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Discharge summary
|
report
|
Admission Date: [**2101-6-7**] Discharge Date: [**2101-6-16**]
Date of Birth: [**2043-2-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3016**]
Chief Complaint:
Shortness of breath, bloody stool
Major Surgical or Invasive Procedure:
Foley catheter placement
History of Present Illness:
58 year old male with widely metastatic (including an
infiltrating mass in his stomach) melenoma unresponsive to IL-2,
s/p cycle 1 dacarbazine [**5-11**], admitted from the ED after
reporting to an OSH with complaints of acute dyspnea. He
reports that he was at his BL of DOE within 15 feet following
his discharge on [**6-1**] (see below) until about 3 days ago. At
that time, he noted that at the top of his spiral stairs, he
became acutely SOB and fell to the floor. He denies CP, LH,
palpitations, LOC, localized weakness. He did soil himself
during this. Over the next two days, he had similar episodes
every time he tried to get out of bed. After he was on the
ground, he would transiently be unable to move because of the
SOB. He would improve after laying on his left side for 20-30
seconds. He would invariably lose control of either his bowels
or urine while on the floor while trying to catch his breath.
He reports the last time it happened at the OSH ED, he was being
sat up without exerting himself. He was scheduled to see his
oncologist for taxol infusion today, but this happened again so
he was instructed to present to an OSH, where he was noted to
have melena and a HCT of 24. He was given 1 U pRBCs at the OSH
and transferred here. He denies any change of his chronic
fevers and nightsweats. He denies N/V, change in his abd pain,
focal weakness, seizure activity, postictal state. He denies
change in his cough and he denies hemoptysis. He has no
dysuria. He also says he had constipation with no bowel
movement for about 4 days. He added a stool softener about [**2-23**]
days ago and subsequently had 5 bowel movements. His last BM
was this morning.
He recently was admitted from [**5-25**] to [**6-1**] on the oncology
service. He was admitted for worsening dyspnea and ongoing
upper GI bleed. He was initially admitted to the MICU where he
was determined to be HD stable and was treated supportively for
his dyspnea, fatigue, RUQ pain (from liver mets), N/V. His
dyspnea was felt to be [**2-22**] to his metastatic melanoma and he was
found to have a left mainstem endobornchial tumor. It was
debrided but not stentable. Repeat CXR showed improvement. He
was felt to have a slow upper GI bleed, was transfused one unit
prior to discharge (HCT on d/c was 25) and he was continued on
his home PPI. He was also given a dose of taxol on the day of
discharge. Hospice was discussed but he felt he wanted another
round of chemotherapy to possibly prolong his life and alleviate
symptoms. He was DNR/DNI except brief reversal for his bronch.
He was also tachycardic during his stay, felt [**2-22**] malignancy and
pulm stimuli. He had a negative CTA at OSH and no effusion by
ECHo at OSH. He also had low grade fevers during his stay with
no clear souce for infection, but because of a possibility of
post-obstructive pna, he was given an 8 day course of
levofloxacin.
In our ED, he was noted to have a HCT of 24 despite the unit he
received at the OSH. He denied hemoptysis or trouble breathing
above his recent DOE. He was tachy 110 to 115. An 18G and 2
20G IVs were placed. He was T/C and consented, though not
transfused bc pRBCs had not arrived. GI was made aware and
recommended NG lavage (not done downstairs). They saw him upon
arrival and felt that he did not need an EGD at this time both
because it is unlikely he has a brisk bleed at this point and
there would be little to do for a slow bleed from the implanted
tumor. If he bled briskly, they would recommend EGD but more
for the possibility that there could be something else fixable
to intervene on.
Past Medical History:
HTN
COPD - used albuterol inhaler
Metastatic Melenoma: symptoms [**12-29**] melena
DX:[**2-4**] after UGI Bleed when endoscopy showed gastric mass, 2
moles on back bx and confirmed as melenoma.
STAGING: CT Torso - multiple bilateral pulmonary nodules with a
dominant mass in the LLL. LLL mass biopsy c/w melanoma. PET-CT
on [**2101-2-21**] was notable for FDG-avid adenopathy in the mediastinum
and left suprahilar region, multiple bilateral lung nodules,
multiple liver lesions, a lymph node adjacent to the pancreatic
head, and an "extremely" avid lesion in the greater curvature of
the mid-body of the stomach. There was also FDG avidity in
C2/C3 posterior elements, the right medial ilium, and the left
inferior pubic ramus. An MRI of the brain was negative.
TREATMENT: HD IL-2 here at [**Hospital1 18**] from [**Date range (1) 86250**] (received 8
of 14 doses) and [**Date range (1) 86251**]/10 (received 9 of 14 doses). Limited
by acute renal failure and dyspnea. Failed. Tumor progressed.
Started [**2101-5-11**] Dacarbazine, cycle 1.
Social History:
Partner, [**Name (NI) **]. Quit smoking [**12/2100**], prior > 100 pack smoker.
Prior alcohol use up to 12 cases of beer per week, now none.
Prior to illness was the call center manager of a catalog
company.
Family History:
Mother - lung cancer, death 30s, she was a smoker
Physical Exam:
Admission Physical Exam:
VS HR 112 RR 13 BP 117/69 99% 4L
Gen: well appearing, NAD, laying flat in bed
HEENT: NCAT, MMM. poor dentition. nonicteric sclera.
CV: tachy, no m/r/g. nl S1/S2. No JVD.
Pulm: decreased BS on left. right lung clear with no w/r/r.
Abd: multiple hard nodules throughout abdomen. Mild diffuse TTP
without rebound/guarding.
Ext: no c/c/e. 2+ distal pulses.
Neuro: AOx4. CN 2-12 intact. Strength 4+/5 diffusely and equal
bilaterally. Sensation to light touch intact throughout.
.
Floor Physical Exam:
VS T97.6 BP 118/68 HR 108 RR 22 100%RA
Gen: Well appearing, no apparent distress, lying comfortably in
bed with family at bedside
HEENT: NCAT, EOMI, moist mucus membranes. Poor dentition.
CV: Tachycardic, no murmurs/gallops/rubs, normal S1/S2
Pulm: Decreased breath sounds on left, right CTA. No
wheezing/rhonchi/rales
Abd: Palpable hard nodules diffusely spread across abdomen.
Minimal TTP in all four quadrants. +BS, soft, non-distended.
Neuro: Alert and oriented. CN2-12 grossly intact. Strength and
sensation grossly intact - ?weakness
Pertinent Results:
[**2101-6-7**] 08:00PM HCT-23.2*
[**2101-6-7**] 03:39PM HGB-8.4* calcHCT-25
[**2101-6-7**] 03:37PM GLUCOSE-96 UREA N-17 CREAT-0.4* SODIUM-136
POTASSIUM-4.9 CHLORIDE-98 TOTAL CO2-23 ANION GAP-20
[**2101-6-7**] 03:37PM WBC-5.4 RBC-2.89* HGB-7.5* HCT-24.0* MCV-83
MCH-25.9* MCHC-31.2 RDW-19.9*
[**2101-6-7**] 03:37PM NEUTS-75.4* LYMPHS-20.1 MONOS-3.7 EOS-0.4
BASOS-0.4
[**2101-6-7**] 03:37PM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-2+
MACROCYT-OCCASIONAL MICROCYT-2+ POLYCHROM-OCCASIONAL
SPHEROCYT-OCCASIONAL OVALOCYT-1+ SCHISTOCY-OCCASIONAL
BURR-OCCASIONAL
[**2101-6-7**] 03:37PM PLT COUNT-601*#
[**2101-6-7**] 03:37PM PT-13.9* PTT-29.3 INR(PT)-1.2*
.
EKG:
Sinus tach 114. LAD. q in III. Nl intervals. borderline low
voltage in limb leads. No change from previous.
.
CXR [**2101-6-7**]:
IMPRESSION: Interval nearly resolution of previously noted
left-sided pleural effusion with improved aeration of the left
lung base. Multiple masses within both lungs compatible with
metastases. Probable lymphangitic spread of tumor within the
left lung.
.
ECHO [**2101-6-8**]:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The pulmonary artery systolic pressure could not
be determined. There is a very small/minimal pericardial
effusion. There are no echocardiographic signs of tamponade.
Brief Hospital Course:
#. Dyspnea/fatigue: On previous admission, his worsening dyspnea
was felt to be due to his metastatic melanoma and he underwent
debridement of his tumor (no stent). His dyspnea acutely
worsened 3-4 days prior to this admission and was accompanied by
platypnea. Etiology for his dyspnea could include worsening of
his pulmonary metastatic disease (CXR improved from previous in
terms of his pulm effusion); pneumonia (CXR improved, no
leukocytosis, currently afebrile); cardiac sources including MI
(though EKG baseline and no CP); pericardial effusion (no rub,
ECHO at OSH 3 weeks ago reportedly without effusion); shunt
including vascular abnormalities related to tumor, AVMs, or PE.
His improvement while laying with his good side down also
suggests V/Q mismatch from pulmonary disease or pulmonary
embolism. However, he does not actually desaturate when he sits
up, suggesting extrathoracic compression may cause some of his
dyspnea, this degree of acute symptoms would be unusual. Echo
obtained [**6-8**] did not reveal any additional valvular or dynamic
abnormalities to explain his dyspnea. Did not pursue CTA given
no O2 requirement and would likely not be able to anticoagulate
given GI bleed. Continued to complain of dyspnea with exertion,
but had appropriate saturation on room air (94-95%). Patient
remained unable to engage in very much physical therapy
secondary to dyspnea on exertion, but continued to saturate
appropriately while in bed, on room air. Patient does become
symptomatic with slight dips in Hct, so he was aggressively
transfused.
- Continue to have patient work with physical therapy
- Nasal cannula/supplemental oxygen as needed
- Blood transfusions at least weekly (Hct goal >25)
#. UGI Bleed: He has a known melenoma metastasis eroding into
his stomch lining. GI was contact[**Name (NI) **] but did not think that he
had a brisk bleed. EGD would not be helpful if the bleed is
related to his metastasis to his stomach (likely). He was
transfused 1 u PRBC with appropriate Hct increase. Initially on
[**Hospital1 **] PPI but then decreased to daily. Patient was transferred to
the floor where he had 3-4 episodes of coffee ground emesis. His
PPI was transitioned to intravenous twice daily, and he was
started on Carafate. Patient already had three PIVs and remained
asymptomatic, hemodynamically stable. His Hct also remained
stable and his nausea was controlled. He received another unit
of pRBC for symptomatic relief (dyspnea) in-house.
- If HD change or evidence of brisk bleed, GI to do emergent
scope for possible source other than tumor
- Continue Omeprazole 40mg twice daily for acid reflux and
stomach ulcers
- Continue Sucralfate 10-15mL four times daily to protect
against the stomach ulcers
- Continue Zofran and Compazine as needed for nausea/vomiting
control
.
#. Tachycardia: He has persistent tachycardia felt to be due to
underlying malignancy and pulmonary stimuli. He was ruled out
for PE on OSH CTA and had no effusion on OSH Echo prior to last
admission. Likely this is no change from his recent baseline
rates. He could be dehydrated given little PO intake per
patient. Primary cardiac etiology including effusion or
cardiomyopathy could be present, but less likely. ECHO without
structural explanation.
.
#. Metastatic Melenoma: Widely metastatic. His current medical
care goals are comfort but will continue to receive palliative
Taxol and blood transfusions (for dyspnea control).
- Patient primary oncologists, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] will contact the facility with next appointment
date/time.
.
#. Fever: Reports continued low grade fevers. Not febrile here.
He was given an 8 day course of levofloxacin for concern for
postobstructive pneumonia, of which he completed. Fever most
likely related to underlying malignancy. Finished antibiotic
course and remained afebrile.
.
# Urinary obstruction: Noted to have difficulty with urination
[**6-8**] with complete inablity on [**6-9**]. Foley placed and 800cc
removed. No saddle anesthesia and good rectal tone but with
enlarged prostate. Patient was started on tamsulosin for BPH
with improvement of his symptoms. Foley was discontinued 2 days
prior to discharge and patient was able to void for a few days
but then retained ~750ccs. Foley was re-placed.
- Please do a repeat Foley discontinuation, trial void in one
week from discharge (~ [**6-23**])
.
# Constipation: Patient complained of poor stool frequency prior
to hospitalization (no bowel movement since [**6-7**]). Physical
exam with mildly hypoactive bowel tones intially but normalized.
KUB was unrevealing and patient was started on rigorous bowel
regimen. He subsequently had multiple liquid bowel movements
that were CDiff negative and resolved with decreasing frequency
of bowel regimen. Patient was having soft but normal bowel
movements at time of discharge.
Medications on Admission:
1. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*0*
2. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
3. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
4. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
5. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for sleep.
Disp:*30 Tablet(s)* Refills:*0*
6. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
7. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
9. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for anxiety/nausea.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Medications:
1. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Two (2)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
2. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
3. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for sleep.
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for sob, wheezing.
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for Constipation.
7. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for anxiety.
8. Morphine 20 mg/5 mL Solution Sig: Five (5) mg PO every four
(4) hours as needed for severe pain or breathlessness.
Disp:*30 mL* Refills:*0*
9. Lorazepam 2 mg/mL Concentrate Sig: One (1) mg PO every six
(6) hours as needed for anxiety, agitation.
Disp:*30 mL* Refills:*0*
10. Atropine 1 % Drops Sig: Two (2) drops Ophthalmic every four
(4) hours as needed for secretions: SUBLINGUALLY.
Disp:*5 mL* Refills:*0*
11. Nebulizer & Compressor For Neb Device Sig: One (1)
device Miscellaneous once a day as needed for shortness of
breath or wheezing.
12. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
13. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
14. Sucralfate 100 mg/mL Suspension Sig: [**11-4**] mL PO four times
a day.
15. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
16. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours.
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospice House
Discharge Diagnosis:
Primary: Metastatic melanoma causing dyspnea and upper GI bleed
Secondary: Hypertension, COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
-You were admitted with significant shortness of breath. This
was felt likely due to the spread of your melanoma to your
lungs. Your breathing is also sensitive to low red blood cell
counts (anemia); your anemia is caused by the metastasis of your
cancer eroding your stomach lining. Your breathing was closely
monitored and you were started on medications to decrease
vomiting, protect your stomach lining.
.
-It is important that you continue to take your medications as
directed. We made the following changes to your medications
during this admission:
--> START Tamsulosin 0.4mg before bed for your enlarged prostate
--> START Sucralfate 10-15mL four times daily to protect your
stomach ulcers
--> START Omeprazole 40mg twice daily for acid reflux and
stomach ulcers
--> START Zofran and Compazine as needed for nausea
--> START Lorazepam as needed for anxiety
--> Morphine, Lorazepam and Atropine solutions will be provided
for your comfort
.
-Contact your doctor or come to the Emergency Room should your
symptoms return. Also seek medical attention if you develop any
new fever, chills, trouble breathing, chest pain, nausea,
vomiting or unusual stools.
Followup Instructions:
Please follow-up with your primary oncologists, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Their office will contact [**First Name8 (NamePattern2) **]
[**Name (NI) **] with the specific date and time. You can also reach the
Hematology/[**Hospital **] clinic at: ([**Telephone/Fax (1) 16668**]
[**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**]
|
[
"600.01",
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"578.1",
"564.09",
"285.22",
"197.8",
"197.7",
"486",
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"197.0",
"196.2",
"V87.41",
"401.9",
"785.0",
"285.1",
"V66.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.25"
] |
icd9pcs
|
[
[
[]
]
] |
16199, 16305
|
8333, 13311
|
348, 375
|
16443, 16443
|
6496, 8310
|
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|
5335, 5386
|
14408, 16176
|
16326, 16422
|
13337, 14385
|
16619, 17781
|
5936, 6477
|
275, 310
|
403, 4026
|
16458, 16595
|
4048, 5092
|
5108, 5319
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,237
| 170,046
|
27358+57541
|
Discharge summary
|
report+addendum
|
Admission Date: [**2107-8-26**] Discharge Date: [**2107-8-31**]
Service: MEDICINE
Allergies:
Clindamycin / Restoril / Benadryl
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Transfer from [**Location (un) **] for further management of chf/af/cad
Major Surgical or Invasive Procedure:
A-line placement
History of Present Illness:
86yo m w/ CAD s/p RCA stent in [**1-3**] w/ 70%LAD & 100% om1
lesions(not intervened upon), CHF (diastolic w/ EF >55%),
permn't pacer for reported tachy-brady syndrome, colon &
prostate CA who is transferred from [**Location (un) **] for further
management of CHF/AF/CAD.
.
Mr. [**Known lastname 67025**] presented to [**Location (un) **] on [**8-24**] c/o weakness (referred by
PCP). He was found to be in AF w/ rapid ventric. reponse (HR
120's). O2 sats were in the 80's on RA w/ tachypnea. CXR
demonstrated large b/l pleural effusions which had been
previously worked up at [**Hospital1 1774**] ([**7-5**]) & were then found to be
transudates. Labs at [**Location (un) **] were notable for HCO3=43, BUN=34,
Creat=1.4, BNP=1900. While at [**Location (un) **], the pt was diuresed,
initially w/ lasix 40mg IV BID, and later w/ acetazolamide on
the day after admission. It is unclear from the records how
much he diuresed. On the AM of [**2107-8-26**], the pt was found
unarousable w/ an ABG=7.3/80/40. He was placed on bipap &
diuresed. Repeat ABG=7.38/65/59. Soon after, he was
transferred to [**Hospital1 18**] for further management/intervention.
.
The patient himself describes having had dyspnea (esp. w/
exertion) of unclear duration (perhaps months) along w/ fatigue,
weight loss, and decreased appetite. ?PND. He reports no CP,
palpitations, syncope, or edema.
Past Medical History:
-CAD: RCA stent [**12/2106**], 70% LAD lesion, 100% OM1 lesion on the
cath
-CHF (diastolic, EF>55%)
-?COPD
-Pacemaker placed [**2103**] for ? tachy-brady syndrome
-Hiatal hernia
-GERD
-Prostate CA s/p radiation
-Colon cancer s/p resection [**8-/2106**]
-incidental 6-mm right upper lobe nodular opacity on Chest CT
(at [**Hospital1 18**] [**5-5**])
Social History:
Lives with wife and son (who has mental health problem), still
working as a CPA, independent in ADLs. Smoked 1 pack per week x
10 yrs, quit 40yrs ago. Rare etoh, quit 3 yrs ago.
Family History:
Father died of blood clot to [**Last Name (un) 6722**] location at 62, mother died
of unknown intra-abdominal malignancy in her 80's.
Physical Exam:
Admission:
VS- t 97, bp 115/69, hr 62, rr 31, spo2 95%2l
gen- pleasant, thin elderly male, mild distress
heent- anicteric, op clear but slightly dry
neck- no jvd/lad/thyromegaly
cv- rr, distant hrt sounds, nml s1s2, unable to apprec m/r/g
pul- Barrel chest, rapid shallow breathing, speaking in
shortened sentences. Decreased air flow at bases, no crackles
abd- soft, nt, nd, nabs, no hsm
extrm- no cyanosis/edema, warm/dry
neuro- awake & ox3, no focal cn/motor/sensory deficits
Pertinent Results:
Admission Labs:
[**2107-8-27**] 01:52AM BLOOD Glucose-128* UreaN-33* Creat-1.3* Na-143
K-3.5 Cl-99 HCO3-38* AnGap-10
[**2107-8-27**] 04:36AM BLOOD Type-ART pO2-64* pCO2-77* pH-7.31*
calTCO2-41* Base XS-8
[**2107-8-27**] 06:41AM BLOOD Type-ART pO2-128* pCO2-93* pH-7.25*
calTCO2-43* Base XS-9
[**2107-8-27**] 07:45AM BLOOD Type-ART pO2-53* pCO2-79* pH-7.32*
calTCO2-43* Base XS-9
[**2107-8-27**] 07:45AM BLOOD Type-ART pO2-53* pCO2-79* pH-7.32*
calTCO2-43* Base XS-9
[**2107-8-27**] 01:04PM BLOOD Type-ART pO2-63* pCO2-74* pH-7.37
calTCO2-44* Base XS-13
[**2107-8-27**] 08:42PM BLOOD Type-ART Temp-36.8 pO2-55* pCO2-63*
pH-7.35 calTCO2-36* Base XS-6
[**2107-8-27**] 01:52AM BLOOD WBC-6.9 RBC-4.45* Hgb-13.6* Hct-40.7
MCV-92 MCH-30.5 MCHC-33.4 RDW-16.6* Plt Ct-266#
.
ECHO ([**8-27**])
Conclusions:
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). The right ventricular cavity is
dilated. There is abnormal septal motion/position consistent
with right ventricular pressure/volume overload. The aortic root
is moderately dilated. The ascending
aorta is mildly dilated. The aortic valve leaflets are mildly to
moderately thickened. There is a minimally increased gradient
consistent with minimal aortic valve stenosis. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is mild pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2107-5-26**],
findings are similar.
.
Discharge Labs:
[**2107-8-31**] 09:49AM BLOOD WBC-7.2 RBC-4.83 Hgb-14.4 Hct-44.0 MCV-91
MCH-29.7 MCHC-32.6 RDW-16.9* Plt Ct-291
[**2107-8-31**] 09:49AM BLOOD PT-16.4* PTT-34.7 INR(PT)-1.5*
[**2107-8-31**] 09:49AM BLOOD Glucose-166* UreaN-36* Creat-1.2 Na-143
K-3.8 Cl-99 HCO3-35* AnGap-13
[**2107-8-31**] 09:49AM BLOOD Calcium-9.2 Phos-2.1* Mg-2.3
Brief Hospital Course:
86yo man w/ CAD s/p RCA stent in [**1-3**], LAD & LCx lesions
reportedly not intervened upon, diastolic CHF w/ MR, permn't
pacer for reported tachy-brady synd, presenting from [**Location (un) **] w/
CHF & AF w/ RVR. Also, found to be in respiratory distress with
acute on chronic respiratory acidosis. His hospital course for
this admission is as follows:
.
1. CHF: Pt was fluid overloaded on CXR. Likely of diastolic
etiology given nml EF. MR & AF w/ RVR likely further
complicating diastolic filling. Pt was diuresed aggresively
with lasix. His R pleural effusion was tapped & c/w transudate
(as in past per records). Repeat echo similiar to prior study
in [**5-5**]. He was beta-blocked to improve cardiac filling & rate
control his afib. Because of low SBP's 80's-110's he could only
tolerate low doses of metoprolol, currently at 25mg PO bid.
Given patient responded well with initial IV lasix diuresis, and
he was put back to his home doses of lasix PO 80mg on [**2107-8-30**],
and he is euvolemic at the time of discharge.
.
2. Afib: Likely contributing to CHF picture. Given chronicity
of a-fib & subtherapeutic INR now, cardioversion not attempted
initially. Rate controlled with metoprolol. Digoxin held.
Coumadin held initially because of thoracentesis & possibility
of additional procedures, and restarted on [**8-29**] with low dose
5mg PO qday and continued monitoring his INR, discharge INR 1.5.
Patient will need to continue metoprolol 25mg PO bid and
Coumadin 5mg PO qhs, and continued monitoring of INR q2-3 days
at the extended facility to keep INR between [**3-4**] (goal).
.
3. Hypoxia & hypercarbia: likely combination of COPD & CHF. Pt
treated with BiPAP after he was found to be hypoxic & in
respiratory acidosis. An a-line was placed for closer monitoring
of BP & ABGs initally. Pt retained CO2 even at Fi02 of 40%,
thus he was maintained on low flow O2 and transitioned back to
NC, then to RA. Goal O2 sat is 88-92%. He was at around 90-92%
on RA at the time of discharge.
.
4. Acidemia: likely due to acute on chronic resp acidosis +/-
metabolic alkalosis from diuresis. This improved as pt was
treated with low-flow O2, diuresed and effusion tapped, which
showed transduate picture.
.
5. Hypokalemia, hypernatremia: hypokalemia likely secondary to
hypokalemic, hypochloremic metabolic alkalosis from primary
respiratory acidosis. We replaced free water and potassium, and
pt responded well with this regimen.
.
6. CAD: relatively stable, will continue ASA and metoprolol.
.
7. Code status: full code, daughter [**Name (NI) **] [**Last Name (NamePattern1) 110**] is HCP
.
8. FEN: heeart healthy soft diet
.
9. Prophylaxis: Pt eating, heparin 5000 U sc tid
Medications on Admission:
Meds at Home:
-Combivent MDI 4 puffs QID,
-Digoxin 0.125 alternating w/ 0.0625
-Lisinopril 2.5qd
-FeSO4 325qd
-Imdur 50qd
-Toprol 12.5qhs
-Lasix 20bid
-Coumadin 5qd
.
Meds on Transfer:
-Combivent
-FeSO4
-Imdur 15qd
-Diamox 50qd
-ASA EC 81qd
-Protonix 40qd
Discharge Medications:
1. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold for SBP<100 and HR<60.
9. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed.
10. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
Primary:
Diastolic congestive heart failure
Atrial fibrillation
Mitral regurgitation
Chronic obstructive pulmonary disease
Acute on chronic respiratory acidosis
Secondary:
Coronary artery disease
Colon cancer
Prostater cancer
Permanent Pacer for ? Tachy-brady syndrome
Gastroesophageal reflux
Hiatal Hernia
Incidental 6-mm right upper lobe nodular opacity on Chest CT (at
[**Hospital1 18**] [**5-5**])
Discharge Condition:
patient in stable condition, tolerating soft liquid diet, no
N/V/D, afebrile, no Shortness of breath, chest pain, and O2 sat
between 90-92% on Room air.
Discharge Instructions:
Please make sure to keep your O2 saturation between 88-92%. Do
not let O2 sat above 92%.
.
If you experience any chest pain, shortness of breath, fever,
severe nausea and vomiting, or any other serious medical
problems, please seek medical attention immediately.
.
Please take all your medications as prescribed.
.
Please follow up with Dr. [**Last Name (STitle) **] on [**2107-9-16**] at 2:20pm.
.
Please follow a heart healthy diet.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**]
Date/Time:[**2107-9-16**] 2:20
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2107-8-31**] Name: [**Known lastname 11639**],[**Known firstname 133**] W Unit No: [**Numeric Identifier 11640**]
Admission Date: [**2107-8-26**] Discharge Date: [**2107-8-31**]
Date of Birth: [**2021-8-6**] Sex: M
Service: MEDICINE
Allergies:
Clindamycin / Restoril / Benadryl
Attending:[**First Name3 (LF) 949**]
Addendum:
The patient's acid base seemed to indicate a chronic respiratory
acidosis that was well compensated. He was not previously on
medications for COPD, however he does have a smoking history,
and given this, he was started on a fluticasone inhaler. Given
his presumed COPD, he should have his O2 saturation kept
strictly < 93%. During his 1st night in the CCU his O2
saturation was kept at 98% with subsequent hypercarbic
respiratory failure requiring BiPap while titrating down his
FiO2. He should likely have pulmonary function tests at some
point as an outpatient to confirm this diagnosis.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 5025**] & Rehab Center - [**Location (un) **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 950**] MD, [**MD Number(3) 951**]
Completed by:[**2107-8-31**]
|
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icd9cm
|
[
[
[]
]
] |
[
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] |
icd9pcs
|
[
[
[]
]
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|
5197, 7897
|
313, 332
|
9670, 9825
|
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360, 1742
|
2995, 4824
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1764, 2114
|
2130, 2312
|
8108, 8180
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
955
| 185,674
|
21774
|
Discharge summary
|
report
|
Admission Date: [**2160-11-10**] Discharge Date: [**2160-11-14**]
Date of Birth: [**2086-6-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2078**]
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
Cardiac cath
History of Present Illness:
74 yo male with hx of hypecholesterolemia and aortic stenosis
who presented to [**Hospital 882**] hospital for an outpatient workup
after having a syncopal episode 2 weeks ago. Pt is very active
and typically goes for a 4 mile powerwalk everyday without ever
having chest pain. He also drinks 5 glasses of morning everyday
before his powerwalk. 2 weeks ago, he was powerwalking and felt
lightheaded and found himself on the ground. He states that his
mental status was clear right after the event. He is unaware
how long he was done. He reports no chest pain, no visual
changes, no seizure like activity, no post-ictal like state, no
weakness, no urinary or bowel incontinence. Pt got up from the
ground and was able to resume his exercise without symptoms.
Since the, he noticed he was getting more "dizzy" near end of
his daily "power walks" of 4.5 miles. Also he occasionally
feels "dizzy" or lightheaded while seated (i.e. at church).
With all of these events, there are no associated symptoms. No
chest pain, no palpitation, no diahoresis, no nausea/voming, no
fever/chills.
Pt then went to [**Hospital 882**] hospital to get an outpatient workup of
his symptoms. Per pt report, workup included "normal" carotid
studies, "normal" stress test, CT showed calcified coronaries
suspicious for L main aneurysm. Pt then underwent elective cath
which revealed 60% proximal LAD lesion (per report but the
cardiologist there thought was more risky lesion), and normal
LCx and RCA. Echo showed moderate AS with calculated area of
1.2 cm2, peak gradient of 48 mm Hg. Per pt, AS is old and has
been stable for 20 years by serial echos. Pt was transferred to
[**Hospital1 18**] for interventional cath.
Past Medical History:
Hypercholesterolemia
HTN- diagnosed 2 weeks ago.
Hx of pericarditis 12 yrs ago
Aortic stenosis -stable over 20 yrs with serial echo
GERD
Social History:
Pt lives alone, power walks 4.5 miles daily, never smoked in
life, and hardly drinks alcohol.
Family History:
Father died from MI at age 68
Physical Exam:
VS: Afebrile HR 72 BP 142/88 RR 16 O2sat 95% RA
GEN; Well appearing, well nourished male in NAD
HEENT: NC/AT, PERRL, EOMI, oropharynx clear, MMM, no JVD
Cor: RRR S1 S2 III/VI systolic murmur loudest at RUSB, LUSB.
Lungs: CTA bilaterally
Abd: soft, NTND
Ext: no edema, groin site C/D/I
Neuro: alert and oriented x3, CNII-XII
Pertinent Results:
CATH [**11-11**]:
PTCA COMMENTS: Initial angiography demonstrated 70% proximal
LAD
stenosis....
At this point a decision was made to obtain arterial access via
the
right arm. The right radial access was unsuccessful due to
inability to
advance the wire despite good pulsatile flow. The brachial
artery was
then accessed successfully. Significant subclavian tortuosity
was
encountered and a catheter was advanced into the aorta in a
retrograde
fashion from the right brachial artery but we still unable to
engage the
artery with a AL1.5 guide catheter. Supravalvular aortography
with the
AL1 catheter in the ascending aorta demonstrated extreme
tortuosity of
the right subclavian and a normal aortic root. Attempts to
remove the
AL1 guide resulted in kinking of the catheter and eventual
removal with
difficulty. Angiography of the brachial artery performed through
the 6F
sheath demonstrated serial stenosis and dye hangup in the artery
at the
mid arm level. The sheath was withdrawn and a 4F glide catheter
was
advanced over a angled stiff wire to the aorta and was used to
exchange
a Choice Floppy wire. Angiography via the sheath in the right
brachial
artery revealed improvement in the suspected pleating artifact.
The wire
was removed and angigraphy was performed via a 4F dilator which
demonstrated significant tortuosity of the brachial artery and
almost
complete resolution of the pleating artifact, normal flow and no
dissection.
EXERCISE MIBI:
IMPRESSION: 1) Moderate to severe apical and distal anterior
wall reversible
defect. 2) Moderate, partially reversible inferior wall defect.
3) Calculated
ejection fraction of 49%.
HEAD CT:
FINDINGS: There is residual IV contrast from patient's recent
cardiac catheteriztion, that limits evaluation for acute
intracranial hemorrhage. There is no mass effect or shift of
normal mid- line structures. The ventricles and sulci are
prominent consistent with some age related involutional change.
The [**Doctor Last Name 352**]- white matter differentiation is preserved. The
partially visualized paranasal sinuses and mastoid air cells are
well aerated.
ABD/PELVIS CT:
IMPRESSION: Large left groin hematoma. No retroperitoneal
hemorrhage.
Large mass in the muscle of the upper right thigh as described
above.
Brief Hospital Course:
1)CAD: Pt was transferred from an outside hospital for a
possible interventional cath for a proximal LAD lesion seen on a
diagnositic cath. Although pt never had chest pain, his symptom
of dizziness and syncope was thought to be possibly related to
ischemia given the finding of the cath done at OSH. Although it
was reported as 60% stenosis, after reviewing the cath images,
it was thought that his lesion was more significant than that.
He underwent cardiac cath with plan to stent the lesion.
However, pt has multiple tortuous arteries making entrance to
the coronaries very difficult. The catheter could not be placed
to the coronaries because of anatomical difficulties. After the
cath, pt developed left groin hematoma requiring pressure to be
applied. During that time, he got vasovagal and became
hypotensive in the SBP of 60's-70's requiring atropine. The
blood pressure came back up the first episode, but he again
vasovagaled the second time requiring dopamine drip as well as
atropine briefly. During these events, pt had conscious but
suddenly became amnesic not remembering the events in the past 2
days. Pt was alert and able to answer questions about the
remote memory. His neurlogical exam was completely benign
except for the lack of short term memory. He as sent for head
CT to rule out stroke/bleed, as well as abdominal CT to rule out
retroperitoneal bleed which were both negative. Pt was
transiently transferred to CCU for observation. Pt's memory
came back within several hours with complete resolution.
Neurology thought that it was transient global amnesia in a
setting of syncope. Pt's Hct droppped from 40->31 but remained
stable at that level. Since pt could not get any intervention
during the cath, he was sent for an exercise MIBI which showed
moderate to severe apical and distal anterior wall reversible
defect, moderate, partially reversible inferior wall defect, and
calculated
ejection fraction of 49%. After long discussion, it was decided
to medically treat the patient since the likelihood of another
unsuccessful cath was high given his arterial anatomy. Since he
was not having symptoms at rest, this approach was thought the
safest way at this time.
2)Syncope: Pt's hx unlikely to be seizure or TIA. The syncopal
episode he had may be arrhythmia or aortic stenosis related or
vasovagal/hypersensitive carotid. During the exercise MIBI, he
did develop SVT of 150's where he felt fatigued. It was thought
that AS would not be the cause since his AS is mild on echo. Pt
was seen by Neurology who felt that it was not neurologic but
recommended outpatient MRA to see if there is any abnormalities
in the vertebrobasilar system. Pt was discharged home with [**Doctor Last Name **]
of Hearts.
3)Hyperlipidemia: Pt was continued on Lipitor
Medications on Admission:
Lipitor 20 mg po qd
Ranitidine 150 mg po qd
ASA 81 mg po qd
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
4. 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*
Discharge Disposition:
Home
Discharge Diagnosis:
Syncope
CAD-60% stenosis of LAD
Discharge Condition:
Hemodynamically stable, no symptoms of dizziness while
ambulating.
Discharge Instructions:
Pt was instructed to take all of the medications as instructed.
Pt needs to wear the [**Doctor Last Name **] of Hearts monitor and press the button
as instructed when he develops symptoms. He should also avoid
strenuous exercise for the next 2 weeks while he is on the
monitor. He shoud seek medical attention if he develops
dizziness, black out spells, chest pain, diaphoresis,
palpitation, nausea/vomiting, arm pain. Notice that Lipitor was
increased to 40 mg, and new medication metoprolol was added. Pt
was given a list of phone numbers for the cardiac rehab which he
should discuss with Dr. [**Last Name (STitle) **] on his next visit.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 911**] in 1 month. [**Telephone/Fax (1) 920**]
Follow up with Dr. [**Last Name (STitle) **] from Neurology in [**1-11**] weeks.
[**Telephone/Fax (1) 2574**]
Follow up with Dr. [**Last Name (STitle) **] in 2 weeks
Completed by:[**2160-11-16**]
|
[
"272.0",
"437.7",
"424.1",
"458.29",
"401.9",
"414.01",
"998.12",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
8421, 8427
|
5052, 7850
|
327, 341
|
8503, 8571
|
2760, 4402
|
9264, 9552
|
2369, 2400
|
7960, 8398
|
8448, 8482
|
7876, 7937
|
8595, 9241
|
2415, 2741
|
278, 289
|
369, 2081
|
4411, 5029
|
2103, 2242
|
2258, 2353
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,793
| 174,098
|
50100
|
Discharge summary
|
report
|
Admission Date: [**2187-4-13**] Discharge Date: [**2187-4-18**]
Service:
CHIEF COMPLAINT: Hypotension and hypothermia.
HISTORY OF PRESENT ILLNESS: The patient is an 89-year-old
woman with a history of metastatic transitional cell
carcinoma, and bilateral hydronephrosis, chronic renal
insufficiency, and right infiltrating ductal carcinoma who
presented to the Emergency Department after being found down
by family members. At that time, the patient was noted to be
both hypotensive and hypothermic.
Per Emergency Department report, she apparently had fallen 24
hours to 36 hours before being found and was unable to rise
secondary to weakness. She denied any loss of consciousness
or focal pain.
On initial presentation, the patient was alert, weak,
conversant, but hypothermic with a rectal temperature
of 92.9. She was bradycardic into the 40s with a blood
pressure of 118/42.
PAST MEDICAL HISTORY:
1. Transitional cell carcinoma with metastatic disease to
the liver and pelvis, bilateral hydronephrosis.
2. Right infiltrating ductal carcinoma of the breast
diagnosed in [**2186-5-30**], status post lumpectomy and
radiation therapy. Chemotherapy was discontinued at the
patient's request.
3. Hypertension.
4. Hypercholesterolemia.
5. Hypothyroidism after ablation.
6. Chronic renal insufficiency.
7. Macular degeneration.
8. Status post left total hip replacement in [**2180**].
9. Bilateral hydronephrosis (as previously described).
10. Anemia.
11. Nephrolithiasis.
MEDICATIONS ON ADMISSION: (At home)
1. Nadolol 40 mg p.o. b.i.d.
2. Diovan.
3. Ferrous sulfate.
4. Lipitor.
5. Epogen.
ALLERGIES: Allergy to ASPIRIN and CODEINE.
SOCIAL HISTORY: The patient lives alone at home. She has a
heavy tobacco use history, but quit more than 20 years ago.
She denies ethanol use.
PHYSICAL EXAMINATION ON PRESENTATION: Initial physical
examination was as follows; temperature of _____, pulse
of 55, blood pressure of 96/43, respiratory rate of 16,
oxygen saturation of 100% on 3 liters nasal cannula. She was
an elderly-appearing, thin, chronically ill-appearing woman
in no acute distress. Her head, eyes, ears, nose, and throat
examination was significant for bilateral irregular post
surgical pupils. Her mucous membranes were dry. Her neck
was supple. No lymphadenopathy was noted. Her lungs were
clear to auscultation bilaterally. Her heart was regular but
bradycardic. Normal first heart sound and second heart
sound. No third heart sound or fourth heart sound were
noted; however, there was a 2/6 systolic murmur at the apex
and a 2/6 systolic murmur at the base. Her abdomen was soft,
nontender, and nondistended, with inguinal lymphadenopathy.
Her extremities were without clubbing, cyanosis or edema.
She had chronic venous stasis changes in her shins
bilaterally. On neurologic examination, she was awake and
oriented to person only.
PERTINENT LABORATORY DATA ON PRESENTATION: Admission
laboratory studies were as follows; white blood cell count
of 26, hematocrit of 34.1, platelets of 339. On her white
blood count, there was left shift with 92% polys, 3% bands,
3% lymphocytes, 2% monocytes. Sodium of 143, potassium
of 4.6, chloride of 106, bicarbonate of 15, blood urea
nitrogen of 57, creatinine of 2 (up from a baseline of 1.4),
blood glucose of 75.
