STitle) **].
Not an operative candidate; also with performance status low
enough to preclude chemo, lung disease precludes XRT. His goals
of care were changed to comfort measures only as he was a poor
candidate for additional treatment
.
# COPD - The patient has a history of severe emphysema. He was
initially on albuterol and atrovent nebulizers. He was
initially continued on his steroid taper started from a previous
COPD flare.
.
# h/o posterior fossa hemorrhage - concern for intracranial
bleed. Neurosurgery felt the new Head CT findings were likely
secondary to artifact and further definition could not be
provided by MRI as he has a [**Last Name (STitle) 4448**]
.
# hypoxic [**Last Name (STitle) **] failure - He was initially ventilated with
AC. It was unclear due to [**Name (NI) **] collapse or infection. When his
goals of care were transitioned to comfort measures he was
extubated, and maintained on a morphine drip with good control
of agitation and he expired.
.
.
# Code - full at time of admission. Goals of care were better
defined with his wife and he was transitioned to comfort
measures only
Medications on Admission:
1. Metronidazole 500 mg tid (complete [**2179-2-24**])
2. Levofloxacin 500 mg daily (complete [**2179-2-24**])
3. Fluticasone-Salmeterol 250-50 mcg one puff [**Hospital1 **]
4. Ipratropium Bromide neb q6h
5. Aspirin 325 mg daily
6. Toprol XL 25 mg daily
7. Docusate Sodium 100 mg [**Hospital1 **]
8. Senna 8.6 mg [**Hospital1 **] prn
9. Ferrous Sulfate 325 (65) mg daily
10. Pantoprazole 40 mg daily
11. Atorvastatin 10 mg daily
12. Albuterol Sulfate neb q4H
13. Mirtazapine 7.5mg qHS
14. Insulin Regular sliding scale
15. Prednisone 60 mg x2 days, then taper by 10mg daily q3 days.
16. Diltiazem HCl 60 mg qid
17. Cepacol 2 mg prn
18. Lorazepam 0.5 mg q6h prn
19. Acetaminophen 325-650mg q4-6h prn
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Pneumonia
Lung Cancer
Discharge Condition:
Expired
|
[
"V66.7",
"414.8",
"V45.01",
"250.00",
"293.0",
"276.51",
"427.31",
"518.84",
"162.8",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"93.90",
"33.22",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
14369, 14378
|
10888, 13589
|
337, 343
|
14443, 14453
|
3441, 3461
|
2950, 2968
|
14340, 14346
|
8105, 8130
|
14399, 14422
|
13615, 14317
|
2983, 3422
|
276, 299
|
8159, 10865
|
371, 1627
|
3470, 4490
|
1671, 2648
|
2664, 2934
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,951
| 166,125
|
3183
|
Discharge summary
|
report
|
Admission Date: [**2108-8-13**] Discharge Date: [**2108-8-29**]
Date of Birth: [**2028-6-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2108-8-13**] Aortic Valve Replacement(25mm CE Pericardial Valve) and
Single Vessel Coronary Artery Bypass Graft(vein graft to obtuse
marginal).
[**2108-8-24**] Implantation of AICD([**Company 1543**] Virtuoso DR)
History of Present Illness:
Mr. [**Known lastname 14963**] is an 80 year old male with known aortic stenosis.
He presented with worsening shortness of breath for the past
several months along with exertional chest discomfort. He denied
symptoms at rest. Cardiac catheterization showed a patent
circumflex stent with disease in the distal LAD and obtuse
marginal branch. Given his worsening congestive heart failure,
he was referred for cardiac surgical intervention.
Past Medical History:
Congestive Heart Failure
Aortic Stenosis
Coronary Artery Disease - s/p PTCA and stenting [**2099**]
Hypertension
Hypercholesterolemia
Obesity
Peripheral Neuropathy
Glaucoma
Benign Prostatic Hypertrophy - s/p TURP
Social History:
Remote tobacco as a child. Denies ETOH. He is a retired
traveling salesman. He currently lives alone.
Family History:
Two brothers underwent CABGs in their 70's - 80's.
Physical Exam:
Discharge Vitals:
General: Elderly male in NAD
HEENT: Oropharynx benign, EOMI
Neck: Supple, no JVD
Lungs: CTA bilaterally
Heart: Regular rate and rhythm
Abdomen: Soft, nontender with normoactive bowel sounds
Ext: Warm, no edema
Pulses: 2+ distally
Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal
deficits noted
Pertinent Results:
[**2108-8-14**] Head CT Scan: There is no evidence of hemorrhage, edema,
mass, mass effect, or acute vascular territorial infarction.
There is mild ventricular and sulcal prominence, most consistent
with age-appropriate involutional change. There is no fracture.
There are air-fluid levels within the bilateral frontal sinuses,
sphenoid air cells, ethmoid air cells, and maxillary sinuses.
Most likely, this is related to the patient's intubated status.
[**2108-8-20**] Upper Extremity Ultrasound: Partially occlusive distal
left basilic vein thrombus with lack of compressibility. Patent
proximal left basilic vein.
[**2108-8-25**] Head CT Scan: There is no evidence of hemorrhage, edema,
mass effect, or infarction. Mild ventricular and sulcal
prominence remains present. There is no fracture.
Previously-described air-fluid levels within the bilateral
frontal, sphenoid, ethmoid and maxillary sinuses are no longer
present.
[**2108-8-28**] 06:45AM BLOOD WBC-14.7* RBC-3.98* Hgb-12.3* Hct-37.2*
MCV-94 MCH-30.9 MCHC-33.1 RDW-14.7 Plt Ct-302
[**2108-8-27**] 07:20AM BLOOD WBC-15.4* RBC-3.99* Hgb-12.0* Hct-35.9*
MCV-90 MCH-30.0 MCHC-33.3 RDW-14.7 Plt Ct-327
[**2108-8-26**] 06:45AM BLOOD WBC-15.8* RBC-3.93* Hgb-12.1* Hct-35.2*
MCV-90 MCH-30.8 MCHC-34.3 RDW-14.8 Plt Ct-364
[**2108-8-28**] 06:45AM BLOOD Plt Ct-302
[**2108-8-26**] 06:45AM BLOOD PT-16.9* PTT-28.3 INR(PT)-1.6*
[**2108-8-29**] 06:35AM BLOOD UreaN-27* Creat-1.5* K-4.3
[**2108-8-28**] 06:45AM BLOOD Glucose-105 UreaN-34* Creat-1.8* Na-140
K-4.6 Cl-107 HCO3-25 AnGap-13
Brief Hospital Course:
Mr. [**Known lastname 14963**] was admitted and underwent an aortic valve
replacement and coronary artery bypass grafting by Dr. [**Last Name (STitle) **].
Please see seperate dictated operative note for surgical
details. Following the operation, he was brought to the CSRU for
invasive monitoring. He initially required ventricular pacing
for complete heart block. On postoperative day one, he was noted
to have gaze deviation associated with deficits in communication
and stereotyped purposeless movement of his left hand. Neurology
was consulted and head CT scan was obtained which showed no
evidence of hemorrhage, edema, mass, mass effect, or acute
vascular territorial infarction. Over the next several days, his
neurologic status improved. He became more alert with more
purposeful movements. He was eventually extubated on
postoperative day three without incident. His complete heart
block gradually resolved with developement of acclerated
junctional rhythm. He was transferred to the floor. He went on
to experience sustained ventricular tachycardia on postoperative
day four. He converted back to a sinus rhythm after intravenous
Amiodarone and Lidocaine were administered, and he was
transferred back to the CSRU. Ep was consulted and placed a
temporary wire and planned for PPM/ICD placement. It was delayed
secondary to phlebitis which was treated with vancomycin and
then keflex. A [**Company **] dual chamber ICD was placed on
[**2108-8-24**]. He was transferred back to the floor. He was seen by
psychiatry after a code purple.he received haldol and a 1:1
sitter. He was seen by speech and swallow who recommended pureed
diet and thin liquids. His confusion resolved. Video swallow
showed mild to moderate dysphagia and a soft diet was
recommended. He slowly improved and was ready for discharge to
rehab on [**2108-8-29**].