RADIOLOGY/IMAGING: Electrocardiogram showed sinus
bradycardia with normal axis, first-degree anterior vesicular
block delay with an increased QTc of 515.
A chest x-ray was unrevealing.
A head CT without contrast did not show any acute
intracranial pathology.
HOSPITAL COURSE: The patient was initially admitted to the
Medical Intensive Care Unit for pressor support, as the
patient had previous advanced directive of do not
resuscitate/do not intubate.
By hospital day four, the patient was weaned off pressors;
however, she subsequently developed left upper extremity
paralysis and a leftward gaze and was unresponsive.
At that time, the family decided to make the patient comfort
measures only with antibiotics and intravenous fluids to be
continued. Under the guidance of palliative care, a morphine
drip was started to make the patient more comfortable. The
patient expired on [**2187-4-18**].
DISCHARGE DIAGNOSES:
1. Transitional cell carcinoma.
2. Cerebrovascular accident.
3. Sepsis.
[**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**]
Dictated By:[**Last Name (NamePattern1) 9348**]
MEDQUIST36
D: [**2187-7-3**] 16:19
T: [**2187-7-4**] 12:30
JOB#: [**Job Number 104595**]
|
[
"591",
"198.0",
"584.9",
"038.9",
"V10.3",
"285.9",
"272.0",
"401.9",
"197.7"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4259, 4643
|
1538, 1682
|
3612, 4238
|
100, 130
|
159, 898
|
921, 1511
|
1699, 3594
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,125
| 127,965
|
36419
|
Discharge summary
|
report
|
Admission Date: [**2119-6-21**] Discharge Date: [**2119-7-7**]
Date of Birth: [**2036-9-21**] Sex: M
Service: MEDICINE
Allergies:
Morphine / Amlodipine
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Transfer for NSTEMI, respiratory failure
Major Surgical or Invasive Procedure:
Intubation
Central line placement
History of Present Illness:
82M h/o HTN, chronic back pain presented at 10:30am to Dr. [**Name (NI) 21977**] office at [**Hospital6 2910**] complaining of
2 days chest congestion and nausea. He denied chest pain, but
for the chest congestion he had been using a heating pad with
some improvement allowing him to sleep. On further review, he
had been feeling somewhat unwell for 4-5 days with increased
DOE, easily fatiguable, and some breathlessness at rest noticed
by his wife. Denied orthopnea, PND, lower extremity edema. Was
having nausea, dry heaves, and anorexia. The night prior to
presentation he developed fever to 101.6F, and was also
complaining of nasal congestion and cough. History is otherwise
per transfer notes and limited due to patient intubated and
sedated.
.
At the OSH, he remained chest pain free but was noted to have
new deep precordial T-wave inversions. Cardiac enzymes revealed
TnI 8.0 and CK 287. He was given ASA 325, beta-blocker, and
started on a heparin IV gtt with plans for medical management of
NSTEMI pending further clincial change. An echo showed mild
global HK and new depressed EF 35-40%.
.
The evening prior to transfer the patient became increasingly
dyspneic. CXR was consistent with acute pulmonary edema and he
was given IV nitro and lasix without significant improvement. He
was intubated and became hypotensive with SBP 70s. Transferred
to [**Hospital1 18**] CCU for further care.
.
On review of systems, per HPI and otherwise limited due to
intubation/sedation. According to OSH records, the patient
denied chills, abdominal pain, diarrhea, urinary frequency, or
dysuria at presentation.
.
Cardiac review of systems is notable per HPI.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
no known cardiac history
-?CAD
-?Afib
3. OTHER PAST MEDICAL HISTORY:
PAST MEDICAL HISTORY:
-hypertension
-asthma
-dyspnea on exertion
-nocturia
-arthritis
-chronic low back pain due to severe degenerative disease
-spinal stenosis
-transaminitis, possibly due to history of alcohol abuse
-rosacea
.
PAST SURGICAL HISTORY:
-s/p laminectomy of L4-5 in [**2110**]
-s/p repair of a deviated septum in [**2110**], knee surgery in [**2098**],
open
reduction internal fixation of the right wrist in the [**2100**] and
a right carpal tunnel release.
Social History:
Married, otherwise unknown occupation.
-Tobacco history: None.
-ETOH: Prior heavy use, but not recently per wife according to
transfer notes.
-Illicit drugs: None.
Family History:
Per old discharge summ
His father died at 65 from a stroke. Brother had a CABG, died at
65. Mother died at 65 of heart failure.
Physical Exam:
On admission -
VS: T=102.8 BP=94/55 HR=79 RR=27 O2 sat= 99% on CMV,FIO2 100,
PEEP 5
GENERAL: Elderly man intubated and sedated in NAD. Able to
follow commands, move all extremities
HEENT: PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis
of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 13 cm.
CARDIAC: Mild burns on left anterior chest with erythema, no
tenderness. PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Rhonchorous anteriorly
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. There
is a burn from a hot water bottle in the left precordial area.
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:
==========
Labs
==========
On admission -
[**2119-6-21**] 02:50AM BLOOD WBC-8.4 RBC-3.55* Hgb-12.2* Hct-35.7*
MCV-101* MCH-34.3* MCHC-34.1 RDW-13.2 Plt Ct-98*
[**2119-6-21**] 02:50AM BLOOD Neuts-72* Bands-8* Lymphs-10* Monos-8
Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-0
[**2119-6-21**] 02:50AM BLOOD Glucose-122* UreaN-35* Creat-2.0* Na-133
K-3.8 Cl-97 HCO3-21* AnGap-19
[**2119-6-21**] 02:50AM BLOOD ALT-118* AST-193* LD(LDH)-366*
CK(CPK)-276* AlkPhos-36* TotBili-1.0
[**2119-6-26**] 04:24AM BLOOD ALT-66* AST-116* AlkPhos-58 TotBili-4.9*
DirBili-4.1* IndBili-0.8
[**2119-6-25**] 05:00AM BLOOD ANCA-NEGATIVE B
[**2119-6-25**] 05:00AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2119-6-21**] 02:50AM BLOOD Triglyc-136 HDL-37 CHOL/HD-4.0 LDLcalc-83
.
On Discharge [**2119-7-7**]: BUN 30, Creat 1.9, hct 27.3, WBC 12.8, BC
[**7-3**] NGTD
GRAM STAIN (Final [**2119-7-7**]):
<10 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.
=========
Micro
=========
[**2119-6-21**]
RESPIRATORY CULTURE (Final [**2119-6-24**]):
HEAVY GROWTH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
.
============
Radiology
============
CT chest [**6-24**]
Ground-glass opacities with central distribution, although more
prominent on the right than on the left, are most consistent
with pulmonary edema, with small right greater than left pleural
effusions. No definite infectious process seen, although
enhancement pattern of the pleural effusion cannot be assessed
without IV contrast.
.
RUQ U/s [**6-27**]
1. Diffusely echogenic liver, compatible with fatty
infiltration. Other
forms of liver disease and more advanced liver disease including
fibrosis/cirrhosis cannot be excluded on this study. No focal
hepatic lesion.
2. No biliary ductal dilatation.
.
CT Torso [**6-27**]
1. Worsening bilateral pulmonary edema, although underlying
pneumonia remains an increasingly likely possibility given
persistent fevers.
2. Endotracheal tube tip is 1.5 cm above the carina
.
CT Chest [**7-3**]
1. Improved multifocal consolidations, no evidence of lung
abscess.
It is a combination of improved pulmonary edema and pneumonia.
2. Decrease in size of bilateral pleural effusions.
.
==========
cardiology
==========
TTE [**6-21**]
Suboptimal image quality.The left atrium is moderately dilated.
There is mild symmetric left ventricular hypertrophy. There is
mild to moderate regional left ventricular systolic dysfunction
with infero-lateral and apical hypokinesis suggested. No masses
or thrombi are seen in the left ventricle. There is no
ventricular septal defect. with normal free wall contractility.
The ascending aorta is mildly dilated. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion
.
C. cath [**2119-6-22**]
FINAL DIAGNOSIS:
1. No flow-limiting coronary artery disease.
2. Severe left ventricular diastolic dysfunction.
3. Moderate pulmonary arterial hypertension.
.
TTE [**6-28**]
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
and global systolic function (LVEF>55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The pulmonary artery systolic pressure could not
be determined. There is a very small circumferential pericardial
effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global biventricular systolic function. Dilated
ascending aorta.
Compared with the prior
Brief Hospital Course:
82M h/o HTN presents with >48 hours chest congestion, nausea
found to have NSTEMI complicated by LV systolic dysfunction and
acute pulmonary edema resulting in respiratory failure.
.
MSSA PNEUMONIA/RESPIRATORY FAILURE: Intubated at OSH for dyspnea
thought to be secondary to decompensated heart failure in
setting of ACS. Given fever, infiltrate, and MSSA in sputum,
patient was treated with Nafcillin for 3 week course per ID. Flu
and legionella ruled out on admission. Patient also received 8
dayd of levaquin for atypical coverage, and flagyl for anaerobic
coverage. Pt was re-intubated on HD#4. CT chest x2 did not
reveal significant abscess or empyema and patient was persistent
febrile throughout much of his hospital course. CXR and Chest CT
were consistent with ARDS. Pulmonary edema improved with
diuresis and CPAP at night. Pt's CXR still show multilobar
consolidations but pt has no sig cough, temp or WBC elevation.
The cause of consolidations on CXR and intermittant WBC
elevation were thought to be pneumonitis [**3-6**] aspiration. Pt was
on a 2 week course of nafcillin that finished today and flagyl
PO for 1 week.
.
CORONARIES: NSTEMI. No prior known history of CAD with normal
stress-echo in [**2117**]. Echo at OSH reveals global HK without
clear focal WMA and newly depressed EF. ECG with T wave
inversions suspicious for apical ballooning, although unclear
evaluation of degree of apical hypokinesis on OSH ECHO. Patient
treated with ASA, Beta-blocker, and Plavix 300, then 75 daily.
Cath revealed clean coronaries and NSTEMI felt to be due to
demand in the setting of pneumonia. Plavix and heparin stopped.
Pt is on metoprolol and statin.
.
PUMP: Acute decompensated CHF with newly depressed EF 35-40%
with mild global HK on echo at OSH. Repeat TTE here shwoed
Moderate [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1915**], Mild LVH, EF 40% infero-lateral and apical
hypokinesis, No thrombi, No AS, 1+ AI, 1+ MR, moderate pulmonary
artery systolic hypertension. Patient was intubated for acute
pulmonary edema at OSH and respiratory failure and was
re-intubated on HD#4 but was successfully extubated after
treatment for pulmonary edema and pneumonia. Pt has been stable
for last 3-4 days, low dose PO Lasix started at discharge. Due
to patient's renal failure, he was on hydralazine for afterload
reduction instead of ACE inhibitor. This should be reconsidered
as pts renal function improves.
.
ACUTE RENAL FAILURE: Cr elevation felt to be [**3-6**] to shock in the
setting of sepsis. Renal ultrasounds showed no evidence of
hydroephrosis or calculi, but were unable to assess for renal
artery stenosis. Cr impoved to 1.9.
.
TRANSAMINITIS: Chronically elevated but higher than recent
baseline, monitor daily in setting of initiating statin therapy.
Downtrended and may have been due to shock liver. RUQ u/s
without ductal dilitation. Now resolved.
.
Aspiration: Pt found to have sig aspiration thought [**3-6**]
weakness, illness and gulping of food. Please see attached recs
from speech therapist for precautions.
.
Hypertension: on Hydralazine for afterload reduction along with
metoprolol. Would change Hydralazine to ACE once creat
normalizes.
Medications on Admission:
Dyazide 37.5-25 daily
Inderal 20mg po bid
Plendil ER 2.5mg daily
Uroxatral 10mg qhs
Doryx 50mg Qsun
Folate
MVI
Vitamin E
Glucosamine
Protonix
.
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Hold for diarrhea.
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) syringe
Injection TID (3 times a day): D/C when pt ambulating.
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain: apply to back at site of pain as needed.
9. 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.
10. 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.
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: sliding
scale units Subcutaneous four times a day: see sliding scale
attached.
14. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary: MSSA Pneumonia, NSTEMI, Aspiration
Secondary: Essential tremor
Discharge Condition:
stable.
Discharge Instructions:
You were transfered to [**Hospital1 18**] for concern of a heart attack. A
cardiac catheterization revealed that you had healthy blood
vessels in your heart. You were felt to have some excess demand
on your heart because of breathing difficulties. You were found
to have a severe pneumonia and were treated with antibiotics.
.
Please seek immediate medical attention if you experience
fevers, chest pain, shortness of breath, abdominal pain,
dizziness, palpitations, or any change in your baseline health
status.
Followup Instructions:
Cardiology:
Dr. [**First Name4 (NamePattern1) 21976**] [**Last Name (NamePattern1) 11679**] Phone: ([**Telephone/Fax (1) 32215**] Date/time: [**7-27**] at
2:30pm.
Completed by:[**2119-7-11**]
|
[
"482.41",
"518.5",
"333.1",
"428.0",
"428.33",
"410.71",
"507.0",
"401.9",
"584.9",
"291.81",
"416.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"37.23",
"96.72",
"88.56",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
13914, 13993
|
9089, 12272
|
322, 357
|
14109, 14119
|
3966, 7856
|
14680, 14874
|
2879, 3009
|
12467, 13891
|
14014, 14088
|
12298, 12444
|
7873, 9066
|
14143, 14657
|
2459, 2681
|
3024, 3947
|
2138, 2176
|
242, 284
|
385, 2044
|
2207, 2207
|
2229, 2436
|
2697, 2863
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,103
| 145,811
|
43508+58627+58628
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2157-3-5**] Discharge Date: [**2157-3-10**]
Date of Birth: [**2087-8-27**] Sex: M
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: This is a 69 year-old man who
presents again for a chief complaint of rectal bleeding. He
was recently admitted on [**2157-2-27**] to [**2157-3-3**] for rectal bleeding
and he represents for continued episodes of rectal bleeding.
Colonoscopy performed on the previous admission was noted to have
an ulcer at the anorectal verge and then was transfused a total
of 7 units of packed red blood cells. His
esophagogastroduodenoscopy revealed mild gastritis. Surgery was
also consulted at that time for evaluation and recommended
conservative management. He was hemodynamically stable when he
was discharged and was given the time for his ulcer to heal since
it may have been secondary to rectal tube trauma and a biopsy was
to be performed at four to six weeks post discharge. However, at
the nursing home on the morning of admission the staff noted a
large episode of bright red blood per rectum. He was transferred
back to the [**Hospital1 69**] Emergency
Department for further management and evaluation. He denies any
abdominal pain, lightheadedness, shortness of breath, chest pain,
fevers, throughout this process. On arrival to the Emergency
Department he had a blood pressure of 43/25, heart rate of
70, aggressive fluid hydration was given as well as 2 units
of packed red blood cells. His blood pressure rose to 120/55.
His admission hematocrit was 30.1. Gastrointestinal and surgery
consults were obtained in the Emergency Department.
PAST MEDICAL HISTORY:
1. Anorectal ulcer.
2. Diabetes mellitus type 2.
3. Hypertension.
4. Obesity.
5. Obstructive sleep apnea.
6. Depression.
7. Status post left parietal cerebrovascular accident.
8. Gout.
9. Rhabdomyolysis.
10. Decubitus ulcers.
ALLERGIES: No known drug allergies.
MEDICATIONS: Celexa 20 mg po q day, multivitamin, thiamine,
folate, Lisinopril 20 mg po q day, Protonix, Mirtazapine 15
mg, iron sulfate 325 mg b.i.d., vitamin C 500 mg b.i.d., zinc
sulfate 120 mg po q day, subQ heparin, Metformin 1 gram
b.i.d., aspirin suppositories.
SOCIAL HISTORY: He is estranged from his wife, not a smoker,
former alcohol use, former real estate worker.
PHYSICAL EXAMINATION: He was an elderly man in no acute
distress. HEENT pupils are equal, round and reactive to
light. Extraocular movements intact. Dry mucous membranes.
Oropharynx clear. Lungs clear to auscultation bilaterally
with no adventitious sounds. Neck veins were flat. No
lymphadenopathy. Cardiovascular S1 and S2, regular. No
murmurs, rubs or gallops. Abdomen soft, nontender,
nondistended with normoactive bowel sounds . Extremities no
edema. Neurological alert and oriented times three.
LABORATORIES ON ADMISSION: White blood cell count 8.5,
hematocrit 30.1, which is a drop from 31.6 on his last
admission. Platelets 297, INR 1. His chem 7 sodium 141,
potassium 4.3, chloride 108, bicarb 24, BUN 18, creatinine
.7, 160 for glucose.
HOSPITAL COURSE: The patient was admitted to the MICU. He was
transfused a total of 7 units of packed red blood cells on
[**2157-3-5**] for his gastrointestinal bleed. He had an emergent
colonoscopy, which showed clots of blood mixed with stool at 40
cm from the rectum and three deep circular nonbleeding ulcers 4
to 8 mm in the rectum and anus. He subsequently went to the
Operating Room on [**2157-3-8**] for ligation of the rectal veins to
eliminate the possibility of the anorectal ulcer causing the
bleed. The etiology of the blood mixed stool at 40 cm is still
unclear, therefore an angiogram of the abdomen was performed on
[**2157-3-9**] and contrast was given to the SMA and [**Female First Name (un) 899**], which showed
no extravasation, no early draining veins and no AV
malformations. His hematocrit had remained stable throughout
hospitalization since his 7 unit transfusion on [**2157-3-5**].
Neuro: He still has residual weakness on the right side from his
left parietal cerebrovascular accident, which may be slightly
worsened. He states he has increased heaviness in his right
foot. He has not had physical therapy while he was in the MICU
and may be decondition. Given his condition and his hypotensive
state on admission most likely easily brings out his right sided
weakness and no repeat imaging was necessary at this time.
Physical therapy was reconsulted.
He has depression, but is not suicidal. He is to follow up with
his psychiatrist at [**Hospital3 7**] and continue Celexa and
Mirtazapine.
Endocrine: He is a diabetic on a regular insulin sliding scale.
At the nursing home he can be titrated up on his Metformin at 1
gram b.i.d. once he is fully taking po.
Cardiovascular: Hypertension - his Lisinopril was stopped in the
hospital due to his hypotensive state. Lisinopril was resumed on
[**2157-3-9**] at 10 mg q day, but can be increased to 20 mg q day.
Infectious disease: The patient had increased erythema and pain
on his left wrist, which was thought to be secondary to a
thrombophlebitis from an arterial line that was placed in the
MICU. The patient was started on oxacillin on [**2157-3-10**]. He
should also continue with warm compresses and elevation of that
hand. Rheumatology had been consulted to rule out a septic joint,
but his joint by physical examination was not consistent with
septic joint and was not tapped at this time.
Sacral decubitus ulcer, which is a stage two. He is to
continue dressing changes t.i.d. with DuoDerm gel, log roll
precautions two q hours at the [**Doctor First Name **] Air mattress. He also has
a right heel necrotic ulcer, which is dry, but should have
Podus boots to relieve the pressure at all times.
DISCHARGE CONDITION: Stable.
DISCHARGE DIAGNOSES:
1. Lower gastrointestinal bleed.
2. Anorectal ulcer status post rectal vein ligation.
3. Colonic polyp at 50 cm from the rectum.
4. Diabetes mellitus type 2.
5. Hypertension.
6. Right sided weakness secondary to left parietal infarct.
7. Depression.
8. Gout.
9. Thrombophlebitis of the left wrist.
10. Sacral decubitus ulcer.
11. Obesity.
12. Obstructive sleep apnea.
FOLLOW UP: The patient is to follow up with Dr. [**Last Name (STitle) 1728**] his
primary care physician. [**Name10 (NameIs) **] is also to follow up with
(gastrointestinal) Dr. [**Last Name (STitle) 93644**].
DISCHARGE MEDICATIONS: Celexa 20 mg po q day, multivitamin
one tab q day, regular insulin sliding scale to be switched
and titrated to Metformin when the patient is fully taking
po. He was previously at 1 gram b.i.d., Thiamine 100 mg q
day, folic acid 1 mg po q day, Protonix 40 mg q.d.,
Mirtazapine 15 mg q.h.s., ferrous sulfate 325 mg q.d.,
vitamin C 500 mg q.d., zinc sulfate 220 mg q day, Colace 100
mg b.i.d., Senna one tab po b.i.d. as needed, Lisinopril 20
mg po q day and Keflex 500 mg po q 6 hours for seven to ten
days.
OTHER TREATMENTS: The patient requires t.i.d. dressing
changes with DuoDerm gel to his stage two sacral decubitus
ulcer and to try to keep that area dry. Log roll precautions
q two hours. [**Doctor First Name **] Air mattress, Podus boots. The patient
will also need physical therapy rehab for his left parietal
infarct and right sided weakness.
The patient should follow up with his new primary care
physician as previous.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Doctor Last Name 18900**]
MEDQUIST36
D: [**2157-3-10**] 10:23
T: [**2157-3-10**] 10:36
JOB#: [**Job Number **]
cc:[**Doctor Last Name 18875**] Name: [**Known lastname 14764**], [**Known firstname **] Unit No: [**Numeric Identifier 14765**]
Admission Date: [**2157-3-5**] Discharge Date:
Date of Birth: [**2087-8-27**] Sex: M
Service: Medicine
ADDENDUM: (To last dictation on [**2157-3-10**]).
The patient was to be discharged to [**Hospital1 **] on [**2157-3-10**], but
given his left hand thrombophlebitis, we kept him overnight to
monitor. We started him on intravenous Oxacillin, monitor his
hematocrit one more day. On the morning of [**2157-3-11**], the
patient's hematocrit had come down from 35.0 to 31.0, and his
subsequent evening hematocrit was 27.1. Another technetium
tagged red blood cell scan was performed that evening which was
negative. The patient was transfused two units of packed red
blood cells, but had no further bleeding.
A complete dictation summary will follow at the time of
[**Name6 (MD) 1034**] [**Name8 (MD) 1035**], M.D. [**MD Number(1) 1036**]
Dictated By:[**Name8 (MD) 14767**]
MEDQUIST36
D: [**2157-3-12**] 10:16
T: [**2157-3-12**] 10:40
JOB#: [**Job Number 14768**]
Name: [**Known lastname 14764**], [**Known firstname **] Unit No: [**Numeric Identifier 14765**]
Admission Date: [**2157-3-14**] Discharge Date: [**2157-3-16**]
Date of Birth: [**2087-8-27**] Sex: M
Service: Medicine
NOTE: This addendum will cover the hospital course from [**3-14**]
until [**3-16**].
HOSPITAL COURSE: On [**3-14**], the patient underwent placement of
PICC line in right basilic vein. He also underwent an ultrasound
of the erythematous nodule on his left wrist. No pseudoaneurysm
was noted. The nodule was consistent with a hematoma superficial
to the plane of the radial artery. On [**3-15**], the patient was
taken to the Operating Room for debridement of the nodule. Nodule
was found to be an infected hematoma with no involvement of the
radial artery. Gram stain shows 2+ gram positive cocci in pairs.
Cultures are still pending. The patient has been treated with
Unasyn and vancomycin. Wound is currently dressed. The
DISCHARGE CONDITION: Stable
DISCHARGE DIAGNOSES: As noted in previous discharge summary.
1. Lower gastrointestinal bleed
2. Anal rectal ulcer status post rectal band ligation
3. Colonic polyp at 50 cm from the rectum
4. Diabetes mellitus type II
5. Hypertension
6. Right sided weakness secondary to left parietal infarct
7. Depression
8. Gallop
9. Infected hematoma of left wrist, status post debridement
10. Sacral decubitus ulcer
11. Obesity
12. Obstructive sleep apnea
FOLLOW UP: Patient will follow up with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], his
new primary care physician. [**Name10 (NameIs) **] number ([**Telephone/Fax (1) 14769**]. He will
also follow up with gastroenterologist, Dr. [**Last Name (STitle) 5503**], phone
number ([**Telephone/Fax (1) 14770**]. The patient will also follow up with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], vascular surgeon, phone number ([**Telephone/Fax (1) 14771**].
DISCHARGE MEDICATIONS: Same as noted in previous discharge
summary. The patient will not take Keflex. Rather, he will
continue vancomycin to complete two week course.
[**Name6 (MD) 1034**] [**Name8 (MD) 1035**], M.D. [**MD Number(1) 1036**]
Dictated By:[**Last Name (NamePattern1) 14772**]
MEDQUIST36
D: [**2157-3-16**] 08:25
T: [**2157-3-16**] 08:24
JOB#: [**Job Number 14773**]
|
[
"250.00",
"780.57",
"998.12",
"401.9",
"278.00",
"455.8",
"997.2",
"569.3",
"707.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.04",
"38.93",
"48.79",
"48.23"
] |
icd9pcs
|
[
[
[]
]
] |
9790, 9798
|
9820, 10253
|
10781, 11179
|
9138, 9768
|
10265, 10757
|
2320, 2823
|
168, 1619
|
2838, 3060
|
1641, 2187
|
2204, 2297
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,488
| 142,899
|
48271
|
Discharge summary
|
report
|
Admission Date: [**2183-1-6**] Discharge Date: [**2183-2-6**]
Date of Birth: [**2114-3-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Quinolones / Levofloxacin / Lorazepam
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Transfer for cardiac catherization
Major Surgical or Invasive Procedure:
[**2183-1-20**] Aortic Valve Replacement(23mm St. [**Male First Name (un) 923**] Mechanical) with
Aortic Endarterectomy
[**2183-1-6**] Cardiac catheterization with Drug-Eluding Stent to the
Left Anterior Descending Artery
[**2183-2-4**] Percutaneous cholecystostomy tube
[**2183-2-4**] Sternal debridement-Vac dsg
History of Present Illness:
This is a 68 year-old male with a history of CAD, s/p Ranger LAD
stent [**2172**] and repeat cath [**2180**] with patent LAD stent [**33**]% LCX
hemodynamically insignificant lesion, Type II DM, ESRD on HD
M-W-F, CHF (EF 55% [**2179**], 20% at OSH), HTN, COPD, Afib, h/o DVT
who was transferred from [**Hospital3 **] for cardiac catherization.
Patient initially presented to [**Hospital3 **] with hypotension, SOB
and falls last week. Prior to admission to [**Hospital3 **] patient was
seen by primary care physician with complaints of weakness and
exertional fatigue. Patient states that over those days he was
feeling light headed and was falling. Patient also endorses +
nausea, + vomiting and + diarrhea in this setting. When
questioned as to why he was falling he stated it was secondary
to his arthritis. His wife thinks that patient's shakiness on
his feet is due to low blood pressure. Apparently this low blood
pressure has been a chronic problem which patient's doctors have [**Name5 (PTitle) 101693**] trying to address. Patient denied having any frank syncope
or dizziness leading to falls. Patient also endorses some chest
pain and on furthur clarification he stated this pain was like
something sitting on his chest and occurred after eating and
relieved with belching. Patient denied exertional angina.
Patient endorses shortness of breath however is unable to really
clarify what this means. Patient is not a great historian.
.
As per outside hospital records, patient had first part of his
nuclear stress test as per his outpatient primary care
physician, [**Name10 (NameIs) **] home and then fell and subsequently went to the
ED. He came back to the ER at [**Hospital3 **] because of the fall,
weakness and dizziness also mentioning some lower chest
discomfort. Patient denies any palpitations or leg edema. In the
ED patient had positive trop to 0.78 in the setting of chronic
renal failure. Patient was transferred here for cath after
dialysis this am with 1 KG removed which he tolerated well.
Patient has been getting Percocet for back and R shoulder pain
since fall.
.
Pt also with 2 weeks of diarrhea prior to admisison concerning
for C diff, now resolved.
.
On review of systems, he denies any prior history of stroke,
TIA, pulmonary embolism, bleeding at the time of surgery,
cough,hemoptysis, black stools or red stools. He denies
exertional buttock or calf pain. All of the other review of
systems were negative. Cardiac review of systems is notable for
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
* Chronic, Systolic Congestive Heart Failure
* Coronary Artery Disease, recent NSTEMI, PCI/stenting [**2172**]
* ESRD on hemodialysis MWF at [**Hospital1 1474**] kidney center [**Telephone/Fax (1) 101694**], right AV fistula, dialysis catheter
* COPD
* Hypertension
* Dyslipidemia
* Type II DM
* History of pacemaker placement [**2159**] for low blood pressure and
atrial fibrillation
* Paroxysmal Atrial Fibrillation
* History of DVT x 2
* History of Embolectomy for right femoral clot [**2167**]
* History of MRSA(nares)
* Asthma
* Hiatal hernia repair c/b infection post operatively
* Rheumatoid arthritis
* Anemia
* left eye vitrectomy and cataract surgery [**2180-12-5**]
* Vitreous hemorrhage left eye [**2175**]
* Bladder cancer [**2159**] s/p cystoscopy and tumor removal, no
recurrence
* Sleep apnea on BIPAP
* Psoriasis
* Peripheral neuropathy
Social History:
Patient is married, retired. Lives at home with his wife
Social history is significant for the absence of current tobacco
use. Patient states he smoked as a teenager. . There is no
history of alcohol abuse, drinks [**11-29**] glasses of wine per week.
Family History:
Mother died at age 39 of a cerebral hemorrhage after syncope and
hitting her head. Father died of pneumonia also at age 39.
Physical Exam:
Gen: obese, chronically ill appearing middle aged male in NAD.
Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva
non-injected.
Neck: obese.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. + III/VI systolic murmur. No thrills, lifts.
No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: + tatoo left arm, + AV fistula on right arm, No c/c/e. No
femoral bruits, cardiac catherization site without bruit or
hematoma
Skin: + Varicose veins bilaterally, + clotted veins on right leg
, + chronic venous stasis changes.
Pulses:
Right: Carotid 1+ Femoral 2+ DP pulse by doppler PT pulse by
doppler
Left: Carotid 1+ Femoral 2+ DP pulse by doppler PT pulse by
doppler
Pertinent Results:
Admission:
[**2183-1-6**] 10:35PM WBC-5.2 RBC-3.95* HGB-12.4* HCT-38.8* MCV-98
MCH-31.4 MCHC-32.0 RDW-18.4*
[**2183-1-6**] 10:35PM PLT COUNT-180
[**2183-1-6**] 10:35PM DIGOXIN-1.0
[**2183-1-6**] 10:35PM CORTISOL-18.9
[**2183-1-6**] 10:35PM TRIGLYCER-103 HDL CHOL-34 CHOL/HDL-3.3
LDL(CALC)-58
[**2183-1-6**] 10:35PM %HbA1c-6.7*
[**2183-1-6**] 10:35PM GLUCOSE-115* UREA N-46* CREAT-7.6*#
SODIUM-134 POTASSIUM-4.8 CHLORIDE-94* TOTAL CO2-24 ANION GAP-21*
[**2183-1-6**] 10:35PM ALBUMIN-3.7 CALCIUM-9.9 PHOSPHATE-8.7*
MAGNESIUM-2.8* CHOLEST-113
[**2183-1-6**] 10:35PM CK-MB-5 cTropnT-0.45*
[**2183-1-6**] 10:35PM ALT(SGPT)-10 AST(SGOT)-16 LD(LDH)-188
CK(CPK)-33* ALK PHOS-90 TOT BILI-1.0
Final hospital day
[**2183-2-6**] 01:45PM BLOOD WBC-26.2* RBC-2.96* Hgb-9.2* Hct-27.8*
MCV-94 MCH-31.1 MCHC-33.1 RDW-18.2* Plt Ct-276
[**2183-2-6**] 01:45PM BLOOD Plt Ct-276
[**2183-2-6**] 01:45PM BLOOD PT-19.4* PTT-42.3* INR(PT)-1.8*
[**2183-2-6**] 06:12PM BLOOD UreaN-64* Creat-6.0* Na-135 Cl-100
HCO3-13*
[**2183-2-6**] 06:12PM BLOOD ALT-40 AST-171* LD(LDH)-445* AlkPhos-179*
Amylase-29 TotBili-1.5
[**2183-2-6**] 06:12PM BLOOD Lipase-18
[**2183-1-9**] 10:25AM BLOOD CK-MB-NotDone cTropnT-0.58*
[**2183-2-6**] 06:12PM BLOOD Albumin-1.6* Calcium-9.0 Phos-9.9*#
Mg-2.5
[**2183-2-6**] 07:41PM BLOOD Type-ART pO2-141* pCO2-64* pH-7.45
calTCO2-46* Base XS-17
[**2183-2-6**] 07:14PM BLOOD Type-ART pO2-156* pCO2-35 pH-7.18*
calTCO2-14* Base XS--14
[**2183-2-6**] 07:41PM BLOOD Glucose-486* Lactate-15.4* Na-163* K-6.3*
Cl-96*
[**2183-2-6**] 06:58PM BLOOD Lactate-11.1* K-4.9
[**2183-2-6**] 04:18PM BLOOD Lactate-6.9*
[**2183-2-6**] 08:28AM BLOOD Glucose-157* Lactate-2.7* Na-133* K-5.6*
Cl-99*
CARDIAC CATH [**2183-1-6**]
1. Selective coronary angiography of this right dominant system
revealed single vessel coronary artery disease. The LMCA had no
angiographically apparent flow limiting disease. The LAD had a
calcified 85% stenosis at the mid segment at the level of the
first Diagonal. The first Diagonalhad two poles, and the lower
pole was occluded. The LCX had no angiographically apparent flow
limiting disease. The RCA had no angiographically apparent flow
limiting disease and supplied collaterals to the LAD. 2. Limited
resting hemodynamics demonstrated systemic hypotension with
central aortic pressure of 81/59 mm Hg, of note this was
simultaneous with a non-invasive blood pressure cuff [**Location (un) 1131**] of
approximately 68-72/40 mm Hg. 3. Successful stenting of the mid
LAD stented with 2 2.5x28 mm Cypher [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 7930**] to 3.5
proximally and 3.0 distally. Final angigraphy revealed 10%
residual stenosis with no dissection or distal emboli. 4.
Unsuccessful brief attempt at revascularizing the lower pole of
the D1. 5. Successful deployment of a Mynx device to the RCFA.
ECHOCARDIOGRAM [**2183-1-7**]
The left atrium is mildly dilated. The right atrium is
moderately dilated. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is severely depressed (LVEF=
25-30 %) with extensive severe hypokinesis of the entire mid to
distal left ventricle. There is relative preservation of basal
lateral and septal wall motion. Tissue Doppler imaging suggests
an increased left ventricular filling pressure (PCWP>18mmHg).
Transmitral Doppler and tissue velocity imaging are consistent
with Grade III/IV (severe) LV diastolic dysfunction. The right
ventricular cavity is moderately dilated with borderline normal
free wall function. The aortic root is mildly dilated at the
sinus level. The aortic valve (?# leaflets) are thickened with
severe aortic stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are moderately thickened. There is severe
mitral annular calcification. There is mild functional mitral
stenosis (mean gradient 4 mmHg) due to mitral annular
calcification. Mild to moderate ([**11-29**]+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *6.6 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.7 cm <= 5.2 cm
Left Ventricle - Inferolateral Thickness: *1.6 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *6.7 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 30% >= 55%
Aorta - Sinus Level: 2.5 cm <= 3.6 cm
Aorta - Ascending: *3.7 cm <= 3.4 cm
Findings
LEFT ATRIUM: Marked LA enlargement. Mild spontaneous echo
contrast in the body of the LA. Mild spontaneous echo contrast
in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Moderate symmetric LVH. Moderately dilated LV
cavity. Suboptimal technical quality, a focal LV wall motion
abnormality cannot be fully excluded. Severely depressed LVEF.
RIGHT VENTRICLE: Mild global RV free wall hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Simple
atheroma in aortic root. Normal ascending aorta diameter. Normal
aortic arch diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Severe AS (AoVA
<0.8cm2). Trace AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Moderate to severe (3+) MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The rhythm appears
to be atrial fibrillation. The patient is in a ventricularly
paced rhythm. Results were personally reviewed with the MD
caring for the patient. See Conclusions for post-bypass data The
post-bypass study was performed while the patient was receiving
vasoactive infusions (see Conclusions for listing of
medications).
Conclusions
PRE-BYPASS:
1. The left atrium is markedly dilated. Mild spontaneous echo
contrast is seen in the body of the left atrium. Mild
spontaneous echo contrast is present in the left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
2. There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity is moderately dilated. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
severely depressed (LVEF= 30 %). with mild global free wall
hypokinesis.
3. There are simple atheroma in the aortic root. There are
simple atheroma in the descending thoracic aorta.
4. There are three aortic valve leaflets. The aortic valve
leaflets are severely thickened/deformed. There is severe aortic
valve stenosis (area <0.8cm2). Trace aortic regurgitation is
seen.
5. The mitral valve leaflets are moderately thickened. Moderate
to severe (3+) mitral regurgitation is seen.
6. There is no pericardial effusion.
Dr. [**First Name (STitle) **] was notified in person of the results.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including Phenylephrine,
Epinephrine and Milrinone and is being AV paced
1. A mechanical prosthesis is well seated in the Aortic
position. Washing jets are seen (normal for this prosthesis).
Mean gradient is 17 mm of Hg. A trace paravalvular leak is
probably seen ( sub-optimal views)
2. LV function is significantly better.
3. MR is now mild.
4. Aorta is intact post decannulation
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD,
Interpreting physician [**Last Name (NamePattern4) **] [**2183-1-20**] 12:56
CAROTID ULTRASOUND [**2183-1-13**]
Severely blunted common carotid artery waveform consistent with
known aortic stenosis. Bilateral mild plaque with 1-39% ICA
stenosis bilaterally. Right vertebral artery occlusion.
Antegrade left vertebral.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the cardiology service with recent
NSTEMI, acute on chronic congestive heart failure(newly
decreased ejection fraction) and hypotension. He urgently
underwent successful stenting of the mid left anterior
descending artery stented with Cypher DES. Final angigraphy
revealed only a 10% residual stenosis with no dissection or
distal emboli - see result section for additional detail. While
in the CCU, sepsis and adrenal insufficiency were ruled out as a
source of his hypotension. His blood pressure improved slightly
with an increase in Midodrine and discontinuation of all
antihypertensive agents. Echocardiogram revealed severe aortic
stenosis with mild to moderate mitral regurgitation. It also
confirmed severe left ventricular dysfunction with an LVEF of
25-30%. Given anticipation for cardiac surgical intervention,
Warfarin was discontinued and he was maintained on subcutaneous
Heparin for anticoagulation. Given recent Cypher stent, he was
also maintained on Aspirin and Plavix. He continued on his
regular hemodialysis schedule and was followed closely by the
renal service. He was also seen be the dental service prior to
aortic valve replacement and underwent tooth extraction without
complication. He otherwise remained stable on medical therapy
and was eventually cleared for surgery.
On [**1-20**], Dr. [**First Name (STitle) **] performed an aortic valve
replacement(mechanical valve) along with aortic endarterectomy.
For surgical details, please see operative report. Following the
operation, he was brought to the CVICU for invasive monitoring.
Postoperative course will now be broken down by systems:
CARDIAC: Prolonged period of postoperative shock/hypotension.
Remained pacemaker dependent with underlying atrial
fibrillation. Initially required aggressive fluid rescuitation
and maintained on Vasopressin and Levophed. Experienced
pulseless ventricular tachycardia on postoperative day three.
ACLS protocol was initiated, CPR was administered and underwent
successfull defibrillation with conversion back to paced rhythm.
Maintained on Amiodarone and transiently started on Milrinone
for evidence of right ventricular failure on echocardiogram. VT
arrest was attributed prolonged QTc and medications were
titrated accordingly. There was no evidence of ischemia.
Hemodynamics gradually improved and inotropes were slowly
weaned. Amiodarone was continued.