Medications on Admission:
Lipitor 20 qd, Gabapentin 300 tid, HCTZ 25 qd, Aspirin 325 qd,
Clonazepam 0.5 qd, Cosopt eye gtts, Lumagen eye gtts, Restasis
eye gtts, Metoprolol 100 [**Hospital1 **], Fenofibrate 200 qd
Discharge Medications:
1. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
6. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
11. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
12. Cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette
Ophthalmic [**Hospital1 **] (2 times a day).
13. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
14. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours) for 5 days: end [**9-3**].
15. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO
DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
Commons Residence At Orchard - [**Location (un) 2624**] (a.k.a. [**Location (un) 5481**])
Discharge Diagnosis:
Congestive Heart Failure(Diastolic)
Aortic Stenosis
Coronary Artery Disease
Postop Ventricular Tachycardia
Postop Phlebitis with Upper Extremity Deep Vein Thrombosis
Hypertension
Hypercholesterolemia
Obesity
Peripheral Neuropathy
Glaucoma
Discharge Condition:
Good
Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call cardiac surgeon if there is concern for wound infection.
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
5)No driving for at least one month.
Followup Instructions:
Dr. [**Last Name (STitle) **] in [**3-22**] weeks, call for appt
Dr. [**Last Name (STitle) 1016**] in [**1-21**] weeks, call for appt
Dr. [**Last Name (STitle) **] in [**1-21**] weeks, call for appt
Labs: TSH in 1 month - started on synthroid for ^tsh results to
Dr [**Last Name (STitle) **]
Scheduled appointments:
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 1401**], M.D. Phone:[**Telephone/Fax (1) 2386**]
Date/Time:[**2108-10-30**] 11:40
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2108-8-31**]
11:00
Completed by:[**2108-8-29**]
|
[
"997.1",
"999.2",
"427.1",
"746.4",
"401.9",
"428.30",
"293.0",
"V45.82",
"272.0",
"428.0",
"342.90",
"451.82",
"997.09",
"414.01",
"426.0",
"365.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.78",
"99.04",
"37.94",
"39.61",
"35.21",
"89.60",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7017, 7133
|
3369, 5212
|
341, 559
|
7416, 7423
|
1810, 3346
|
7759, 8358
|
1399, 1451
|
5450, 6994
|
7154, 7395
|
5238, 5427
|
7447, 7736
|
1466, 1791
|
282, 303
|
587, 1027
|
1049, 1264
|
1280, 1383
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
849
| 107,240
|
10643+56168
|
Discharge summary
|
report+addendum
|
Admission Date: [**2167-9-19**] Discharge Date: [**2167-11-4**]
Service: MICU, GREEN
CHIEF COMPLAINT: The patient is an 80-year-old with recent
complicated hospitalization on the Neurosurgical Service for
fall complicated by subdural hematoma who presented with
decreased mental status with apparent seizure activity.
male with history of diabetes, coronary artery disease,
pacemaker, transient ischemic attacks, status post prolonged
hospitalization at [**Hospital6 256**] from
[**9-19**] through [**10-27**] on the Neurosurgical/SICU
Service for falling down stairs resulting in facial trauma
and right moderate subdural hematoma. His course was
complicated by prolonged intubation and failure to wean
and aspiration, initially followed by recurrent pneumonia,
atelectasis, left lower lobe collapse, congestive heart
failure, and fluid overload, and depressed mental status. He
underwent tracheostomy on [**10-3**] complicated by tracheal
bleeding, pneumothorax, and asystolic arrest. His course was
also complicated by recurrent atrial fibrillation well controlled
by Diltiazem, persistent guaiac positive stools, but GI declined
work-up, renal insufficiency with creatinine range from 2.1-2.9.
He was discharged to rehabilitation on [**2167-10-23**]. His
course at rehabilitation was notable for recent fevers with work-
up reportedly with gram-negative rods in urine and sputum. He
was started on Ciprofloxacin and subsequently Ceftazidine. He
was initially lethargic with thyroid studies showing increased
TSH of 76 and decreased T4 at 2.0. He was begun on Synthroid
0.025 mg per day. Also of note, Diltiazem was changed to Digoxin
for unclear reasons.
From a respiratory standpoint, he started to wean slowly and
most recently on pressure support or 15, PEEP of 5, FIO2 30%
breathing <30 BPM, and tidal volume of >5 cc/kg . Reportedly ABG
seven days ago was pH of 7.41, pCO2 42, pO2 106. He had been
receiving aggressive diuresis with Lasix 100 mg q.12 hours
which slowly increased his bicarb from 28 on transfer on
[**10-28**], to 234 on [**11-2**]. Apparently his mental
status improved somewhat. On [**11-2**] he was alert and
responsive. He was smiling and shaking hands with people.
OF NOTE HE WAS MADE DNR TODAY.
At 2 a.m. he was noted to have what appeared to be a tonic clonic
seizure. He eyes rolled to the back of his head. He turned red.
His body appeared rigid, and he appeared to have a upper
extremity greater than lower extremity, right greater than left
tonic clonic jerking movements. Vitals signs with a blood
pressure of 132/49, heart rate 80, respirations 20, oxygen
saturation 100%. This appeared to last about 15 min per the
nurse but 5 min per the respiratory therapist taking care of him.
Subsequently this all resolved except for continued right arm
shaking for about 10 min. He received Ativan 1 mg IV push.
He was bagged and suctioned. Temperature was 100.2??????.
Ten minutes after this, he was placed on vent settings for 10
min. Subsequent ABG was with a pH of 7.59, pCO2 36, pO2 94.
He remained unresponsive and was transferred to [**Hospital6 1760**].
On transfer he remained unresponsive. Vitals signs were
100.2??????, 70s, 152/71, 100%. Chest x-ray and head CT
unchanged. Vent settings on transfer were SIMB 600 x 10,
FIO2 60%, pressure support 5 PEEP, ABG 7.49, pCO2 49, pO2 82.
Vent was changed to PAP 10/5, FIO2 30%. Neurology was
consulted, and the patient was admitted to MICU.
PHYSICAL EXAMINATION: General: Not following commands. He
seemed to direct eyes toward voice. The patient was in no
acute distress. Vital signs: 97.4??????, 140/62, heart rate 76,
respirations 20, oxygen saturation 90%. HEENT: There was a
1-2 cm laceration over the right parietal scalp, [**2-3**]
ulceration lesion on the left chin with granulation tissue,
exudate. Pupils equal, round and reactive to light.
Oropharynx clear. Dry mucous membranes. Increased jugular
venous distention. No lymphadenopathy. Status post trach.
Trach site clean, dry and intact. Lungs: Coarse breath
sounds with rales. Left lung base irregularly irregular.
Heart: No murmurs, regurgitation. Abdomen: Positive bowel
sounds. Soft, nontender, nondistended. Status post PEG tube
PEG site clean, dry and intact with no erythema.