No further ventricular arrythmias until patient became
increasing acidotic and then had pulseless VT arrest
PULMONARY: Initially extubated on postoperative day two but
required reintubation on postoperative day three following
cardiac arrest. Intermittently underwent bronchoscopies for
thick secretions. Sputum culture grew out Proteus and Hafnia
alvei sensistive to Ciprofloxacin. Eventually re-extubated on on
postoperative day seven.
Reintubated for sternal debridement on [**2-4**] had open chest so
was never extubated post-op.
RENAL: CVVH was initiated postoperatively via left femoral
dialysis port. Once hemodynamics improved, converted to
hemodialysis on [**1-30**].
NEURO: Awoke and extubated after initial AVR then reintubated
and sedated after PEA arrest, again extubated. Then prolonged
period of sedation after sternal debridement with open chest.
GI: Percutaneous chole tube placed on [**2-4**], then brought to OR
for abdominal exploration on [**2-6**] due to worsening lactic
acidosis
ID: Pan-cultured for fevers. Sputum cultures showed Proteus and
Hafnia alvei, while blood cultures grew out Enterococcus. All
lines were removed and cultured. Initially started on
Ciprofloxacin for Proteus/Hafnia and eventually switched to
Ceftriaxone and Vancomycin for septicemia.
HEME: Initially maintained on intravenous Heparin for mechanical
valve and atrial fibrillation. Warfarin was not resumed as
patient had open chest after sternal debridement
NUTRITION: Given complicated postoperative course, he was
started early on tube feeds. Tube feeds needed to be held as
acidosis worsened.
This patient had a long post operative course complicated by a
VT/PEA arrest and then VRE bacteremia. Suring the post-op period
he developed sternal drainage and returned to the operating room
for a sternal debridement. The post-op course was further
complicated by acute cholecystitis and metabolic acidosis
requiring abdominal exploration. During this period of worsening
acidosis the patient suffered a second pulseless VT arrest from
which he could nor be resuscitated. He was pronounced at 19:54
on [**2-6**]
Medications on Admission:
Heparin gtt
Asa 325mg-to get prior to transfer
Celexa
Digoxin 0.125mg tues/thurs/sat
Nexium 40mg
Neurontin 200mg MWF, 100mg Sun, tues/thurs/sat
Hydroxyzine 25mg MWF
SS insulin- last sugar 102 at 11am- NO COVERAGE
Phos lo 1334 mg TID with meals
Toprol xl 12.5mg [**Hospital1 **]
Nephrocaps daily
Vancomycin oral q 6hours
Percocet PRN
Levemir 10 Units q AM (10 am), humalog sliding scale
Coumadin (alternating days 4 mg and then 5 mg )
Discharge Medications:
patient expired
Discharge Disposition:
Expired
Facility:
[**Last Name (un) **] Center - [**Location (un) 701**]
Discharge Diagnosis:
patient expired
Discharge Condition:
expired
Discharge Instructions:
patient expired
Followup Instructions:
patient expired
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2184-2-23**]
|
[
"585.6",
"250.60",
"428.0",
"V10.51",
"403.91",
"427.1",
"574.10",
"410.71",
"E878.1",
"493.20",
"428.40",
"E878.8",
"357.2",
"574.00",
"038.9",
"522.5",
"414.01",
"519.2",
"995.92",
"396.2",
"996.61",
"285.29",
"V64.3",
"998.31",
"785.51",
"427.31",
"E849.7",
"998.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.07",
"34.79",
"99.60",
"38.95",
"96.72",
"39.61",
"37.22",
"23.19",
"00.66",
"38.14",
"39.95",
"51.22",
"00.40",
"51.01",
"35.22",
"89.45",
"96.04",
"50.12",
"77.61",
"88.56",
"00.45",
"93.59"
] |
icd9pcs
|
[
[
[]
]
] |
18945, 19020
|
13877, 18420
|
335, 650
|
19079, 19088
|
5539, 13853
|
19152, 19289
|
4437, 4562
|
18905, 18922
|
19041, 19058
|
18446, 18882
|
19112, 19129
|
4577, 5520
|
261, 297
|
678, 3273
|
3295, 4151
|
4167, 4421
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,395
| 181,452
|
30934
|
Discharge summary
|
report
|
Admission Date: [**2134-6-7**] Discharge Date: [**2134-8-25**]
Date of Birth: [**2083-4-2**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
s/p Motor vehicle crash
Major Surgical or Invasive Procedure:
[**2134-6-17**] Tracheostomy; Percutaneous Gastrostomy & IVC filter
[**2134-6-21**] Extraction of single loose tooth
[**2134-6-21**] Excision of venous strip right arm
History of Present Illness:
40 yo female passenger in motor vehicle crash. Found
unresponsive, intubated at the scene for "agonal respirations."
Information regarding mechanism of the crash is unclear. She was
med flighted
to [**Hospital1 18**], GCS on arrival was 7 with eyes open spontaneously, +
rectal tone, moving all extremities spontaneously, but not
following axial or appendicular commands. CT with R frontal
subarachnoid hemorrhage, punctate R frontal intraparenchymal
hemorrhage, no shift of midline structures.
Past Medical History:
Unknown
Social History:
Born in [**Country 4194**]
Family History:
Noncontributory
Physical Exam:
Upon admission:
O: T: 98 BP: 145/70 HR: 49 R 16 O2Sats 100%
Gen: Critically ill. Intubated and sedated.
HEENT: laceration anterior to left ear, no scalp hematoma,
negative battle sign, no raccoon eyes Pupils: 2mm unreactive to
light bilaterally EOMs- unable to assess.
Neck: in hard C-collar
Lungs: CTA bilaterally.
Cardiac: bradycardic. regular. normal S1/S2.
Abd: Soft, BS+
Extrem: Warm and well-perfused.
Mental status: withdraws upper extremities to deep nailbed
pressure bilaterally. No spontaneous opening of her eyes.
Cranial Nerves:
I: Not tested
II: pupils 2mm unreactive
III, IV, VI: unable to evaluate.
V, VII: absent corneal reflexes bilaterally
VIII: no response to voice
IX, X: + gag reflex
[**Doctor First Name 81**]: deferred
XII: deferred
Motor: Normal bulk. slightly increased tone in lower extremities
with bilateral ankle flexion. withdraws both upper extremities
to
nailbed pressure. occasionally flexes knees bilaterally.
Sensation: withdraws to nailbed pressure bilaterally in upper
extremities. no response to nailbed pressure, +grimace in
eliciting babinski sign.
Rectal + moderate tone, no anal winks detected.
Reflexes: B T Br Pa Ac
Right 2 2 2 3 3
Left 2 2 2 3 3
Toes downgoing bilaterally
Pertinent Results:
[**2134-6-7**] 07:15PM GLUCOSE-125* UREA N-12 CREAT-0.6 SODIUM-137
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-25 ANION GAP-11
[**2134-6-7**] 07:15PM CALCIUM-8.8 PHOSPHATE-2.7 MAGNESIUM-1.8
[**2134-6-7**] 07:15PM WBC-16.7*# RBC-3.77* HGB-12.1 HCT-34.2*
MCV-91 MCH-32.2* MCHC-35.5* RDW-13.1
[**2134-6-7**] 03:38PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2134-6-7**] 03:28PM PLT COUNT-262
[**2134-6-7**] 03:28PM PT-12.5 PTT-19.3* INR(PT)-1.07
[**2134-6-7**] 03:28PM FIBRINOGE-245
[**7-7**] UNILAT UP EXT VEINS US LEFT
Reason: S/P PICC LINE WITH SWELLING
INDICATION: 51-year-old female with left arm swelling, rule out
DVT.
COMPARISON: No previous venous studies for comparison.
FINDINGS: [**Doctor Last Name **]-scale and Doppler son[**Name (NI) 1417**] of the left jugular,
subclavian, axillary, and brachial veins were performed. There
is normal compressibility, flow, and augmentation.
IMPRESSION: No evidence of DVT in the left upper extremity.
Cardiology Report ECG Study Date of [**2134-7-3**] 7:05:12 AM
Baseline artifact. Probable sinus tachycardia. Otherwise, is
within normal
limits. Tracing of [**2134-6-7**] showed ectopic atrial bradycardia
which
has resolved. Otherwise, no important change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
101 140 72 336/394 63 82 65
CHEST (PORTABLE AP)
Reason: ?Pulmonary Infiltrates, Consolidation
[**Hospital 93**] MEDICAL CONDITION:
51 year old woman with diffuse axonal injury, vent dependent w
Fever
REASON FOR THIS EXAMINATION:
?Pulmonary Infiltrates, Consolidation
CHEST, SINGLE AP FILM
History of fever and tracheostomy.
Tracheostomy tube is 3 cm above carina. Heart size is normal.
Compared with the previous study of [**2134-6-20**], there has
been partial resolution of the left basilar atelectasis with
some persistent subsegmental atelectasis in this location. No
new lung lesions. G- tube overlies left upper quadrant.
MR HEAD W/O CONTRAST
Reason: **DWI** please evaluate for diffuse axonal injury
[**Hospital 93**] MEDICAL CONDITION:
51 year old woman with traumatic brain injury
REASON FOR THIS EXAMINATION:
**DWI** please evaluate for diffuse axonal injury
MR SCAN OF THE BRAIN
HISTORY: Evaluate for diffuse axonal injury.
TECHNIQUE: Multiplanar T1- and T2-weighted brain imaging was
obtained.
COMPARISON STUDY: Prior CT scans from [**6-6**].
FINDINGS: The FLAIR images show multiple foci of elevated
signal, with gradient-echo scans showing many of these lesions
having areas of susceptibility seen within the frontal lobes,
linear in distribution on the left side within the left centrum
semiovale, corpus callosal body, left hippocampus, posterior
aspect of the left insular cortex, and left occipital
periventricular white matter. A linear area of elevated signal
is also seen within the posterior limb of the right internal
capsule and right lentiform nucleus as well. These multiple
lesions are consistent with the diagnosis of diffuse axonal
injury, with a hemorrhagic component. The linear distribution of
the left frontal centrum semiovale lesions also raises the
possibility of coexistent hypoxic episode in a so-called
"watershed" distribution that may have occurred at the time of
the accident. Many of these lesions are hyperintense on
diffusion- weighted scans as well.
There is no hydrocephalus or shift of normally midline
structures.
The surrounding osseous and extracranial soft tissues are
notable for moderate right-sided ethmoid and sphenoid sinus
mucosal thickening, which may relate to the patient's intubated
status. A small amount of secretions are also seen within the
posterior nasopharyngeal region.
CONCLUSION: Findings suggestive of diffuse axonal injury with a
hemorrhagic component. Findings were discussed with Chip
[**Doctor Last Name 3903**], physician's assistant, on [**6-10**] at 10:30 a.m.
CHEST (PORTABLE AP)
Reason: eval for PNA please
[**Hospital 93**] MEDICAL CONDITION:
51 year old woman with diffuse axonal injury, vent dependent w
increasing secretions
REASON FOR THIS EXAMINATION:
eval for PNA please
INDICATION: Ventilator-dependent with increasing secretions.
FINDINGS: In comparison with the study of [**2134-7-11**], the
tracheostomy tube remains in place and the right lung is clear.
There is an area of increased opacification in the left lower
lung zone. However, this does not silhouette the heart border or
the hemidiaphragm or obscure the traversing vessels and may well
be an artifact.
If there is clinical suspicion of developing pneumonia, a repeat
film would be suggested.
Brief Hospital Course:
She was admitted to the Trauma service. Neurosurgery was
consulted because of her brain injuries which were nonoperative;
an ICP bolt was placed and she was transferred to the Trauma
ICU. She was loaded with Dilantin and remained on this for
approximately 2 weeks. Serial head CT scans were followed and
were stable. The ICP bolt was eventually removed.
Because she was difficult to wean from the ventilator she
underwent a tracheostomy. During this procedure a percutaneous
feeding tube was placed in order to provide nutritional support.
Tube feedings were initiated and she is tolerating this. The
decision was also made to place an IVC filter given that she
would remain immobile and was at risk for thromboembolic events.
A family/team meeting took place early on to discuss her
prognosis and the likelihood of a poor recovery of cognitive
function. The decision was made by the family to pursue care and
treatment.
She was eventually transferred to the regular nursing unit which
is where she has remained. Physical and Occupational therapy has
worked with her; there have been no significant gains regarding
functional abilities. She does however open her eyes
spontaneously and at times to her name when called, unable to
follow commands.
Recently there were some concerns over right hand/foremarm
swelling, a unilatral ultrasound was performed; no evidence of a
deep vein thrombosis was the final result.
On HD #33 she developed a PICC line sepsis; the catheter was
removed, tip sent for culture. She was started empirically on
Vancomycin. She also developed a urinary tract infection and was
treated with 7 day course Meropenem.
Social work and case management have been closely involved since
admission; additional family/team meetings have recently taken
place to discuss plans for discharge and patient returning back
to [**Country 4194**] where she has family.
Medications on Admission:
Unknown
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as
needed.
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ML's PO BID
(2 times a day).
5. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
6. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
7. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every 4-6 hours
as needed for pain.
8. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Nebulizer Inhalation Q6H (every 6 hours) as needed for shortness
of breath or wheezing.
9. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours).
10. Meropenem 500 mg Recon Soln Sig: Five Hundred (500) MG
Recon Soln Intravenous Q6H (every 6 hours) for 7 days.
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
12. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twelve
(12) Units Subcutaneous twice a day: Give Q AM & Q dinner time.
13. Sliding Scale Regular Insulin Sig: One (1) dose four times
a day as needed for per sliding scale: See Attached.
Discharge Disposition:
Extended Care
Facility:
Mater [**Hospital **] Hospital in [**Location (un) 73140**]
Discharge Diagnosis:
s/p Motor vehicle crash
Subarachnoid hemorrhage
Intraparenchymal hemorrhage
Diffuse Axonal Injury
Urinary Tract Infection
Pneumonia
Discharge Condition:
Good
Followup Instructions:
Follow up as directed by the rehabilitation facility in [**Country 4194**].
Completed by:[**2134-8-31**]
|
[
"525.8",
"486",
"518.81",
"852.05",
"997.3",
"872.8",
"038.9",
"995.91",
"999.31",
"853.05",
"599.0",
"E812.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.57",
"23.09",
"31.1",
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"96.72",
"46.39",
"18.4",
"38.7",
"01.10"
] |
icd9pcs
|
[
[
[]
]
] |
10476, 10562
|
7030, 8913
|
336, 506
|
10738, 10745
|
2427, 3833
|
10768, 10875
|
1122, 1139
|
8971, 10453
|
6383, 6468
|
10583, 10717
|
8939, 8948
|
1154, 1156
|
273, 298
|
6497, 7007
|
534, 1031
|
1711, 2408
|
1170, 1577
|
1592, 1695
|
1053, 1062
|
1078, 1106
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
983
| 104,257
|
49928
|
Discharge summary
|
report
|
Admission Date: [**2119-2-5**] Discharge Date: [**2119-2-10**]
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 1865**]
Chief Complaint:
unwitnessed fall
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
Ms. [**Known lastname 104277**] is a [**Age over 90 **] yo blind female with a dementia and h/o
colon cancer in [**2083**], rectal prolapse, gait disturbance and
osteoporosis who was found down in nursing home. It is unknown
how long she was down, or if there was LOC (though patient
denies), unknown if she hit her head/neck. Patient has had
rectal prolapse for many years per her assistant and uses stool
softeners and has refused treatment in past. Patient says she
has had BRBPR for many years. She also has longstanding RLE
weakness and uses a walker to get around. She says she has
frequent falls.
.
In the ED, her C-spine films were negative as was a head CT. A
surgery consult was called and they reduced the rectal prolapse
at bedside. She did have n/v x1 which resolved with anzemet. Her
VS were stable. She was given 2L IVF and a tetnus shot. Her EKG
showed slight ST depression in V4 and V5 (likely from poor
baseline). U/A and BCx were sent in addition to labs.
.
Patient is demented but ROS on the floor is as follows: she
denies pain except for a burning in her eyes which is long
standing. She denies SOB, CP, dysuria (she has a foley in),
abdominal pain or rectal pain. She denies n/v, f/c.
Past Medical History:
1. Osteoporosis.
2. Colon Cancer in [**2083**].
3. Memory loss.
4. Hypothyroidism
5. History of frequent falls
6. rectal prolapse
7. Infiltrating lobular carcinoma of the breast
8. Mild renal insufficiency baseline creatinine 1.3-1.5
.
PAST SURGICAL HISTORY:
1. Left Hemicolectomy in [**2083**].
2. Open reduction/internal fixation of the left hip in [**2107**].
3. Cataract surgery.
4. Left modified radical mastectomy Dr [**Last Name (STitle) 11635**] [**2113**]
Social History:
The patient lives in the [**Hospital3 537**]. She
has been a widow for eight years.
Family History:
Family history is significant only for a
maternal niece with breast cancer at the age of 78.
Physical Exam:
Vitals - 97, 112/60, 16, 96% RA, FS 173. Weight 56.2 kg
General: ill appearing elderly female smelling of melena
HEENT: Pt would not open mouth for exam. left eye opaque.
LUNGS: diminished breath sounds bilaterally without w/r/r
CV: RRR with 3/6 systolic murmur heard best at USB
ABDOMEN: +BS, midline scar, soft, NTND
EXTREMITIES: R elbow skin tear. No e/c/c. R lateral malleolous
is edematous but non-tender. Echymoses surrounding IV sites.
RECTAL: rectal prolapse with small amount of BRBPR
Pertinent Results:
STudies:
CT C spine [**2119-2-5**]
IMPRESSION: Marked degenerative changes. No acute fracture.
Dilated upper esophagus with fluid level. Please correlate
clinically.
.
Xray pelvis: [**2119-2-5**]
IMPRESSION:
1. Limited study due to overlying bowel gas.
2. No evidence of displaced fracture involving the right hip.
3. Faint lucency along the right iliac [**Doctor First Name 362**] could represent an
artifact, however, cannot rule out a fracture
.
CT pelvis: [**2119-2-5**]
IMPRESSION: No evidence of acute femoral or acetabular fracture.
.
[**2119-2-5**] CXR:
IMPRESSION: No evidence of acute cardiopulmonary process. Large
hiatal hernia.
.
[**2119-2-7**]
EGD:
Impression: Large hiatal hernia
Ulcers in the gastroesophageal junction above the hiatal hernia
Normal mucosa in the stomach
Normal mucosa in the duodenum
.
Pertinent labs:
CE x3 negative
U/A on admission was negative
U/A on discharge is pending and culture pending. Will need to
be followed up.
.
Hct on admission was 44.6 and dropped to 29.7 the next morning
and then repeat was 24.1. After transfusions and EGD, Hct on
discharge was stable at 30.2.
.
Chemistries on discharge: Glucose-106* UreaN-23* Creat-1.2*
Na-144 K-3.9 Cl-111* HCO3-21*
.
CBC on discharge: WBC-9.7 RBC-3.40* Hgb-10.5* Hct-30.2* MCV-89
MCH-31.0 MCHC-34.9 RDW-16.9* Plt Ct-213
Brief Hospital Course:
Ms. [**Known lastname 104277**] is a [**Age over 90 **] year old female with a history of
dementia, chronic falls with gait disturbance, chronic rectal
prolapse, colon cancer in [**2083**] who presented s/p unwitnessed
fall and rectal prolapse. While on the medical floor, pt was
noted to have melanotic stools x2, as well as BRBPR (chronic),
and 1 episode of coffee ground emesis. Her hct decreased from
44.6 on admission to 29.7 the next morning with repeat at 24.1
(recent baseline in [**8-10**] was 30). Her BP was 80/50 transiently,
but this improved after IVF. She received 2 U PRBC's. MICU
admission was requested for frequent vital monitoring and hct
checks prior to endoscopy. She went to MICU on [**2119-2-7**]. Her hct
was stable in the ICU and she remained hemodynamically stable.
She went for EGD the afternoon of [**2119-2-8**] and was transferred
back to the floor. Her hospital course is described by problem
below.
.
# GI Bleed - Extensive discussion with the patient and her
daughter revealed that they did not want a colonoscopy done nor
did they want extensive procedures or surgeries. The patient's
DNR/DNI status was confirmed and treatments would be
symptomatic. A EGD was acceptable in case there was an on going
bleed which could be easily intervened on. EGD showed large
sliding hiatal hernia and a few non-bleeding ulcers in teh GE
junction above the hernia. These ulcers were believed to be the
source of bleeding. She was monitored with serial Hct which were
stable (30.2 on discharge). She was being treated with twice
daily pantoprazole for the ulcers and stool softeners for her
chronic rectal prolapse. She continues to have guiac positive
stools. Hct should be checked on [**2119-2-13**] to ensure no active
blood loss needing transfusion. She will be discharged on
omeprazole [**Hospital1 **].
.
# Hypernatremia: After the episode of GI bleeding, she became
hypernatremic to 152. Her free water deficit was calculated to
be 2.3L and she was repleted with D5W and her hypernatremia
resolved.
.
# Rectal prolapse/BRBPR: chronic issue. Surgery was consulted in
the ED and reduced the rectal prolapse. Again per family and
patient, patient has not wanted further aggressive treatment for
this condition. She does have h/o colon cancer. Last CEA in [**8-10**]
was 4.1 from 2.6 in [**2113**]. Of course a colonoscopy would be
recommended, but the patient and family have declined. She
should be continued on stool softeners to help prevent rectal
straining.
.
# Fall: The patient originally presented with an unwitnessed
fall. Imaging studies revealed no fractures. She was ruled out
for an MI with CE x3 being negative and no events on telemety.
Her fall was likely related to her GI bleed and dehydration. In
addition, this could likely be mechanical given history of
recurrent falls, blindness, and dysequillibrium. Physical
therapy worked with the patient while in house and found her to
be quite weak and needing extensive assisstence. They
recommended rehab for physical therapy as the patient currently
lives in [**Hospital3 **] with help only during the week days.
The patient's daughter agreed.
.
# low grade fevers: She had a low grade fever of 100.1 one time,
and a U/A and culture was pending at discharge. This will need
to be followed up in case she had a UTI.
.
# Hypothyroidism: continued levothyroxine.
.
# CRI: Cr is around baseline 1.2 (1.3-1.5). Her Cr was stable
through admission.
.
# Dementia: continued home medications.
.
# Eye burning: chronic issue. Patient legally blind. Her eye
drops were continued.
.
#FEN: regular diet with ensure supplements TID; replace lytes
prn. Hypernatremia as above. Hypophosphatemia and hyokalemia
were issues while in house. Please check electrolytes as in
discharge instructions on [**2119-2-13**] and replete as needed.
.
#PPX: pneumoboots for DVT ppx given bleeding, PPI for GI ppx,
bowel regimen
.
#Codes status: DNR/DNI. Confirmed with daughter [**Name (NI) **] [**Last Name (NamePattern1) 14**]
who is the HCP, as [**Name2 (NI) **] of patient is main concern. No
invasive procedures or surgery.
.
# Contacts:
Daughter: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 14**] [**Telephone/Fax (1) 104278**](c) [**Telephone/Fax (1) 104279**] (h)
[**Telephone/Fax (1) 104280**] X 404 work
[**Doctor First Name **] (caretaker): [**Telephone/Fax (1) 104281**] (c) [**Telephone/Fax (1) 104282**] (h)
.
# Dispo: [**Location (un) **] rehab in [**Location (un) 620**]. Patient has follow up with
Dr. [**Last Name (STitle) **] (PCP) on [**2-20**] at 11:10AM. [**Hospital1 18**] [**Telephone/Fax (1) 250**].
Medications on Admission:
Prilosec.
Multivitamin.
Synthroid 25 MCG P.O. q. d.
Namenda *NF* 10 mg Oral [**Hospital1 **]
Arimidex *NF* 1 mg Oral QAM Ascorbic Acid 500 mg PO QAM
Donepezil 10 mg PO QAM
Levobunolol *NF* 1 DROP OU [**Hospital1 **]
PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE [**Hospital1 **]
Vitamin E 400 UNIT PO BID
Discharge Medications:
1. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO QAM (once a day
(in the morning)).
2. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
4. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
5. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
6. Hexavitamin Tablet Sig: One (1) Cap PO QAM (once a day
(in the morning)).
7. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
11. Levobunolol 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
12. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO every twelve (12) hours.
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
14. Outpatient Lab Work
Please check CBC and electrolytes including sodium, potassium,
BUN, Cr, Cl, Bicarb, magnesium, phosphate, calcium glucose on
[**Hospital1 766**] [**2119-2-13**].
15. DVT ppx
Please place pneumoboots to lower extremities.
16. Neutra-Phos [**Telephone/Fax (3) 4228**] mg Packet Sig: One (1) PO three
times a day for 1 days: please start in AM on [**2119-2-11**].
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] - [**Location (un) 620**]
Discharge Diagnosis:
Primary diagnosis:
UGI bleed- ulcers
s/p fall
rectal prolapse with chronic BRBPR
hypernatremia
.
Secondary diagnosis:
hypothyroidism
CRI with basline Cr 1.3-1.5
h/o colon cancer
Discharge Condition:
Stable Hct and vital signs. Tolerating oral intake.
Discharge Instructions:
You were admitted after a fall. You likely fell because you
were dehydrated from bleeding in your stomach. You were found to
have ulcers in your stomach and should now take prilosec twice a
day instead of once a day.
.
You have a urinalysis and culture pending at the time of
discharge. You will need to have this followed up as an
outpatient. You will receive a call if your culture is positive
for infection and you will then need antibiotics.
.
Please check CBC and electrolytes including sodium, potassium,
BUN, Cr, Cl, Bicarb, magnesium, phosphate, calcium glucose on
[**Location (un) 766**] [**2119-2-13**]. Please replete as needed. Please fax the results
to Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 3382**].
.
Given your hospitalization, you will need physical therapy to
help rebuild your strength. This is why you are going to a
rehab facility.
.
Please continue your medications as prescribed.
.
Please return to your physician or to the emergency room if you
have fevers >101, chills, black or tarry stools, large amounts
of blood from the rectum or bloody emesis, lightheadedness or
any other symptoms which are concerning to you.
Followup Instructions:
Please make an appointment with Dr. [**Last Name (STitle) **], your PCP, [**Name10 (NameIs) 766**]
[**2119-2-20**] 11:10AM. Please call [**Telephone/Fax (1) 250**] if you need
to change this appointment.
Completed by:[**2119-2-10**]
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29,767
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28933
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Discharge summary
|
report
|
Admission Date: [**2124-4-13**] Discharge Date: [**2124-4-28**]
Date of Birth: [**2074-9-8**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Terbutaline / Epinephrine / Glucocorticoids /
Alupent / Iodine / Prednisone
Attending:[**First Name3 (LF) 9454**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is 49 year old male with severe COPD (requiring
multiple intubations), diastolic CHF (EF 60% from [**2-/2122**]), CAD
with reported prior MIs, and history of non-compliance with meds
and signing out AMA who presents with shortness of breath. He
reportedly had been having difficulty breathing for 3-4 weeks
and was admitted to [**Hospital 31429**] Hospital in NH earlier on [**2124-4-10**]
where he was treated for a COPD exacerbation. He also notes
that "something was wrong with [his] kidneys." He left AMA
yesterday because he didn't feel like he was being treated
appropriately. However, his shortness of breath persisted with
cough and vomiting, so he presented to our ED. He describes
intermittent fevers. He denies any palpititions, orthopnea,
PND, or edema. He has sharp pain/pressure with deep inspiration
typical of prior COPD exacerbations or pneumonias.
.
In the ED, initial VS were recorded: Afebrile, P 80, BP 133/78,
breathing 40 times a minute with increased work of breathing.
His breath sounds were tight sounding with diffuse expiratory
wheezes. Labs showed a WBC of 16.7 with 92%N but no bands.
Lytes remarkable for BUN 68 and Cr 2.5. EKG showed sinus
tachycardia. CXR showed low lung volumes and bibasilar R>L
atelectasis with RML atelectasis/partial collapse. He was given
nebs, methylprednisolone 125mg IV, levofloxacin 750mg IV, and
oxycodone 10mg. He was to be admitted to the floor, but given
persistent tachycardia despite 2L NS, he was admitted instead to
the MICU. On transfer, VS: T 98.6, P 118, BP 102/44, RR 20,
O2sat 92% 4 liters.
.
Pt currently very disgruntled. He c/o persistent cough and
difficulty breathing. In regards to his renal failure, this was
first diagnosed at another hospital several months ago. He
believes he has had decreased urine output with sensation of
urinary retention. He has not been eating or drinking well. He
has been on lasix and ACE-I and denies any new medications or
increased doses; he denies NSAID use.
.
Review of systems:
As above. Also, chronic pain in "every bone, everywhere." ROS
otherwise negative.
Past Medical History:
COPD s/p multiple intubations - h/o refusal to use steroids or
BIPAP. Not on home O2 due to insurance issues.
CAD s/p "at least 3" MI's with multiple cardiac caths
Diastolic CHF
Multiple sclerosis per patient - attributes b/l tremor to this.
stated was diagnosed 2 years ago followed by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 12838**]
([**Telephone/Fax (1) 69783**]. However, in past, when Dr. [**Last Name (STitle) 12838**], there was no
record of patient.
Diverticulosis s/p bowel resection
Glucose intolerance in past in setting of steroids
Social History:
He is married, but his wife resides in a state psychiatric
facility. He currently lives alone in CT although he has been
spending time in the past few weeks with friends or family. He
is on disability. History of smoking with unknown # of pack
years, currently denies smoking, ETOH, or recreational drug use.
Family History:
Father had emphysema, died of an MI at age 56. Mother died of an
MI at age 70. Otherwise non-contributory.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: Coarse BS b/l with diffuse wheezes
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Soft, mild diffuse TTP but not on deep auscultation,
no g/r, obese but non-distended, vertical incision not infected
appearing, BS+
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AAO x 3, intention tremor b/l
Pertinent Results:
[**2124-4-13**] 10:50PM URINE HOURS-RANDOM UREA N-906 CREAT-112
SODIUM-27
[**2124-4-13**] 10:50PM URINE OSMOLAL-508
[**2124-4-13**] 08:29PM URINE HOURS-RANDOM
[**2124-4-13**] 08:29PM URINE GR HOLD-HOLD
[**2124-4-13**] 08:29PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2124-4-13**] 08:29PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2124-4-13**] 08:29PM URINE RBC-[**6-8**]* WBC-0-2 BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2124-4-13**] 08:29PM URINE EOS-NEGATIVE
[**2124-4-13**] 06:10PM GLUCOSE-160* UREA N-68* CREAT-2.5*#
SODIUM-139 POTASSIUM-5.0 CHLORIDE-101 TOTAL CO2-25 ANION GAP-18
[**2124-4-13**] 06:10PM estGFR-Using this
[**2124-4-13**] 06:10PM cTropnT-<0.01
[**2124-4-13**] 06:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2124-4-13**] 06:10PM WBC-16.7*# RBC-5.20# HGB-13.1* HCT-40.5
MCV-78*# MCH-25.3*# MCHC-32.4 RDW-18.8*
[**2124-4-13**] 06:10PM NEUTS-91.8* LYMPHS-4.6* MONOS-2.9 EOS-0.4
BASOS-0.2
[**2124-4-13**] 06:10PM PLT COUNT-439#
[**2124-4-13**]: Portable CXR:
FINDINGS: Single AP upright portable view of the chest was
obtained. There
are low lung volumes that accentuate the bronchovascular
markings. Atelectasis at the lung bases is seen, right greater
than left. Prominence of the hila is relatively stable. The
aorta is tortuous, the cardiac silhouette is top normal in size.
IMPRESSION:
1. Low lung volumes, which accentuate the bronchovascular
markings.
Bibasilar, right greater than left atelectasis with increase in
likely right middle lobe atelectasis/partial collapse.
[**2124-4-14**]: Renal Ultrasound with dopplers
FINDINGS: The right kidney measures 11.0 cm and the left kidney
measures 12.7 cm. There is no hydronephrosis. No stone or cyst
or solid mass is seen in either kidney. The spleen is noted to
be enlarged, measuring 13.0 cm.
DOPPLER EXAMINATION: Color Doppler and pulse-wave images were
obtained. Note is made that this is a limited Doppler
examination due to the patient's inability to hold his breath.
Arterial waveforms demonstrating sharp upstrokes are seen in the
main renal artery of each kidney. Venous flow is identified in
the hilum of each kidney. Intraparenchymal resistive indices are
limited but appear normal to mildly elevated.
IMPRESSION:
1. No hydronephrosis and no renal mass or stone identified.
2. Limited Doppler examination with no indication of a renal
artery stenosis.
[**2124-4-24**] PA&Lat CXR: IMPRESSION: No evidence of pulmonary
vascular congestion to suggest fluid overload. No focal
consolidation. Bibasilar linear atelectasis.
Discharge lab results:
[**2124-4-26**] 05:40AM BLOOD WBC-13.8* RBC-4.92 Hgb-12.5* Hct-40.6
MCV-83 MCH-25.5* MCHC-30.9* RDW-18.8* Plt Ct-219
[**2124-4-26**] 05:40AM BLOOD Plt Ct-219
[**2124-4-26**] 05:40AM BLOOD Glucose-333* UreaN-35* Creat-0.6 Na-132*
K-4.8 Cl-92* HCO3-28 AnGap-17
Brief Hospital Course:
49 year-old man with h/o severe COPD, dCHF, CAD, h/o
noncompliance, p/w persistent dyspnea/hypoxia after signing out
AMA from OSH where undergoing COPD treatment and found to have
persistent renal failure.
.
# Hypoxia/dyspnea: His presentation was most consistent with a
COPD exacerbation; he was congested sounding but unable to bring
up secretions. CXR showed only atelectasis. He has a history
of dCHF but appeared more intravascularly dry on exam. He had
no fevers or consolidations to suggest pneumonia; his
leukocytosis was likely due to the steroids started at the OSH.
PE was possible given his tachycardia, but the patient is at low
risk by Wells' Criteria. We also considered cardiac ischemia
given his history of CAD, but he had no chest pain or ischemic
EKG changes and cardiac enzymes were negative. He had no
arrhythmia on telemetry other than sinus tachycardia.
The patient was started on standing ipratropium and xopenex nebs
q6h with prn xopenex, though he initially refused most of these
treatments. His compliance improved when he learned that we
were avoiding albuterol (had been told not to take Combivent b/c
of his CAD). The patient was also started on solumedrol 60mg
IV Q8, started on [**4-14**] and continued for 7 days, with a plan to
then taper. When his symptoms did not improve, he was increased
to Solumedrol 80mg IV Q8hrs briefly. His course was extended
and he did not begin tapering until [**4-23**], when his solumedrol
dose was decreased for a day before converting to oral
prednisone. He will complete a 10-day taper as an outpatient
before stopping prednisone [**2124-5-8**]. Given his prolonged course
of high-dose steroids, he was started on Bactrim, pantoprazole,
calcium and vitamin D. He will stop the Bactrim and
pantoprazole after stopping prednisone, but continue Ca + Vit D.
The patient is often irritable and unstable while on steroids,
and at one point threw a commode towards a health care worker.
His stability improved with lowering steroid doses.
Levofloxacin started in the emergency department was
continued(day 1 = [**4-13**]) for an empiric course of 5 days.
Incentive spirometry was encouraged. The patient was very
opposed to using home Oxygen, so after 10 days of oxygen at 5L
by nasal cannula, he was slowly weaned starting [**4-23**]. He was
stable off of Oxygen at the time of discharge and was able to
ambulate with physical therapy.
The patient was very opposed to any pulmonary rehab, home VNA,
or increase in services. These were repeatedly offered and
refused.
.
# Sinus tachycardia: Improved but did not fully resolve. Likely
multifactorial with components from dehydration, anxiety, and
albuterol nebs. Pt tachyardic and tachypneic but afebrile; his
clinical picture was not consistent with SIRS/sepsis as also
explainable by COPD. Again, low risk for PE. Substance
withdrawal a possibility; he denied EtOH use but concern for
oxycodone overuse at OSH given #90 oxycontin prescribed [**4-9**] and
#10 left on admission on [**4-10**]. His tox screen was negative. He
remained low-level tachycardic even after restarting diltiazem.
This is most likely his baseline.
.
# Acute renal failure on admission: FeNa of 0.4% suggested a
prerenal etiology. He got 2L IVF in ED. U/A was not frankly
c/w UTI. Renal ultrasound negative for obstruction. His
creatinine normalized. Initially his home lisinopril, lasix
were held, but were later restarted without any increase in his
creatinine.
.
# H/o glucose intolerance/steroid induced diabetes: He had
persistent hyperglycemia, thought to be due to his steroid use,
though there was concern for underlying glucose intolerance.
The patient was unwilling to comply with any diabetic diet. His
dose of QHS Lantus was slowly increased up to 20 units, but he
remained very hyperglycemic, requiring large doses of Humalog
with each meal. He was discharged with a decreasing dose of
Lantus given his non-compliance and the concerns for
hypoglycemia. After he has completed his steroids, he should
have a fasting glucose in case of underlying chronic diabetes.
We recommended that he have a visiting nurse to help with his
insulin but he refused.
# Pain control: Pt reports chronic pain on oxycodone. There were
questions on admission of med overuse. He refused to name his
pharmacy to confirm his dose. He was found to be hiding his
oxycontin doses one day prior to discharge.
# CAD: Has a h/o multiple MIs. On admission, the chest pain he
described sounded more pleuritic, atypical. EKG was w/o ischemic
changes; CE neg x 2. He was started on an Aspirin given his
risk factors. He again complained of chest pain [**4-24**]. EKG was
again unchanged and his pain improved with Maalox.
# Noncompliance: He has a h/o multiple AMA discharges. Social
work was consulted and efforts were made to work with the
patient, however he was extremely challenging to work with. He
refused treatments at times, vital signs. He was non-compliant
with a diabetic diet and did not listen to instructions. He
refused rehab, home PT or VNA.
Medications on Admission:
Medications (based on patient report):
Aspirin 325 mg daily
Lisinopril 20 mg daily
Furosemide 40 mg daily
Xopenex prn
Ipratropium Bromide prn
Montelukast 10 mg daily
Clonazepam 2 mg tid ?
Oxycodone SR 20 mg tid ?
HISS
Discharge Medications:
1. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Xopenex HFA 45 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2)
puffs Inhalation every six (6) hours.
Disp:*1 inhaler* Refills:*2*
7. Xopenex HFA 45 mcg/Actuation HFA Aerosol Inhaler Sig: [**1-1**]
puffs Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
8. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every six (6) hours.
Disp:*1 inhaler* Refills:*2*
9. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Three
(3) Tablet Sustained Release 12 hr PO Q8H (every 8 hours).
11. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
13. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
14. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a
day for 10 days: Take 5 tablets on [**3-29**], 4 on [**3-31**], 3 on
[**4-2**], 2 on [**4-4**], and 1 on [**4-6**].
Disp:*30 Tablet(s)* Refills:*0*
15. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily) for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
10 days.
Disp:*10 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
17. Lantus 100 unit/mL Cartridge Sig: as directed Units
Subcutaneous once a day for 10 days: Use 15 U on [**3-29**], 13 U
on [**3-31**], 8 U on [**4-2**], 5 U on [**4-4**].
Disp:*1 cartridge* Refills:*0*
18. Outpatient Physical Therapy
Patient should work with outpatient physical therapy to optimize
strength and mobility.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
COPD exacerbation
.
Secondary Diagnosis:
CAD
Diastolic CHF
Diverticulosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with shortness of breath. This
was due to a COPD exacerbation. You were treated with
antibiotics, nebulizers, and steroids. Your breathing improved
prior to hospital discharge. We recommended that you go to rehab
but you refused deciding you wanted to go home. We also
recommended you have a visiting nurse to help with your sugars
but you did not want a visiting nurse.
.
We have made the following changes to your medications:
1. We started you on Prednisone, which you should continue for
10 days after discharge and taper as follows:
- 5 tablets on [**3-29**]
- 4 tablets on [**3-31**]
- 3 tablets on [**4-2**]
- 2 tablets on [**4-4**]
- 1 tablet on [**4-6**]
2. We increased your Lisinopril to 20 mg daily
3. We started you on Aspirin 325 mg daily
4. We started you on Xopenex and Ipratropium inhalers
5. We started you on Bactrim, Protonix, and Lantus, which you
should use while you are taking Prednisone (for the next 10
days)
6. We started you on Nitroglycerine, which you should use as
needed for chest pain.
7. We started you on Calcium and Vitamin D for your bone health,
as you are now taking Prednisone.
8. We also started you on long acting Insulin called Lantus
while you are on Prednisone.
-please take 15 units on [**3-29**]
-please take 13 units on [**3-31**]
-please take 8 units on [**4-2**]
-please take 5 units on [**4-4**]
Please check your blood sugar once a day, if they are above 450
or below 70 please call your primary care doctor.
We recommend that you stop smoking.
Followup Instructions:
Please arrange outpatient follow up with your primary care
physician and cardiologist.
Completed by:[**2124-4-30**]
|
[
"V15.81",
"428.0",
"491.21",
"518.0",
"414.01",
"E932.0",
"427.89",
"249.00",
"562.10",
"338.29",
"300.00",
"412",
"584.9",
"786.59",
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] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14727, 14733
|
7059, 10238
|
369, 376
|
14870, 14870
|
4100, 7036
|
16611, 16729
|
3453, 3561
|
12387, 14704
|
14754, 14754
|
12144, 12364
|
15053, 15487
|
3576, 4081
|
15516, 16588
|
2441, 2527
|
310, 331
|
404, 2422
|
14814, 14849
|
14773, 14793
|
10252, 12118
|
14885, 15029
|
2549, 3110
|
3126, 3437
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,877
| 114,070
|
17001
|
Discharge summary
|
report
|
Admission Date: [**2195-8-17**] Discharge Date: [**2195-8-25**]
Date of Birth: [**2115-8-29**] Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: The patient is a 79 year-old
woman with a known thoracoabdominal aortic aneurysm, status
post resection in [**2192**], returns for additional repair and
revision. Patient's past medical history is significant for
abdominal aortic aneurysm repair, hypertension,
hypercholesterolemia, right adrenal mass osteoarthritis,
osteoporosis, PMR and chronic low back pain.
MEDICATIONS AT TIME OF ADMISSION: Include aspirin, Lipitor,
Norvasc and Fosamax.
ALLERGIES: She has no known drug allergies.
PHYSICAL EXAMINATION: Heart rate 60, blood pressure 153/70,
respiratory rate 20. General: No acute distress. Chest clear
to auscultation bilaterally. Cardiac is regular rate and
rhythm, S1, S2. Abdomen is soft, nontender, nondistended with
normal active bowel sounds. Pulses were symmetric throughout.
LABORATORY DATA: Sodium 137, potassium 3.9, chloride 106,
CO2 25, BUN 21, creatinine 0.7, glucose 162, ALT 17, AST 19,
alkaline phosphatase 61, total bilirubin 0.4, albumin 3.5.
White count 10.2, hematocrit 31, platelets 100. PT 15.6, PTT
37, INR 1.6. Chest x-ray with mild pulmonary edema.
Electrocardiogram: Sinus rhythm, rate of 62, no ischemic
changes.
SOCIAL HISTORY: Lives with husband. [**Name (NI) 1139**] free x12 months.
Occasional alcohol use. No recreational drug use.
HOSPITAL COURSE: Patient was a direct admission to the
operating room where she underwent a redo left pericardium
and replacement of the descending aorta with #30 Gel weave
graft. Her bypass time was 44 minutes with a crossclamp time
of 39 minutes. Please see the operating report for full
details. She tolerated the operation well and was transferred
from the operating room to the cardiothoracic intensive care
unit. At the time of transfer she was in sinus rhythm at 68
beats per minute with a mean arterial pressure of 90. The
patient did well in the immediate postoperative period but
was kept sedated throughout the day of her surgery. On
postoperative day 1 she remained hemodynamically stable
requiring intermittent infusions of nitroglycerine and
Nipride to control the blood pressure. During the course of
postoperative day 1 the patient's sedation was discontinued.
She was successfully weaned from the ventilator and
successfully extubated. On postoperative day 2 the patient
continued to be hemodynamically stable with adequate
oxygenation. However, later in the day the patient complained
of abdominal tenderness. A right upper quadrant ultrasound
was done which showed sludge in the gallbladder. Abdominal CT
also done at that time showed thrombus at the origin of the
superior mesenteric artery and the decision was made to bring
the patient to the operating room for an exploratory
laparotomy following angiography of the aorta and selective
angiograms of the superior mesenteric artery. Superior
mesenteric artery to superior thoracic artery bypass graft
was performed. The following day the patient was again
brought to the operating room for a relook to assess for any
ischemic bowel of which none was identified. The patient was
again recovered in the intensive care unit and he remained
hemodynamically stable requiring small doses of Levophed to
maintain an adequate blood pressure. During the course of the
next 24 hours the patient was kept sedated following which
the sedation was weaned to off. At that time several attempts
were made to wean the patient from the ventilator during
which the patient became increasingly dyspneic following each
episode. She was resedated and placed back on full
ventilatory support. On postoperative day 5 from her
thoracotomy and 2 from her laparotomy the patient was
successfully extubated but she remained in the intensive care
unit for continued pulmonary toilet and closer hemodynamic
monitoring.
Over the next several days the patient's diet was gradually
advanced. She was transitioned from intravenous to oral
medications. However, on postoperative day 8 it was noted
that her white count had begun to rise. Her central access
was discontinued and a PICC line was placed. Antibiotic
coverage was changed to Flagyl, Vancomycin and Levaquin and
she was pancultured. On postoperative day 8 the patient was
transferred to the cardiothoracic intensive care unit to the
floor for continued postoperative care and rehabilitation.
Once on the floor the patient's activity level was increased
with the assistance of the nursing staff as well as physical
therapy. She remained afebrile. However, her white count
continued to climb. Her cultures failed to reveal any cause
for her elevated white count. Chest x-ray showed a moderate
left pleural effusion and infectious disease consult was
called at that time. Additionally the patient was noted to be
fluctuating in and out of atrial fibrillation. Her amiodarone
was increased as was her beta blockade and she was begun on
Coumadin and heparin. Per infectious disease this patient's
Vancomycin and levofloxacin were discontinued. She remained
on Flagyl for an additional three days which was ultimately
discontinued as well. Patient continued to make progress with
her physical therapy. INR became therapeutic. Her heparin
infusion was discontinued and on postoperative 15 it was
decided that the patient was stable and ready to be
transferred to rehabilitation for continuing postoperative
care.
At the time of this dictation the patient's physical
examination is as follows: Temperature 98.3, heart rate 68,
sinus rhythm. Blood pressure 137/64, respiratory rate 20, O2
saturation 94% on room air. Weight preoperatively 63.3 kilos,
at discharge 69.8 kilos. Laboratory data: White count 12.8,
PT is 18.3, PTT is 69.9, INR is 2.2. Sodium 134, potassium
3.8, chloride 95, CO2 33, BUN 16, creatinine 0.8, glucose 84.
General: Lying in bed comfortably. Neurologic: Alert and
oriented x3, moves all extremities. Nonfocal examination.
Pulmonary: Diminished breath sounds on the left [**1-12**] of the
way up, otherwise clear. Cardiac: Regular rate and rhythm, S1
and S2. Left thoracoabdominal incision with staples. Incision
line clean and dry with minimal erythema at staple sites.
Abdomen is soft, nontender with normal active bowel sounds.
Extremities are warm with trace edema. Right groin incision
with a small area of eschar and minimal erythema from the
staples.
Patient is to be discharged to rehabilitation.
DISCHARGE CONDITION: Good.
DISCHARGE DIAGNOSES:
1. Status post re-do left thoracotomy and replacement of the
descending aorta with a #30 Gel weave graft.
2. Exploratory laparotomy with celiac to superior mesenteric
artery bypass followed by re-exploration.
3. Hypertension.
4. Hypercholesterolemia.
5. Right adrenal mass.
6. Osteoarthritis.
7. Osteoporosis.
8. PMR.
9. Chronic low back pain.
Sh[**Last Name (STitle) 14388**]o follow up with Dr. [**Last Name (STitle) **] in 2 to 3 weeks, Dr. [**Last Name (Prefixes) 2545**] in 4 weeks, Dr. [**First Name (STitle) **] in 2 to 3 weeks, Dr.
[**Last Name (STitle) **] in 2 to 3 weeks.
DISCHARGE MEDICATIONS: Include isotalopram 10 mg q.d.,
Flovent 2 puffs b.i.d., warfarin as directed to maintain a
target INR of 2 to 2.5. She is to receive 2 mg on Tuesday,
[**8-25**], Metamucil 1 packet b.i.d., multivitamin 1 q.d.,
zinc sulfate 220 mg q.d., Lopressor 50 mg b.i.d., Darvocet
100/650 1 to 2 tablets 4 to 6 hours p.r.n., amiodarone 200 mg
q.d., Lasix 40 mg q.d. and potassium chloride 20 mEq q.d.
Additionally the patient is to receive regular insulin
sliding scale.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2195-8-25**] 12:37:49
T: [**2195-8-25**] 14:05:47
Job#: [**Job Number 47827**]
|
[
"441.4",
"997.1",
"401.9",
"272.0",
"557.1",
"427.31",
"441.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.26",
"88.42",
"88.47",
"38.45",
"38.93",
"38.44",
"39.61",
"54.12"
] |
icd9pcs
|
[
[
[]
]
] |
6493, 6500
|
6521, 7112
|
7136, 7852
|
1465, 6471
|
681, 1321
|
165, 658
|
1338, 1447
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,397
| 130,076
|
38133
|
Discharge summary
|
report
|
Admission Date: [**2148-7-31**] Discharge Date: [**2148-8-27**]
Date of Birth: [**2075-5-2**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
IVC filter placed [**2148-8-3**]
History of Present Illness:
This is a 73yo male with CAD s/p CABG or STENT?, Hodgkins
Lymphoma, recent admission in [**Month (only) 116**] for extensive bilateral
femoral vein clots, who presents with dyspnea, cough, hypoxemia,
found to have b/l pulmonary embolisms.
Of note, this patient was admitted to oncology from [**Date range (1) **]
for bilateral DVTs of common femoral, superficial femoral,
politeal,
and calf veins. At that time, he was started Dalteparin
(Fragmin) daily for treatment of this. He reports that he had
been compliant with this.
The patient reports that he has been feeling short of breath for
several months. When he left the hospital last [**Month (only) 116**], he was short
of breath, and this has been worsening since then. He reports
that his excercise tolerance has worsened progressively since
being discharged from the hospital. He feels short of breath
with mininal exertion. He also reports coughing nightly for the
past few days. This morning, he "just couldnt take it anymore"
and decided to come in. He denies any acute worsening in his
breathing, and reports that it has been progressive.
On review of systems. He denies chest pain, palpations. has
cough, shortness of breath, dyspnea on exertion. denies fevers.
reports chills and feeling cold all of the time. reports 10
pounds of unintentional recent weight loss. all other review of
systems negative.
In the ER, intial vitals were 103/43, HR 96, RR 22, O2sat 77% on
RA. Reportedly altered when hypoxic, but mental status improved
once on oxygen. A CTA was done showing clot in right main
pulmonary artery and branch arteries in the LLL. He was started
on heparin. He also remains hypoxemic. Attempt was made to put
him in 6l NC, but he became tachpyneic and [**Last Name (LF) 52536**], [**First Name3 (LF) **] is now
back on NRB.
Past Medical History:
- Crohn's disease diagnosed in [**2147**].
- Hypercholesterolemia.
- Hypertension.
- Carotid stenosis status post bilateral CEA
- Barrett's esophagus.
- CAD s/p stent [**2-18**] (was on plavix stopped [**5-18**])
- TIA.
- seizure disorder
PAST SURGICAL HISTORY: - s/p bilateral CEA ~ 5 years ago
- s/p L shoulder surgery
Social History:
doesnt currently smoke, but quit 20 years ago. smoked 10 years,
[**2-10**] pack a day, so 5packyears. used to drink 1 glass wine daily,
but hasnt in the past few months. Lives with wife
Family History:
parents had MIs in old age. one granddaughter with asthma.
Physical Exam:
Vitals: T: 98.2 BP: 98/56 P: 85 R: 25 18 O2: 95% on NRB
General: Alert, oriented, clearly short of breath with speaking
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: mostly Clear to auscultation bilaterally, rhonchi clear
with cough.
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
Ext: b/l edema left worse than right.
Pertinent Results:
[**7-31**] CTA
IMPRESSION:
1. Acute PE involving right main/branch and left lower lobe
pulmonary
arteries. No evidence of right heart strain.
2. Diffuse bilateraly pulmonary ground-glass opacities may be
due to
pulmonary edema/ARDS, although infection/inflammation or
hemorrhage not
excluded. Superimposed infarction cannot be excluded.
3. Mediastinal and hilar lymph nodes may be reactive.
[**2148-8-14**] CT Chest:
1. Diffuse bilateral pulmonary ground-glass opacities most
likely represent infection or inflammation; however, the
differential diagnosis also includes pulmonary edema,
hemorrhage, or superimposed infarction.
2. Stable mediastinal and hilar lymphadenopathy.
3. Persistent pulmonary embolism involving the right main
pulmonary artery
extending into the right middle and lower lobes but with no
evidence of right heart strain.
4. Bilateral small pleural effusions with associated compressive
atelectasis.
5. Subcentimeter lesion in segment I/VI of the liver, too small
to
characterize, but may represents a hepatic cyst. Recommend
attention on
followup.
6. Clots in left external iliac vein, right common femoral, and
left common femoral veins.
7. Hypodensity in the upper pole of the right kidney is most
consistent with a renal cyst. Bilateral hypodensities are too
small to characterize but likely represent renal cysts.
[**2148-8-14**]: CT Abd/ pelvis
Brief Hospital Course:
When patient came to the ED on [**2148-7-31**], his initial intial
vitals were 103/43, HR 96, RR 22, O2sat 77% on RA. He was
altered when hypoxic, but mental status improved once on oxygen.
A CTA was done showing clot in right main pulmonary artery and
branch arteries in the LLL. He was started on heparin. Attempt
was made to put him in 6 L NC, but he became tachpyneic and
[**Last Name (LF) 52536**], [**First Name3 (LF) **] he went back on a non-rebreather. He was then
admitted to the [**Hospital Unit Name 153**].
[**8-27**]
Expired
[**2148-8-26**]:
- No escalation of care
- Atrius H/O aware and agrees
-
[**2148-8-25**]:
-Family meeting.
-Change in Code Status to DNR/DNI
[**2148-8-24**]:
Clinically deteriorated: febrile all day (never defervesed - t
max 103.6), increased secretions and cough. less alert.
desaturated on [**11-17**] PSV/CPAP with 50% Fio2 and sinus
tachycardic to 150s-160s. Pan-cultured. U/A negative. Initially
thought it was [**3-12**] agitation/delirium - was given Zyprexa. Also
thought pt had large cuff leak contributing to increased
secretions and aspiration leading to VAP. Thoracics came back
and was unimpressed. Thought trach looked fine and was more
concerned with clinical picture. Still agitated, given Versed
for sedation. Continued to be agitated, febrile and tachycardic.
Given fluid boluses. Tachycardia persisted. CXR - increased
haziness bilaterally from morning CXR; EKG: sinus tachycardia.
Continued to desaturate. Placed on CMV (TV 500, RR 14, FIO2
100%, PEEP 10). Pressures began to drop to 80-90s systolic. More
fluid given. Not responsive. Started on Neo. A-line placed. ABG:
7.43/35/82/27 on 100% FIO2. Deeply sedated with propofol and
fentanyl. Family made aware of clinical status and requested
that we persist with current measures.
- Other considerations: changing NGT to OGT; starting antifungal
11-3am: attempts were made to wean patient off 100% FIO2,
however did not tolerate. patient pressure continued to drop.
was thought [**3-12**] increase in PEEP. Fluid responsive. However MAPs
not ideal so went up on pressor - now max'ed out.
[**2148-8-23**]:
-pt spiked fever in the afternoon
-pt started on vancomycin, ciprofloxacin, and cefepime
empirically
-nurses suctioning bright red blood from trach- stopped heparin
gtt for now
-t-[**Doctor First Name **] aware, asked to check Hct, recommend BAL tmrw; call them
if bleeding worsens
[**2148-8-22**]:
-increased BB to 25 TID
-got ct abd pelv
[**2148-8-21**]:
- rec'd PICC today
- sedation weaned, much more interactive
- up titrated beta blocker although HR remains in 100s
- attempted Trach mask trials - increased secretions, likely [**3-12**]
fluid overload
- given IV lasix 40mg - met goal of 1-2L negative
- GI consulted for PEG placement - no recs yet
- rec'd valium - SBP dropped to 80s systolic responded with
250cc bolus
- did not sleep all night
[**2148-8-20**]:
-weaning sedation
-discussion ongoing for PEG vs. Dobhoff between oncologist Dr.
[**First Name (STitle) 2405**] and T-[**Doctor First Name **] Dr. [**First Name (STitle) **];
-plans for Dobhoff tomorrow in IR
-start coumadin tmrw
[**2148-8-19**]:
-HR still 100-130s
-got trach placed , no immediate complications
-agitated overnight, needed to increase sedation w/ fentanyl
-back on IV heparin
[**2148-8-18**]:
-NPO after MN for peg/ trach placement and heparin held at 4 am
[**8-17**]:
- Settings on PS [**11-15**], doing well
[**2148-8-16**]:
-plan is to have trach/ peg placed on monday [**8-19**] between 8 am
-12 pm. Heparin and tube feeds must be stopped 4 hours prior.
please contact anesthesia attending to make them aware of
possible emergency airway
-wife must sign consetns for trach and peg
- anesthesia booked for monday [**8-19**] between 8-10am, case #
[**Numeric Identifier 85087**] (booking called at [**Numeric Identifier 85088**])
- dilantin 6.6, corrected to 13.8 when account for albumin.
continued current dosing.
-HCT 21, stable. Check tomorrow, if low, give UPRBC, guiac
stools
[**8-15**]:
-family meeting: proceeed with trach, peg tube
-CT [**Doctor First Name **] came and constented pt's wife over the phone for trach
and peg placement. he may get his surgery tomorrow. they will
page to let us know. we will need to stop tube feeds and heparin
4 hours prior.
-Onc: hodkins stable, nodes smaller
-d/c bactrim, now on atovaquone
-mucomyst given for secretions
-ABD CT: thickening of fundus and ascending colon- questionable
worsening Hodgkin's
-discharge summary updated
[**8-14**]
- CT chest CT/ abd/ pelvis ordered to eval for progression of
Hodgkin's
-CT [**Doctor First Name **] consulted re trach placement
- BMT recs: switch bactrim to atovaquone (worry that bactrim
allergy may be causing increased eos). Done.
- stool send for ova/ parasites (as source of eos)
- Family [**Doctor First Name 85089**] scheduled for 2 PM with entire family tommorrow -
Probably should get onc and BMT on board
- Onc will be present at [**Last Name (LF) 85089**], [**First Name3 (LF) **] review scan with radiology
prior
[**8-13**]:
-go down on PEEP
-CVP 10, give gently lasix 20
-family meeting: aware that this is chronic process, they want
trach. Will clarify tomorrow that this is definitely what he
needs.
-stopped bactrim because negative bAL PCP x2
[**8-12**]
-nutrition consulted for recs to decrease fluid intake
[**8-11**]:
Resp took off ARDS net protocol, put patient on PS, RR went down
into 20s, good sats, PCO2 41 at 3 PM
- Spiked fever to 103 at 2 PM, tyylenol given and blood cultures
sent
- Given 2 x 40 Lasix boluses by 3 PM; peeing well over 2 L but
still overall positive due to tube feeds; by 10 PM, MAPs in 70s,
still slightly tach to 110s, will hold off on another bolus of
Lasix for now
- Was becoming tachycardic and tachypneic, went up to PS of 15
at midnight
- Talked to son about possibility of a trach and that he may not
come off the vent
-BCx, UCx, sputum cx sent
[**8-10**]
-run of A. Fib/ A. flutter (atrial ectopy hybrid) around 2200,
started on digoxin. Norepinephrine changed to phenylepinephrine
(alpha agonist only, no beta agonist)
- pt given 500 cc fluid bolus at 22:30 for hypotension, goal was
to make fluid even over 24 hrs
- tube feeds restarted
-CTA shows unchanged PE, sl. worse ground glass opacities,
traction bronchiectasis suggestive of underlying interstitial
fibrotic
lung disease, New left pleural effusion with associated
atelectasis
- K, Phos repleted with pot phos iv 15 ml/ 250 cc NS
-B-lucan positive from labs on [**8-1**]. 300s. Started him on
bactrim treatment. Already getting steroids.
-20 IV lasix x2
[**8-9**]
- increased resp distress with hypoxia on BiPAP this AM-
reintubated.
- repeat CTA- dictation- no new filling defects, sl worsened
ground glass opacities, sm effusions. f/u final read.
-tube feeds restarted after CTA
-metoprolol d/c'ed
-solumedrol decreased from 50 to 40
[**8-8**]
-diet advanced to full thin liquids
-tube feeds restarted at 20 ml/hr, advance to 50 ml/hr
- metoprolol started at 12.5 mg q6h for HTN, tachycardia (home
dose 200 mg po qD)
-f/u ECG, enzymes, lytes in PM
- 3rd c diff negative
- NGT placed
[**8-7**]
-extubated, coughing, satting high 80-low 90
-c. diff neg x2, check last c.diff
- hdyrocortisone 50 q12
-continue vanco, levo, cefepine for now and evaluate after 10
days
-overnight, had episodes ot tachy (130s) and desats to mid 80s.
Went up on O2 to 35, started Incentive spirometer use.
-ABG was in fact accurate showing resp alkalosis with A-a
gradient of 119 suggesting PE, infection,
[**8-6**]
- tube feeds started- Nutren Pulmonary Full strength with
Beneprotein, 21 gm/day, rate started at 20 ml/ hr, advance rate
by 10 ml q4hto goal of 40 ml/hr. (Once propofol d/c'ed- increase
to 50/hr and stop benefiber)
- Family meeting wiht pt's wife and daughter in afternoon for
update on status
-po flagyl started until c. diff ruled out
-possible bleomycin toxicity, keep on room air unless PaO2< 88
- tube feeds restarted
- 500 cc bolus given for CVP of 5
[**8-5**]:
- sucralfate added for blood in OG tube on [**8-4**]
- Sedation decreased, pressors decreased
- Tachypnea during SBT, and increased secretions, will attempt
to extubate tomorrow AM
- Copious Diarrhea, C. diff sent
- 5 am, patient turned, became hypotensive to SBP to 70s, 2 L NS
hung, PAC bigemeny, low K, K repleted, pressure stabilized with
fluid and decreased Propofol
- RSBI about 60, Labile vitals on SBT
[**8-4**]:
-worsened resp distress in AM, despite improved CXR.
-gentle diuresis to improve ventilation
-more sedated. Now on Fent, Versed, Propofol 20, 1.3 Neo. on
400/30, 25%, Peep=8.
-goal to stop propofol tomorrow morning and switch to PSV and
see what happens.
-tried A-line but unsuccessful at several attempts
[**2148-8-3**]
73 y/o w/ ivc filter, start on pcp [**Name9 (PRE) **]
[**Name9 (PRE) 85090**] to floor at 3:30 pm
-dilantin level low. Pt given loading dose of phenytoin of 500
mg iv at 7 pm and standing dose increased from 200 mg Q8 to 250
mg Q8.
-check dilantin level in pm of [**8-4**]
-vanco changed from 1000 mg q12 to 100o q8 h. vanc trough
ordered for [**8-4**]
[**8-2**]
- Will get IVC filter placed at 8 AM
- Weaned off Propofol
[**2148-8-1**]
-new A-line placed
-central line placed
-worsening respiratory failure: received 10 L of fluids in last
24 hrs. around 8pm, respiraotory status worsened. mottled feet
up to knees. blood gas shows metabolic acidosis. CXR showed
increased bilateral opacities. ARDS vs fluid overload (causing
non-AG met acidosis and worsening CXR), vs infectious process vs
PE vs DAH 2' rheum condition.
-checked [**Doctor First Name **], ANcA, GBM, antiphopholipid Ab Syndrome (clot
burden)
-echo: normal EF, no signs of right heart strain
-LE U/s: no interval change of clot. femoral, superficial
femoral, popliteal involvement bilaterally
-metabolic acidosis -->met acidosis + resp acidosis after
increasing PEEP and FiO2 which improved oxygenation from 47
-->188.
[**7-31**] overnight
- pt was requiring FiO2 of 100% on CPAP and was sating in
mid-80's
-intubated and placed on volume support
- placed on vanco, zosyn and bactrim for ground glass findings
on chest CT concerning for pneumonia and possible PCP
[**Name Initial (PRE) **] phenytoin was changed to iv as pt unable to take po at this
time
Medications on Admission:
Medications: Per wife:
Prednisone one pill in AM and 2 pills at night (likely 10mg and
20mg, will check with PCP)
Vitamin D 800mg daily
Iron 325mg three times daily
folic acid 1 g daily
dalteparin 15,000 units sub Q daily
Mesalamine 4 pills twice daily
Phenytoin 100 mg- 6 pills at night
Metoprolol 200 mg po daily
Isosorbide 60 mg po every morning
Discharge Disposition:
Expired
Discharge Diagnosis:
EXPIRED
Discharge Condition:
EXPIRED
Discharge Instructions:
EXPIRED
Followup Instructions:
EXPIRED
Completed by:[**2149-5-22**]
|
[
"V46.11",
"272.0",
"038.9",
"427.32",
"V45.82",
"401.9",
"276.6",
"785.52",
"995.92",
"433.10",
"201.90",
"345.90",
"787.91",
"275.3",
"285.9",
"530.85",
"518.81",
"515",
"486",
"V87.41",
"555.9",
"276.52",
"453.42",
"415.19",
"276.1",
"427.31",
"V12.54",
"E930.7",
"433.30",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"33.22",
"96.04",
"31.1",
"33.24",
"38.7",
"38.91",
"33.21",
"88.51",
"38.93",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
15445, 15454
|
4747, 15046
|
323, 357
|
15505, 15514
|
3348, 4724
|
15570, 15608
|
2746, 2806
|
15475, 15484
|
15072, 15422
|
15538, 15547
|
2467, 2527
|
2821, 3329
|
264, 285
|
385, 2183
|
2205, 2444
|
2543, 2730
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,765
| 173,711
|
41954+58487
|
Discharge summary
|
report+addendum
|
Admission Date: [**2178-9-22**] Discharge Date: [**2178-10-3**]
Date of Birth: [**2114-8-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
aortic stenosis/coronary artery disease
Major Surgical or Invasive Procedure:
Aortic Valve replacement (25mm St. [**Male First Name (un) 923**] tissue), coronary artery
bypass grafts x3(LIMA-LAD,SVG-dg,svg-pda) on [**2178-9-28**]
History of Present Illness:
This 64 year old male underwent catheterization at [**Hospital3 **]
recently, after a positive stress test. He has known coronary
disease, having undergone percutaneous intervention in the past.
He has had subsequent dyspnea on exertion which has recently
worsened. Catheterization revealed significant coronary disease
and aortic stenosis with preserved LV function. He was admitted
now for elective operation.
Past Medical History:
Aortic stenosis, obesity, HTN, OSA/CPAP, high cholesterol,
previous cath showing 3 V CAD s/p PTCA [**2174**], left ankle surgery
[**36**]'s
Social History:
Mr. [**Known lastname **] [**Known lastname **] lives with his wife. [**Name (NI) **] is a manufacturing
engineer. He smoked in the past, but quit 30 years ago. He
drinks less than one drink per week.
Family History:
Hi father died at age 78 of an unknown cause and his mother died
at age 82 of congestive heart failure.
Physical Exam:
Physical Exam
Pulse:76 Resp:16 O2 sat: 99% RA
B/P Right:130/78 Left:
Height: 71 inches Weight: 285#
General:AAOx3 in NAD
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 [x] grade II/VI SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] Obese
Extremities: Warm [x], well-perfused [x] Edema - none
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:2+ Left:2+
DP Right:2+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right:2+ Left:2+
Carotid Bruit Right/Left:transmitted murmur
Pertinent Results:
[**2178-9-22**] 11:44PM BLOOD WBC-6.3 RBC-4.58* Hgb-13.9* Hct-40.7
MCV-89 MCH-30.4 MCHC-34.2 RDW-13.1 Plt Ct-181
[**2178-9-22**] 11:44PM BLOOD Glucose-116* UreaN-16 Creat-0.9 Na-144
K-3.7 Cl-106 HCO3-30 AnGap-12
Conclusions
PREBYPASS: Normal systolic funciton with LVEF > 55% with no
segmental wall motion abnormalities. The left atrium is mildly
dilated. No mass/thrombus is seen in the left atrium or left
atrial appendage. There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The ascending, transverse and descending thoracic
aorta are normal in diameter. There are three aortic valve
leaflets. The aortic valve leaflets are moderately thickened.
Aortic valve area is 1.0-1.5 by planimetry, unable to do
continuity equation (not able to get good deep TG lax CWD
profile).The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no pericardial effusion.
Essentially: moderate AS in large man (bsa = 2.45) for CABG
NO PFO, normal coronary sinus. Lateral mitral annular tissue
Doppler e' = 11 cm/sec. Normal appearing transmitral and
pulmonary venous pwd flow profiles.
POSTBYPASS: Normal functioning bioprosthetic AV. No AI, No AS.
RV with transient dysfunction immediate post pump, impropved
with time. Otherwise no change.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16164**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2178-9-28**] 12:32
[**2178-10-3**] 06:40AM BLOOD WBC-5.8 RBC-2.79* Hgb-8.5* Hct-24.7*
MCV-88 MCH-30.6 MCHC-34.6 RDW-13.6 Plt Ct-187
[**2178-10-3**] 06:40AM BLOOD UreaN-22* Creat-0.9 Na-141 K-4.1 Cl-104
Brief Hospital Course:
Following admission the usual preoperative workup was
undertaken. Dental extraction of # 19 was performed on [**9-25**].
On [**9-28**] he was returned to the Operating Room where aortic
valve replacement and coronary bypass grafting was undertaken.
See operative note for details. He weaned from bypass in stable
condition on Neosynepherine and propofol. He weaned from the
ventilator eaily and required another 24 hours to wean the
pressor.
He was transferred to the floor on POD 2. Physical Therapy was
consulted for strength and mobility. CTs and temporary pacing
wires were removed according to protocol without incident. Beta
blockade and diuresis was started when he was hemodynamically
stable and adjusted appropriately. Discharge was planned for
POD#4 but developed fever to 101. He was pan cultured. WBC was
normal. CXR showed atelectasis. He was afebrile for the ensuing
24 period and was cleared for discharge to home on POD# 5. All
follow-up appointments were advised.
Medications on Admission:
ASA 81 daily Fish oil 1200 mg with a meal daily Lisinopril
10 mg daily Zocor 80 daily
Medications on transfer: Lisinopril 10 daily, Lipitor 40 daily,
Toprol XL 25 mg daily, ASA 81 daily
Discharge Medications:
1. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain, fever.
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
6. metoprolol tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2
times a day).
Disp:*15 Tablet(s)* Refills:*2*
7. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
care centrix/ [**Hospital3 **] care
Discharge Diagnosis:
Aortic stenosis
coronary artery disease
s/p aortic alve replacement
s/p coronary artery bypass grafting
hypertension
obstructive sleep apnea
obesity
hypercholesterolemia
s/p coronary angioplasty
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema 1+ lower extremity edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr.[**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2178-11-4**] 1:00pm in the
[**Hospital **] Medical office building [**Last Name (NamePattern1) **]. [**Hospital Unit Name **]
Please call to schedule appointments with:
Primary Care/Cardiologist: Dr. [**Last Name (STitle) 29070**] ([**Telephone/Fax (1) 37284**]in [**3-17**]
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:[**2178-10-3**] Name: [**Known lastname **] [**Known lastname 14355**],[**Known firstname **] Unit No: [**Numeric Identifier 14356**]
Admission Date: [**2178-9-22**] Discharge Date: [**2178-10-3**]
Date of Birth: [**2114-8-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 741**]
Addendum:
There is a reference to the patients medical condition while he
was recovering from suregery in the CVICU about his being in
hypoovolemic shock with a metabolic acidosis.
The patient had neither hypovolemic shock or metabolic acidosis.
He was post-op avr/cabg with poor vasmotor tone post-op he
weaned off vasoactive support by POD1. His acidosis was while
weaning from sedation- he extubated within several hours of
arrival in CVICU.
Discharge Disposition:
Home With Service
Facility:
care centrix/ [**Hospital3 **] care
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2178-11-27**]
|
[
"414.01",
"278.00",
"E878.2",
"997.39",
"401.9",
"272.0",
"327.23",
"424.1",
"V45.82",
"V85.39",
"518.0",
"522.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"23.09",
"36.15",
"35.21",
"36.12",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
8786, 8976
|
3955, 4942
|
350, 504
|
6243, 6483
|
2180, 3932
|
7323, 8763
|
1348, 1454
|
5179, 5915
|
6025, 6222
|
4968, 5054
|
6507, 7300
|
1469, 2161
|
271, 312
|
532, 948
|
5079, 5156
|
970, 1112
|
1128, 1332
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,762
| 140,961
|
46284
|
Discharge summary
|
report
|
Admission Date: [**2110-10-13**] Discharge Date: [**2110-10-20**]
Date of Birth: [**2045-12-15**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 832**]
Chief Complaint:
myelopathy
Major Surgical or Invasive Procedure:
c4-c6 decompression with c3-c7 fusion for spinal stenosis
History of Present Illness:
This is a 64 yoF with diastolic CHF, DM2, probable OSA who was
found to have cervical spine stenosis after falling backwards
while trying to step up a high curb, and who as admitted for
cervical spinal decompression and fusion. She has some
balance/gait issue at baseline due to cervical stenosis (C4~6)
but is able to ambulate without any assistance.
.
Her post-operative course was complicated by a new O2
requirement (low 90s on 4L NC on call-out) likely due to
decompensated CHF in the setting of COPD, low grade post-op
fever to 100.5, delerium, typical CP ruled out for MI and
tachycardic with persistent O2 requirement concerning for PE
that was also ruled out by CTPA. She was also been seen by
ophthalmology for a corectopic right pupil, which is due to an
anterior chamber itraocular lens (AC-IOL).
.
ON THE FLOOR VS were 98 BP:126/46 P:99 R:16 O2:98%.
.
<b>Review of systems:</b>
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
.
Past Medical History:
Cervical stenosis,
Diabetes mellitus
Chronic osteorthritis, s/p both knee replacements in [**2100**]
Hypothyroidism,
HTN
Hypercholesterolemia
R cataract repair followed by lens placement
s/p hysterectomy in [**2101**] for fibroids
Urinary incontinence
Diastolic dysfunction/impaired LV relaxation.
Emphysema. OSA CPAP
Severe OA of the C-spine, hands. Bipolar disorder. Prior
tobacco/alcohol abuse.
Social History:
-Smoked for 45 pack years and quit 6 yrs ago. Heavy pot smoking
but sober now for 23 years.
-Lives alone completely independently. Retired human resources
person but still works intermittently - most recently as a
census collector. No HCP (daughter [**Name (NI) **] [**Name (NI) **],
[**Telephone/Fax (1) 98422**], is next of [**Doctor First Name **] but not formally HCP.)
Family History:
-Son died of juvenile onset DM complications
-Mother died of CAD at age 85 ([**2109**])
Physical Exam:
Physical Exam on Transfer to the Medical Floor:
Gen: pleasant, Alert and oriented, in NAD
HEENT: NCAT, right eye with tall narrow pupil (corectopic),
minimally reactive, left eye WNL
Neck: In collar
Lungs: unable to assess given body habitus and in collar,
anteriorly clear to auscultation
CV: tachy regular, nl s1s2, no m/r/g
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: no significant edema. No calf tenderness or edema.
Neuro: Grossly non-focal
Physical Exam on Discharge:
Gen: pleasant, Alert and oriented, in NAD
HEENT: NCAT, right eye with tall narrow pupil (corectopic),
minimally reactive, left eye WNL; MMMs
Neck: In collar
Lungs: CTAB no adventitial sounds
CV: RRR, nl s1s2, no m/r/g
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: no significant edema. No calf tenderness or edema.
Neuro: Grossly non-focal
Pertinent Results:
[**2110-10-13**] 03:55PM GLUCOSE-133* UREA N-22* CREAT-1.3* SODIUM-139
POTASSIUM-4.8 CHLORIDE-109* TOTAL CO2-23 ANION GAP-12
[**2110-10-13**] 03:55PM estGFR-Using this
[**2110-10-13**] 03:55PM CALCIUM-8.8 PHOSPHATE-3.7 MAGNESIUM-2.0
[**2110-10-13**] 03:55PM WBC-6.0 RBC-3.45* HGB-10.2* HCT-30.1* MCV-87
MCH-29.5 MCHC-33.8 RDW-15.3
[**2110-10-13**] 03:55PM PLT COUNT-269
[**2110-10-13**] 03:55PM PT-12.1 PTT-23.7 INR(PT)-1.0
[**2110-10-13**] 02:20PM O2-50 PO2-113* PCO2-45 PH-7.36 TOTAL CO2-26
BASE XS-0 INTUBATED-INTUBATED
[**2110-10-13**] 02:20PM GLUCOSE-116* LACTATE-0.8 NA+-139 K+-4.9
CL--106
[**2110-10-13**] 02:20PM HGB-11.3* calcHCT-34
[**2110-10-13**] 02:20PM freeCa-1.19
Imaging:
[**10-13**] C-Spine: INTRAOPERATIVE RADIOGRAPH: A single
intraoperative radiograph for localization is markedly limited.
There is a localizer device posterior to the C2/C3 disc
interspace and C3 vertebral body. Additional localizer device is
seen more inferiorly. The lower cervical vertebral bodies are
not well evaluated secondary to overlying soft tissue. For
further details, please see the intraoperative report.
[**10-14**] CXR Port: Comparison is made with preop evaluation, [**6-3**], [**2109**]. There are low lung volumes. Bibasilar opacities left
greater than right are consistent with atelectasis. There is
mild vascular congestion. Enlargement of the cardiac silhouette
is partially due to the projection and low lung volumes. There
is no evidence of pneumothorax or large pleural effusions.
Cervical spine hardware is noted. There is unchanged deviation
of the trachea towards the right side. This could be due to an
enlarged thyroid.
[**10-16**] CXR Port: Comparison is made to prior study performed a
day earlier. There are persistent low lung volume. Mild
interstitial edema has minimally improved. Bibasilar opacities
consistent with atelectasis, left greater than right are
unchanged. Right mid lung opacity has resolved consistent with
resolved atelectasis. There is no pneumothorax. Cervical
hardware is present.
[**10-16**] CTPA: IMPRESSION:
1. No evidence of pulmonary embolism.
2. Bibasilar atelectases with trace pleural effusions
bilaterally.
3. Centrilobular emphysema.
The study and the report were reviewed by the staff radiologist.
[**10-17**] CXR PA-L: IMPRESSION: Mild pulmonary vascular congestion.
Please note cervical hardware appears grossly normal; however, a
chest x-ray is not the recommended modality for evaluation of
this hardware and consider dedicated C-spine radiographs for
more appropriate evaluation.
[**10-16**] C-Spine: compared to CT from [**2110-5-30**].: New mild
prevertebral soft tissue swelling, likely postsurgical. No acute
fracture. C7 not depicted on lateral view.