Extremities: There was 2+ edema in the extremities. There
was a right PICC line in place. Scattered petechia. Eyes
opened spontaneously. He directed eyes to voice but did not
follow commands. Pupils reactive and equal but somewhat
sluggish. Unable to test other cranial nerves. Tone
increased throughout. Withdraws to pain. Moves all four
extremities. Toes upgoing bilaterally.
LABORATORY DATA: Sodium 143, potassium 3.6, chloride 100,
bicarb 34, BUN 109, creatinine 2.9, glucose 136; white count
10.1, hematocrit 28.8, glucose 230; calcium 8.2, magnesium
2.1, phosphate 2.5; INR 1.5; TSH 75.8; T1 927, T4 2.8 on
[**10-29**]; digoxin level pending; urinalysis greater than
50 white blood cells, no yeast, rare bacteria; urine culture,
blood culture, and sputum culture pending.
Chest x-ray showed infiltrate at left base consistent with
pneumonia vs atelectasis, small left pleural effusion,
right base atelectasis and distinct vascular margins which
could represent component of interstitial edema.
Head CT showed moderate size right subdural measuring 1.6 cm,
slightly increased from last CT. No evidence of acute
hemorrhage.
ASSESSMENT AND PLAN: This is an 80-year-old male with a
history of diabetes, coronary artery disease, transient
ischemic attacks, recent prolonged hospitalization, for
subdural hematoma status post fall, complicated by failure to
wean, who presented with depressed mental status post seizure
at [**Hospital6 85**].
1. Neurological: He appeared to have had a seizure and was
postictal upon presentation. Predisposition likely underlying
subdural hematoma and possible cerebrovascular disease. Unclear
what might have precipitated this event overnight. The patient
had a low-grade fever, recently diagnosed hypothyroidism begun on
Synthroid, which all may be potential contributors. Head CT
showed no new bleed or midline shift.
Neurology recommended Fosphenytoin load of 1.2 mg IV with
subsequent 300 mg once a day 12 hours afterloading dose.
This was subsequently changed to Dilantin 300 mg once a day.
EEG was obtained with no evidence for active seizure
activity.
2. Respiratory status: history of failure to wean, with
multifactorial etiology, initial massive nasal bleeding,
aspiration, recurrent pneumonia, congestive heart failure, and
fluid overload, pneumothorax requiring chest tube, s/p trach
placement, and intermittent atalectasis.
At this time, he appeared to have a left lower lobe
infiltrate. Reportedly sputum was with gram-negative rods. He
has been aggressively diuresed with Lasix with increasing bicarb
and metabolic alkalosis.
Sputum cultures at [**Hospital1 **] showed Pseudomonas and other gram
positive organisms, and urine culture showed Klebsiella. The
patient was continued on Ceftazidine and Ciprofloxacin.
Ceftazidine dose was 1 g q.d. and Ciprofloxacin was 200 mg q.12
hours. Infectious Disease was consulted and agreed with
antibiotic dosing. Chest PT was continued and suctioning.
With regard to metabolic alkalosis and congestive heart
failure, the plan was to hold Lasix for now, replete
chloride. With regard to ventilation, the patient was
oxygenating well with baseline FIO2 of 30%. Recommended
changing back to baseline CPAP setting of 15 and 5.
Infectious disease: The patient had a low-grade fever with
apparent pneumonia. He was continued on Ceftazidine and
Ciprofloxacin.
Cardiovascular: He had a history of rapid atrial
fibrillation. Digoxin was held and levels were checked.
Diltiazem was changed to Digoxin. The patient was also well
controlled on beta-blocker and calcium channel blocker.
Currently holding Aspirin anticoagulation given recent
subdural bleed.
Endocrine: Diabetes was followed with fingerstick glucose
and placed on regular Insulin sliding scale.
Hypothyroidism: The patient was continued on Levothyroxine
at 0.025 mg per day.
Chronic renal failure: Likely secondary to diabetes. Lasix
was held through this hospitalization. Will continue to
follow BUN and creatinine.
Hematology: The patient was repleted with Vitamin K.
Continue to follow PT and PTT.
GI: Chronic guaiac positive stools. Continue with Protonix.
Continue to check stools. Follow serial hematocrit.
FEN: Total body fluid overloaded but intravascularly
depleted. Holding Lasix for now and restarting tube feeds at
30 cc/hr.
Lines: Right PICC line, tracheostomy, PEG tube, Foley
catheter.
CODE STATUS: DNR CONFIRMED BY DAUGHTER.
DISCHARGE STATUS: Fair.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSIS: Seizure.
DR.[**Last Name (STitle) 2437**],[**First Name3 (LF) **] 12-664
Dictated By:[**Name8 (MD) 4575**]
MEDQUIST36
D: [**2167-11-4**] 07:56
T: [**2167-11-4**] 07:47
JOB#: [**Job Number 34928**]
Name: [**Known lastname 6212**], [**Known firstname 651**] A. Unit No: [**Numeric Identifier 6213**]
Admission Date: [**2167-11-3**] Discharge Date: [**2167-11-9**]
Date of Birth: [**2087-6-25**] Sex: M
Service: MICU-GREEN
ADDENDUM:
HOSPITAL COURSE:
1. Pulmonary: The patient was on IPS ventilation 10 cmH2) and
PEEP=5. Beginning [**11-6**], the patient was put on
tracheostomy collar trials and tolerated this well, initially
started on two hours and each subsequent day increased by one
hour, so that on [**11-9**], was tolerating approximately four to five
hours of trach collar. The plan is to continue these trials.
2. Pneumonia: Repeat chest x-ray on [**11-6**] showed no interval
change. The patient has persistent interstitial markings;
however, clinically the patient was improving, afebrile
during this hospitalization, no cough. Secretions were
3. Hypernatremia: The patient's sodium was up to 149.
During hospitalization this was corrected with free water
boluses and the patient currently receiving free water
boluses via the G-tube at 100 cc tid.
DIAGNOSES:
1. Seizure, generalized with post-ictal state.
2. Status post tracheostomy.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1809**]
Dictated By:[**Name8 (MD) 2882**]
MEDQUIST36
D: [**2167-11-9**] 10:29
T: [**2167-11-9**] 10:35
JOB#: [**Job Number 6214**]
|
[
"482.1",
"427.31",
"780.39",
"276.0",
"414.01",
"250.40",
"585",
"518.82",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
8825, 9338
|
9355, 10527
|
3489, 8769
|
114, 3466
|
8794, 8803
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,960
| 103,876
|
5821
|
Discharge summary
|
report
|
Admission Date: [**2151-12-13**] Discharge Date: [**2151-12-20**]
Date of Birth: [**2104-4-9**] Sex: F
Service: MEDICINE
Allergies:
Compazine
Attending:[**First Name3 (LF) 1881**]
Chief Complaint:
increasing DOE
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a 47 yo female with h/o HTN, osteoporosis, sleep
apnea and severe COPD with FEV1 of 13 % who orginally presented
on [**12-13**] with 2-3 weeks of increasing dyspnea that has limited
her ability to the point she had difficulty ambulating even a
few steps and had increased her home 02 from 2-4L in this [**3-19**]
week period. The day prior to admission she had some rhinorrhea
and cold sx. She was admitted to the ICU due to increased work
of breathing. She was briefly on CPAP, but was quickly weaned to
NC and was stable. Previous symptoms suggestive of URI and
possible COPD exacerbation. Ruled out for flu by nasal aspirate.
Given stressed dosed steroids and started on Levofloxacin to
complete a 7 day course. Pt ruled out for PE with CTA and MI by
cardiac enzymes. For remainder of her ICU stay she was on 5 L of
NC as per her new baseline. in addition, she has chronic
tachycardia and was started on diltiazem.
.
On transfer from the ICU, she reports that her breathing seems
to be at baseline. She was able to get up and walk about 50 feet
with PT. Denies CP, worsened SOB, palpitations, headache, N/V.
She has her chronic back pain. She does report some abdmiinal
fullness and crampimg which has improved today after a BM with
bowel regimen
.
ROS: Positive as above and also for occasional feeling of
lightheadedness on standing, occasional sharp substernal chest
pain (isolated episodes, 2-3 times in the last several weeks)
now resolved. Otherwise she has no symptoms of vomiting,
headache, dysuria, abdominal pain, cough, change in sputum
(always yellow), passing out.
.
In the ED: patient's intial vitals were HR 140, BP 110/80, RR
30, 02 sat 100% RA. She received Xoponex, Combivent neb x 1,
Ativan, Methylprednisolone, 1 L NS, magnesium. Additionally
blood cultures were sent. Patient had increasing work to breathe
and then required CPAP.
.
On admission to the ICU, the patient required CPAP, but was able
to answer questions appropriately and did not have any acute
symptoms of pain or dyspnea. She was quickly weaned to nasal
canula and felt that her breathing had improved.
Past Medical History:
1. COPD, PFTs in [**9-19**] with FEV1 0.30 (13%), FVC 1.02 (34%) and
FVC/FEV1 38% - on Home O2 at 3L NC, on chronic steroids, hx of
prolonged intubation requiring trach for resp failure in [**1-15**],
[**3-21**]. She was recently taken off the lung transplant list at the
[**Hospital6 1708**] due to compression fractures. Has
previous history of asthma per OMR
2. Hypertension
3. Anxiety
4. Leukocytosis of unknown etiology with negative BMBx.
5. Osteoporosis with compression fractures
6. Shoulder pain
7. History of positive PPD s/p 6mos of isoniazid
8. Mitral valve prolapse
9. Obstructive sleep apnea on BiPAP (15/12 every night)
Social History:
Single, quit smoking one year ago. Prior to that, she used to
smoke less than a pack a day since the age of 16. She has no
alcohol consumption, and lives with her mother and has one
child.
Family History:
Great uncle had MI in 50s, Maternal & Paternal GMs had CVAs in
50s.
Physical Exam:
Vitals: T 96.5 HR 124 BP107/58 P104 R17 O2 100% CPAP
Gen: Well-appearing woman in NAD.
HEENT: NC/AT. MMM no erythema/exudate. JVP not seen. Neck supple
w/o LAD.
Pulm: Faint crackles B bases.
CV: Distant heart sounds.
Abd: Soft, tender to palpation diffusely especially on RUQ, no
rebound or guarding. Bowel sounds are hypoactive. No
organomegaly
Ext: 2+ dorsalis pedis/radial pulses; no edema, clubbing, or
cyanosis.
Neuro: AAOx3. CNII-XII grossly intact. 5/5 strength throughout
Pertinent Results:
[**2151-12-13**] 01:00PM BLOOD WBC-18.3* RBC-3.88* Hgb-11.3* Hct-33.3*
MCV-86 MCH-29.1 MCHC-33.9 RDW-14.1 Plt Ct-485*
[**2151-12-13**] 01:00PM BLOOD Neuts-94.1* Bands-0 Lymphs-4.1*
Monos-1.6* Eos-0.2 Baso-0.1
[**2151-12-13**] 01:00PM BLOOD Glucose-160* UreaN-15 Creat-0.8 Na-137
K-4.5 Cl-92* HCO3-38* AnGap-12
[**2151-12-13**] 01:00PM BLOOD ALT-22 AST-28 LD(LDH)-228 AlkPhos-127*
Amylase-50 TotBili-0.1
[**2151-12-13**] 01:00PM BLOOD Lipase-16
[**2151-12-13**] 05:41PM BLOOD CK-MB-8 cTropnT-0.04*
[**2151-12-13**] 01:00PM BLOOD Calcium-9.6 Phos-3.2# Mg-2.0
[**2151-12-13**] 05:41PM BLOOD TSH-0.23*
[**2151-12-14**] 04:10AM BLOOD Free T4-1.0
[**2151-12-20**] 09:10AM BLOOD WBC-19.0* RBC-3.62* Hgb-10.1* Hct-31.7*
MCV-87 MCH-27.9 MCHC-32.0 RDW-14.5 Plt Ct-374
[**2151-12-17**] 04:25AM BLOOD PT-12.5 PTT-27.0 INR(PT)-1.1
[**2151-12-20**] 09:10AM BLOOD Glucose-109* UreaN-12 Creat-0.8 Na-136
K-3.8 Cl-89* HCO3-41* AnGap-10
[**2151-12-20**] 09:10AM BLOOD Calcium-9.3 Phos-3.5 Mg-1.8
.
CTA CHEST W&W/O C &RECONS [**2151-12-13**] 11:55 PM
INDICATION: 37-year-old woman with COPD and increasing dyspnea
on exertion in the setting of chest pain. Evaluate for pulmonary
embolism.
CTA OF THE CHEST: No filling defects or pulmonary emboli are
identified within the pulmonary arteries to the level of the
segmental branches. Scattered aortic calcifications are seen,
however the aorta is within normal caliber and contour
throughout its course.
CT OF THE CHEST WITH IV CONTRAST: Soft tissue window images
demonstrate no pathologically-enlarged mediastinal, hilar, or
axillary lymphadenopathy. The heart and pericardium are normal
in appearance. No pleural or pericardial effusions are seen.
Lung window images demonstrate no pulmonary nodules or
parenchymal consolidation. Scattered emphysematous changes are
seen diffusely throughout the lungs.
Limited images of the superior portion of the abdomen
demonstrate a cyst with calcification within the superior pole
of the left kidney. The visualized parts of the liver, spleen,
right kidney, adrenal glands, and pancreas are within normal
limits.
BONE WINDOWS: Compression deformities are seen within several
mid thoracic vertebral bodies, of indeterminate age.
CT RECONSTRUCTIONS: Multiplanar reconstructions were essential
in delineating the anatomy and pathology.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Extensive emphysematous changes are seen bilaterally.
3. Hypodensity within the superior pole of the left kidney with
wall calcification likely represents a complex cyst.
4. Multiple compression farctures of the thoracic vertebrae.
.
CHEST (PORTABLE AP) [**2151-12-13**] 12:46 PM
INDICATION: Shortness of breath.
FINDINGS: Allowing for apical lordotic projection,
cardiomediastinal contours are within normal limits. There are
no focal areas of consolidation within the lungs, and no pleural
effusions are identified on this single projection. Attenuation
of the upper lobe vasculature is suggestive of underlying
emphysema.
IMPRESSION: Emphysema. No pneumonia.
Brief Hospital Course:
A/P: 47 yo with COPD admitted with increasing respiratory
disress now stable at baseline and transferred to floor.
.
# Respiratory distress- As the patient has severe disease and
has a history of intubation and severe decompensation, the
patient was felt to require MICU care but rapidly improved. The
cause for her decompensation is likely a viral infection given
her recent fatigue and shortness of breath coupled with her
occasional rhinorrhea. Already r/o flu and r/o MI. (Of note,
bronchial washing in OMR were logged incorrectly and are not
from this patient) Will continue to treat for COPD
- prednisone 40mg; plan [**Month/Day/Year 15123**] back to prednisone 20mg over the
next 3 days
- completed 7 days Levofloxacin for COPD exacerbation
- Ipratroprium, atrovent q6h prn
- continue home pulm meds: montelukast, advair 500-50,
tiotropium 18mcg daily
- viral cultures negative
- RISS while on steroids
.