Discharge labs:
[**2110-10-20**] 07:25AM BLOOD Glucose-109* UreaN-45* Creat-1.7* Na-140
K-4.0 Cl-102 HCO3-31 AnGap-11
[**2110-10-19**] 07:15AM BLOOD Glucose-109* UreaN-54* Creat-2.5* Na-141
K-4.2 Cl-100 HCO3-33* AnGap-12
[**2110-10-18**] 07:15AM BLOOD Glucose-102* UreaN-41* Creat-2.1* Na-141
K-4.5 Cl-101 HCO3-33* AnGap-12
[**2110-10-17**] 01:05PM BLOOD Glucose-146* UreaN-27* Creat-1.3* Na-141
K-4.2 Cl-101 HCO3-28 AnGap-16
Brief Hospital Course:
Ms. [**Known lastname 98423**] was admitted for a posterior cervical fusion on
[**10-13**]. She tolerated the procedure well, was placed in a
cervical collar, and was managed post-operatively by
neurosurgery. Her post-operative course was complicated by a new
O2 requirement (low 90s on 4L NC on call-out) due to
decompensated dCHF in the setting of COPD, low grade post-op
fever to 100.5, delerium, typical CP ruled out for MI, and sinus
tachycardia likely due to pain, ruled for PE.
# Cervical spine decompression and fusion: See [**2110-10-13**]
operative report for details. Briefly Dr. [**Last Name (STitle) 739**]
performed 1. Cervical laminectomies, C4, C5, and C6. 2.
Arthrodesis, C3, C4, C5, C6, and C7. 3. Instrumentation, C3 to
C7, nonsegmental. 4. Use of allograft for instrumentation, as
well as autograft.5. Placement of [**Location (un) 8766**] head holder for axial
spinal stabilization. The patient tolerated the procedure well.
.
# Post-operative hypoxia due decompensated dCHF: Patient
admitted with known diastolyic dysfunction according to previous
ECHO from 9/[**2108**]. Post-operatively she became hypervolemic due
to IVF and was transferred in respiratory distress on NRB to the
MICU for close monitoring and diuresis; CXR at that time was
equivocal for possible infiltrate and the patient was started on
ceftriaxone and azithromycin for possible CA-PNA. In the ICU,
the patient complained of typical chest pain; EKG showed no
ischemic changes and serial cardiac enzymes were flat; ECHO was
unchanged from previous study. The patient improved with
diuresis and was transferred to the floor. She continued
diuresis on the floor and O2 sats improved, being discharged on
RA with sats in the low 90s. Diuresis resulted in [**Last Name (un) **] as
detailed below.
.
# Post-operative fever: On the floor the patient was taken off
of antibiotics in the absence of any clinical sequellae of PNA -
no cough, fever, or leukocytosis; her fever was attributed to
post-operative atelectacis and she defervesced off of
antibiotics.
.
# Post-operative sinus tachycardia concerning for PE: The
patient remained persistently tachycardic the first day on the
floor in the setting of hypoxia, requiring 4L NC to maintain
sats in the low 90s, satting low 80s on RA. Given her moderate
modified [**Location (un) 20872**] pre-test proability, she was ruled out for PE
with a negative CTPA.
.
# [**Last Name (un) **]/Chronic renal insufficiency: Diuresis resulted in [**Last Name (un) **] in
the setting of chronic renal impairement, baseline Cr 1.3.
Diuresis was stopped and oral rehydration was encouraged, with
Cr showing a trend toward normalization to 1.7 the day of
discharge from a peak of 2.5.
.
# Diabetes mellitus: Controlled on HISS and restarted on home
oral hypoglycemics prior to discharge EXCEPT for metformin,
which was held in the setting of [**Last Name (un) **]. **Metformin will need to
be restarted when Cr. normalizes.**
.
# Post-operative pain: Pain was controlled on the floor with 1g
acetaminophen QID, oxycontin, and oxycodone.
.
# Post-operative delerium: In the ICU patient was noted to be
oriented x 1 or x 2 and thought to be delerious. On the floor
delerium resolved with resolution of hypoxia, OOB to chair, and
minimization of opiates with the addition of acetaminophen as
detailed above.
.
# OA: Relafen 750 mg [**Hospital1 **] was held on dicharge in the seeting of
[**Last Name (un) **]. **This will need to be restarted once Cr normalizes to
baseline.**
.
# Hypothyroidism: Levothyroxine was downtitrated to 150mcg daily
from 175 because TSH was low.
.
# OSA: In process of being worked up, pt currently on 2L O2 at
home at night but not on PPV. Followed as an outpatient for this
problem. **This will need follow-up as an outpatient.**
.
INACTIVE ISSUES:
.
# Correctopic Pupil OD (Right Eye): Ophthalmology consulted and
noted the abnormality was due to an anterior chamber intraocular
lens implanted after cataract extraction.
.
# Bipolar Disorder: Maintained on pre-admission meds without
changes; buproprion 150mg daily, and lamotrigine 200mg daily.
.
# Hypercholesterolemia, primary prevention: Continued
pre-admission medications simvastatin 10 mg daily and ASA 81 mg
daily.
.
# Insomnia: Discharged on pre-admission Lunesta.
.
# Bladder spasm: Discharged on pre-admission Solifenacin 10 mg
daily.
.
# Allergies: Discharged on pre-admission fexofenadine.
.
# CODE: DNR but ok to intubate per discussion with patient and
daughter
.
TRANSITIONAL ISSUES:
Above in **
Medications on Admission:
ASA/[**Doctor First Name **]/Relafen/Metformin ( all held post operatively),
Glipizide, Lamictal, Lisinopril, Simvastatin, Synthroid,
Wellbutrin
Discharge Medications:
1. bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day.
2. lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*44 Tablet(s)* Refills:*2*
4. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
5. simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. solifenacin 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Lunesta 1 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO once a day.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
11. senna 8.6 mg Tablet Sig: 1-2 Tablets PO once a day as needed
for constipation.
Disp:*60 Tablet(s)* Refills:*2*
12. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
Disp:*240 Tablet(s)* Refills:*2*
13. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*15 Tablet(s)* Refills:*2*
14. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain for 14 days.
Disp:*80 Tablet(s)* Refills:*0*
15. oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO DAILY (Daily).
Disp:*14 Tablet Sustained Release 12 hr(s)* Refills:*0*
16. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea for
14 days.
Disp:*40 Tablet, Rapid Dissolve(s)* Refills:*0*
17. Rehabilitation Lab Work
Please check BUN/Cr [**10-21**] and fax to Rehabilitation physician
18. Rehab medication instruction
Please restart Lisinopril 30mg dailyt as previously prescribed
after Cr returns to baseline of 1.3
Please restart Metformin 500mg SR daily when Cr returns to
baseline of 1.3
Please restart relafen 750mg [**Hospital1 **] with food when Cr returns to
baseline
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] manor
Discharge Diagnosis:
Primary Diagnoses:
-Spinal stenosis
-c4-c6 decompression with c3-c7 fusion for spinal stenosis
-Hypoxia due to intravenous fluids
-Acute kidney injury due to medication induced dehydration
-chronic heart failure
Secondary Diagnoses:
-Type 2 Diabetes
-Hypothyroid
-COPD
-Hypertension
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:
It has been a privilege to take care of you at [**Hospital1 18**].
You were hospitalized for a spinal surgery, which you tolerated
well. After the surgery you were given IV fluids, which made you
short of breath. We removed this fluid with medications and your
breathing improved. The removal of fluid, made your kidneys
dehydrated, but this resolved after we stopped the medication
and you made an effort to drink more fluids.
Our records show that your last thyroid test was a little high,
so we are reducing your levothyroxine medication which you take
for hypothyroid.
No changes were made to your medications other than as detailed
below. Please continue taking your other medications as
previously prescribed.
# STOP Lisinopril temporarily until your kidneys return to
normal; you can restart your previously prescribed dose in 2
days
# STOP Metformin temporarily until your kidneys return to
normal; you can restart your previously prescribed dose in 1 day
# STOP Relafen temporarily until your kidneys return to normal;
you can restart your previously prescribed dose in 2 days
# STOP: Levothyroxine 175 mcg daily
# START: Levothyroxine 150 mcg daily
# START: Metoprolol for your heart
# START: Oxycontin long-acting pain medication
# START: Oxycodone short-acting pain medication
# START: Acetaminophen for pain
# START: Senna for constipation
# START: Colace for constipation
# START: Zofran for nausea
Please attend the follow-up appointments detailed below. The
neurosurgical team has left you the following additional
instructions.
?????? Do not smoke.
?????? Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery.
?????? No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
?????? Limit your use of stairs to 2-3 times per day.
?????? Have a friend or family member check your incision daily for
signs of infection.
?????? Wear your cervical collar at all times.
?????? You may shower briefly without the collar or back brace;
unless you have been instructed otherwise.
?????? Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. unless directed by your
doctor.
Followup Instructions:
Department: SPINE CENTER
When: THURSDAY [**2110-11-13**] at 1:15 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3736**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: THURSDAY [**2110-11-13**] at 12:55 PM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2110-11-5**] at 3:40 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: WEDNESDAY [**2110-11-5**] at 4:00 PM
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2110-11-5**] at 4:00 PM
With: DR [**Last Name (STitle) **]/DR [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"276.51",
"250.00",
"721.1",
"327.23",
"496",
"428.33",
"244.9",
"403.90",
"428.0",
"585.9",
"997.1",
"780.62",
"293.9",
"272.0",
"518.5",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.03",
"81.63"
] |
icd9pcs
|
[
[
[]
]
] |
13561, 13610
|
6802, 10582
|
328, 388
|
13938, 13938
|
3611, 6351
|
16512, 17690
|
2521, 2610
|
11509, 13538
|
13631, 13844
|
11340, 11486
|
14114, 16489
|
6368, 6779
|
2625, 3149
|
13865, 13917
|
3177, 3592
|
11301, 11314
|
1304, 1690
|
278, 290
|
416, 1286
|
10599, 11280
|
13953, 14090
|
1712, 2114
|
2130, 2505
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,757
| 107,532
|
4592
|
Discharge summary
|
report
|
Admission Date: [**2196-1-11**] Discharge Date: [**2196-1-13**]
Date of Birth: [**2133-11-10**] Sex: M
Service: MEDICINE
Allergies:
Lipitor / Food Extracts
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
palpitations
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 62 year old male with history of significant CAD with
CABG in [**2177**] and PTCI in [**2193**] as well as chronic systolic CHF
and episodes of ventricular tachycardia s/p AICD placement in
[**2192**] who presented tonight after an ICD firing. Per the patient
he has been feeling a bit off for about a month now with
occasional episodes of dizziness and palpitations with standing.
Over the fast five days, however, this has been considerably
worse. He reports every time he stands up suddenly or exerts
himself he will feel palpitations and get light-headed though
he can breathe out hard and will feel this go away. he has
never lost consciousness, he just feels weak and generally very
unwell when this happens. He has no chest pain associated with
this. The patient received a defibrillator shock from his ICD
at around 10:00 pm on [**2196-1-10**] and presented to the emergency
room soon afterward.
.
In the ED, he was noted to go into intermittent episodes of VT
with overdrive pacing and vagal maneuvers quickly leading to a
reversion to sinus rhythm. He remained hemodynamically stable.
He was started on an amiodarone IV load and admitted to the
cardiology service. After arrival to the cardiology service the
patient had multiple episodes of VT terminating similar to the
events in the ED. Thus, he is transferred to the CCU for closer
monitoring.
.
Cardiac review of systems is notable for palpitations and
presyncope as noted. It is also notable for the presence of
chronic dyspnea on exertion related to asthma without lower
extremity edema, orthopnea, or PND. He denies chest pain of
syncope.
Past Medical History:
CARDIAC HISTORY:
-Coronary Artery Disease s/p the following interventions
****CABG in [**2177**] with LIMA to LAD, SVG to OM2, SVG to OM1, SVG
to R Marg. Cath results from [**2189**] as below showed LMCA 95%
lesion.
****NSTEMI [**2192-12-31**] cath at OSH(no interventions)
****PTCI [**2194-1-29**] showing: Three vessel coronary artery disease,
occluded SVG to the OM1 and OM2, diffusely diseased SVG to the
RCA acute marginal, Patent LIMA to the LAD)
-Chronic Systolic Heart Failure with EF 30%, last echo in [**2193**]
-NSVT in [**2192**] s/p ICD placed in [**1-/2193**]
-Dyslipidemia
-HTN
<br>
Other Past History:
- OSA on CPAP
- Asthma
- Diverticulitis
- Esophagitis
Social History:
Social history is notable for previous heavy tobacco use with
patient smoking >50 pack years. He has quit for two months
currently. Minimal alcohol use. No illicit drug use. He lives
with his wife and works as a carpenter/tiler.
Family History:
Notable for two identical twin sons with CAD in their 30's.
Dad-heart disease at 78 YO
Physical Exam:
VS: T=97.9, BP=116/60 HR=65, RR=15 O2 sat= 97% on 2L
General Appearance: Well nourished, No acute distress,
Overweight / Obese
Eyes / Conjunctiva: PERRL, No(t) Pupils dilated
Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Diminished), (Left
radial pulse: Present), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Wheezes : diffuse wheezes, Diminished: ), diminished air
movement
Abdominal: Soft, Non-tender, Bowel sounds present, Obese
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing
Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand
Skin: Warm, No(t) Rash: , No(t) Jaundice
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): person, place, time, situation,
Movement: Purposeful, Tone: Normal
Pertinent Results:
ADMISSION LABS:
[**2196-1-11**] 12:00AM BLOOD WBC-9.3 RBC-4.65 Hgb-14.7 Hct-42.4 MCV-91
MCH-31.6 MCHC-34.7 RDW-13.2 Plt Ct-176
[**2196-1-11**] 12:00AM BLOOD Neuts-57.2 Lymphs-33.0 Monos-5.8 Eos-2.6
Baso-1.5
[**2196-1-11**] 12:00AM BLOOD PT-12.0 PTT-25.3 INR(PT)-1.0
[**2196-1-11**] 12:00AM BLOOD Glucose-116* UreaN-21* Creat-1.1 Na-140
K-3.8 Cl-104 HCO3-24 AnGap-16
[**2196-1-11**] 12:00AM BLOOD ALT-34 AST-28 LD(LDH)-211 CK(CPK)-270
AlkPhos-62 TotBili-0.5
[**2196-1-11**] 12:00AM BLOOD CK-MB-5
[**2196-1-11**] 12:00AM BLOOD cTropnT-<0.01
[**2196-1-11**] 12:00AM BLOOD Calcium-9.8 Phos-4.0 Mg-2.0
[**2196-1-12**] 04:17AM BLOOD TSH-1.9
[**2196-1-12**] 04:17AM BLOOD T3-77* Free T4-1.3
[**2196-1-11**] 12:10AM BLOOD Lactate-1.8
--------------------
DISCHARGE LABS:
[**2196-1-13**] 07:25AM BLOOD WBC-7.9 RBC-4.45* Hgb-14.1 Hct-41.0
MCV-92 MCH-31.6 MCHC-34.3 RDW-13.1 Plt Ct-149*
[**2196-1-13**] 07:25AM BLOOD PT-12.9 PTT-28.1 INR(PT)-1.1
[**2196-1-13**] 07:25AM BLOOD Glucose-117* UreaN-20 Creat-1.0 Na-138
K-3.7 Cl-102 HCO3-27 AnGap-13
[**2196-1-13**] 07:25AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.1
[**2196-1-12**] 04:17AM BLOOD TSH-1.9
[**2196-1-12**] 04:17AM BLOOD T3-77* Free T4-1.3
--------------------
STUDIES:
.
EKG ([**2195-1-11**]): NSR at 67. Normal axis. Prolonged QT with left
bundaloid morphology. Likely left atrial abnormality. Compared
to previous EKG of [**2195-12-1**] there is no significant change.
.
TTE ([**2196-1-11**]):
The left atrial volume is severely increased. Left ventricular
wall thicknesses are normal. The left ventricular cavity is
moderately dilated. There is moderate regional left ventricular
systolic dysfunction with near-akinesis of the inferior and
inferolateral segments and mild hypokinesis of the other
segments. The aortic valve leaflets are mildly thickened (?#).
There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
Compared with the prior study (images unavailable for review) of
[**2194-4-7**], there is mild aortic regurgitation on the current
study. The other findings are similar.
.
CXR ([**2196-1-11**]):
Transvenous right ventricular pacer defibrillator lead follows
the expected course, left axillary pacemaker. Heart is mildly
enlarged, exaggerated by large mediastinal paracardiac fat
collection. Lungs are fully expanded and not hyperinflated and
clear. No pleural effusion or pneumothorax.
Brief Hospital Course:
This is a 62 y.o. male with CAD, chronic systolic CHF, and
history of VT s/p AICD placement presenting after AICD firing
with multiple episodes of ventricular tachycardia consistent
with VT storm.
.
# VT Storm: Patient's VT is likely scar mediated VT in the
context of his known CAD and previous episodes of ventricular
tachycardia. Unclear what has precipitated increased frequency
of VT. Perhaps new ischemic event versus progressive remodeling
(though >1 year since last intervention/known event). Device
complication (i.e. lead movement) seems extremely unlikely at
this juncture. Patient was started on amiodarone gtt at
1mg/min, which was brought town to 0.5mg/min after he stopped
having VT episodes. Electrolytes were repleted aggressively to
maintain K>4 and Mg>2. Amiodarone gtt was discontinued on the
afternoon of [**1-12**], and he was started on PO amiodarone 400mg
TID. The original plan was take him to EP lab on [**1-13**] for VT
ablation, but since he was VT-free on amiodarone, the procedure
was held off. PLAN: continue on PO amiodarone and follow up in
device clinic, ablating if medication failure
.
# Coronaries: ECG not suggestive of active ischemia though given
CABG and multiple PTCA patient undoubtedly has disease. [**Month/Year (2) **] and
statin were continued. Patient did not want to continue
metoprolol as he believes it exacerbates his asthma symptoms.
Notably, he does have more wheezing after receiving metoprolol.
As a result, he was not discharged home with BB.
.
# Chronic Systolic CHF: Patient with minimal oxygen requirement
and appears euvolemic on exam. Not on diuretic therapy as
outpatient and no history of decompensations. Valsartan was
continued. BB was held as above. He was discharged off of a
beta blocker for two reasons: Amiodarone has a betablocking
effect and he required more albuterol (tachygenic) while taking
it, given his asthma
.
# Asthma: Patient describes poorly controlled symptoms at
baseline and refused Beta agonist due to relationship to
tachycardia. Clinically looking well. Patient felt that
beta-blocker was making his asthma symptoms worse, and refused
to take metoprolol. As a result, he was not discharged home
with beta-blocker. He was put on Fluticasone inhaled daily, and
Ipratropium nebs PRN in the hospital for asthma control.
.
# OSA: Stable and patient uses CPAP at home. CPAP was
continued.
.
# Esophagitis: Stable. Pantoprazole was continued.
.
# Diet: Patient received cardiac healthy diet. He tolerated POs
well.
.
# Contact: Wife [**Name (NI) 4489**] [**Telephone/Fax (3) 19492**]
------------------
------------------
------------------
TO BE FOLLOWED
1) Patient to have device clinic f/u in 30 days
2) Patient needs pulm f/u with PFTs given amio
3) Patient needs Liver enzyme evaluation in 30 days while on
amio and crestor
------------------
------------------
------------------
Medications on Admission:
albuterol inhaler on a p.r.n. basis
clopidogrel 75 mg daily
fluticasone nasal spray on a p.r.n. basis
Imdur 60 mg daily
metoprolol succinate 50 mg daily
Fluticasone/Salmeterol: 500/50 [**Hospital1 **]
pantoprazole 20 mg daily,
rosuvastatin 20 mg daily
Dyazide one tablet daily
Valsartan 160 mg daily
Aspirin 81 mg daily.
Discharge Medications:
1. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal twice a day.
2. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Dyazide 37.5-25 mg Capsule Sig: One (1) Capsule PO once a
day.
7. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] ().
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
10. NitroQuick 0.4 mg Tablet, Sublingual Sig: One (1) tab
Sublingual [**Last Name (un) **] 5 minutes for total of 3 doses as needed for
chest pain: If you still have chest pain after 3 nitroglycerin
tablets, call 911.
11. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
12. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**12-26**]
puffs Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
13. Singulair 10 mg Tablet Sig: One (1) Tablet PO once a day.
14. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): Take 2 tablets twice daily until [**2196-1-20**], then decrease
to 400 mg once daily.
Disp:*120 Tablet(s)* Refills:*2*
15. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO three
times a day for 7 days.
Disp:*21 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Ventricular tachycardia
Coronary Artery Disease
Chronic Systolic congestive heart failure: EF 25%
Asthma
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You had ventricular tachycardia that caused your ICD to fire.
You were started on amiodarone, a medicine to prevent the
ventricular tachycardia from occuring and to keep your heart
rate low. This medicine has been very effective in preventing
ventricular tachycardia while you have been in the hospital.
Amiodarone has a long half life or time of effectiveness. You
are undergoing a loading dose of amiodarone now so you will take
400 mg twice daily for one week, then decrease to 400 mg daily
until you see Dr. [**Last Name (STitle) **] again. Please call Dr. [**Last Name (STitle) **] at
[**Telephone/Fax (1) 62**] if the ICD fires again. You have phlebitis from an
IV line that leaked. YOu should continue to use warm compresses
and keep the arm elevated above your heart when sitting or lying
down as much as possible. You will take an antibiotic for one
week for this. Please call Dr. [**Last Name (STitle) **] if you notice that this
area is getting more red, swollen or painful.
Other medication changes:
1. Stop taking Metoprolol XL (Toprol) The amiodarone should keep
your heart rate low instead.
2. Take Cephalexin three times a day for one week to treat the
phlebitis in your right upper arm.
Weigh yourself every morning, call Dr. [**First Name (STitle) **] if weight goes up
more than 3 lbs in 1 day or 6 pounds in 3 days.
Followup Instructions:
Primary Care:
Provider: [**Name10 (NameIs) 2483**],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 191**] MEDICAL UNIT (SB)
Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2196-7-25**] 11:20
Electrophysiology:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 62**] Date/Time: [**2-18**] at
9:00. Your device will be checked by [**First Name8 (NamePattern2) 16883**] [**Last Name (NamePattern1) **], the nurse
practitioner who works with Dr. [**Last Name (STitle) **] at the same time.
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2196-5-31**]
9:00
Cardiology:
Provider: [**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 62**] Date/Time: [**1-26**] at 11:20am.
Provider: [**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2196-5-31**] 9:40
Completed by:[**2196-1-13**]
|
[
"401.9",
"327.23",
"V45.81",
"272.4",
"428.22",
"428.0",
"427.1",
"412",
"493.90",
"V45.02",
"530.19"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11636, 11642
|
6750, 9642
|
298, 305
|
11791, 11791
|
4088, 4088
|
13296, 14469
|
2925, 3013
|
10013, 11613
|
11663, 11770
|
9668, 9990
|
11936, 12928
|
4851, 6727
|
3028, 4069
|
12948, 13273
|
246, 260
|
333, 1963
|
4104, 4835
|
11805, 11912
|
1985, 2659
|
2675, 2909
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,070
| 127,721
|
48495
|
Discharge summary
|
report
|
Admission Date: [**2135-11-22**] Discharge Date: [**2135-12-9**]
Date of Birth: [**2057-3-14**] Sex: M
Service: MEDICINE
Allergies:
Iodine / Enalapril / Aspirin
Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
COPD exacerbation complicated by afib with RVR requiring
intubation
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
78 yo male with COPD who was seen in the ED a few days ago and
sent home presents in respiratory distress, hypoxic. Three days
ago, he presented to the ED with 5 days of diffuse wheezing on
exam. He got solumedrol, nebulizers, CXR was clear. Initial room
air sats were 89% RA at rest, improved to 93% RA in the morning
with desat with ambulation to 89-90%. During this ED visit, he
was able to walk througout entire ED with only minimal
desaturation, which is improved over even baseline (uses scooter
at home). He was diagnosed with a URI and was discharged on a
Prednisone taper and when he presented today, he was on day #3
of his prednisone taper. He presented 12/4/6 with one day of
diffuse wheezing, dyspnea, and a dry cough. In the ED, he
received Combivent nebs, Solumedrol, and azithromycin. His
initial gas on room air was 7.39/79/56/42; Bipap was started and
his gas improved to 7.43/54/93/37. He mentated well throughout
and tolerated Bipap well initially. However, he began to breathe
faster with increased use of accessory muscles; he was
subsequently intubated. Initial vent settings were TV 400, RR
10, FiO2 100%, PEEP 5. He was given 100mcg fentanyl and 1mg
ativan for sedation. His ABG after intubation was
7.16/85/499/32.
Approximately ten minutes later, his systolic blood pressure
dropped to 95/60 and his rhythm was atrial fibrillation with
rapid RVR. Rate control was attempted with 0.5mg IV digoxin but
was unsuccessful. He then got IV diltiazem 5 mg x 2 that brought
his rate to 120's with stable pressure. However, his blood
pressure then dropped to 70's systolic. He was transiently on
phenylephrine (10ug/min to 40ug/min) and a received a total of 5
L normal saline. A CTA was negative for PE and a bedside echo
showed some hypokinesis in the anterior wall. He was paralyzed
with 10mg vecuronium and 150 micrograms of fentanyl as he was
dissyncronous with vent and was thought to be autopeeping.
Following this his blood pressure increased to systolic 160's.
In the [**Hospital Unit Name 153**] on admission, he was moving all fours and had a
stable blood pressure. An arterial line was placed. BP 124/58,
HR 71, Sat 100%.
Past Medical History:
1. Chronic obstructive pulmonary disease.
2. Diagnosis of prostate cancer ([**2132**]).
3. Benign prostatic hypertrophy.
4. Dyslipidemia.
5. Hypertension.
6. Gastroesophageal reflux disease.
7. Anemia.
8. Cystic mass on MRI.
9. Atrial fibrillation
10. S/p myocardial infarction [**6-22**]
Social History:
Ex-alcohol abuse; patient reports that he has completed a detox
program and no longer drinks alcohol. Ex-smoker (90 pack year
history).
Family History:
Mother- strokes x2.
Physical Exam:
HR 71, bp 124/58, resp 12, 100% on current vent settings
Vent: AC, FiO2 80%, PEEP 5, RR 12, TV 500
Gen: sedated
HEENT: clear OP, MMM, pinpoint pupils
Neck: supple, no LAD, unable to appreciated JVD. No carotid
bruits.
CV: irregularly irregular, normal S1/S2, no murmurs, rubs, or
gallops
Lungs: Bilateral breathsounds without wheezes, ronchi, or rales
appreciated
Abd: Soft, NABS, NT, ND, no HSM
Ext: No edema, 2+ DP pulses bilaterally. 1+ ankle edema
bilaterally
Skin: no lesions
Neuro: sedated
Pertinent Results:
[**2135-11-22**]
WBC-13.2*# RBC-4.58* HGB-14.0 HCT-41.3 MCV-90 MCH-30.7 MCHC-34.0
RDW-14.8
PLT COUNT-223
NEUTS-81.0* LYMPHS-15.7* MONOS-3.2 EOS-0.1 BASOS-0.1
PT-11.8 PTT-22.7 INR(PT)-1.0
CK(CPK)-40 cTropnT-<0.01 CK-MB-NotDone
GLUCOSE-116* UREA N-25* CREAT-0.8 SODIUM-139 POTASSIUM-3.9
CHLORIDE-93* TOTAL CO2-35*
TYPE-ART PO2-56* PCO2-79* PH-7.31* TOTAL CO2-42* BASE XS-8
[**11-22**] EKG: Sinus tachycardia with frequent PACs, rsr' in lead V1
ST-T wave changes, Since previous tracing, A-V association is
now present, inferior Q waves less apparent Clinical correlation
is suggested
[**11-22**] CTA chest:
1. No evidence of pulmonary embolism with slightly malpositioned
endotracheal tube and hyperinflated cuff, tip approximately 2 cm
above carina. These findings were discussed with the ordering
physician, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], on date of exam shortly after exam
acquisition.
2. 6mm left lower lobe pulmonary nodule with bilateral likely
pleural-based soft tissue densities. The pleural lesions appear
stable when compared to prior chest x- rays however in
combination with nodule and patient's history, a 3- month
followup non- contrast chest CT is recommended.
3. Bilateral emphysematous changes with nonspecific right and
left lower lobe patchy pulmonary opacities which may represent
areas of pneumonitis or early pneumonia.
4. Air pockets adjacent to subclavian [**Last Name (un) 21644**] bilaterally,
correlate clinically if line placement was attempted.
[**11-22**] echocardiogram: The left atrium is normal in size. There is
moderate regional left ventricular systolic dysfunction with
severe hypokinesis to akinesis of the basal one-half of the
anterior septum and anterior wall, and of the basal inferior and
inferolateral walls. Right ventricular chamber size and free
wall motion are normal. The aortic root is moderately dilated.
The aortic valve is not well seen, but color Doppler
interrogation reveals no significant aortic regurgitation. Mild
(1+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
[**11-30**] CT Abdomen/pelvis with contrast: .Partial or early small
bowel obstruction with a transition point in the terminal ileum.
No obvious source of obstruction is identified. Small amount of
free intraperitoneal fluid. Diverticulosis without evidence of
acute diverticulitis. Multifocal aspiration or atypical
pneumonia in the lung bases. Small bilateral pleural effusions.
Unchanged nonobstructing 3 mm stone in the right kidney.
Brief Hospital Course:
The patient was admitted to the medical intensive care unit,
where he was managed for COPD exacerbation (steroids),
congestive heart failure, and superimposed MRSA (broad spectrum
antibiotics). He was intially tolerating a combination of Bi-PAP
and FM after extubation [**2135-11-27**], but required re-intubation
after acute desaturation on [**12-1**] thought to be secondary to a
mucous plug. He also had dark guaiac positive bowel movement on
[**2141-12-3**] and again on [**12-5**] with Hct drop. He received 3
units PRBC's on [**12-4**]; GI was consulted and recommended PPI
therapy without invasive intervention in view of his respiratory
status. CT abdomen showed partial/early SBO on admission which
subsequently resolved per serial examinations. The patients
atrial fibrillation with RVR was difficult to control required
multiple nodal blocking agents including diltiazem gtt,
metoprolol and digoxin. In the setting of this, he developed
demand ischemia. The cardiology service was consulted, who
recommended medical therapy in view of his ongoing multiple
comorbidities. The [**Hospital 228**] health care proxy and primary care
physician met with the ICU team and, in view of pt's multiple
ongoing co-morbidities and poor prognosis, decided to pursue
comfort measures only. The patient was transferred to the
general medical floor on the evening of [**2135-12-8**] and was
pronounced dead on [**2135-12-9**] at 11:15 a.m. His health care proxy
was notified, who declined autopsy.
Medications on Admission:
albuterol
atrovent
diethylstilbestrol
diltiazem
colace
hydrochlorothiazide
atrovent
multivitamin
prednisone
ranitidine
hydralazine
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary: Respiratory failure
Secondary: COPD exacerbation, bacterial pneumonia, atrial
fibrillation, small bowel obstruction, gastrointestinal bleed
Discharge Condition:
Deceased
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
Completed by:[**2135-12-9**]
|
[
"V09.0",
"600.00",
"491.21",
"185",
"560.9",
"518.81",
"272.0",
"578.9",
"276.0",
"428.0",
"482.41",
"427.31",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"99.15",
"96.71",
"96.72",
"96.04",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7872, 7881
|
6197, 7691
|
358, 370
|
8073, 8234
|
3594, 6174
|
3042, 3063
|
7902, 8052
|
7717, 7849
|
3078, 3575
|
251, 320
|
398, 2551
|
2573, 2872
|
2888, 3026
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,739
| 168,599
|
17497
|
Discharge summary
|
report
|
Admission Date: [**2165-5-29**] Discharge Date: [**2165-5-30**]
Date of Birth: [**2093-3-27**] Sex: M
Service: MEDICAL INTENSIVE CARE UNIT
CHIEF COMPLAINT: Hypotension.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 38821**] is a 72 year-old male
with pancreatic cancer diagnosed in [**Month (only) 547**] when he presented
with abdominal pain and jaundice. He is status post
Gemcitabine. He presented to the hospital on [**5-29**] for
elective PICC placement for home intravenous fluid. A left
PICC was placed without immediate complications, however, on
the return trip home the patient felt dizzy and returned to
the hospital where he was found to be febrile with a
temperature to 102, hypotensive with blood pressure to 60/38
and tachycardia to the 130s. He responded to aggressive
fluid resuscitation and received Ceftriaxone, Levofloxacin,
Clindamycin and Ceftazidime in the Emergency Room. He was
then transferred stably to the Intensive Care Unit.
REVIEW OF SYSTEMS: He denies recent headache, neck
stiffness, rhinorrhea, sore throat or coughing. He does
report dyspnea on exertion ever since his diagnosis of
pancreatic cancer. He denies chest pain, orthopnea or
paroxysmal nocturnal dyspnea. He has chronic abdominal pain,
which has not changed in quality or severity. He denies
diarrhea, dysuria, skin rashes or skin breakdown.
PAST MEDICAL HISTORY:
1. Pancreatic cancer status post Gemcitabine therapy, which
was recently discontinued.
2. Renal cell carcinoma status post nephrectomy.
3. Prostate cancer status post prostatectomy.
4. Hypertension.
5. Hypercholesterolemia.
MEDICATIONS:
1. Lexapro 20 mg once a day.
2. MiraLax.
3. Colace 100 mg twice a day.
4. Oxycontin 20 mg three times a day.
5. Metoprolol 50 mg twice a day.
6. Compazine prn.
7. Oxycodone prn.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives with wife and worked for
treasury department. Wife is former RN. Prior smoker and
prior alcohol use.
PHYSICAL EXAMINATION: On examination temperature 97.6, heart
rate 82, blood pressure 102/55, respirations 18. Sating 99%
on 2 liters nasal cannula. In general the patient appeared
fatigued and in no acute distress. HEENT pupils are equal,
round and reactive to light. Oropharynx is clear. Mucous
membranes are moist. Neck no JVD, lymphadenopathy or
thyromegaly. Cardiac regular rate and rhythm. No murmurs,
rubs or gallops. Lungs crackles on the right side half of
the way up and crackles at the left base. Abdomen soft,
slightly distended and tympanic, mildly tender in the
bilateral lower quadrants. No percussion tenderness or
rebound. No hepatosplenomegaly. Normoactive bowel sounds.
Extremities no edema, 1+ distal pulses. Neurological Cranial
nerves II through XII intact. Motor grossly normal.
LABORATORY: White blood cell count 9.0, hematocrit 22.5, INR
1.5. His chemistries were within normal limits. Liver
function tests were within normal limits except for an
elevated alkaline phosphatase at 447, albumin 2.1, calcium
7.1, magnesium 1.5. Chest x-ray showed an opacity at the
right base. A KUB showed mildly dilated loop of small bowel.
ASSESSMENT/PLAN: The patient is a 73 year-old male
presenting with fever, hypotension and tachycardia.
HOSPITAL COURSE: 1. Hypotension: The patient was initially
felt to have evolving sepsis given accompanying fever and
question pneumonia on chest x-ray. He responded well to
intravenous fluids with stabilization of his blood pressure.
He did not require pressors. He was treated for the
pneumonia with Ceftriaxone and Azithromycin initially and
then switched to po Levofloxacin. Due to the constellation
of hypotension, fever, rapid improvement and history of
pancreatic cancer lower extremity dopplers were obtained and
revealed bilateral deep venous thrombosis in the right common
femoral vein and the left common femoral vein. He was
subsequently started on anticoagulation with heparin and
Coumadin.
2. Hypoxia: The patient initially required oxygen by nasal
cannula for oxygen supplementation, but over the course of
his hospitalization was able to be weaned to room air.
3. Anemia: The patient has had chronic anemia since his
cancer diagnosis and presented with a hematocrit of 22.5. He
was transfused with 2 units of packed red blood cells with
subsequent symptomatic improvement.
4. Pain management: The patient was continued on his
outpatient pain regimen of Oxycontin and Oxycodone.
5. Pancreatic cancer: The patient's prognosis is quite grim
at this point. He has had minimal response to chemotherapy.
After Dr. [**Last Name (STitle) **], his oncologist discussed the prognosis
with the family the patient and his wife opted for home with
hospice. His code status was changed to DNR/DNI.
DISCHARGE STATUS: Discharged to home with hospice.
DISCHARGE MEDICATIONS:
1. Lovenox 80 mg subq b.i.d. until INR therapeutic.
2. Coumadin 2.5 mg po once a day.
3. Levofloxacin 500 mg once a day for a seven day course.
4. Lexapro 20 mg po once a day.
5. Oxycontin and Oxycodone prn.
6. Sublingual morphine prn.
7. Ativan prn.
8. Levsin prn.
9. Colace 100 mg po twice a day.
10. Dulcolax 10 mg po or pr once a day prn.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**]
Dictated By:[**Name8 (MD) 4925**]
MEDQUIST36
D: [**2165-6-6**] 05:33
T: [**2165-6-12**] 06:42
JOB#: [**Job Number 48851**]
|
[
"453.8",
"197.7",
"415.19",
"276.5",
"285.9",
"401.9",
"272.0",
"799.4",
"157.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
4876, 5477
|
3296, 4853
|
2025, 3278
|
1005, 1374
|
174, 188
|
217, 985
|
1396, 1863
|
1880, 2002
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,042
| 188,285
|
33973
|
Discharge summary
|
report
|
Admission Date: [**2139-7-3**] Discharge Date: [**2139-7-15**]
Date of Birth: [**2102-9-23**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p Stab wound to abdomen
Major Surgical or Invasive Procedure:
[**2139-7-3**] Exploratory laparotomy
History of Present Illness:
36 yo male with PMHx of depression, EtOH abuse, manic
disorder admittted s/p assault with multiple stab wounds to
abdomen and left shoulder. Pt relates that that he had been
attacked by an associate of his friend on [**7-4**] in
[**Hospital1 **]. Pt had been drinking and was involved in an argument
with his friend. [**Name (NI) **] was stabbed multiple times following a
scuffle. Pt was taken to the OR upon admission for exploratory
laparotomy and incision and drainage of back stab wounds.
Past Medical History:
Bipolar disorder
Social History:
h/o substance abuse
Reportedly homeless
Family History:
Noncontributory
Pertinent Results:
[**2139-7-3**] 10:11PM GLUCOSE-120* UREA N-8 CREAT-0.6 SODIUM-145
POTASSIUM-4.1 CHLORIDE-114* TOTAL CO2-22 ANION GAP-13
[**2139-7-3**] 10:11PM CALCIUM-8.0* PHOSPHATE-4.1 MAGNESIUM-1.5*
[**2139-7-3**] 10:11PM WBC-14.0*# RBC-3.46* HGB-10.7* HCT-32.5*
MCV-94 MCH-31.1 MCHC-33.1 RDW-12.9
[**2139-7-3**] 10:11PM PLT COUNT-251
[**2139-7-3**] 06:30PM ASA-NEG ETHANOL-288* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2139-7-7**] 6:43 AM
No prior CTs available for comparison.
FINDINGS:
The heart is normal in size. There is no pericardial effusion.
The tracheobronchial tree is patent. There are multiple mildly
enlarged mediastinal lymph nodes. For the example, the largest
lymph node in the pretracheal region measures 0.9 cm in short
axis and 1.8 cm in long axis. There is an enlarged right hilar
lymph node that measures 1.0 cm in short axis and 2.0 cm in long
axis. Numerous prevascular, subcarinal and paratracheal lymph
nodes are noted that measure less than 1 cm in greatest
dimension.
Several small bilateral axillary lymph nodes are seen. Most of
these lymph nodes, however, contain fatty hila, small part of
normal internal architecture. The largest lymph node is seen in
the right axilla measures 0.8 x 1.2 cm.