# Tachycardia: Patient with chronic history of sinus
tachycardia. Cause unclear. Fluid resuscitated. TFTs checked.
- Continue dilt
.
# Osteoporosis: Patient with history of persistent fractures as
a result of persistent steroid administration.
- Continue Forteo as per outpatient regimen
- Con't Vitamin D and calcium
.
# Hypertension- Currently normotensive, will continue on home
regimen
.
# Leukocytosis- Infectious causes ruled out and afebrile. Likely
[**3-18**] steroids
- Con't to monitor
.
# Abdominal discomfort: Likely [**3-18**] constipation as improved with
bowel movement and LFT unremarkable.
- continue bowel regimen
.
# Anxiety: Continue outpatient medications.
.
# Sleep apnea: continued nightly CPAP.
.
# Pain control: Likely due to chronic fractures. Will continue
oxycodone SR and IR for pain control as per outpatient regimen.
.
# FEN- [**Doctor First Name **] diet, has elevated HCO3 due to chronic CO2 retention
at baseline, monitor lytes.
Medications on Admission:
1. Prednisone 20 mg (finished [**Doctor First Name 15123**] 2 weeks ago)
2. Furosemide 80 mg PO DAILY
3. Advair Diskus 500-50 mcg/Dose Disk with Device 1 Inh [**Hospital1 **]
4. Montelukast 10 mg PO QHS
5. Verapamil 80 mg PO Q8H
6. Nexium 40 mg PO BID
7. Tiotropium Bromide 18 mcg Capsule Inh DAILY
8. Quetiapine 25 mg PO BID
9. Mirtazapine 15 mg PO once a day
10. Gabapentin 600 mg PO HS
11. Oxybutynin Chloride 5 mg PO BID
12. Citracal Plus 2 tabs qam, 1 tab qhs
13. Cholecalciferol (Vitamin D3) [**Numeric Identifier 1871**] unit PO 2x weekly
14. Dulcolax QHS PRN
15. Clonazepam 1 mg PO QHS
16. Clonazepam 0.5 mg PO QAM
17. Sertraline 50 mg PO DAILY
18. Potassium 20 mEq PO BID
19. MVI PO Daily
20. Lisinopril 5 mg po daily
21. Senna QHS PRN
22. Potassium 20 mEq QD
23. Baclofen 10 mg TID
24. Oxycodone SR 10 mg [**Hospital1 **]
25. Forteo QD
Discharge Medications:
1. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
Two (2) pufss Inhalation twice a day.
2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 7 days: two tabs (=40mg) daily on [**12-21**] and [**12-22**], then 20mg
daily ([**Month/Day (4) 15123**] back to home dose).
6. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
8. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for anxiety.
9. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO HS (at bedtime) as needed for
constipation.
11. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
14. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 2X/WEEK (MO,FR).
15. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for pain.
16. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
17. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Insulin Lispro (Human) 100 unit/mL Solution Sig: Two (2)
units Subcutaneous ASDIR (AS DIRECTED): 2 units for FSBG
151-200, 4 units for FSBG 201-250, 6 units for FSBG 251-300, 8
units for FSBG 301-350, 10 units for FSBG 351-400.
19. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
20. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
21. Verapamil 120 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
22. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
23. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
24. Teriparatide 750 mcg/3 mL Pen Injector Sig: Three (3) ML
Subcutaneous daily () as needed for osteoporosis.
25. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
26. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for constipation.
27. Albuterol Sulfate 90 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation every 4-6 hours as needed for dyspnea.
28. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: [**2-15**] puff
Inhalation every 4-6 hours as needed for dyspnea.
29. Potassium Chloride 20 mEq Packet Sig: One (1) packet PO once
a day: 1 packet = 20 mEq.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
1. COPD, PFTs in [**9-19**] with FEV1 0.30 (13%), FVC 1.02 (34%) and
FVC/FEV1 38% - on Home O2 at 4L NC, on chronic steroids, hx of
prolonged intubation requiring trach for resp failure in [**1-15**],
[**3-21**]. She was recently taken off the lung transplant list at the
[**Hospital6 1708**] due to compression fractures. Has
previous history of asthma per OMR
2. Hypertension
3. Anxiety
4. Leukocytosis of unknown etiology with negative BMBx.
5. Osteoporosis with compression fractures
6. Shoulder pain
7. History of positive PPD s/p 6mos of isoniazid
8. Mitral valve prolapse
9. Obstructive sleep apnea on BiPAP (15/12 every night)
Discharge Condition:
Stable. Requires 4 liters oxygen by nasal cannula.
Discharge Instructions:
Call your doctor for increasing shortness of breath or
increasing oxygen needs or anything that is medically concerning
to you.
Followup Instructions:
Provider: [**Name10 (NameIs) 1571**] BREATHING TEST Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2151-12-23**] 2:25
Provider: [**Name Initial (NameIs) **]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2151-12-23**] 2:45
Call Dr [**Last Name (STitle) **] for an appointment within the next month.
[**Telephone/Fax (1) 250**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**] MD, [**MD Number(3) 1883**]
|
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icd9cm
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|
3103, 3294
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,138
| 155,115
|
14548
|
Discharge summary
|
report
|
Admission Date: [**2132-7-21**] Discharge Date: [**2132-7-24**]
Service: [**Hospital 332**] Medical Intensive Care Unit
CHIEF COMPLAINT: Hypotension.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 42945**] is a pleasant 86
yo gentleman with a h/o hepatitis C, cirrhosis complicated by
Grade 2 varices, Parkinson's disease and autonomic instability
with a positive tilt table test. The patient was in his usual
state of health until the night prior to admission when his
girlfriend found him standing with his shorts around his knees in
the living room disoriented with urinary leakage. According to
the girlfriend, the patient has had several days of lethargy,
weakness, and urinary incontinence. She reports marked
weakness and confusion over that period. There was no fever,
chills, sore throat, headache, dysuria, shortness of breath,
chest pain, cough, diarrhea, abdominal pain or decreased
pedal intake. The patient was unsure whether he had taken
all of his medications as directed.
At that point the girlfriend called 9-1-1 and the paramedics
transported the patient to [**Hospital **] Hospital where he was found to
have a blood pressure of 81/50. He also had one episode of
nonbilious, nonbloody emesis there. At the outside hospital,
the patient was started on Dopamine and given three liters of
intravenous fluid for volume resuscitation. The patient was
then transferred to [**Hospital6 256**]
Emergency Department where the patient received two
additional liters of normal saline with increase in the
patient's blood pressure to 106/70, roughly and the Dopamine
was rapidly weaned off. The patient had blood cultures taken
and urine cultures drawn and was administered 4 mg of
Dexamethasone empirically and he was transferred to the
[**Hospital Ward Name 332**] Med/[**Doctor First Name **] ICU for further monitoring. On arrival to the
Fenard Intensive Care Unit his blood pressure was noted to be
100/50 without any Dopamine.
PAST MEDICAL HISTORY: 1. Chronic hepatitis C complicated by
cirrhosis, Grade 2 varices, minimal ascites. 2. Parkinson's
disease. 3. Vasovagal syncope. 4. Autonomic dysfunction
with positive tilt table test. 5. History of urinary tract
infection and urosepsis in thje context of pelvic fracture
that he suffered in [**2132-5-25**]. No surgery. 6. Hepatitis.
7. History of hypotension with low blood pressures. He
thinks his blood pressures range generally between 95 and 100
systolic, although in the last on-line from an outpatient
clinic visit his blood pressure was roughly 112/80.
MEDICATIONS ON ADMISSION: 1. Aldactone 25 mg p.o. q.d.; 2.
Sinemet 25/100 p.o. t.i.d.; 3. Zoloft 50 mg p.o. q.h.s.;
Lactulose 30 cc q.h.s.; 5. Levoxyl 110 mcg p.o. q. AM; 6.
Vancomycin; 7. Lasix 40 mg p.o. b.i.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Lives alone. He has a girlfriend who comes
up roughly a daily or every other day basis to help him out.
He is a retired printer. He has since his discharge from
rehabilitation following the pelvic fracture a visiting nurse
come in three times a week, occupational therapy and physical
therapy visiting him. He says he quit smoking 50 years ago
cigarettes, but does smoke an occasional cigar. He denies
any alcohol or illicit drug use. He gets assistance with his
activities of daily living as previously mentioned and he
walks with a walker.
REVIEW OF SYSTEMS: Review of systems is only remarkable with
some dizziness upon arising and that has been with him for
several years and unsteady gait which has slowly progressed
over that time. He has been essentially worked up by a
neurologist and attributes it to Parkinson's disease.
PHYSICAL EXAMINATION: On presentation, the patient's
temperature was 97.8, his blood pressure was 100/50. His
pulse was 61 and regular. His respiratory rate was 14. He
was sating 99% on room air. General: He was a pleasant,
elderly gentleman lying flat in bed in no acute distress.
Head, eyes, ears, nose and throat: Normocephalic,
atraumatic, anicteric, left surgical lens from cataract
surgery. His pupils were equal, round and reactive to light.
Oropharynx had mild erythema, some whitish exudate in the
left tonsil, previous membranes were moist. Neck was supple.
Jugulovenous pressure was 600. Carotids were 2+ bilaterally.
No bruits, no lymphadenopathy. Cardiovascular, he had
distant heartsounds, likely from his thick chest, regular
rate and rhythm. He had soft systolic murmur at the left
sternal border, no rubs, gallops or heaves appreciated.
Lungs: Lungs were clear to auscultation bilaterally.
Abdomen: Abdomen was soft, nontender, nondistended with no
hepatosplenomegaly appreciated, although the patient has
documented splenomegaly. No masses. He was guaiac negative
and normal tone. There was no costovertebral angle
tenderness. No prostate tenderness to palpation. He had a 5
by 6 cm right inguinal hernia which was not tender and
nonreducible. Extremities, he had 1+ pitting edema at the
ankles bilaterally. There was no clubbing. Skin: Skin was
without rashes and no petechiae. Neurological: He was alert
and oriented times three. Cranial nerves II through X were
grossly intact. He was moving all extremities symmetrically
in bed. He had a mild left pronator drift, no flap and no
tremor. He had no saddle paresthesias and no appreciated
weakness of the lower extremity.
LABORATORY DATA: On arrival the patient's white blood cell
count was 5.4, his hematocrit was 29.9, his platelets were
39. He had 85% polys, 10% lymphocytes, 5% monocytes. His PT
was 15.9, PTT 33.2 and INR 1.7. Lower baseline, roughly 1.5.
His chem-7 was sodium 131, potassium 4.5, chloride 97,
bicarbonate 27, BUN 31, creatinine 1.4. Calcium, magnesium
and phosphorus were roughly normal. His ALT was 19, AST 57,
alkaline phosphatase 105, total bilirubin 2.1, amylase 50,
lipase 26. His TSH was within normal limits. His Cortisol
level was 11, his lactate was 11.6, his creatinine kinase was
40 and MB was not done and his tropinin was negative. He had
blood cultures, urine cultures that were pending at the time
of discharge. His iron was 56. He had a urinalysis which
initially showed 8 reds and 8 whites, but repeat urinalysis
was completely negative. The patient had B12 and Folate
level pending at the time of discharge. He had an ultrasound
of his abdomen that showed a small amount of ascites and his
nodularity was consistent with cirrhosis but no intrahepatic
ductal dilatation. He had bilateral simple renal cysts.
Electrocardiogram: Electrocardiogram was notable for normal
sinus rhythm with frequent premature atrial contractions and
premature ventricular contractions, left axis deviation and
with PR 24 milliseconds. Flat T in 3 and V1, biphasic T in
AVL. Chest x-ray from the outside hospital showed no
congestive heart failure or infiltrates.
HOSPITAL COURSE: 1. Hypotension - Following administration
of a total of 5 liters of normal saline and a transient
Dopamine the patient's blood pressure was stabilized at
100/50 on arrival to the floor in the Intensive Care Unit.
He was noted over the subsequently three to four days to have
dizziness, blood pressure down to the 80s systolic with maps
generally in the high 50s and low 60s and most notably the
dips in her blood pressure were related to his sleeping. He
was documented to be orthostatically hypotensive by physical
therapy but was asymptomatic during the hospital stay. The
hypotension was probably due to hypovolemia from decreased
p.o. intake and the continued use of his diuretics. In
addition to his cirrhosis and low vasomotor tone, the
vasomotor tone is also likely exacerbated by his known
autonomic dysfunction and his positive tilt table test. Of
note, he did not mount a tachycardiac response to the
hypotension at any time. He continued to make good urine
even with the moderately low blood pressures and he had a
poor memory recall but otherwise neurological status was
normal and he was alert and oriented throughout the hospital
stay. The patient's diuretics were held through the hospital
stay and on [**7-24**], he was given a trial of Midodrine for
his orthostatic hypotension.
2. Level of confusion - The patient was alert and oriented
through his hospital stay. He did have some memory deficits.
The differential diagnosis for the memory deficit was his
Parkinson's disease versus hepatic encephalopathy versus
hypothyroidism. Much less likely NPH given his urinary
incontinence, gait instability and dementia. Given the
patient's known history of Parkinson's disease it is likely
this is the likely diagnosis. The patient did have two large
bowel movements with Lactulose but he was confused before he
had the bowel movements. It was difficult to say whether he
had encephalopathy or was playing any role at all. He was
continued on Lactulose at the time of discharge.
3. Urinary incontinence - The patient continued to have
small amounts of urinary incontinence in-house. The etiology
of this is uncertain. He does not appear to have prostate
enlargement by physical examination and the type of
incontinence, whether this is urge incontinence, flow
incontinence or stress incontinence is not quite sure. We
are doing a post void residual on the day of discharge and
the results should be available shortly after discharge. The
rehabilitation facility would like to the results of those,
contact Intensive [**Name2 (NI) **] Unit. We will be watching for urinary
retention now that the patient has started on Midodrine.
4. Cirrhosis - The patient had no active issues related to
the cirrhosis during the hospital stay. His INR was slightly
increased versus baseline on admission as was his total
bilirubin but both of these declined. He was given a dose of
Vitamin K and we would have liked to continue on his
diuretics but his blood pressure would not tolerate it and he
should be reassessed at his follow up visit with his primary
care physician. [**Name10 (NameIs) **] was continued on his Lactulose 30 cc p.o.
q.d. to titrate one to two stools per day.
5. Anemia - The patient had a hematocrit of approx. 28 upon
day of discharge. His iron study was not consistent with an
iron deficiency anemia, his MCV was 99 and he had a B12 and
Folate level pending. He was started empirically on Folate 1
mg p.o. q.d. and this was likely a component of his cirrhosis
contributing to the anemia. There was no evidence of any
active bleed during his hospital stay and all stools were
guaiac negative. Again, his INR was decreased with the
administration of the dose of subcutaneous Vitamin K.