The heart is normal in size. There is no pericardial effusion.
The tracheobronchial tree is patent. The aorta and pulmonary
arteries are normal in caliber. There is no evidence of
pulmonary embolism.
Examination of the lung windows demonstrate several bullae in
paraseptal location at both lung apices.
There are scattered bilateral patchy opacities in both upper and
lower lobes as well as bibasilar patchy consolidations involving
short aspects of both lower lobes. This may be of either
infectious or inflammatory in etiology.
There are several pockets of gas in the left axilla. This may be
either iatrogenic or related to recent stab wound.
There is no evidence of pneumothorax.
BONE WINDOWS: No suspicious lytic or sclerotic lesions are
identified. There is a small, somewhat rounded 6 mm lucency in
the sternum (series 3, image 48), which most likely reflects a
focal area of rarefaction in a patient without known malignancy.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Bilateral patchy opacities in both upper and lower lobes,
which may be either infectious or inflammatory in etiology.
3. Enlarged mediastinal and right hilar lymph nodes. A followup
dictated chest CT is recommended when the patient's condition
improved, to evaluate for interval change of pulmonary opacities
and lymphadneopathy.
4. Several gas pockets in the soft tissues of the left axilla
which may iatrogenic or may also be related to a recent stab
wound.
CT CHEST W/CONTRAST [**2139-7-12**] 11:50 AM
CT OF THE CHEST: The paratracheal lymph nodes seen on the prior
study are unchanged in size. There are some small prevascular
and AP window lymph nodes. The heart, pericardium, and great
vessels appear unremarkable. The central airways are patent
without endoluminal lesion.
In the lungs, again seen are bullous changes along the medial
aspect of the right upper lobe. There has been worsening of
ground-glass opacities, now involving a large portion of the
left upper lobe, which were previously much more focal, and
there has been coalescence into a more consolidative focal
opacity in the posterior left upper lobe with air bronchograms
(series 2, image 27). However, in the right upper lobe, there
has been improvement in the multiple opacities seen previously,
which are now more ground-glass in appearance rather than dense
as they were on the prior study. See for example series 2, image
17. More inferiorly, in the right middle lobe, there has also
been slight improvement with a more ground-glass rather than
dense consolidative appearance compared to the previous study.
In the left lower lobe; however, the ground-glass opacities
appear to have slightly worsened and are more extensive
involving the superior segment now to a greater degree than
previously, and the consolidative focal area of opacity in the
left base appears roughly stable though slightly changed in
configuration. There are small bilateral pleural effusions. In
the right lower lobe, areas of more linear opacity have
improved, which were probably atelectatic in nature.
CT OF THE ABDOMEN: There has been a midline incision with skin
staples still noted. There is a small amount of postoperative
fluid just inferior to the incision line with a focal area along
the inferior incision, where the staples have been removed.
Within the left lobe of the liver, there is a fluid collection
measuring 3.8 x 2.9 cm with small foci of air within it
non-dependently. Just posterior and possibly continuous with
this, there is a second fluid collection measuring 3.6 x 2.6 cm,
also with a small focus of air within it and probably within the
liver capsule as well (series 2, image 65). Apart from these
areas, there is no free intra-abdominal air remaining. There
remains mesenteric stranding, particularly in the anterior
abdomen along the area of incision. The gallbladder, adrenal
glands, spleen, pancreas, and kidneys appear unremarkable. Small
retroperitoneal and mesenteric nodes are identified, measuring
up to 9 mm. A small amount of ascites tracks into the pelvis.
The abdominal aorta is of normal caliber. The portal vein is
patent. Loops of small and large bowel appear normal in caliber
and contour. The appendix appears normal. Contrast flows freely
past the stomach, and has reached the rectum.
CT OF THE PELVIS: The bladder, prostate, seminal vesicles, and
rectum are unremarkable. As above, there is a small amount of
free fluid in the pelvis. There is no lymphadenopathy. As
described above, there is a small amount of fluid just under the
area of incision along the abdominal and pelvic midline, which
is probably related to postoperative seroma, although infection
cannot be excluded.
OSSEOUS STRUCTURES: There are no concerning lytic or sclerotic
lesions. There are no fractures apparent.
Within the dermis of the posterior left chest, just behind the
scapula, there are two radiodensities, which are somewhat linear
and may represent a skin staples. Please correlate with exam.
IMPRESSION:
1. Multifocal ground-glass and patchy opacities involving both
lungs, some areas which have demonstrated improvement in the
right lung, however, some areas in the left lung which have
worsened since the previous study.
2. Fluid collections with small foci of air as above within the
left lobe of the liver. A small pocket of fluid just under the
incision line in the lower abdominal/pelvic midline. Infection
in these areas cannot be excluded.
3. No residual free intraperitoneal air. Small amount of free
fluid in the pelvis.
GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I) [**2139-7-13**] 11:09
AM
ULTRASOUND-GUIDED LIVER ASPIRATION: The risks and benefits of
the procedure were explained to the patient, and written
informed consent was obtained. A preprocedure timeout was
performed using two patient identifiers. Preprocedure scanning
demonstrates a 3-cm heterogeneous predominantly cystic
collection in the left lobe of the liver. Posterior to this
collection is an ill-defined echogenic area, likely
corresponding to the additional collection seen on CT. A
suitable spot was chosen in the mid abdomen for drainage. The
area was prepped and draped in standard sterile fashion. 1%
lidocaine was instilled for local anesthesia. Using ultrasound
guidance, a 20-gauge spinal needle was advanced into the
collection and approximately 5 cc of bloody fluid was aspirated
with near complete collapse of the fluid collection. The sample
was sent for microbiologic analysis. The patient tolerated the
procedure well with no immediate complications. Moderate
sedation was provided using 2 mg of Versed and 100 mcg of
fentanyl in divided doses, and the patient's hemodynamic
parameters were monitored continuously throughout the 20 minute
intraservice time. The attending radiologist, Dr. [**Last Name (STitle) **], was
present and supervising throughout.
IMPRESSION: Successful ultrasound-guided aspiration of left
hepatic fluid collection, with drainage of 5 cc of bloody fluid,
sent for microbiologic analysis.
Brief Hospital Course:
He was admitted to the Trauma service and taken to the operating
room urgently for
exploratory laparotomy, oversewing of stomach laceration,
control of liver laceration bleeding and irrigation and closure
of left chest laceration. There were no reported complications.
Postoperatively he was taken to the Trauma ICU where he remained
for several days.
He was later transferred to the regular nursing unit. He did
have significant pain management issues; initially he was on PCA
narcotics with IV for breakthrough and once he was able to
tolerate po's he was changed to short acting narcotics. He
required higher doses of the oral narcotics and was changed to
long acting narcotics. He was noted to become very sleepy with
higher doses of short acting narcotics. The Acute Pain Service
was consulted to optimize his pain regimen; Neurontin and
NSAID's were added.
He was noted with a fever spike to >103 F; he was cultured,
chest xray done which revealed a significant pneumonia. He was
treated with IV antibiotics but continued to have fevers.
Infectious Disease was the consulted and made several
recommendations regarding his antibiotics, including oral
antibiotics that he was discharged on (Levo & Flagyl for 14
days).
Despite his fevers and consistent reinforcement from medical and
nursing staff he contiued to leave the hopsital to smoke
cigarettes; he did this multiple times during the day. At one
point security officers had to be called and assisted with
returning patient back to his room.
Social work was closely involved during his hospital stay
because of issues surrounding his substance use, nature of the
trauma and his homeless situation. A safe discharge plan was
formulated.
Discharge Medications:
1. Buspirone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
2. Risperidone 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
3. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
Disp:*120 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 weeks.
Disp:*42 Tablet(s)* Refills:*0*
8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
9. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
10. Motrin 600 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain: take with food.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Stab wound to abdomen
Liver laceration
Pneumonia
Discharge Condition:
Good
Discharge Instructions:
Continue with the antibiotics as prescribed for the next 2
weeks, complete the entire course.
Return to the Emergency room if you develop any fevrs, chills,
headache, dizziness, increased shortness of breath, productive
cough, chest pain, abdominal pain different from the pain you
have been experiencing [**Last Name (un) 5720**] your recent surgery, nausea,
vomiting, diarrhea, increased redness or drainage from your
incision and/or any otehr symptoms that are concerning to you.
Followup Instructions:
Follow up next wek with Dr. [**Last Name (STitle) **] in Surgery clinic, call
[**Telephone/Fax (1) 2359**] for an appointment.
Follow up in the Pain Clinic in the next 1-2 weeks, call
[**Telephone/Fax (1) 1652**] for an appointment.
Completed by:[**2139-7-16**]
|
[
"E878.8",
"305.1",
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"875.0",
"507.0",
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icd9cm
|
[
[
[]
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[
"50.91",
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|
[
[
[]
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12273, 12279
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295, 334
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230, 257
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362, 858
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,898
| 164,523
|
2442
|
Discharge summary
|
report
|
Admission Date: [**2180-11-21**] Discharge Date: [**2180-11-25**]
Date of Birth: [**2105-4-3**] Sex: M
Service: MEDICINE
Allergies:
Motrin / Ambien
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
syncope, chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization
EGD
History of Present Illness:
Patient was admitted today to [**Hospital1 1516**] and being transferred to CCU.
Please refer to [**Hospital1 1516**] note for further detail.
In brief, Mr. [**Known lastname **] is a 75 yo male with CAD s/p MI and CABG in
[**2162**] (LIMA-LAD, SVG-OM1-OM2, occluded SVG - PDA), s/p two cypher
stents to SVG-OM1-OM2 graft in [**2175**], HTN and HLD. He was
transferred from OSH after a syncope at 3 am this morning. EKG
in ED showed evidence of a recent IMI (new Q waves with residual
ST elevations).
.
Per [**Hospital1 1516**] admission note, urgent cath showed occlusion of the
jump segment of his SVG-OM1 graft, which was stented
successfully with 2 drug-eluting stents. However, the OM1 was
jailed and could only be rescued to TIMI 2 flow.
.
On the floor today, he had one episode of chest pain in the
afternoon which resolved with sublingual nitro after which he
had SBP 70s; this resolved. He had no recurring chest pain
during the day. This evening at 9PM, he tried to get out of bed
to use commode. Eyes rolled back into head, became unresponsive,
SBP 70s with no change in rate. Was placed in Trendelenberg, was
given IVF, woke up on his own.
.
Upon interview by resident, patient was awake, oriented,
comfortable, angry about lab draws and denied any chest pain
during episode. Tele was not caught at time of episode because
he was getting up to use the bathroom.
.
Patient was fatigued and did not want to share history on
admission to CCU. He did deny chest pain. Per admission note, he
complains of chronic fatigue but found that 1-2 weeks ago he
started to have shortness of breath to the degree that he was
only able to walk a few steps. Of note, the patient paused
aspirin and plavix three weeks ago for 12 days for his laser BPH
surgery.
Past Medical History:
- CAD s/p MI and CABG in [**2163**] (LIMA-LAD, SVG-OM1-OM2, occluded
SVG - PDA), s/p two cypher stents to SVG-OM1-OM2 graft in [**2175**].
- HTN
- HLD
- Cardiomyopathy (EF 40-45%)
- Tachybrady syndrome due to SSS s/p [**Company 1543**] Adapta
dual-chamber pacemaker ([**2166**])
- GERD
- OSA on CPAP
- Panhypopituitarism s/p large pituitary adenoma w/ pituitary
apoplexy and hemmorhage s/p resection ([**2152**]) on hormone
replacement w/ hydrocortisone, levothyroxine and testosterone
- Chronic renal insufficiency
- Blindness of right eye ([**2152**])
- Cataract left eye
- Polyps in vocal cords
- Otosclerosis
- Chronic pancreatitis (from unknown cause)
- Gammopathy of unknown significance
- Neuropathy in lower extremities
- BPH s/p laser surgery
- Osteopenia
- h/o gastric ulcers
- s/p cholecystectomy
- h/o depression
- h/o restless legs disorder
Social History:
He stopped smoking 23 years ago but has a history of 80 pack
years (32 years x 2.5 p/d). He does not drink any alcohol. No
illicit drug use. Retired. He was a shipyard worker. He
completed some college and also has an accounting background.
Family History:
His mother died at 62 of heart failure. His father died at 48 of
lung cancer. He has 2 sisters, one of whom has well controlled
hypertension. He has a 45-year-old daughter also with an
otosclerosis. He has a son with high cholesterol and depression.
He has three grown children and seven grandchildren.
Physical Exam:
GENERAL: Comfortably, in NAD. Oriented x3.
HEENT: Dry mucous membranes. Per [**Hospital1 1516**] notes: Blind on right eye,
Bitemporal hemiquadrantopsia
CARDIAC: RR, normal S1, S2. No m/r/g.
LUNGS: CTAB anteriorly. Exam was difficult because patient had
to lie flat.
ABDOMEN: Soft, NTND.
EXTREMITIES: No LE edema. R sided groin site clean, no oozing or
ecchymosis. 2+ pedal pulses.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
.
LABS/STUDIES
EKG ([**2180-11-21**]): Heart Rate: 59, Inferior Q waves with 1/2 MM STE
II,III, repeat EKG with hypotension shows STE in < 1mm II, and
II
Pertinent Results:
[**11-21**] CARDIAC CATHETERIZATION:
COMMENTS:
1. Coronary angiography in this left dominant system
demonstrated three
vessel disease. The LMCA, LAD, and LCx were known to be occluded
and
were not evaluated. The RCA was a small, non-dominant vessel
with
diffuse disease.
2. Arterial conduit angiography demonstrated that the
SVG-OM1-OM2 was
occluded at the segment from OM1-OM2. The SVG-PDA was not
accessed as it
was known to be occluded. The LIMA-LAD was not engaged.
3. Limited resting hemodynamics revealed normal systemic
arterial blood
pressure with SBP 105mmHg and DBP 52mmHg.
4. Successful PTCA and stenting of the jump segment of
SVG-OM1-OM2 with
two overlapping 3.0x28mm Promus drug eluting stents.
5. Successful rescue of jailed OM1 with PTCA alone restoring
TIMI 2
flow.
6. Successful closure of right femoral arteriotomy with 6F
angioseal.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Occluded OM1-OM2 jump graft.
3. Successful PCI of SVG-OM1-OM2 with DES x2 overlapping.
4. Successful rescue of jailed OM1 with PTCA alone restoring
TIMI2 flow.
5. Successful RFA angioseal.
[**11-23**] ECHO
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. LV systolic function appears moderately-to-severely
depressed (ejection fraction 30 percent) secondary to
akinesis/dyskinesis of the inferior and posterior walls. There
is no ventricular septal defect. Right ventricular chamber size
is normal. 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. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. Trivial mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is no pericardial effusion.
Compared with the findings of the prior report (images
unavailable for review) of [**2180-4-12**], the left ventricular
ejection fraction is further reduced.
EGD [**11-24**]
Impression: Small hiatal hernia
Irrregular z-line noted and patchy areas of erythema consistent
with esophagitis was noted at GE junction. A single tongue of
salmon colored mucosa was noted at the GE junction suggesting
possible Barrett's esophagus.
Erythema in the antrum compatible with antral gastritis
4 mm ulcer in the pre-pyloric region
Otherwise normal EGD to third part of the duodenum
Recommendations: Recommend continuing protonix at 40 mg PO bid.
Patient will need outpatient GI follow up for testing for
H.pylori by H.pylori breath test and treat if necessary.
Will need repeat endoscopy after 2 months to ensure ulcer
healing.
DISCHARGE LABS:
Brief Hospital Course:
Mr. [**Known lastname **] is a 75 yo male with CAD (s/p CABG x4 [**2162**], s/p two
cypher stents to SVG-OM1-OM2 in [**2175**]), HTN and HLD who was
transferred from OSH after an episode of syncope and chest pain
whose cath showed occlusion of the jump segment of his SVG-OM1
graft which was subsequently dilated.
.
# SYNCOPE: Managed empirically on stress dose steroids in the
setting of a known history of panhypopituitarism until the
patient's Hct dropped to 24.5 from 32 at baseline and was found
to have melena. At that time he was transfused 2 units of pRBCs
and started on an IV PPI; GI was subsequently consulted. The
patient's Hct responded appropriately to the transfusion, he was
transfused a further 1 unit of pRBCs and transitioned to PO
Protonix, and stress dose steroids were stopped; He had EGD with
GI here which showed ulcer in the pre-pylorus with non-active
bleeding. His Famotidine was stopped and Protonix started on
discharge.
.
# Inferior STEMI: Patient underwent a Cath for ST elevations
suggestive of an inferior MI. Please see cath report for full
details. In brief, Patient was noted to have three vessel
coronary disease, occluded OM1-OM2 jump graft, successful PCI of
SVG-OM1-OM2 with DES x2 overlapping, and successful rescue of
jailed OM1 with PTCA alone restoring TIMI2 flow. He was
continued on ASA, Plavix, Statin. He was changed from Atenolol
to Toprol XL to maximize [**Hospital 1902**] medical management. He was not
started on an ACE inhibitor due to his elevated Creatinine level
of 1.4.
.
#Chronic Systolic Heart Failure: Last known EF is 40-45% in
[**4-/2180**], and a repeat ECHO this admission demonstrated an EF of
30%. Please see TTE report for full details.
# Chronic renal insufficiency: His creatinin on admission was
1.4 which is his baseline. Possibly this is due to his
gammopathy of unknown significance. Remained stable.
.
# Panhypopituitarism: Patient was given one time dose hydrocort
50 IV on transfer to CCU but then continued on home standing
doses. Continued levothyroxine, held testosterone while
inpatient but restarted on discharge.
Medications on Admission:
ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - PO daily
CLOPIDOGREL [PLAVIX] - 75 mg Tablet - 1 Tablet(s) PO daily
ATENOLOL - 50 mg Tablet - [**2-12**] Tablet(s) by mouth once a day
SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day
URSODIOL - (Prescribed by Other Provider) - 300 mg Capsule - 1
Capsule(s) by mouth q8
FAMOTIDINE - 40 mg Tablet - one Tablet(s) by mouth once daily in
the morning
GABAPENTIN - 400 mg Capsule - 1 Capsule(s) PO 3 times daily
HYDROCORTISONE - 10 mg Tablet - 1 Tablet(s) by mouth 2 tabs in
the morning, and [**2-12**] tab in the afternoon - No Substitution
LEVOTHYROXINE [LEVOXYL] - 125 mcg Tablet - 1 Tablet(s) by mouth
daily - No Substitution
TESTOSTERONE [ANDROGEL] - 50 mg/5 gram (1 %) Gel in Packet - one
daily. (5 grams per day total)
CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - 1,000 mcg/mL
Solution - Inject 1000mcg IM monthly as directed
CALCIUM CARBONATE [CALTRATE 600] - 2 x 2/day
FOLIC ACID - 0.4 mg Tablet - 3 Tablet(s) by mouth once a day
MULTIVITAMIN - (OTC) - Tablet - 1 Tablet(s) by mouth daily
OMEGA-3 FATTY ACIDS-VITAMIN E [OMEGA-3 FISH OIL] - (OTC; 1200mg
daily) - Dosage uncertain
Discharge Medications:
1. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
6. hydrocortisone 5 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
7. hydrocortisone 20 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
8. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. AndroGel 1 %(50 mg/5 gram) Gel in Packet Sig: One (1)
Transdermal once a day.
10. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: One
(1) Injection once a month.
11. calcium carbonate 600 mg (1,500 mg) Tablet Sig: One (1)
Tablet PO once a day.
12. folic acid 400 mcg Tablet Sig: Three (3) Tablet PO once a
day.
13. omega-3 fatty acids Capsule Sig: One (1) Capsule PO
DAILY (Daily).
14. Protonix 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*
15. multivitamin Oral
16. metoprolol succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Acute on Chronic Systolic Congestive Heart Failure
Gastrointestinal Bleeding
Recent ST Elevation Myocardial Infarction
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 to take care of you in the hospital. You were
admitted because you fainted. In the hospital, we were concern
that your symptoms were due to cardiac ischemia and so we did a
procedure called a cardiac catheterization to open up a blockage
in your heart. This procedure went well and stents were placed
to keep the blocked artery open. After the procedure, we
discovered that you had a bleed from and ulcer in your stomach.
This likely happened because you were on blood thinning
medications. We believe this bleeding has stopped. You will
followup with GI. Your blood levels have remained stable.
Because you have heart failure, please weigh yourself every
morning, call Dr. [**Last Name (STitle) 171**] if weight goes up more than 3 lbs in 1
day or 5 pounds in 3 days.
At your next cardiology visit or PCP visit, please have your
physician discuss ACE inhibitor treatment. You were not started
on this medication prior to discharge due to an elevated
creatinine level.
Also, please make the following changes to your medications:
STOP Famotidine and START Protonix 40 mg twice daily
STOP Atenolol and START Toprol XL 25 mg once daily
No other changes were made to your medications.
Finally, please go to all of the followup appointments that are
listed below. Please call Dr.[**Name (NI) 5103**] office to see if your
cardiology appointment can be rescheduled for the next 7 to 10
days.
Followup Instructions:
Primary Care:
Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) **]
Phone: [**Telephone/Fax (1) 9347**]
Date/Time: [**12-8**] at 10:00am
.
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2180-11-28**] at 11:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12538**], M.D. [**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: CARDIAC SERVICES
When: WEDNESDAY [**2180-12-13**] at 9:00 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2180-12-13**] at 9:40 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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|
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11645, 11694
|
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|
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13092, 13453
|
238, 259
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354, 2113
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11872, 12016
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|
3008, 3250
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,278
| 184,626
|
22812
|
Discharge summary
|
report
|
Admission Date: [**2102-12-11**] Discharge Date: [**2102-12-20**]
Date of Birth: [**2055-5-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
thoracocentesis, pleuredesis, thoracoscopy
History of Present Illness:
PGY-1 Accept note
Spoke with admitting moonlighter and confirmed relevant apsects
of HPI and PMH with pt., as outlined in the excellent admit
note. In brief, Mr. [**Known lastname **] is a 47yo with metastatic RCC who has
failed sugen and most recently 1 month of sorafenib therapy that
was discontinued [**12-4**] [**3-16**] increased left sided pain,
constipation, general fatigue. He continued to feel worse, with
increased dyspnea, first on exertion then at rest. Over the
last week, he has also developed increasing abdominal girth
which he attributes to gas, and bilateral LE edema, which he has
never had before. CT in ED showed increased interval increase
in size of metastatic lesions, R sided pleural effusion, and new
ascites. He was tapped 2.5L of serosanguinous fluid, exudative
by light's criteria, likely malignant. Post-thoracentesis CXR
still shows nearly complete white out of L lung field.
Currently, pt. states he feels much better than last night. He
denies, CP, HA, confusion, nausea currently. Did have some
diarrhea o/n yesterday, likely [**3-16**] kayexylate and po contrast.
He does state he is thirsty.
Past Medical History:
metastatic RCC as noted in Oncologic History
CAD s/p CABG [**2091**]
HTN
hypercholesterolemia
DVTs
Social History:
lives upstairs from mother, divorced with 3 children,
girlfriend [**Name (NI) 1258**], + [**Name2 (NI) **], no etoh
Family History:
nc
Physical Exam:
Afebrile o/n now T: 96.2 BP: 109/85 HR: 110, RR:20 02 sat 96%
on 4L
Gen: tired, ill appearing man, breathing comfortably, no
retractions, able to speak full sentences.
HEENT: anicteric, PERRLA, EOMI, MMM, OP clear
Neck: Supple, no [**Doctor First Name **]
CV:: tachycardic, occ. s3 vs. split s2, no murmurs, rubs
Chest: Absent BS on L from posterior, dull to percussion to [**2-13**]
lung. Wheezes, crackles at apex anteriorly. R side clear without
wheezes, crackles
Abd:: Soft, moderately distended, no focal TTP, though has some
gneralized discomfort when palpated. + BS. Able to faintly
palpate mass vs. spleen in his mid/left abdomen. Liver span wnl.
Ext: 2+ pitting edema to knees bilaterally, R>L edema, no calf
tenderness.
Pertinent Results:
[**2102-12-11**] 04:30PM CALCIUM-8.8
[**2102-12-11**] 04:30PM LIPASE-37
[**2102-12-11**] 04:30PM ALT(SGPT)-188* AST(SGOT)-90* ALK PHOS-423*
AMYLASE-29 TOT BILI-0.3
[**2102-12-11**] 04:30PM GLUCOSE-100 UREA N-41* CREAT-1.1 SODIUM-120*
POTASSIUM-6.3* CHLORIDE-94* TOTAL CO2-20* ANION GAP-12
[**2102-12-11**] 04:39PM HGB-13.2* calcHCT-40
[**2102-12-11**] 04:39PM K+-5.8*
[**2102-12-11**] 08:28PM PT-12.8 PTT-22.1 INR(PT)-1.1
[**2102-12-11**] 08:28PM PLT SMR-LOW PLT COUNT-120*
[**2102-12-11**] 08:28PM NEUTS-89* BANDS-4 LYMPHS-2* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-3* MYELOS-0
[**2102-12-11**] 08:28PM WBC-7.4 RBC-3.99* HGB-12.2* HCT-34.6* MCV-87
MCH-30.5 MCHC-35.2* RDW-19.2*
[**2102-12-11**] 08:28PM LIPASE-37
[**2102-12-11**] 08:28PM ALT(SGPT)-186* AST(SGOT)-95* AMYLASE-28 TOT
BILI-0.3
[**2102-12-11**] 08:28PM GLUCOSE-87 UREA N-37* CREAT-1.0 SODIUM-123*
POTASSIUM-6.5* CHLORIDE-91* TOTAL CO2-22 ANION GAP-17
[**2102-12-11**] 08:29PM NA+-122* K+-6.2*
[**2102-12-19**] 03:56AM BLOOD WBC-7.5 RBC-2.97* Hgb-9.0* Hct-26.9*
MCV-90 MCH-30.2 MCHC-33.4 RDW-19.4* Plt Ct-112*
[**2102-12-12**] 04:00AM BLOOD Fibrino-604* D-Dimer-5305*
[**2102-12-19**] 03:56AM BLOOD Glucose-111* UreaN-76* Creat-2.7* Na-130*
K-5.6* Cl-100 HCO3-17* AnGap-19
[**2102-12-19**] 03:56AM BLOOD Calcium-8.0* Phos-5.6* Mg-2.4
[**2102-12-18**] 11:16AM BLOOD Lactate-1.3
.
CT torso:
CT CHEST WITH IV CONTRAST: There is a markedly enlarged left
pleural effusion occupying the majority of the left hemithorax,
causing shift of the mediastinum rightward. This limits detailed
evaluation of mediastinal lymph nodes. The heart is normal in
size. The great vessel are grossly unremarkable. There is
compression of the distal left pulmonary arterial vasculature
given large left pleural effusion. There is a large pericardial
lymph node, increased in size compared to prior study, today
measuring 21 mm in shortest axis, previously 8 mm.
CT ABDOMEN WITH CONTRAST: The liver is unremarkable. The
gallbladder is within normal limits. The pancreas appears
stable. Surrounding the pancreas are multiple metastatic lesions
also encasing the celiac axis, SMA and periportal regions which
overall appears increased in size and extent compared to
[**2102-10-30**]. There is no overt demonstration of vascular
occlusion.
Patient is status post left nephrectomy. The left adrenal lesion
previously seen today appears slightly larger in size and little
more hypovascular, which could represent necrotic change of a
metastatic lesion. The left retroperitoneal aggregate of soft
tissue density consistent with metastatic mass is similar in
size today, measuring 81 x 53 mm, previously 86 x 45 mm. The
retroperitoneal lymphadenopathy extending along the course of
nearly the entire aorta is also similar in size.
There has been interval new development of a small-to-moderate
amount of ascites.
CT PELVIS WITH IV CONTRAST: The urinary bladder wall is slightly
thickened, as demonstrated on prior studies. There are multiple
inguinal and iliac enlarged lymph nodes, with similar appearance
in size compared to [**2102-10-30**]. The rectum, sigmoid
colon, prostate are unremarkable.
BONE WINDOWS: There are mixed sclerotic and lytic changes seen
within the L4 vertebral body, similar in appearance compared to
prior study, concerning for metastatic focus. There are no new
suspicious lytic or sclerotic bony lesions.
IMPRESSION:
1. Large dense left pleural effusion with significant rightward
shift of the mediastinum. These findings were discussed with Dr.
[**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) 334**] at 10:00 p.m. on [**2102-12-11**].
2. Interval progression of metastatic disease manifested by a
large left pleural effusion and new-onset ascites.
3. Overall, slight interval increase in size of soft tissue
metastatic lesions within the chest, abdomen, and pelvis.
.
Bilateral LE, no signs of DVT
Brief Hospital Course:
Patient is a 47 yo male who was initially admitted with
worsening shortness of breath. He was first admitted to medical
services and then after repeat thoracentesis and pleuradesis on
[**12-14**] with prolonged hypotension he was transferred to the ICU.
ICU Issues included hypotension, hyponatremia and
thrombocytopenia as well as management of pleural effusions.
Hypotension was managed with fluid boluses, hyponatremia
improved with saline. Thrombocytopenia was thought secondary to
splenic squestration as HIT antibodies were negative. Patient
was maintained on a chest tube post procedure with continued
output until it was self-discontinued.
Despite medical management, the patient continued to have
dyspnea as well as poor liver and kidney function and worsening
of mental status.
Given that the CT done on [**12-11**] showed significant worsening of
his metastatic disease and that the patient had failed multiple
chemotherapeutic regimens, the decision was made to direct the
care towards comfort after discussions with family and the
patient. Patient was being screened for hospice care and
palliative care had been consulted. However, patient deceased
in hospital on [**12-20**].
Medications on Admission:
sutent 50mg (off since [**2102-12-4**])
zofran 8mg q8h
oxycontin 60mg [**Hospital1 **]
oxycodone 5mg q6hprn
neurontin 400mg [**Hospital1 **]
dilaudid 4mg q6h
dexamethasone 4mg tid
zestril 10mg
zocor
Discharge Medications:
none
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Metastatic renal carcinoma
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
n/a
|
[
"197.2",
"584.9",
"253.6",
"189.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.24",
"34.04",
"34.92"
] |
icd9pcs
|
[
[
[]
]
] |
7988, 8007
|
6512, 7709
|
325, 369
|
8077, 8087
|
2584, 6489
|
8144, 8150
|
1812, 1816
|
7959, 7965
|
8028, 8056
|
7735, 7936
|
8111, 8121
|
1832, 2565
|
278, 287
|
397, 1539
|
1561, 1662
|
1678, 1796
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,041
| 181,738
|
7916+55892
|
Discharge summary
|
report+addendum
|
Admission Date: [**2141-4-11**] Discharge Date: [**2141-4-23**]
Date of Birth: [**2081-3-17**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Acute pancreatitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 60 yo man with PMH of anoxic brain injury in [**2116**]
during
varicocele surgery with subsequent action myoclonus and seizure
disorder (on depakote). He presented to the ED with epigastric
pain
and is found to have pancreatitis. His symptoms were associated
with nausea and vomiting. His pain is severe and radiates
throughout his abdomen. No fevers or chills. No diarrhea or
constipation. No BRBPR. No CP, SOB, cough, or dysuria.
Past Medical History:
1. HTN
2. hypercholesterolemia
3. DM type II
4. h/o anoxic brain injury s/p intraoperative MI in [**2116**] during
varicocele surgery
5. Depression, with h/o SI and ~15 psych admissions in the past
6. Anxiety and panic attacks
7. Peripheral neuropathy
8. L5 radiculopathy on left with chronic LBP
9. GERD
10. action myoclonus (on klonapin and valproate)
Social History:
From [**Male First Name (un) 1056**]. Graduated from [**Initials (NamePattern4) **] [**Male First Name (un) 1056**]. Was a physical
education teacher but can no longer work [**12-31**] physical
disability. Divorced, lives alone, son living in [**Name (NI) **]
state and daughter living in [**Male First Name (un) 1056**] with his ex- wife. [**Name (NI) **]
not smoked or had EtOH since [**2116**]. Has 2 PCAs to assist with
ADLs.
Family History:
NC
Physical Exam:
96.6, 91, 132/82, 13, 99% NRB
GEn: NAD, appears comfortable and nontoxic, anicteric
Chest: decreased breaths sound at bases
CV: RRR
Abd: moderately distended, tender in epigastric area, nonrigid,
no guarding
Guaiac negative
Ext: warm and well perfused
Pertinent Results:
[**2141-4-11**] 04:15PM BLOOD WBC-16.7*# RBC-4.86 Hgb-14.6 Hct-43.5
MCV-90 MCH-30.1 MCHC-33.6 RDW-13.8 Plt Ct-227
[**2141-4-17**] 06:20PM BLOOD WBC-10.3 RBC-3.00* Hgb-9.3* Hct-26.9*
MCV-90 MCH-31.1 MCHC-34.7 RDW-14.3 Plt Ct-161
[**2141-4-20**] 05:35AM BLOOD WBC-10.8 RBC-3.34* Hgb-9.9* Hct-29.9*
MCV-90 MCH-29.7 MCHC-33.2 RDW-14.1 Plt Ct-177
[**2141-4-12**] 03:15AM BLOOD Glucose-294* UreaN-21* Creat-1.0 Na-140
K-7.2* Cl-110* HCO3-20* AnGap-17
[**2141-4-20**] 05:35AM BLOOD Glucose-143* UreaN-13 Creat-0.5 Na-137
K-3.4 Cl-100 HCO3-24 AnGap-16
[**2141-4-11**] 04:15PM BLOOD ALT-60* AST-95* LD(LDH)-220 CK(CPK)-139
AlkPhos-89 Amylase-4695* TotBili-0.4
[**2141-4-14**] 02:41AM BLOOD ALT-97* AST-60* LD(LDH)-351* AlkPhos-64
Amylase-415* TotBili-0.8
[**2141-4-20**] 05:35AM BLOOD ALT-20 AST-28 LD(LDH)-344* AlkPhos-163*
Amylase-106* TotBili-0.6
[**2141-4-11**] 04:15PM BLOOD Lipase-[**Numeric Identifier 4731**]*
[**2141-4-13**] 03:24AM BLOOD Lipase-816*
[**2141-4-20**] 05:35AM BLOOD Lipase-34
[**2141-4-20**] 05:35AM BLOOD Calcium-8.7 Phos-4.1 Mg-1.8
[**2141-4-12**] 09:15AM BLOOD Triglyc-163*
[**2141-4-13**] 03:24AM BLOOD TSH-1.3
[**2141-4-11**] 04:15PM BLOOD Valproa-93
[**2141-4-11**] 04:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
US ABD LIMIT, SINGLE ORGAN [**2141-4-11**] 6:43 PM
IMPRESSION: No evidence of cholelithiasis or acute
cholecystitis.
.
CT ABDOMEN W/CONTRAST [**2141-4-11**] 4:27 PM
IMPRESSION: Moderate amount of fluid and fat stranding
surrounding the pancreas consistent with acute pancreatitis. No
secondary complications of pancreatitis identified at this time.
.
CHEST (PORTABLE AP) [**2141-4-13**] 11:18 AM
IMPRESSION: No newly appeared parenchymal opacities.
.
CHEST (PORTABLE AP) [**2141-4-17**] 4:05 AM
As compared to the previous examination, there is a minimal
increase in density of the left perihilar lung areas. Otherwise,
the radiographic appearance is unchanged. The morphology and
sequence of change could suggest increasing overhydration.
.
Brief Hospital Course:
This is a 60 year old male who was admitted with abdominal pain
and found to have acute pancreatitis, etiology unclear.
Acute Pancreatitis: He was admitted to the SICU and had a
received aggessive fluid resuscitation. He was NPO with a NGT.
He was hypotensive and tachycardic. He received several fluid
boluses secondary to hypovolemia and low urine output. His
LFT's, Amylase, Lipase trended down. His abdominal pain
continued to lessen and distension improved. His diet was
advanced along slowly and he was tolerating a regular diet and
abdomen was soft.
Hypertension: He had some hypertension to the 170-180's. His
Lopressor dose was increased. Once tolerating a diet, his home
meds were restarted.
Fluid Overload: After several days of aggressive fluid
resuscitation, he required Lasix IV to offload some fluid. He
had mild CHF and bilateral vascular markings on CXR. He had an
appropriate response to the Lasix.
Hyperglycemia: He was started on an Insulin gtt for BS control.
We were able to wean his to SQ Insulin based on a sliding scale.
When he was tolerating a diet again, he was restarted on his
home meds.
Respiratory: He required a face tent for humidified O2 and was
receiving Nebs PRN. After good pulmonary hygeine, he was weaned
off the O2.
Neurology: He has a history of anoxic brain injury and myoclonic
jerks and was on his home Depakote. In terms of the seizures,
patient reports that he has seizures every 2 or 3 days, and his
last one was 3 days ago. The seizures, per the patient, are
characterized by loss of conciousness. Per discussion with his
sister the patient has shaking periods where he loses
conciousness and has a postictal
period, lasting 30 mins.
In the ICU, he seemed quite somulent, disorietned and agitate.
Neurology was consulted for the possibility of drug induced
pancreatitis secondary to
depakote as no other causes of pancreatitis have been
identified. it seems
that Depakote as the etiology is a reasonable idea. He does not
have any of the typical more common explanations such as
hypertriglyceridemia, alchololism or gallstones. He has
multiple
reasons for his encepnahlopathy, most notably his significant
Co2
retention and narcotics.
He was started on Keppra for seizure coverage, as it is renally
excreted, fairly well tolerated and a firstline [**Doctor Last Name 360**] for
myoclonus. As he is quite sedated and in danger of further
respiratory depression, we will give a somewhat muted loading
dose and maintenance
Medications on Admission:
Clonazepam 4 qAM, 4 afternoon, 2 qHS, valproic acid 500 qAM, 250
afternoon, 250 qHS, metformin 1000'', glipizide 5, asa 81,
lisinopril 40, simvastatin 40, nifedipine 30, protonix 40
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.
Disp:*40 Tablet(s)* Refills:*0*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Levetiracetam 500 mg Tablet Sig: 2.5 Tablets PO BID (2 times
a day) for 3 days: Change to 1250mg PO BID on 5/\23 and to
1500mg PO BID on [**4-24**] as recommended by Neuro .
Disp:*15 Tablet(s)* Refills:*0*
6. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO twice a
day: Start on [**4-24**].
Disp:*180 Tablet(s)* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
9. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. GlipiZIDE 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Clonazepam 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day): 4mg qam, 4mg at 1600 .
12. Clonazepam 2 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
13. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Acute Pancreatitis
Discharge Condition:
Good
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Please resume all regular home medications and take any new
meds
as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily
* No heavy lifting (>[**9-13**] lbs) for 6 weeks.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 174**] (GI-Pancreatologist) in [**1-31**]
weeks. Call ([**Telephone/Fax (1) 22346**] to schedule an appointment.
Please follow-up with your PCP [**Last Name (NamePattern4) **] 2 weeks. Call to schedule.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 20751**], M.D. Phone:[**Telephone/Fax (1) 1682**]
Date/Time:[**2141-4-25**] 11:30
Provider: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **],MD Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2141-4-25**] 1:00
Provider: [**Name10 (NameIs) 13368**] [**Last Name (NamePattern4) 13369**], MD Phone:[**Telephone/Fax (1) 1652**]
Date/Time:[**2141-5-1**] 10:40
Completed by:[**2141-4-21**] Name: [**Known lastname **],[**Known firstname 3071**] Unit No: [**Numeric Identifier 4986**]
Admission Date: [**2141-4-11**] Discharge Date: [**2141-4-23**]
Date of Birth: [**2081-3-17**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4987**]
Addendum:
As the patient was not cleared to go home by physical therapy,
he remained in the hospital for additional sessions. He was then
cleared for home and discharged home on [**2141-4-23**].