6. Parkinsons - The patient was continued on his Sinemet and
it was thought this may be contributing to both his gait
instability and his memory difficulties.
7. Renal insufficiency - The patient's mild renal
insufficiency was corrected with volume resuscitation and the
creatinine was 1.2 on the day of discharge.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To rehabilitation facilty.
DISCHARGE DIAGNOSIS:
1. Hypotension due to hypovolemia and diuretic use
2. Urinary incontinence.
3. Dementia
4. Cirrhosis
5. Macrocytic anemia due to liver disease
6. Mild renal insufficiency
7. Parkinson's disease
8. History of right hip fracture
DISCHARGE MEDICATIONS:
1. Midodrine 2.5 mg p.o. t.i.d. while awake
2. Lactulose 30 cc p.o. q. day, titrate to one to two stools
per day
3. Folic acid 1 mg p.o. q.d.
4. Levothyroxine 112 mcg p.o. q.d.
5. Sertraline 50 mg p.o. q.d.
6. Carbidopa Levodopa 25-100 one tablet p.o. t.i.d.
FOLLOW UP PLANS: The patient is to follow up with his
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 32496**] in [**Location (un) **],
#[**Telephone/Fax (1) 42946**], within one week of discharge from
rehabilitation facility for consideration of restarting of
his diuretics to monitor his response to Midodrine. He is to
follow up with the Liver Clinic as previously scheduled.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**]
Dictated By:[**Last Name (NamePattern1) 11801**]
MEDQUIST36
D: [**2132-7-24**] 13:01
T: [**2132-7-24**] 15:22
JOB#: [**Job Number 42947**]
|
[
"070.51",
"294.10",
"285.8",
"276.5",
"788.30",
"332.0",
"571.5",
"458.0",
"593.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11319, 12275
|
11060, 11296
|
2598, 2828
|
6903, 10960
|
3708, 6885
|
3413, 3685
|
150, 164
|
193, 1971
|
1994, 2571
|
2845, 3393
|
10985, 11039
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,380
| 159,188
|
52342
|
Discharge summary
|
report
|
Admission Date: [**2112-2-28**] Discharge Date: [**2112-3-3**]
Service: MEDICINE
Allergies:
Morphine Sulfate / Lipitor / Amiodarone
Attending:[**Doctor First Name 1402**]
Chief Complaint:
VT ablation
Major Surgical or Invasive Procedure:
Ventricular tachycardia ablation ([**2112-2-29**])
History of Present Illness:
Mr. [**Known lastname 61836**] is an 86 year-old man with a history of HTN, HL,
CAD s/p CABG in [**2084**] and multiple PCIs/stents (most recently in
[**2105**]), ischemic cardiomyopathy (EF 15-20%), VT s/p ICD placement
in [**2099**] and VT ablation in [**2108**], and chronic atrial fibrillation
on Coumadin who presents for repeat VT ablation. Over the last
year, he has been having frequent episodes of VT that, while
terminated with ATP, have resulted in syncope, most recently on
[**2112-1-28**] while in [**State 108**]. He has not tolerated amiodarone
therapy in the past. He is now being admitted for INR check and
heparin bridge in anticipation of a repeat VT ablation procedure
tomorrow ([**2112-2-29**]) with possible need for intra-procedural
Tandem heart.
Per Dr.[**Name (NI) 7914**] clinic note dated [**2112-2-23**], patient had
syncope on [**1-28**] with "surge come over him" with resultant
loss of consciousness. Transtelephonic transmission from his ICD
revealed an episode of VT in the fast VT zone at 290
milliseconds for which he received ATP twice in the VT zone,
followed by slowing of his tachycardia to 330 milliseconds and
ATP in the VT zone, which successfully terminated the
tachycardia. Patient underwent a CT scan for structural
evaluation for possible VT albation showing diffuse native
coronary artery disease.
Despite these issues, he denies any symptoms of heart failure
including PND, orthopnea, shortness of breath, leg edema,
claudication-type symptoms, and otherwise has been feeling okay.
He continues to exercise and has no new symptoms.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, hemoptysis, black stools
or red stools. He denies recent fevers, chills or rigors. He
denies exertional buttock or calf pain.
Patient endorses 3-month history of mild productive cough, no
recent sick exposure. Also endorses low-back pain since fall in
[**2-2**] with muscle spasms. Denies bowel/bladder symptoms. Current
pain level 0.
All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
.
On admission, patient denies any other complaints or concerns.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
Hypertension
Hyperlipidemia
Coronary artery disease s/p anterolateral MI in [**2084**] s/p CABG
and multiple PCIs
Ischemic cardiomyopathy, EF 15-20% on [**8-/2111**] TTE
Ventricular tachycardia s/p ICD in [**2099**], VT ablation in [**2108**]
Chronic atrial fibrillation on Coumadin
1+ AR, 2+ MR, 3+ TR on [**8-/2111**] TTE
-CABG: SVG-OM, SVG-LAD, and SVG-PDA in [**2084**]
-PERCUTANEOUS CORONARY INTERVENTIONS:
- [**9-/2105**]: Patent SVG->PDA; RCA, SVG-OM and SVG-LAD were known
occluded. No intervention.
- [**8-/2105**]: 3vCAD and diastolic dysfunction; DES to SVG-RCA
ostium; c/b VF not responsive to ICD shocks and requiring
external defibrillation.
- [**10/2101**]: Rotational atherectomy & PTCA of OM1 upper and lower
poles.
- [**8-/2101**]: PTCA and stents x3 to mid, proximal, and upper pole of
OM1; SVG-PDA diffusely diseased with 90% touchdown stenosis
requiring PTCA & stent.
-PACING/ICD: S/p [**Company 1543**] [**Last Name (un) 24119**] DR 7278 single chamber ICD in
[**2099**].
3. OTHER PAST MEDICAL HISTORY:
Anxiety
Gastritis
Osteoarthritis
Cataracts s/p bilateral extraction
Social History:
Lives with his wife, has 2 children (1 deceased), spends 4
months a year in [**State 108**]. Used to work as a state policeman.
-Tobacco history: Denies.
-ETOH: Rare.
-Illicit drugs: Denies.
Family History:
Father with "heart disease." Mother with CHF>
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
VS: T 95 BP 139/90 P 70 RR 18 SaO2 99 RA Wt 73 kg
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple wit
CARDIAC: Irregular, [**2-28**] holosystolic murmur LLSB, [**3-27**]
holosystolic murmur LLSB. No r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
I. Labs
A. Admission
[**2112-2-28**] 02:58PM BLOOD WBC-5.5 RBC-4.82 Hgb-14.0 Hct-42.4 MCV-88
MCH-29.1 MCHC-33.1 RDW-15.2 Plt Ct-122*
[**2112-2-28**] 02:58PM BLOOD PT-15.8* PTT-27.1 INR(PT)-1.4*
[**2112-2-28**] 02:58PM BLOOD Glucose-105* UreaN-39* Creat-1.3* Na-140
K-4.3 Cl-103 HCO3-24 AnGap-17
[**2112-2-28**] 02:58PM BLOOD Calcium-9.6 Phos-4.0 Mg-2.4
B. Discharge
[**2112-3-3**] 07:05AM BLOOD WBC-5.3 RBC-4.23* Hgb-12.4* Hct-37.0*
MCV-87 MCH-29.3 MCHC-33.6 RDW-15.4 Plt Ct-106*
[**2112-3-3**] 07:05AM BLOOD Plt Ct-106*
[**2112-3-3**] 07:05AM BLOOD PT-20.5* PTT-76.3* INR(PT)-1.9*
[**2112-3-3**] 07:05AM BLOOD Glucose-102* UreaN-21* Creat-1.2 Na-138
K-4.1 Cl-103 HCO3-25 AnGap-14
[**2112-3-3**] 07:05AM BLOOD Calcium-9.1 Phos-2.6* Mg-1.9
II. Radiology
A. CXR
CHEST RADIOGRAPH
INDICATION: Assessment of ET tube placement.
COMPARISON: [**2111-6-17**].
FINDINGS: As compared to the previous radiograph, the patient
has received an endotracheal tube. The tip of the tube projects
4.5 cm above the carina. There is no evidence of complications,
notably no pneumothorax.
Unchanged pacemaker in left pectoral position. Unchanged
moderate
cardiomegaly with retrocardiac atelectasis, but no evidence of
overt pulmonary edema. No focal parenchymal opacities have newly
occurred. Presence of a minimal left pleural effusion cannot be
excluded.
III. Cardiology
A. EKG
Atrial fibrillation. Rightward axis. Consider biventricular
hypertrophy.
Compared to the previous tracing of [**2111-7-8**] ST segment
depression in
leads V3-V4 has improved. The other findings are similar.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
69 0 148 462/477 0 90 -133
Brief Hospital Course:
86-year-old male with HTN, HL, CAD s/p CABG and multiple PCIs,
ischemic CM (EF 15-20%), VT s/p ICD in [**2099**] and ablation in
[**2108**], and chronic afib presenting with unstable VT s/p
uncomplicated VT ablation on [**2112-2-29**].
CCU Course:
The patient was admitted to the CCU s/p VT ablation intubated
and lying flat. When his PTT was < 180, the sheath was pulled.
Six hours later, post cath check was unremarkable. The patient
was weaned off propofol and pressor support (phenylephrine which
was started intraoperatively while on propofol). He was
successfully extubated. Heparin IV gtt and coumadin were
restarted and he was continued on his home medical regimen. The
EP fellow adjusted his pacer settings to pace at 70 instead of
40. He slept well and was ready for transfer back to his
primary team for bridging of heparin gtt to coumadin prior to
discharge.
Floor course:
# Ventricular tachycardia s/p ICD in [**2099**], s/p VT ablation in
[**2108**] and [**2112-2-29**]
Patient admitted for repeat VT ablation in setting of recurrent
symptomatic episodes of VT. Rhythm had been unstable causing him
to have episodes of syncope felt to be dangerous, especially in
the setting of warfarin. He has not tolerated amiodarone in the
past. He underwent VT ablation under general anesthesia with no
apparent complications and brief course in the CCU (as above).
He was monitored on telemetry with no sustained VT episodes but
frequent polymorphic ectopy for which VVI pacing (home setting
of 40) was increased to 70 bpm on discharge given ectopy noted.
On outpatient basis, the pacemaker could be re-programmed to 40
bpm. He was bridged with heparin to an INR of 1.9 and
subsequently discharged. He was continued on his home
carvedilol, lisinopril, digoxin and aspirin. Of note, there is a
hematoma at the cath left femoral cath site with no bruit.
# Atrial fibrillation (CHADS2 score = 3)
His underlying rhythm is atrial fibrillation. He was continued
on aforementioned medications including warfarin for
anticoagulation and beta-blocker for rate control.
# Hypertension
He was continued on aforementioned anti-hypertensive
medications.
# CAD s/p MI and CABG
He was continued on aforementioned cardiac medications.
# Chronic systolic heart failure, ischemic, EF 15-20 %
No active signs or symptoms or heart failure. He was continued
on ACEi and beta blocker as above.
# Anxiety
He was continued on lorazepam.
# Gastritis
He was continued on [**Year/Month/Day **]
.
CODE: Full
.
COMM: [**Name (NI) **], HCP (wife, [**Name (NI) **] [**Name (NI) 61836**]), [**Telephone/Fax (1) 108212**]
.
Medications on Admission:
Reconciled with patient verbally and with patient provided drug
list
Aspirin 81 mg daily
Carvedilol 9.375 mg qAM, 6.25 mg qPM, 9.375 mg qHS
Lisinopril 2.5 mg daily
Nitroglycerin SL 0.4 mg q5min x 3 prn chest pain
Coumadin 5 mg qhs
Digoxin 125 mcg every other day
Furosemide 20 mg [**Hospital1 **]
[**Hospital1 6196**] 40 mg PO qD
Lorazepam 0.5 mg 1-2x/day prn anxiety
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. carvedilol 6.25 mg Tablet Sig: 1.5 Tablets PO QAM (once a day
(in the morning)).
3. carvedilol 6.25 mg Tablet Sig: 1.5 Tablets PO QHS (once a day
(at bedtime)).
4. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO MID-DAY ().
5. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tab
Sublingual AS DIR: take q5 min x 3 prn chest pain, call EMS if
chest pain not relieved .
7. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
9. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for anxiety.
12. guaifenesin 100 mg/5 mL Liquid Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Ventricular tachycardia
Secondary diagnosis: Dyslipidemia, hypertension, coronary artery
disease s/p CABG, history of NSTEMI, ischemic cardiomyopathy
(last EF 15-20 %), chronic atrial fibrillation, aortic
regurgitation, mitral regurgitation, anxiety, gastritis,
osteoarthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Weight 72.5 kg on discharge
O2sat 94-99% RA on ambulation
Discharge Instructions:
You were admitted for a ventricular tachycardia ablation
procedure. You did well during hospitalization.
The following changes were made to your medications:
- INCREASE coumadin to 5mg in the evenings until your follow up
with the [**Hospital 197**] Clinic on [**3-8**]
- START robitussin as needed for cough
than 3 lbs.
Followup Instructions:
You will need your coumadin level (INR checked):
Department: [**Hospital1 18**] [**Location (un) 2352**] - ADULT MED
When: TUESDAY [**2112-3-8**] at 11:15 AM
With: ADULT MEDICINE NURSE [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
We also scheduled you to follow up with your primary care
doctor:
Department: [**Hospital1 18**] [**Location (un) 2352**] - ADULT MED
When: THURSDAY [**2112-3-10**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
You will also have Cardiology follow-up:
Name: [**Last Name (LF) **], [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD
Location: [**Hospital1 18**] - CARDIAC SERVICES
Address: [**Location (un) **], [**Hospital Ward Name **] 7, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 62**]
We are working on a follow up appointment with Dr. [**Last Name (STitle) **]
within 4-6 weeks. You will be called at home with the
appointment. If you have not heard from the office within 2 days
or have any questions, please call the number above
Department: CARDIAC SERVICES
When: TUESDAY [**2112-3-15**] at 10:30 AM
With: ICD CALL TRANSMISSIONS [**Telephone/Fax (1) 59**]
Building: None None
Campus: AT HOME SERVICE Best Parking: None
|
[
"427.31",
"535.50",
"272.4",
"401.9",
"V58.61",
"428.22",
"300.00",
"428.0",
"V45.81",
"280.0",
"414.00",
"414.8",
"396.3",
"V45.02",
"412",
"427.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.34"
] |
icd9pcs
|
[
[
[]
]
] |
10921, 10927
|
6828, 9437
|
259, 312
|
11267, 11267
|
5158, 6805
|
11823, 13379
|
4153, 4314
|
9855, 10898
|
10948, 10948
|
9463, 9832
|
11476, 11800
|
4329, 5139
|
2834, 3828
|
208, 221
|
340, 2726
|
11012, 11246
|
10967, 10991
|
11282, 11452
|
3859, 3929
|
2748, 2814
|
3945, 4137
|
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