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 42**] VNA
[**Name6 (MD) 116**] [**Last Name (NamePattern4) 4988**] MD [**MD Number(1) 4989**]
Completed by:[**2141-4-25**]
|
[
"276.7",
"V85.24",
"338.29",
"729.2",
"348.30",
"345.90",
"356.9",
"530.81",
"401.9",
"276.2",
"571.8",
"577.0",
"276.52",
"E937.9",
"E936.3",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.15",
"96.07"
] |
icd9pcs
|
[
[
[]
]
] |
10508, 10707
|
3990, 6471
|
332, 339
|
8119, 8125
|
1947, 3967
|
9182, 10485
|
1655, 1659
|
6703, 7977
|
8078, 8098
|
6497, 6680
|
8149, 9159
|
1674, 1928
|
274, 294
|
367, 810
|
832, 1190
|
1206, 1639
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,410
| 173,211
|
47726+59025
|
Discharge summary
|
report+addendum
|
Admission Date: [**2114-9-16**] Discharge Date: [**2114-9-17**]
Date of Birth: [**2039-9-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Dyspnea, LE edema
Major Surgical or Invasive Procedure:
Major Procedures:
None
History of Present Illness:
74 yo M hx CAD s/p IMI, AF with CMP (EF 40%) p/w dyspnea for the
past few days, lower leg edema, and rapid AF to 180. The patient
denies CP, palpatations, LH. He has not been feeling well for
the past few days, and for that reason, has not taken any of his
medications since thursday. The SOB made him come in to the ED
yesterday. The SOB is on exertion, not at rest. He generally has
LE edema, but his legs have never as swollen as they are now.
.
In the ED, he responded to 30mg IV diltizem, and is now on gtt,
at 15mg/hr. Has old RBBB. On BB and CCB at home, and has been
non compliant with all his medications for the past 2 days
(including lovenox)
.
On admission to CCU, rate in 110-120's, VSS. no longer
complaining of SOB.
.
ROS:
- denies history of stroke, TIA, PE, bleeding during surgery,
myalgias, cough, hemoptysis, black stools or red stools.
- denies recent fevers, chills or rigors.
- ROS positive for hx of DVT (popliteal, while anticoagulated on
coumadin, now in lovenox), and occassional joint pain.
.
Cardiac ROS:
- positive for DOE, LE edema.
- denies chest pain, paroxysmal nocturnal dyspnea, orthopnea,
palpitations, syncope or presyncope.
Past Medical History:
HTN
Atrial fibrillation
Dyslipidemia
h/o L popliteal vein DVT
History of anxiety and depression.
Peptic ulcer disease.
Diaphragmatic hernia.
CKD
Prostate CA dx [**5-2**] T2a prostate cancer
R hernia repair [**2069**]
Cardoimyopathy, ? tachycardia induced
.
Social History:
married, lives with wife, retired walks reg for exercise. quit
cig 30yrs ago (~ 15 pack years). no etoh. Walks without a
walker.
Family History:
No family history of prostate cancer.
Physical Exam:
PHYSICAL EXAMINATION:
VS: T 97.2, BP 161/105, HR 121, RR 22, O2 100% on 2l
Gen: pleasant black male in NAD, resp or otherwise. Oriented x3.
Mood, affect appropriate.
HEENT: NCAT. injected conjuctiva. PERRL, EOMI. non pallor or
cyanosis of the oral mucosa.
Neck: Supple with non elevated JVP.
CV: irregularly irregular, no murmurs appreciated. non displaced
PMI
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. bibasilar crackles, no
wheezes or rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: 4+ LE edema
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
.
EKG demonstrated rate of 155, RBBB, atrial fibrillation.
.
Pertinent Results:
Chest Xray [**2114-9-15**]
No acute pulmonary process
.
LLE LENI [**2114-9-15**]
No evidence of left lower extremity DVT. Popliteal vein appears
to compress normally in comparison to prior examination but exam
was limited in this region.
.
CTA Chest [**2114-9-15**]
No central or segmental pe. distal branches obscured due to
breathing. ?mild chf.
.
2D-ECHOCARDIOGRAM performed on [**2114-5-1**] demonstrated:
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity is
mildly dilated. Overall left ventricular systolic function is
normal (LVEF 60%; this value represents the estimated ejection
fraction following a normal left ventricular filling period).
There is no ventricular septal defect. The right ventricular
cavity is dilated. Right ventricular systolic function appears
depressed. The ascending aorta is mildly dilated. 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. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
Compared with the findings of the prior study (images reviewed)
of [**2113-12-14**], the ventricular rate is now well-controlled
and the left ventricular ejection fraction is increased.
.
ETT performed on [**2112-10-4**] demonstrated:
4.5 minutes of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4001**] protocol (3.5METs) and stopped for
fatigue. The ST segments are uninterpretable in the setting of
RBBB with diffuse ST-T wave abnormalities at baseline. The
rhythm was sinus with frequent AEA (isolated APDs) and frequent
VEA (isolated multifocal VPDs, ventricular couplets and
ventricular bigeminy). The hemodynamic response to exercise was
appropriate.
Brief Hospital Course:
This patient is a 74 y/o M with history of a fib,
cardiomyopathy, HTN, gerd, DVT (on lovenox), p/w SOB, LE edema
and in Afib with RVR.
.
1. AFib RVR: Patient has been noncompliant with his medications
for the last few days, secondary to "not feeling well." on
lovenox, on rate control, working with Dr. [**Last Name (STitle) **] as
outpatient to control without starting amiodarone.
- Patient on Diltizem drip 20mg/hr. Start wean
- Load with PO dilt, 60 QID
- Metoprolol 100mg [**Hospital1 **] (on 200mg toprol as outpatient)
- monitor vital signs, consider cardioversion for instability
-> Pt admitted to CCU. Rate control achieved with 200mg toprol
XL and verpamil 240mg and diltiazem weaned. Patient discharged
on above regimen. Lovenox continued at therapeutic doses for
anticoagulation for DVT and A. Fib.
.
2. CHF, diastolic acute on chronic: patient with significant LE
edema, has not taken diuretics for last 2 days, bibasilar
crackles, SOB, O2 requirement
- back on home dyazide
- 10mg Lasix IV
- goal out 1L today
-> Patient diuresed well with net ouf 750cc day 1 and net out on
day of discharge. Symptomatically improved. Home lasix dose
increased to 20mg PO. Given 10meq PO Potassium as mildly
hypokalemic during hospital stay.
.
3. CAD: ? old infarct on EKG. No history of MI, stress
uninterpretable secondary to RBBB
- continue ASA, Statin, BBlocker, ACEI
- f/u with outpatient provider.
.
4. Dyspnea: likely secondary to a fib and CHF exacerbation. no
wheezes
- treat a fib with rate control
- diurese
-> Improved and 93% on RA on day of discharge.
-> CTA of chest showed no significant PE but ? RLL filling
defect. Low suspicion for PE, patient anticoagulated in any
case and study not repeated. LE USD negative for DVT with
compression of popliteal vein (also limited study). CT Scan of
chest demonstrated lymphadenopathy noted on prior scans and
stable RUL nodule. Recommend repeat CT in [**5-8**] months for
lymphadenopathy, and outpatient CT scan or PET scan for
lymphadenopathy. Discussed with PCP who is aware and agrees
with plan.
.
5. depression - stable
- continue paxil
.
6. GERD, Hiatal Hernia - stable
- Ranitidine decreased for Cr 1.4 to daily dosing.
- continue pantoprazole
.
Code: presumed full
.
Dispo: Tranfer to home directly from CCU. F/u as below.
.
Medications on Admission:
-aspirin 325
-Lovenox 12/.8mL [**Hospital1 **]
-Toprol XL 200 mg daily
-verapamil 240
-Lasix 10
-atorvastatin 10
-ranitidine 150 twice a day
-pantoprazole 40
-triamterene & hydrochlorothiazide 37.5/25
-paroxetine 10
-benicar 40 daily
Discharge Medications:
1. Outpatient Lab Work
Chem-7 on friday [**2114-9-21**]
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Enoxaparin 60 mg/0.6 mL Syringe Sig: Two (2) syringe
Subcutaneous [**Hospital1 **] (2 times a day): Please inject 120mg or 1.2ml
twice per day. Disp:*120 syringe* Refills:*1*
5. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2*
6. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
8. Ranitidine HCl 150 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 Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
11. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Olmesartan 20 mg Tablet Sig: Two (2) Tablet PO daily ().
Disp:*30 Tablet(s)* Refills:*2*
13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO DAILY (Daily) for 3 days.
Disp:*3 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Atrial Fibrillation,
2. Acute on chronic systolic and diastolic heart failure.
3. Dilated cardiomyoapthy
3. Gastroesophageal reflux disease
4. Hypertension
5. Depression
6. Lung Nodule
7. Lymphadenopathy
Discharge Condition:
Stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: as per primary physician.
You were admitted to the hospital for evaluation of shortness of
breath, and lower extremity swelling. These symptoms are likely
related to your heart failure and having missed doses of your
medications. While in the hospital your doses of medication
were increased and fluid was removed. Upon leaving the hospital
your dose of furosemide was increased to 20mg PO daily. In
addition, please take a dialy potassium supplement of 10meq per
day for the next 3 days. Please take this and all other
medications as directed. Should you develop any new shortness
of breath, lower extremity swelling please call your primary
physician or present to the Emergency Room. If you develop any
sudden severe chest pain or other symptoms concerning to you
please call your PCP or return to the ED.
Followup Instructions:
Please follow-up as follows:
1. Laboratory Draw this Friday, [**2114-9-21**] - as instructed.
2. Repeat CT scan in [**5-8**] months for interval change in lung
nodules.
3. Discuss with your PCP regarding PET scan or CT scan for
lymphadenopathy in lung nodules. PCP [**Name Initial (PRE) 12309**].
4. Please call your PCP for an appointment for next week.
[**Last Name (LF) **],[**First Name3 (LF) **] D. [**Telephone/Fax (1) 2205**]. She is awaiting your call and will
follow-up your lab results.
5. Follow-up with your Cardiologist as directed.
Name: [**Known lastname 5282**],[**Known firstname **] Unit No: [**Numeric Identifier 16188**]
Admission Date: [**2114-9-16**] Discharge Date: [**2114-9-17**]
Date of Birth: [**2039-9-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4868**]
Addendum:
After discharge, LMWH level was returned showing that it was
slightly sub-therapeutic 0.4 (0.6 low end of therapeutic range).
It was unclear whether the level had been drawn at the
appropriate interval s/p lovenox dosing (typically drawn [**3-2**]
hours after dosing). As a result, it was determined that it
would be optimal to have the patient f/u with his PCP for [**Name Initial (PRE) **]
second check of his LMHW level prior to adjusting his dose.
This was discussed with PCP and patient who are in agreement
with the plan. Patient advised to continue taking lovenox as
directed 120mg [**Hospital1 **]. On day of lab test, will take 120mg at 8am
(as per normal) and then present for blood draw at PCP's office
at 12pm. No further changes to original discharge summary and
plan.
Discharge Disposition:
Home
[**Name6 (MD) **] [**Last Name (NamePattern4) 4869**] MD [**MD Number(2) 4870**]
Completed by:[**2114-9-19**]
|
[
"414.01",
"311",
"272.4",
"585.9",
"276.8",
"530.81",
"425.4",
"V15.81",
"428.33",
"428.0",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12119, 12264
|
4868, 7169
|
333, 358
|
9370, 9379
|
2920, 4845
|
10363, 12096
|
1996, 2035
|
7454, 9091
|
9141, 9349
|
7195, 7431
|
9403, 10340
|
2050, 2050
|
2072, 2901
|
276, 295
|
386, 1551
|
1573, 1832
|
1848, 1980
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,139
| 196,529
|
15754
|
Discharge summary
|
report
|
Admission Date: [**2190-1-14**] Discharge Date: [**2190-1-28**]
Date of Birth: [**2130-6-13**] Sex: F
Service: GEN [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: The patient is a 59 year old
female who suffers from insulin dependent diabetes,
hyperlipidemia and chronic renal failure. She was found to
have a pancreatic mass and was referred to Dr.[**Name (NI) 9886**]
office for surgical management. She initially presented to
her primary care physician after being evaluated for liver
function tests which were initially found to be elevated and
were felt to be due to the starting of Lipitor. The statin
was subsequently discontinued, however, the elevated LFTs
remained. On workup she had a right upper quadrant
ultrasound and that revealed a mass in the head of the
pancreas. This was done in [**2189-9-10**] when patient had no
complaints of any abdominal symptoms. Because of her history
of chronic renal insufficiency, she was subjected to a CT
scan without contrast that revealed a mass in the head of the
pancreas as consistent with ultrasound findings. This mass
appears to be necrotic and over 5 cm in size. There also
appears to be pathologic retroperitoneal lymph nodes at the
level of the pancreas. Because of the limits of these
studies, she subsequently, in [**2189-10-11**], had an open MRI
which revealed a 7.4 x 5.2 cm mass in the region of the head
of the pancreas with mild enhancement. There were also noted
bilateral periaortic adenopathy inferior to and at the level
of the renal veins. Subsequent CT guided fine needle
aspiration fracture was performed which was reported as
positive for malignant cells consistent with adenocarcinoma.
It was at this point that she was referred to [**Hospital1 346**] for further management and second
opinion.
REVIEW OF SYSTEMS: Essentially patient was always in her
usual state of health, although she noted slight fatigue over
the past several months, but attributed this to her chronic
renal insufficiency and her diabetic status. She is also
chronically anemic. She denied history of fever, chills,
night sweats, weight loss, cough, chest pain, shortness of
breath, abdominal pain, change in bowel habits or change in
her urine or stool color. There was no rash, jaundice or
swollen lymph nodes. She had a very good appetite. It is of
note that she is markedly obese. She also reported that she
probably gained some weight in the last year.
PAST MEDICAL HISTORY: As outlined above.
ALLERGIES: She is reporting allergy to Levaquin and
intolerance to the statin class of medications.
OUTPATIENT MEDICATIONS: Include insulin, Avapro, Synthroid,
metoprolol, Lasix, erythropoietin.
SOCIAL HISTORY: She denied tobacco use and drank alcohol
rarely.
FAMILY HISTORY: There is no significant family history of
cancer.
HOSPITAL COURSE: After thorough evaluation including more MR
scans and extensive calls between Dr. [**Last Name (STitle) 468**] and the
patient, she was admitted for a scheduled Whipple procedure
on the day of admission. On the day of admission patient was
taken to the O.R. for a scheduled planned resection of
pancreatic mass with Whipple procedure. Intraoperatively a
large mass was found in the center of the pancreas.
Therefore, a central pancreatomy was performed with Roux-en-Y
pancreaticojejunostomy and open cholecystectomy. Blood loss
was estimated at 500 cc and patient received 9 liters of
crystalloid during the operation. She was moved to the PACU
in stable condition, extubated.
Postoperatively patient made average 20 cc per hour in urine
output. Her systolic blood pressure was between 100 to 120
for several hours, which was lower than her baseline. She
was bolused with normal saline for approximately 2 liters.
On post-op day one she was transferred to the intensive care
unit for management of her fluid status. Over the next
several days her renal function started to worsen. Her
creatinine increased from 3.4 to peak at 5.4 on postoperative
day six. Renal service was consulted on postoperative day
one and these findings were attributed to the transient
hypoperfusion of the kidneys and with proper fluid
management, her creatinine has been stable and trending down.
She has remained afebrile and with her blood pressure
returning to her baseline of 130s. She was successfully
transferred to the floor on postoperative day eight.
Subsequently she started to pass flatus and her diet was
gradually increased. She tolerated p.o. intake. Her serum
amylase was stable at 14. Her amylase from the [**Doctor Last Name 406**] drain
was also stable at 13 on postoperative day 12. Her output
from urine was adequate. There was approximately 130 cc of
fluid draining from her [**Doctor Last Name 406**] drain on postoperative day 12.
Given that she was tolerating p.o. intake well, the [**Doctor Last Name 406**]
drain was discontinued on [**1-25**] and her Foley was also
discontinued on the same day. She continued to improve
physically. By the day of discharge she was able to ambulate
with a walker. She took an adequate amount of p.o. intake.
Of note, on postoperative days one to six she was in the
intensive care unit and TPN was initiated for three days to
increase her nutritional status, which was subsequently
discontinued one day after she was transferred to the floor.
Given that she tolerated the procedure well and recovered
well, she is discharged to home with VNA services. According
to the renal service recommendations, she was discharged
without an ACE inhibitor.
DISCHARGE MEDICATIONS:
1. Dilaudid 1 mg q.four to six hours as needed.
2. Tums one tablet t.i.d.
3. Reglan 10 mg q.six hours p.r.n.
4. Levothyroxine 75 mcg q.day.
5. Metoprolol 25 mg b.i.d.
6. Epogen 10,000 units three times per week.
Her insulin regimen was initiated by the Jocelin consulting
service with glargine 36 units q.bed time and Humalog sliding
scale to cover her daily need for insulin.
Pathology findings from the samples taken intraoperatively
showed an endocrine cell neoplasm on the pancreas sample.
There was no invasion with free margins of tumor. The tumor
expressed cytokeratin and also expressed glucagon and also
synaptophasin. It does not express chromogranin gastrin
insulin or somatostatin.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To home with services.
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**]
Dictated By:[**Dictator Info 45372**]
MEDQUIST36
D: [**2190-1-27**] 11:26
T: [**2190-1-27**] 12:00
JOB#: [**Job Number 45373**]
|
[
"250.01",
"575.11",
"585",
"272.4",
"157.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"52.96",
"52.59",
"51.22"
] |
icd9pcs
|
[
[
[]
]
] |
2776, 2827
|
5572, 6277
|
2845, 5549
|
2620, 2692
|
1828, 2450
|
187, 1808
|
2473, 2595
|
2709, 2759
|
6302, 6606
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,192
| 174,899
|
29051
|
Discharge summary
|
report
|
Admission Date: [**2171-11-21**] Discharge Date: [**2172-1-28**]
Date of Birth: [**2093-7-31**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
Bilateral pulmonary embolus
Major Surgical or Invasive Procedure:
Inferior vena cava filter
Midline intravenous catheter
Cystoscopy
History of Present Illness:
other than kidney stones, presents with R side pain and SOB. He
reports that 4 days of worsening shortness of breath. He was
only able to walk 4 steps at a time. Prior to this, he was able
to accomplish all of his activities of daily living and had not
shortness of breath. He denies cough, chest pain, hemoptysis,
fever, chills, nausea, vomiting, abdominal pain or back pain. He
initially presened to [**Hospital1 **] found to have large bilateral
saddle PE. There are no records available from [**Location (un) 620**], although
the pt was started on heparin gtt and transferred to [**Hospital1 18**]
because there were no ICU beds at [**Location (un) 620**]. Of note, his
creatinine was 2.0. On arrival to ED here T 97.1 p90 165/71 20
94 on 3L. LE US was perfomed revealing Nonocclusive thrombus in
the left common femoral vein. He was admitted to [**Hospital Unit Name 153**] for
further mgmt, then to CCU, and finally transferred to medicine
for further care.
Past Medical History:
Nephrolithiasis
Social History:
Widower, patient lives alone. No smoking, Etoh use daily 1.5
glasses of wine. He drives.
Family History:
Mother died of cancer.
Physical Exam:
VS: 97.0 axillary / 134/72 / 68 / 18 / 95% 2.5L nc
GEN: Pleasant, alert, normal affect, in no acute distress
HEENT: MMM, OP clear, no LAD, PERRL, EOMI
Chest: CTA bilaterally, 8cm JVD
Heart: Irregularly irregular, no m/r/g, no ventricular heave
Abd: Soft, +BS, ND, NT
Ext: No c/c, no peripheral edema, 2+ DP pulses bilaterally, no
calf tenderness bilaterally
GU: large right scrotal hernia
Pertinent Results:
Hematology:
[**2171-11-21**] 10:00PM BLOOD WBC-10.1 RBC-3.97* Hgb-14.5 Hct-41.0
MCV-103* MCH-36.4* MCHC-35.2* RDW-14.4 Plt Ct-222
[**2171-12-24**] 05:15AM BLOOD WBC-4.9 RBC-3.40* Hgb-12.0* Hct-33.4*
MCV-98 MCH-35.2* MCHC-35.8* RDW-13.7 Plt Ct-106*
[**2172-1-17**] 06:35AM BLOOD WBC-3.2* RBC-3.25* Hgb-10.9* Hct-31.7*
MCV-98 MCH-33.6* MCHC-34.5 RDW-13.7 Plt Ct-150
[**2172-1-22**] 06:10AM BLOOD WBC-3.9* Plt Ct-138*
[**2171-11-21**] 10:00PM BLOOD Neuts-88.0* Lymphs-6.6* Monos-5.2 Eos-0.1
Baso-0
[**2172-1-16**] 06:35AM BLOOD Neuts-53.8 Lymphs-35.2 Monos-7.6 Eos-3.1
Baso-0.3
[**2171-11-21**] 10:00PM BLOOD PT-16.2* PTT-131.4* INR(PT)-1.5*
[**2172-1-3**] 05:05AM BLOOD PT-13.2* PTT-44.7* INR(PT)-1.2*
.
Chemistry:
[**2171-11-21**] 10:00PM BLOOD Glucose-122* UreaN-46* Creat-1.7* Na-136
K-6.3* Cl-103 HCO3-20* AnGap-19
[**2172-1-16**] 06:35AM BLOOD Glucose-85 UreaN-14 Creat-0.9 Na-140
K-3.5 Cl-106 HCO3-29 AnGap-9
[**2171-11-22**] 05:26AM BLOOD ALT-26 AST-39 LD(LDH)-190 CK(CPK)-36*
AlkPhos-76 Amylase-23 TotBili-0.6
[**2172-1-4**] 07:50AM BLOOD LD(LDH)-153 TotBili-0.5
[**2171-11-22**] 05:26AM BLOOD Lipase-18
[**2171-11-21**] 10:00PM BLOOD cTropnT-0.11* proBNP-[**Numeric Identifier **]*
[**2171-11-24**] 01:01AM BLOOD CK-MB-NotDone cTropnT-0.08*
[**2171-11-24**] 07:35AM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2171-11-24**] 07:35AM BLOOD Calcium-8.1* Phos-2.7 Mg-1.9 Iron-24*
Cholest-103
[**2171-11-26**] 10:15AM BLOOD Albumin-2.8* Calcium-8.1* Phos-2.6*
Mg-2.2
[**2171-11-24**] 07:35AM BLOOD calTIBC-150* VitB12-357 Folate-6.6
Ferritn-420* TRF-115*
[**2171-11-24**] 07:35AM BLOOD Triglyc-61 HDL-33 CHOL/HD-3.1 LDLcalc-58
[**2171-11-25**] 05:20AM BLOOD TSH-2.3
[**2171-12-11**] 11:46PM BLOOD TSH-2.4
[**2171-11-26**] 10:15AM BLOOD CEA-1.7 PSA-3.5
[**2171-11-23**] 10:27AM BLOOD PEP-NO SPECIFI
[**2171-11-28**] RPR non-reactive
.
Urine:
Creatinine, Urine 147 mg/dL
Total Protein, Urine 249 mg/dL
Protein/Creatinine Ratio 1.7* Ratio 0 - .2
.
Prot. Electrophoresis, Urine +/- MULTIPLE PROTEIN BANDS SEEN,
WITH ALBUMIN PREDOMINATING' Immunofixation, Urine - NO
MONOCLONAL IMMUNOGLOBULIN SEEN, NEGATIVE FOR BENCE-[**Doctor Last Name **] PROTEIN
.
URINE CULTURE (Final [**2172-1-22**]):
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML..
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| STAPH AUREUS COAG +
| |
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R <=0.5 S
IMIPENEM-------------- =>16 R
LEVOFLOXACIN---------- =>8 R
MEROPENEM------------- =>16 R
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
PIPERACILLIN---------- 8 S
PIPERACILLIN/TAZO----- 8 S
TETRACYCLINE---------- 2 S
TOBRAMYCIN------------ =>16 R
VANCOMYCIN------------ <=1 S
.
ECG ([**11-20**]): Sinus rhythm with frequent atrial premature beats.
Left axis deviation with left anterior fascicular block.
Prominent early R wave progression with ST-T wave abnormalities
in the anterior leads. Consider myocardial ischemia versus right
ventricular overload. Clinical correlation is suggested. No
previous tracing available for comparison.
.
BILATERAL LOWER EXTREMITY ULTRASOUND ([**11-20**]): [**Doctor Last Name **]-scale,
color, and spectral Doppler analysis of the right and left
common femoral, superficial femoral, and popliteal veins was
performed. There is no evidence of right lower extremity DVT.
There is nonocclusive thrombus extending from the left common
femoral vein to the proximal portion of the left superficial
femoral vein. The mid and distal superficial femoral veins on
the left showed no evidence of thrombus.
IMPRESSION: Nonocclusive thrombus extending from the left
common femoral vein to the proximal portion of the left
superficial femoral vein. No evidence of right lower extremity
DVT.
.
TTE ([**11-21**]):
1. The left atrium is mildly dilated. No atrial septal defect or
patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers.
A small pulmonary AV shunt is probably present.
2. The left ventricular cavity size is normal. There is severe
global left ventricular hypokinesis. Overall left ventricular
systolic function is severely depressed.
3. The right ventricular cavity is dilated. There is severe
global right
ventricular free wall hypokinesis.
4. The aortic valve leaflets (3) are mildly thickened. Mild (1+)
aortic
regurgitation is seen.
5. The mitral valve leaflets are mildly thickened. Trivial
mitral
regurgitation is seen.
6. There is mild pulmonary artery systolic hypertension.
7. There is a small, loculated (apical) pericardial effusion
with fibrin
deposits on the surface of the heart..
.
CT abdomen/pelvis with contrast ([**11-21**]):
1. Very large bowel-containing right inguinal/scrotal hernia
without evidence of obstruction or ischemia.
2. Thickening of the bladder wall with possible intraluminal
blood clots.
3. Small bilateral pleural effusions and pericardial effusion.
4. No intraabdominal mass or lymphadenopathy.
.
BLADDER ULTRASOUND STUDY ([**11-24**]): Numerous images of the bladder
demonstrate a diffusely abnormal wall with irregular thickness
and contour, predominantly on the anterior aspect. Some areas of
the irregularly thickened anterior wall demonstrate increased
vascularity. There is echogenic fluid in the bladder with debris
seen in the dependent portion, some of which is mobile.
IMPRESSION: Irregularly thickened bladder wall, most pronounced
anteriorly with small areas of increased vascularity. Given the
appearance of the wall, a cystoscopy is recommended to exclude
malignancy.
.
CT head without contrast ([**11-26**]):
FINDINGS: There is no intracranial hemorrhage. There is no
midline shift, mass effect, or hydrocephalus. There are areas
of low attenuation within the periventricular white matter, most
consistent with chronic microvascular ischemic change. The
[**Doctor Last Name 352**]-white matter differentiation is preserved. There are no
fractures.
IMPRESSION: No intracranial hemorrhage. No mass effect.
.
TTE ([**12-26**]):
The left atrium is moderately dilated. Left ventricular wall
thickness, cavity size, and systolic function are normal (LVEF
60-70%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion. Compared with the
findings of the prior study (images reviewed) of [**2171-11-22**], contractile function of the right ventricle is now normal.
The left ventricle was poorly visualized on the prior study, but
was probably normal.
.
Urine cytology ([**1-12**]): NEGATIVE FOR MALIGNANT CELLS. No
urothelial cells seen. Predominantly neutrophils. Red blood
cells.
.
Cystoscopy ([**1-24**]): (per Dr.[**Initials (NamePattern4) 825**] [**Last Name (NamePattern4) **] note) 3+
trabeculated bladder. Bladder stone. No evidence malignancy.
Brief Hospital Course:
78M with no known past medical history originally p/w CP & SOB,
found to have saddle PEs, ARF, and urinary retention. Patient
arrived to the [**Hospital1 18**] ED from [**Location (un) 620**] with known bilateral saddle
pulmonary emboli. He was continued on heparin, started on IV
fluids, and transferred to the CCU given evidence of heart
failure on echo (EF 25%, RV dysfunction). An US of his lower
extremities showed a clot in his left common femoral vein. He
was anticoagulated. On day 2 of his hospital course, a removable
IVC Filter was placed successfully without complications. The
patient developed agitation and delerium, threatened to leave
AMA, but was deemed not competent to make medical decisions.
Guardianship was pursued and evenutally decided on [**1-17**]. His
course was also complicated by UTI for which he received
antibiotics. See below for further details.
Course on the floor as follows:
#) Bilateral saddle PEs: Presented with CP and SOB, found to
have bilateral PEs and DVT with evidence of heart failure and RV
dysfunction. Anticoagulated with heparin and then coumadin
briefly but then d/c'd coumadin in favor of lovenox as planned
for inpaitent cystoscopy for malignancy workup (see below). s/p
IVC filter on [**2171-11-22**] given DVT present and concern for further
embolization. He was continued on lovenox for anticoagulation
until cystoscopy performed [**2172-1-24**] and then started on coumadin.
He will continue lovenox until reaches goal INR [**1-25**] at which
time coumadin can be discontinued. Following resolution of the
acute issues, he has remained hemodynamically stable with no
respiratory complaints. Discussed removal of IVC filter with IR
but they believe high likelihood of failure and procedural risks
so deferred. Further hypercoagulability evaluation deferred to
outpatient. Followup with PCP. [**Name10 (NameIs) **] patient will need daily INR
checks until therapeutic on coumadin at which time lovenox can
be discontinued.
.
#) Dementia, agitation, altered mental status: Patient was very
agitated, confused early in hospital stay. Likely etiology was
toxic-metabolic [**1-24**] acute illness and urinary infection in the
setting of chronic dementia. Improved somewhat with resolution
of acute medical problems but not completely. He repeatedly
attempted to leave AMA and required code purple intermittently
with physical restraints. Psychiatry was consulted and the
patient was started on standing haldol [**Hospital1 **] with improvement and
resolution of his agitation. There was concern regarding his
ability to understand his illness, comply with treatment, and
care for self. He required a 1:1 sitter due to flight risk and
occasional agitation. Guardianship was established (see below).
At discharge the patient was calm, cooperative, and conversant.
.
#) Urology: UTI, urinary retention, acute renal failure,
abnormal bladder ultrasound. On hospital day 4 the patient
developed a UTI. He was initially treated with ceftriaxone,
which was then switched to ciprofloxacin. His Foley catheter was
removed, but patient developed urinary retention with drainage
of 1.4L from his bladder. Renal failure was likely post-renal
due to obstruction and resolved with drainage of bladder.
Urology was consulted for very difficult foley placement and he
was started on flomax. PSA was normal. The foley was initially
left in place due to the difficulty of placement and the fact
that he was asymptomatic; he was continued on ciprofloxacin, but
he developed symptoms of bladder irritation on [**1-20**]. Repeat
urine culture grew pseudomonas resistant to quinolones and MRSA.
Ciprofloxacin was discontinued and ceftazadime and vancomycin
were started to complete a 2 week course (started on [**1-20**] and
[**1-22**], respectively). A midline catheter was placed [**1-22**] and
should be removed on [**2172-2-4**] after completing his course of IV
antibiotics. He failed two voiding trials the week prior to
discharge and therefore an indwelling foley was left in place
with urology followup for urodynamics studies and consideration
of TURP. Also found to have bladder U/S with irregular wall
thickening. Concern was for malignancy, however urine cytology
was negative and the patient underwent cystoscopy on [**2172-1-24**]
which revealed no evidence of malignancy. Plan for outpatient
urology followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 770**] on [**2172-2-6**].
.
#) Malignancy screening: Given hypercoagulability, initiated
cancer screening as possible etiology. Abdominal/pelvic CT was
notable for a thickened bladder wall and further followed up
with a bladder US that confirmed the finding. Urine cytology and
cystoscopy was negative. Chest CT at presentation showed
bibasilar nodular densities in the setting of bilat PEs, and
repeat study revealed that these had completely resolved.
However, an indicental finding of hypoattenuating liver lesion
was noted that should be followed up with MRI per radiology as
an outpatient. He was also scheduled for screening colonoscopy
with Dr. [**First Name (STitle) 2643**]; instructions for the bowel preparation are
attached with the discharge information. Followup with urology
per above.
.
#) Thrombocytopenia: Platelets 222 on arrival, and noted slow
downward progression during initial hospital course with nadir
in low 100s. Possibly [**1-24**] consumption for underlying blood
clots, but not clear. Hematology was consulted. Did not appear
to meet trends for either Type I or II HIT; HIT antibody was
sent and was negative. No other signs of DIC, TTP. Initially on
heparin, then coumadin, and finally lovenox. Discontinued
protonix secondary to small likelihood that PPI/H2 blockers
cause thrombocytopenia. Platelets slowly increased and
normalized around 150. Would continue to monitor weekly as
outpatient.
.
#) Cardiac: No known CAD and on no cardiac meds at home. Upon
arrival, echocardiogram initially with EF 25% and RV dysfunction
likely [**1-24**] PE, so ACEi and BB were initiated for presumed
cardiomyopathy. Repeat echo was performed after acute events
resolved and showed preserved EF with normal wall motion. ACEi
and BB were then discontinued. He remained in sinus rhythm,
normotensive. Euvolemic on exam. Ambulating wihtout difficulty.
No further issues.
.
#) Scrotal hernia: Large scrotal hernia noted on exam, althogh
patient asymptomatic. Abdomen/pelvis CT scan with large amount
of bowel in hernia sac. No evidence of incarceration, volvulus.
Patient declining eval for herniorraphy and given no symptoms
unlikely need at this time. Monitor as outpatient with surgery
referral as indicated.
.
#) Disposition: On [**2171-12-1**], the patient appeared to be
medically clear discharge, however it was clear that patient was
not safe to go home given limited mobility, anticoagulation,
lack of social supports, and extremely limited understanding of
his condition. He was deemed to lack capacity to understand
risks/benefits of refusing care and inability to care for self
at home safely. In addition, it was discovered that his home was
condemned by public health department. As a result, guardianship
was pursued with family and his attorney. Official guardianship
appointed [**2172-1-17**] between [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], JD and [**Name (NI) **] [**Name (NI) 32153**]
(cousin; [**Telephone/Fax (1) 69985**]).
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever or pain.
Disp:*60 Tablet(s)* Refills:*0*
2. Hexavitamin Tablet Sig: One (1) Cap PO QAM (once a day
(in the morning)).
Disp:*30 Cap(s)* Refills:*2*
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID prn as needed
for constipation.
Disp:*60 Tablet(s)* Refills:*0*
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID
prn.
Disp:*60 Capsule(s)* Refills:*2*
7. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
8. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Ceftazidime-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One
(1) gram Intravenous Q8H (every 8 hours) for 5 days.
10. Heparin Flush Midline (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
12. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous Q 12H (Every 12 Hours) for 7 days.
13. Enoxaparin 60 mg/0.6 mL Syringe Sig: Sixty (60) mg
Subcutaneous twice a day: discontinue when INR >2.
14. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO at bedtime.
15. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime). Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 731**] - [**Location (un) 2498**]
Discharge Diagnosis:
Primary:
1) Bilateral Saddle Pulmonary Emboli
2) Delirium
3) Alcohol Withdrawal
4) Dementia
5) Urinary retention
6) Complicated urinary tract infection
7) Thrombocytopenia NOS
.
Secondary:
1) Macrocytic anemia
2) History of alcoholism
3) Hypertension
4) Lung nodules NOS
Discharge Condition:
Good
Discharge Instructions:
Please take all medications as prescribed.
.
Call your doctor or return to the ED immediately if you
experience worsening chest pain, shortness of breath, nausea,
vomiting, sweating, fevers, chills, bleeding, or other
concerning symptoms.
Followup Instructions:
You are scheduled for the following appointments. Please contact
the [**Name2 (NI) 11686**] provider with any questions or if you need to
reschedule.
.
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 11302**]. [**Hospital1 18**], [**Street Address(2) **], [**Location (un) 620**], MA. ([**Telephone/Fax (1) 69986**]. [**2172-2-3**] at 1:30pm. You were found to have a possible
abnormality in your liver. It was suggested that you have an MRI
of your liver for further evaluation. You will need to be
accompanied by an attendant or your guardian.
.
Urology: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD. [**Hospital1 18**]. Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2172-2-6**] 3:10. Followup for urodynamics studies and
consideration of possible TURP procedure.
.
Colonoscopy: GI WEST,ROOM ONE GI ROOMS Date/Time:[**2172-3-6**] 10:30
Gastroenterology: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1983**]
Date/Time:[**2172-3-6**] 10:30. Colonoscopy. You must arrive by
9:30am. You will need to complete a bowel prep starting the day
before this appointment. Please see the sheet given to you at
discharge for instructions on how to perform the preparation.
|
[
"599.0",
"303.91",
"287.5",
"550.90",
"596.8",
"294.8",
"594.0",
"V09.0",
"584.9",
"291.0",
"041.11",
"415.19",
"453.41",
"428.0",
"788.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"57.32",
"38.93",
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
18976, 19098
|
9785, 11800
|
344, 411
|
19413, 19419
|
2015, 9762
|
19706, 20966
|
1567, 1591
|
17258, 18953
|
19119, 19392
|
17229, 17235
|
19443, 19683
|
1606, 1996
|
277, 306
|
439, 1406
|
11815, 17203
|
1428, 1445
|
1461, 1551
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,415
| 164,535
|
45551
|
Discharge summary
|
report
|
Admission Date: [**2187-11-9**] Discharge Date: [**2187-11-14**]
Date of Birth: Sex: F
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old
female with a past medical history significant for atrial
fibrillation of unknown duration and atrial septal defect who
was admitted for a heart block following cardioversion.
The patient has a history of atrial fibrillation noted by her
primary care physician in [**Name9 (PRE) **] - previous duration is
unknown. She was referred to Dr. [**Last Name (STitle) 911**] for further
evaluation. He started the patient on a beta blocker, and
ACE inhibitor, and also anticoagulated her on Coumadin with
plans for cardioversion.
The patient was admitted on [**11-9**] for a transesophageal
echocardiogram and direct current cardioversion. The patient
successfully underwent to direct current cardioversion;
however, following this, she had a 15-second pause in her
heart beat and a subsequent junction rhythm at 38 beats per
minute to 40 beats per minute. She was given atropine,
dopamine, and isoproterenol with an increase in her
junctional rhythm to the 60s. She was continued on an
isoproterenol drip with her heart rate remaining stable in
the 60s; still junctional. The patient denied any dizziness,
or shortness of breath, or chest pain with this. She was
transiently hypotensive with a systolic blood pressure in the
70s immediately following her bradycardia; however, this
quickly resolved. She was then transferred to the Coronary
Care Unit for further monitoring.
PAST MEDICAL HISTORY:
1. Atrial fibrillation of unknown duration.
2. Atrial septal defect.
MEDICATIONS ON ADMISSION: (Home medications included)
1. Coumadin 3.5 mg by mouth once per day.
2. Prilosec.
3. Remeron
4. Atenolol 25 mg by mouth once per day.
5. Lisinopril 2.5 mg by mouth once per day.
ALLERGIES: AMOXICILLIN and SULFA.
SOCIAL HISTORY: No tobacco use. Alcohol use revealed one
glass of wine per month.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed the patient's temperature was 98.8 degrees
Fahrenheit, her blood pressure was 120/57, her heart rate was
64, her respiratory rate was 18, and her oxygen saturation
was 93% to 100% on room air. In general, a pleasant and
well-developed female in no acute distress. Head, eyes,
ears, nose, and throat examination revealed pupils were
equal, round, and reactive to light. The extraocular
movements were intact. The oropharynx was clear.
Cardiovascular examination revealed bradycardia with a
regular rhythm. There were no murmurs, rubs, or gallops.
The lungs were clear to auscultation bilaterally. The
abdominal examination revealed positive bowel sounds. The
abdomen was soft, nontender, and nondistended. Extremity
examination revealed no edema or cyanosis. Neurologic
examination revealed no focal deficits.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
revealed the patient's white blood cell count was 6.9, her
hematocrit was 36.3, and her platelets were 247. Her
prothrombin time was 19.1, her partial thromboplastin time
was 29.1, and her INR was 2.4.
PERTINENT RADIOLOGY/IMAGING: Electrocardiogram revealed a
junctional rhythm at a rate of 54 with retrograde P waves.
Left axis. No ST changes.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. CARDIOVASCULAR ISSUES: (a) Coronary artery disease:
The patient with no known history of coronary artery disease.
She had no chest pain or ischemic symptoms during her
hospitalization.
(b) Pump: The patient with impaired systolic function. A
recent echocardiogram revealed global left ventricular
dysfunction with an ejection fraction of 40% to 50%. On a
beta blocker and ACE inhibitor as an outpatient; however,
these were held following her admission, in the setting of
her dysrhythmia and her pause following direct current
cardioversion.
Following pacemaker placement, she was placed back on a beta
blocker which was titrated up. This was tolerated well.
(c) Rhythm: The patient with a history of atrial
fibrillation of unknown duration who was admitted for a
transesophageal echocardiogram and direct current
cardioversion. Her transesophageal echocardiogram showed no
thrombi, and she was successfully cardioverted. However,
following this, she went into sinus asystole with a pause of
approximately 15 seconds and then recovered with a junctional
rhythm in the 40s. This was thought to be due to severe
sinus node dysfunction given her long-term atrial
fibrillation.
The patient was initially started on isoproterenol and
monitored to see if her sinus function recovered. She was
observed in the Unit for close monitoring. The patient's
sinus function did not recover, and she continued to be in a
junctional rhythm.
Following several days without any recovery of function, the
decision was made to place a pacemaker. The pacemaker was
placed on [**11-12**]. She then underwent repeat direct
current cardioversion. Following this, the patient was
A-paced with a rate in the 70s. She was started on sotalol
which was titrated up to a dose of 80 mg by mouth twice per
day. She was also started on Coumadin and had followup
scheduled in the Device Clinic.
The patient was admitted on Coumadin per her home regimen for
her atrial fibrillation. Her INR was supratherapeutic on
admission, and her heparin was initially held. Following her
pacemaker placement, the patient was restarted on Coumadin
with a plan to follow up in the [**Hospital 197**] Clinic for
monitoring of her INR.
2. GASTROESOPHAGEAL REFLUX DISEASE ISSUES: The patient was
admitted with a history of gastroesophageal reflux disease
and was maintained on a proton pump inhibitor per her home
regimen.
3. PSYCHIATRIC ISSUES: The patient with a diagnosis of
depression. The patient was continued on Remeron per her
outpatient regimen.
4. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient was
maintained on a cardiac diet which she tolerated well. Her
electrolytes were followed throughout her hospitalization.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: Discharge status was to home.
MEDICATIONS ON DISCHARGE:
1. Sotalol 80 mg by mouth twice per day.
2. Pantoprazole 40 mg by mouth q.24h.
3. Remeron 15 mg by mouth at hour of sleep.
4. Clindamycin 600 mg by mouth q.8h. (times one week).
5. Coumadin 4 mg by mouth once per day.
The patient was instructed to discontinue aspirin when her
INR is therapeutic at 2.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up in the Device
Clinic on [**11-20**].
2. The patient was instructed to follow up as scheduled with
Dr. [**Last Name (STitle) 911**] and her primary care physician.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Last Name (NamePattern1) 97155**]
MEDQUIST36
D: [**2187-12-31**] 15:18
T: [**2188-1-1**] 07:25
JOB#: [**Job Number 97156**]
|
[
"997.1",
"530.81",
"458.29",
"E879.8",
"429.9",
"300.4",
"427.31",
"414.01",
"427.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.45",
"37.72",
"37.83",
"88.72",
"99.61"
] |
icd9pcs
|
[
[
[]
]
] |
6201, 6510
|
1687, 1908
|
6543, 7032
|
3343, 6074
|
6089, 6175
|
157, 1566
|
1588, 1660
|
1925, 3309
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,697
| 175,030
|
7454
|
Discharge summary
|
report
|
Admission Date: [**2167-7-5**] Discharge Date: [**2167-7-10**]
Service: MEDICINE
Allergies:
Codeine
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with bare metal stents to the proximal
and mid left anterior descending artery.
History of Present Illness:
89yoF with PMH CAD s/p LAD STEMI in [**2157**], DM II, h/o CVA, HL
presents after 1 day of generalized weakness. This morning,
patient was on the commode and felt presyncopal and unable to
transfer from the commode, therefore was brought to the ER. Per
daughter, patient has had five discrete episodes of weakness
over the past week, but none as bad as this. Patient denies
chest pain, shortness of breath. Previous STEMI was heralded by
pain between the shoulder blades, of which she denies. Denies
any jaw, back, or arm pain.
.
On review of systems, positive for chronic cough. No change in
her cough severity. She denies myalgias, joint pains,
hemoptysis, black stools or red stools. She denies recent
fevers, chills or rigors. She denies dysuria, urgency,
frequency. She denies new neurologic symptoms. Last BM this AM,
no diarrhea or abdominal pain. No history of GI bleed, no melena
or BRBPR. 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.
.
In the ED, initial vitals were 98.4 96 103/58 16 98% RA. EKG
showed 1-1.5mm ST elevations in V1 and V2 with depressions in I,
II, AVL. Code STEMI was called. She received ASA 325mg and was
started on heparin gtt. She was guaiac negative. Cardiology
reviewed the EKG's and did not feel that she needed to
emergently go to the cath lab. Troponin was 2.59. It was felt
that she should come to the CCU in light of known reduced EF of
35-40% and ACS. On CXR, she was found to have R sided
infiltrate, but was transported to CCU prior to receiving her
planned levaquin and ceftriaxone for CAP. VS on transfer to the
CCU were HR 79, RR 16, BP 96/50, Pox 97RA.
.
On the floor, the patient has no complaints. She denies chest
pain, n/v, diaphoresis, SOB, back pain/jaw pain/arm pain.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, -Hypertension
2. CARDIAC HISTORY:
-CABG: N/A
-PERCUTANEOUS CORONARY INTERVENTIONS: s/p STEMI in [**2157**] w/ stent
to LAD
-PACING/ICD: N/A
3. OTHER PAST MEDICAL HISTORY:
-Osteoporosis
-CVA - small vessel stroke in R MCA territory [**7-23**] (no residual
effects)
-Osteoarthritis (knees)
-b/l rotator cuff injuries
-Status post hysterectomy 20 years ago
-L posterior tibialis injury (L leg brace)
-R bimalleus fracture (external cast)
-Aspiration PNA in [**4-/2166**], treated with CTX, azithromycin,
clindamycin
-s/p cataracts surgery
Social History:
Lives with her daughter and mostly stays in the house. Able to
stand by the sink to wash dishes and brush her teeth.
Non-smoker, drinks rarely, no drug abuse.
Family History:
No cardiovascular disease. No diabetes mellitus.
Physical Exam:
On Admission:
GENERAL: WDWN F 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 with JVP of 7 cm in 45 degree angle.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Bibasilar crackles
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No edema, +venous stasis changes. +corn on left
foot
PULSES:
Right: trace DP and PT pulses, dopplerable
Left: trace DP and PT pulses, dopplerable
.
On Discharge:
GENERAL: WDWN F 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 without JVD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: CTA-B
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No edema, +venous stasis changes. +corn on left
foot
PULSES:
Right: trace DP and PT pulses, dopplerable
Left: trace DP and PT pulses, dopplerable
Pertinent Results:
CBC trend:
[**2167-7-5**] 09:58AM BLOOD WBC-14.6*# RBC-4.37 Hgb-13.9 Hct-42.0
MCV-96 MCH-31.8 MCHC-33.1 RDW-14.2 Plt Ct-142*
[**2167-7-6**] 03:22AM BLOOD WBC-7.8 RBC-3.78* Hgb-12.0 Hct-36.1
MCV-96 MCH-31.8 MCHC-33.2 RDW-14.1 Plt Ct-117*
[**2167-7-6**] 04:50PM BLOOD WBC-8.3 RBC-3.31* Hgb-10.9* Hct-31.7*
MCV-96 MCH-32.8* MCHC-34.2 RDW-14.2 Plt Ct-114*
[**2167-7-7**] 05:42AM BLOOD WBC-10.2 RBC-3.59* Hgb-11.5* Hct-34.1*
MCV-95 MCH-32.2* MCHC-33.9 RDW-14.2 Plt Ct-127*
[**2167-7-8**] 06:27AM BLOOD WBC-9.4 RBC-3.48* Hgb-10.9* Hct-33.5*
MCV-96 MCH-31.4 MCHC-32.6 RDW-14.2 Plt Ct-130*
[**2167-7-9**] 02:18AM BLOOD WBC-7.6 RBC-3.17* Hgb-10.4* Hct-30.3*
MCV-95 MCH-32.9* MCHC-34.5 RDW-14.1 Plt Ct-141*
[**2167-7-10**] 06:30AM BLOOD WBC-6.2 RBC-3.34* Hgb-11.0* Hct-32.0*
MCV-96 MCH-32.9* MCHC-34.3 RDW-14.1 Plt Ct-143*
[**2167-7-10**] 05:30PM BLOOD Hct-32.1*
Coags:
[**2167-7-5**] 09:58AM BLOOD PT-13.7* PTT-21.6* INR(PT)-1.2*
[**2167-7-6**] 03:38AM BLOOD PT-15.7* PTT-66.4* INR(PT)-1.4*
[**2167-7-7**] 05:42AM BLOOD PT-13.9* PTT-23.2 INR(PT)-1.2*
[**2167-7-7**] 03:02PM BLOOD PT-13.7* PTT-24.3 INR(PT)-1.2*
[**2167-7-8**] 06:27AM BLOOD PT-14.8* INR(PT)-1.3*
[**2167-7-9**] 02:18AM BLOOD PT-15.3* PTT-62.6* INR(PT)-1.3*
[**2167-7-10**] 06:30AM BLOOD PT-18.2* INR(PT)-1.6*
.
Chem panel
[**2167-7-5**] 09:58AM BLOOD Glucose-250* UreaN-21* Creat-0.7 Na-139
K-4.3 Cl-103 HCO3-23 AnGap-17
[**2167-7-6**] 03:22AM BLOOD Glucose-134* UreaN-21* Creat-0.8 Na-141
K-4.2 Cl-106 HCO3-25 AnGap-14
[**2167-7-7**] 05:42AM BLOOD Glucose-182* UreaN-25* Creat-1.0 Na-138
K-4.0 Cl-105 HCO3-24 AnGap-13
[**2167-7-7**] 03:02PM BLOOD Glucose-175* UreaN-28* Creat-1.2* Na-136
K-3.9 Cl-103 HCO3-23 AnGap-14
[**2167-7-8**] 06:27AM BLOOD Glucose-208* UreaN-35* Creat-1.6* Na-135
K-4.4 Cl-101 HCO3-24 AnGap-14
[**2167-7-9**] 02:18AM BLOOD Glucose-200* UreaN-45* Creat-1.9* Na-132*
K-4.8 Cl-101 HCO3-25 AnGap-11
[**2167-7-10**] 06:30AM BLOOD Glucose-231* UreaN-51* Creat-1.9* Na-136
K-4.7 Cl-102 HCO3-27 AnGap-12
.
Biomarkers:
[**2167-7-5**] 09:58AM BLOOD CK-MB-45* MB Indx-15.2* proBNP-9744*
[**2167-7-5**] 09:58AM BLOOD cTropnT-2.59*
[**2167-7-6**] 03:22AM BLOOD CK-MB-14* MB Indx-10.1* cTropnT-2.26*
[**2167-7-6**] 11:10PM BLOOD CK-MB-25* MB Indx-15.3*
[**2167-7-5**] 09:58AM BLOOD CK(CPK)-296*
[**2167-7-5**] 03:33PM BLOOD CK(CPK)-245*
[**2167-7-6**] 03:22AM BLOOD CK(CPK)-139
[**2167-7-6**] 11:10PM BLOOD CK(CPK)-163
.
HgA1c:
[**2167-7-5**] 03:32PM BLOOD %HbA1c-6.4* eAG-137*
.
Lipids:
[**2167-7-6**] 03:22AM BLOOD Triglyc-64 HDL-58 CHOL/HD-1.7 LDLcalc-27
.
TSH
[**2167-7-6**] 03:22AM BLOOD TSH-2.0
.
Dig
[**2167-7-8**] 06:27AM BLOOD Digoxin-0.6*
.
Imaging:
TTE: [**2167-7-6**]
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. There is
moderate to severe regional left ventricular systolic
dysfunction with septal, anterior, and distal LV/apical
hypokiensis to akinesis. No masses or thrombi are seen in the
left ventricle. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2162-11-30**], the LVEF has decreased.
.
Cardiac Cath: [**7-7**]
1. Coronary angiography in this right dominant system
demonstrated three
vessel disease. The LMCA had 50% stenosis. The LAD had 90%
origin
stenosis and was 100% occluded in the mid vessel (stent
occlusion). The
LCx had 70-80% origin stenosis. The RCA had 70-80% proximal
stenosis.
2. Resting hemodynamics revealed elevated left ventricular
filling
pressures with LVEDP 33 mmHg. There was no significant pressure
gradient
across the aortic valve on catheter pullback. There was systemic
arterial normotension.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Elevated left ventricular filling pressures.
.
CXR: [**7-9**]
There is continuous resolution of pulmonary edema, currently
almost completely resolved in upper and mid lung zones and
potentially may be minimally present in the lung bases in
conjunction with bibasilar atelectasis and pleural effusion.
There is no pneumothorax. Cardiomediastinal silhouette is
unchanged.
Brief Hospital Course:
89yoF with PMH CAD s/p LAD STEMI in [**2157**], DM II, h/o CVA, HL
presents with STEMI vs NSTEMI.
.
# NSTEMI: Pt was admitted with complaints of general weakness
and found to have positive troponin leak with EKG changes
including minimal ST elevation in V1-V2 and ST depressions and T
wave pseudonormalization in lateral and inferior leads in the
absence of symptoms of angina. There was question of STEMI due
to ST elevations in V1 and AVR but these did not appear
significantly changed from baseline ECG. She had a non-emergent
cath on [**7-6**] which showed multivessel disease: 50% LM, prox LAD
90% [**Last Name (un) **] circ 80% RCA 75%. BMS were placed in the prox and mid
LAD. Of note compared to [**2157**] cath [**Last Name (un) **] circ disease is new and
RCA is worsened from 50 to 75%. Echo showed hypokinesis in LAD
distribution (septal, anterior, and distal LV/apical hypokiensis
to akinesis. EF =30%) which was not new but worsened compared to
echo in [**2162**] (mild regional left ventricular systolic
dysfunction with severe hypokinesis to akinesis of the distal
anterior wall, distal septum, and apex, EF 35-40%). She was not
felt a candidate for CABG and was managed medically with plavix
(should continue daily for one month), aspirin 325, atorvastatin
80 (LDL 27, HDL 58), lisinopril, and metoprolol succinate.
.
# PUMP: On arrival in the CCU post cath, patient tachypneic w/
6L oxygen requirement (sats in mid 90s) and crackles b/l on
exam; to the 20 mg lasix IV given in cath lab put out about 1L
w/ no improvement in sxs. She had a brief period of SVT/flutter
and lasix 20 mg IV was repeated -> diuresed 1300 cc's in total.
Her echo showed EF of 30% with septal, anterior, and distal
LV/apical hypokiensis to akinesis. She was started on an ACEI
(first captopril and then lisinopril) and her home atenolol was
switched to metoprolol succinate. She was discharged on these
medications, as well as digoxin (see below).
.
# Atrial fibrillation/flutter: Patient was in NSR on admission,
but since was found to have paroxysmal episodes of SVT to 140??????s
which may be consistent with AVNRT vs Aflutter sustained upto 15
minutes, as well as paroxysmal Afib. Patient was asymptomatic
throughout these episodes with tendency to drop SBP to the 70's
which resolved with slower rate. It was speculated that her
initial presenting complaint of recurrent episodes of faintness
and weakness in recent days may all be due to similar paroxysmal
tachyarrythmias. She was treated with metoprolol 25 mg TID for
rate control (uptitrated to 100 mg succinate on discharge) and
digoxin loaded on [**7-7**] with a discharge dose of 0.125 qOD. She
was also loaded w/ amiodarone when she had a recurrent episode
of AF/AFlutter on dig. She was discharged on amiodarone 200 mg
TID for one week, followed by amiodarone 200 mg daily, as well
as coumadin for anticoagulation given a CHADS2 score 4 (she was
on a heparin gtt in house). Given she is on amiodarone she will
need monitoring of her LFTs and PFTs. She will also require INR
monitoring.
.
# Leukocytosis: Had leukocytosis on admission but this was
likely [**3-18**] to hemoconcentration. CXR on admission did show some
bibasilar infiltrates R>L and patient was witnessed to have
some coughing after thin liquids. UA was positive although
patient is not overtly symptomatic, culture came back with fecal
contamination. An infection could have triggered for her
tachyarrythmias and MI. Received levo and CTX on admission to
CCU on [**7-5**] but later in the setting of absence of fever and no
leukocytosis felt that pulmonary presentation was consistent
with congestion +/- pneumonitis rather than pneumonia. Was
treated with 3 days of bactrim for UTI. On [**7-9**], leukocytosis
resolved, temperatures were afebrile and urine cultures were
negative.
.
# Aspiration: Seen by Speech and swallow. There evaluation:
swallowing pattern correlates to a Functional Oral Intake Scale
(FOIS) rating of 5 out of 7. Per their recommendations patient
was started on soft solids and thin liquids and put on
aspiration precautions.
.
# Acute renal insufficiency: Patient developed increasing
creatinine (from 1->1.2->1.6->1.9 on discharge). Was attributed
to diuresis. She was discharged off of her home metformin and
glipizide to follow up with her PCP.
.
# Diabetes Mellitus: Was maintained on insulin sliding scale in
house and metformin was held. HbA1c was checked and 6.4. She
discharged off of metformin and glypizide given her [**Last Name (un) **] with
instructions to restart per her PCP.
.
CODE: DNR/DNI (There were numerous conversations about this, but
ultimately patient and daughter decided code status was
DNR/DNI).
Medications on Admission:
-Atorvastatin 10 mg daily
-Zestril 10 mg daily
-Aspirin 325 mg daily
-Clopidogrel 75 mg QSunday (regimen worked out with PCP for CVA)
-Atenolol 75mg daily
-Glipizide 2.5mg [**Hospital1 **]
-Metformin 500 mg [**Hospital1 **]
Discharge Medications:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
5. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
Disp:*15 Tablet(s)* Refills:*2*
6. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
Disp:*90 Tablet(s)* Refills:*2*
8. amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) for 1 weeks.
Disp:*21 Tablet(s)* Refills:*0*
9. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
11. Outpatient Lab Work
please check Chem-7, CBC and INR on Tuesday [**2167-7-14**] with results
to Dr. [**Last Name (STitle) **] at phone: [**Telephone/Fax (1) 7477**] fax: [**Telephone/Fax (1) 12227**]
Discharge Disposition:
Home With Service
Facility:
Greater [**Location (un) 1468**] VNA
Discharge Diagnosis:
ST Elevation myocardial infarction
Acute Kidney Injury
dyslipidemia
diabetes mellitus type 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You had some dizziness and weakness at home and was admitted to
[**Hospital1 18**]. Your ECG and echocardiogram showed changes that were
consistant with a heart attack. A cardiac catheterization showed
you had 2 blockages in your left anterior descending artery that
were opened with 2 bare metal stents. These stents will remain
in your arteries forever but there is an increased risk over the
next month that they could clot off and cause another heart
attack. Therefore, it is critically important that you take
aspirin 325 mg and Plavix every day for the next month to
prevent a blood clot. Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking
Plavix unless Dr. [**Last Name (STitle) **] says it is OK. You also developed
atrial fibrillation with a rapid heart rate. This rate was
controlled with digoxin and amiodarone. The atrial fibrillation
means that you are at an increased risk of stroke. Warfarin
(coumadin) was started to help prevent a stroke. You will need
to have your warfarin level (called an INR test) frequently to
make sure it is not too high or too low. The goal INR is
2.0-3.0. Your next INR check will be [**7-14**].
.
We made the following changes to your medicines:
1. Increase the plavix frequency to every day for at least one
month as noted above
2. Continue to take aspirin 325 mg daily
3. Change Atenolol to Metoprolol succinate to slow your heart
rate and help your heart recover from the heart attack
4. Increase the Lipitor to 80 mg daily for now to help your
heart recover
5. Decrease the Zestril to 2.5 mg daily. This may be increased
as your blood pressure rises
6. Start taking digoxin every other day to slow your heart rate.
7. Start taking amiodarone three times a day for one week for a
loading dose to slow the atrial fibrillation and hopefully
convert you in to a normal heart rhythm.
8. Hold metformin until after you see Dr. [**Last Name (STitle) **].
.
Your heart is weaker after the heart attack and you will need to
watch for fluid overload in the form of swelling or trouble
breathing. Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if
weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days.
You received a varicella (shingles) vaccine on [**7-10**] to prevent a
shingles outbreak. You will need to have another injection in 1
month by Dr. [**Last Name (STitle) 27322**].
Followup Instructions:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) 2191**] [**Name Initial (NameIs) **]. [**Last Name (un) 27323**]Date/Time:
Office will call you with an appt in [**Month (only) **]. Please call them if
you have not heard from them in a week.
Temporary PCP:
[**Telephone/Fax (1) 7477**] fax: [**Telephone/Fax (1) 12227**] Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**7-15**] at
9:30am.
.
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) 122**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Location (un) **]CARDIOLOGY
Address: [**Location (un) **], 7TH FL, [**Location (un) **],[**Numeric Identifier 6422**]
Phone: [**Telephone/Fax (1) 5068**]
Appt: [**7-28**] at 3pm
Completed by:[**2167-7-13**]
|
[
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"410.71",
"414.2",
"427.32",
"412",
"250.00",
"V45.82",
"272.4",
"427.0",
"733.00",
"V49.86",
"427.31",
"V12.54",
"584.9",
"401.9",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"00.40",
"00.46",
"36.06",
"00.66",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
15382, 15449
|
9126, 13804
|
233, 339
|
15586, 15586
|
4422, 8669
|
18170, 18933
|
3066, 3117
|
14079, 15359
|
15470, 15565
|
13830, 14056
|
8686, 9103
|
15764, 18147
|
3132, 3132
|
2368, 2475
|
3801, 4403
|
183, 195
|
367, 2260
|
3146, 3787
|
15601, 15740
|
2506, 2873
|
2282, 2348
|
2889, 3050
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,694
| 140,172
|
34093
|
Discharge summary
|
report
|
Admission Date: [**2172-5-15**] Discharge Date: [**2172-5-23**]
Date of Birth: [**2145-8-22**] Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Sudden onset, worst headache of life
Major Surgical or Invasive Procedure:
Angiogram, coiling of pericolosal aneurysm
History of Present Illness:
26 y/o male with past medical history of congential deformed
right hand and ecezema in usual state of health sitting on the
health developed sharp worse headache of life bifrontal he
describes 10 times worse than a headache from drinking something
too cold with radiation to the jaw. He had associated nausea and
posterior neck pain but otherwise denied any assoc symptoms.
Past Medical History:
Eczema, deformed right hand from birth.
PSH: Tonsilectomy and Wisdom teeth removal
Social History:
Married with 4 kids, occ cigar, occ wine (less than 2 a month).
Works as an EMT
Family History:
Has a cousin who died suddenly of ? brain anuersym age 50
Physical Exam:
On Admission:
O: T: 99.2 BP:143/63 HR:93 R 21 O2Sats 98%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**3-18**] EOMs full
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. Right hand congenital deformity
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**2-17**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact however left sided
droop noted.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-20**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right 2+
Left 2+
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
Pertinent Results:
Head CTA([**5-15**]):
IMPRESSION: Small aneurysm detected on the left anterior
cerebral artery, apparently located in the segment A2/A3 as
described in detail above, there is no evidence of associated
phenomena such as vasospasm, no other aneurysmatic formations
are visualized.
Head CT ([**5-16**]):
IMPRESSION: Intervention on ACOM aneurysm with no associated
intracranial hemorrhage.
Brief Hospital Course:
26M presents after sudden onset of bifrontal headache. On NCHCT
he was found to have SAH and transferred to [**Hospital1 18**] ED. Pt is an
EMT and was finishing a 24 hour shift (8am-8pm) with some
overtime. At 11:30am, he had just come out of the bathroom
after having a bowel movement and sat on his couch for his
relief to arrive when he had a headache like "someone switched
it on". Headache was sharp, bifrontal and [**7-26**] in severity with
radiation to the jaw. He had associated nausea and posterior
neck pain but otherwise denied any associated symptoms.
He underwent emergent embolization with Dr. [**First Name (STitle) **] on [**5-15**]. He
tolerated the procedure well without incident. He was observed
in the ICU until [**5-19**] at which time he was deemed appropriate for
Step-down observation. Prior to transfer to step-down he
underwent a CTA/P study which revealed no perfusion
abnormalities. Patient had been ambulating well, without
disturbances in balance since the procedure, and therefore did
not require PT/OT evaluation prior to discharge. On [**5-20**] his
headache worsened and a repeat CTA/P was normal. The patient
remained stable and his pharmacy was contact[**Name (NI) **] prior to
discharge to ensure that he will have a sufficient supply of his
nimodipine.
Medications on Admission:
None
Discharge Disposition:
Home
Discharge Diagnosis:
SAH, PERICOLOSAL ANEURYSM
Discharge Condition:
Stable
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
Followup Instructions:
Follow-Up Appointment Instructions
?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in _______weeks.
?????? You will / will not need a CT scan of the brain with / without
contrast.
Completed by:[**2172-5-23**]
|
[
"692.9",
"437.3",
"755.50",
"430"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.72",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
4254, 4260
|
2897, 4199
|
311, 356
|
4331, 4340
|
2485, 2874
|
5375, 5661
|
978, 1037
|
4281, 4310
|
4225, 4231
|
4364, 5352
|
1052, 1052
|
235, 273
|
384, 759
|
1634, 2466
|
1066, 1341
|
1356, 1618
|
781, 865
|
881, 962
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,135
| 126,259
|
30825+57720
|
Discharge summary
|
report+addendum
|
Admission Date: [**2185-7-11**] Discharge Date: [**2185-8-3**]
Date of Birth: [**2105-10-9**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Pt came to the [**Hospital1 18**] for an elective repair of an aortic
aneuryms and iliac aneurims
Major Surgical or Invasive Procedure:
Tracheostomy
Percutaneous gastrostomy tube
History of Present Illness:
79 yo male with know pulmonary hypertension and COPD. He was
oxygen dependant at home. In the preop area his O2 Sat was 80's
on 3 L of oxygen nasal canula.
As soon as the patient was sedated for intubation he arrested.
His hear rhythm was pulses ness electrical activity. He was
shocked into a perfusing rhythm , and transferred to the CSRU
for further treatment and investigation of the cause for his
hemodynamic instability
Past Medical History:
Pulmonary hypertension, COPD, CVA, Gout
Physical Exam:
Lungs ronchi bilateraly
heart RRR
Abd soft
Ext warm
CNS awake alert
Pertinent Results:
Echo:[**2185-7-11**]
Conclusions:
The left atrium is normal in size. There is moderate symmetric
left
ventricular hypertrophy with small cavity size and hyperdynamic
systolic
function (LVEF>75%). Valvular [**Male First Name (un) **] is not clearly seen, but there
is premature
closure of the aortic valve c/w obstructive cardiomyopathy. The
right
ventricular free wall is hypertrophied. The right ventricular
cavity is mildly
dilated with moderate free wall hypokinesis and
akinesis/dyskinesis of the
distal third of the free wall. The aortic leaflets are mildly
thickened.
Aortic stenosis is not suggested. No definite aortic
regurgitation is seen.
The mitral leaflets are mildly thickened. No mitral
regurgitation is seen (but
images are suboptimal and cannot be fully excluded)l. Moderate
to severe [3+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic
hypertension. There is a small pericardial effusion. There is an
anterior
space which most likely represents a fat pad.
Ultraosund r vesesls
DVT in the left jugular vein with non-occlusive thrombus in the
left subclavian vein.
[**2185-7-26**]
Micro Blood culture
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 2 S
Brief Hospital Course:
Patient was transferred to CR [**Doctor First Name **] for further treatment. Found to
have an outflow obstruction in the heart. After 1 week of
attempts of extubation he underwent a tracheostomy and a
percutaneous gastrostomy tube.
Multiple times when diuresis was attempted he changed his rhythm
to a fib, a flutter requiring anticoagulation.
he also during the hospitalization developed a ventilator
associated pneumonia, with positive blood cultures. This
cultures were proven to me MRSA> He did not responded well to
Vancomycin so we switch the antibiotics to Linezolid with
adequate response.
He is now doing better, appropriately treated for his pneumonia
and receiving anticoagulation
He will be DC to rehab soon
Medications on Admission:
Lasix 40", Cardizem 180', lipitor 20',Coumadin 5'
Discharge Medications:
Active Medications [**Known lastname **],[**Known firstname **] J
1. IV access: Central Line Order date: [**7-11**] @ 1315 13.
Magnesium Sulfate 2 gm / 50 ml SW IV PRN
prn magnesium less than 2.0 Order date: [**7-11**] @ 1616
2. Acetaminophen 650 mg PO Q6H:PRN Order date: [**7-18**] @ [**2198**] 14.
Metoclopramide 10 mg IV Q6H Order date: [**7-21**] @ 1602
3. Albuterol 4 PUFF IH Q4H Order date: [**7-12**] @ 1605 15.
Metoprolol 12.5 mg PO DAILY Order date: [**7-28**] @ 0847
4. Amiodarone 400 mg PO DAILY Order date: [**7-28**] @ 0831 16.
Miconazole Powder 2% 1 Appl TP QID:PRN Order date: [**7-18**] @ 2301
5. Beclomethasone Dipropionate *NF* 80 mcg/Actuation Inhalation
[**Hospital1 **] Order date: [**7-12**] @ 1605 17. Nystatin Oral Suspension 5 ml
PO QID Order date: [**7-19**] @ 0735
6. Calcium Gluconate 2 gm / 100 ml D5W IV PRN
prn ca less than 1.12 Order date: [**7-11**] @ [**2086**] 18. Nystatin
Cream 1 Appl TP [**Hospital1 **] Order date: [**7-20**] @ 0028
7. Famotidine 20 mg PO BID Order date: [**7-18**] @ 0805 19.
OxycoDONE-Acetaminophen Elixir [**5-12**] ml PO Q4H:PRN Order date:
[**7-19**] @ 0735
8. Furosemide 40 mg IV DAILY Order date: [**7-26**] @ 0808 20.
Potassium Chloride 40 mEq / 100 ml SW IV PRN K < 3.6 Order
date: [**7-11**] @ 1545
9. Heparin IV
No Initial Bolus
Initial Infusion Rate: 850 units/hr
check ptt 6 hours after infusion starts Order date: [**7-27**] @
1204 21. Sildenafil Citrate 25 mg PO TID Order date: [**7-19**] @
0935
10. IV access request: PICC Place Indication: Antibiotics
Urgency: Urgent Order date: [**7-27**] @ 1108 22. Warfarin MD to
order daily dose PO DAILY Order date: [**7-24**] @ 0959
11. Ipratropium Bromide MDI 6 PUFF IH Q6H Order date: [**7-12**] @
1605 23. Warfarin 3 mg PO ONCE Duration: 1 Doses Order date:
[**7-27**] @ 1204
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
Pulmonary Hypertension
ventilator associated pneumonia
Discharge Condition:
stable
Discharge Instructions:
Dc to rehab
treatment of pneumonia for 14 days
Followup Instructions:
Dr [**Last Name (STitle) 1391**]
1 month
([**Telephone/Fax (1) 4852**] Office Fax: ([**Telephone/Fax (1) 72961**]
Completed by:[**2185-7-28**] Name: [**Known lastname 12142**],[**Known firstname **] J Unit No: [**Numeric Identifier 12143**]
Admission Date: [**2185-7-11**] Discharge Date: [**2185-8-3**]
Date of Birth: [**2105-10-9**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 231**]
Addendum:
Pt was scheduled to be discharged to Rehab, but was not accepted
secondary to Hct of 24.9 (pt was asymptomatic otherwise). Pt
was transfused 2U PRBC's, post-transfusion Hct 30. On day of
discharge to Rehab, the pt is hemodynamically stable, Hct 32.4
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2876**] - [**Location (un) 4415**]
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**]
Completed by:[**2185-8-3**]
|
[
"425.1",
"416.8",
"E878.8",
"996.62",
"428.0",
"997.1",
"274.9",
"038.11",
"442.2",
"427.5",
"427.31",
"501",
"V64.1",
"496",
"482.49",
"E879.8",
"E849.7",
"V09.0",
"998.59",
"424.2",
"427.32",
"995.91",
"999.9",
"441.4",
"E938.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.61",
"96.04",
"43.11",
"99.04",
"38.93",
"96.72",
"99.60",
"31.1",
"00.14",
"89.64"
] |
icd9pcs
|
[
[
[]
]
] |
6340, 6570
|
2600, 3322
|
411, 455
|
5434, 5442
|
1078, 2577
|
5537, 6317
|
3425, 5242
|
5356, 5413
|
3348, 3399
|
5466, 5514
|
990, 1059
|
274, 373
|
483, 910
|
932, 975
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,871
| 188,121
|
5529
|
Discharge summary
|
report
|
Admission Date: [**2180-5-2**] Discharge Date: [**2180-5-6**]
Service: MICU
CHIEF COMPLAINT: Shortness of breath and hypotension.
HISTORY OF PRESENT ILLNESS: This is an 83-year-old male
recently discharged from [**Hospital6 1129**] with
a diagnosis of mantle cell lymphoma of the blastic variant
diagnosed on [**2180-4-5**] by bone marrow biopsy.
He was found to have an echocardiogram there which showed
severe aortic stenosis, severe tricuspid regurgitation, and
severe mitral regurgitation with a ruptured chordae. No
treatment was offered the patient because of his
comorbidities.
He was seen in our Transfusion Unit today and received 2
units of packed red blood cells and was noted to be wheezing
and hypotensive. He also had several hours of chest pain and
was coughing brown sputum.
He was given 80 mg of Lasix and was transferred to the
Emergency Room where he had run of eight beats of ventricular
tachycardia. He was noted to have an elevated troponin and
was given ceftriaxone and vancomycin because of his cough
with sputum. He was admitted to [**Hospital Ward Name 1826**] Intensive Care Unit
for management of atrial fibrillation with a rapid
ventricular response, an elevated troponin, and congestive
heart failure.
PAST MEDICAL HISTORY:
1. Legally blind since birth.
2. Congestive heart failure with severe aortic stenosis,
tricuspid regurgitation, and mitral regurgitation.
3. Coronary artery disease.
4. Atrial fibrillation.
5. Status post pacemaker placement in [**2175**].
6. Diverticulosis and diverticulitis; most recently in
[**2179-7-24**].
7. Remote pulmonary embolus complicated by ventricular
tachycardia 40 years ago.
8. Total knee repair and bilateral inguinal hernia repair.
9. Benign prostatic hypertrophy.
10. Carpal tunnel syndrome.
11. Hypercholesterolemia.
12. Chronic renal failure (with a baseline creatinine of 2).
13. Gastroesophageal reflux disease.
14. Gout.
15. Gallstones.
16. Depression.
17. Mantle cell lymphoma (see History of Present Illness).
ALLERGIES: Allergies include ZANTAC, ZOLOFT, EFFEXOR,
AMBIEN, PENICILLIN, and CEPHALOSPORINS (which may cause
rash).
MEDICATIONS ON ADMISSION: Medications included Proscar,
Colace, aspirin, trazodone, Bacitracin, allopurinol,
Coumadin, Tylenol, Lasix, digoxin, metoprolol, and Neurontin.
SOCIAL HISTORY: Social history significant for a
40-pack-year smoking history.
FAMILY HISTORY: Family history significant for cirrhosis and
multiple sclerosis.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
was significant for a blood pressure of 102/60, respiratory
rate was 16, weight was 106 kilograms, temperature was 99.2,
and heart rate was in the 100s. He was 90% on room air and
96% on 2 liters. He was tachypneic in mild-to-moderate
distress with jugular venous distention to his ear. A 2/6
systolic murmur, loudest at the base with a holosystolic
murmur at the apex. Crackles two-thirds of the way in both
lung fields with wheezing and decreased air movement.
Ecchymoses of his abdomen. Heme-positive stool.
Neurologically, he was perseverative and delirious.
PERTINENT LABORATORY VALUES ON PRESENTATION: Admission
laboratories were significant for a white blood cell count of
40 and a hematocrit of 28. Creatinine was 2.5 and blood urea
nitrogen of 89. INR was 1.7. Troponin was 10.3. Digoxin
level was 2.8.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray revealed mild
congestive heart failure and a question of lingular
infiltrate.
HOSPITAL COURSE: He was given intravenous Lasix. He was
seen by Cardiology who felt that he had no interventional
options for ballooning of his aortic stenosis and no change
of surviving surgery for his other valve lesions.
He was seen by Hematology/Oncology who confirmed the
impression of [**Hospital6 1129**] that he had
mantle cell lymphoma based on bone marrow biopsy review and
gave a grim prognosis to the patient and his family.
Because of the inability to exclude pneumonia, he was covered
with levofloxacin and ceftriaxone.
Laboratories were sent to work up his renal failure.
However, on discussion with family and the patient it was
felt he was unlikely to benefit from further aggressive care.
Therefore, a long discussion was held with the patient's
wife, as well as [**Name (NI) **] and [**Name (NI) 501**] [**Known lastname 22311**], and several
family members, and goals of care were changed to comfort
measures only. The patient was made do not resuscitate/do
not intubate. He was placed on as needed morphine and Ativan
with a scopolamine patch as needed.
He continued to have runs of ventricular tachycardia; one of
which proved fatal at 6:10 on the morning of [**2180-5-6**].
The patient was pronounced dead, and the family was notified.
DR.[**First Name (STitle) **],[**First Name3 (LF) **] 11-575
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2181-2-8**] 16:33
T: [**2181-2-9**] 11:37
JOB#: [**Job Number 22312**]
|
[
"428.0",
"425.4",
"530.81",
"424.1",
"593.9",
"V45.01",
"202.80",
"272.0",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
2430, 3503
|
2186, 2332
|
3522, 5002
|
104, 142
|
171, 1253
|
1276, 2159
|
2349, 2413
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,540
| 195,743
|
17877
|
Discharge summary
|
report
|
Admission Date: [**2194-9-15**] Discharge Date: [**2194-10-23**]
Date of Birth: [**2127-4-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
Chest pain, abdominal pain
Major Surgical or Invasive Procedure:
-Intubation
-Central Line placement
-ERCP
-EGD
-Colonoscopy
-D/C cardioversion
-Aspiration and drainage of liver abscesses with drain placement
-PICC line placement
History of Present Illness:
Mr. [**Name13 (STitle) 4027**] is a 67 yo man with PMH notable for colon cancer and
RCC, COPD, CAD who presents who awoke with left sided chest pain
this morning. Pain radiated across chest and was [**2194-5-8**]. The
pain has been persistent since this morning without any relief.
He has had some associated shortness of breath. No associated
n/v today though he does report vomiting 3 days ago. Notably, he
has noticed decreased urine output over the last day. He denies
any blood is his stool. No fevers but +chills.
On arrival to the ED he was diaphoretic and SOB. BP 116/97 on
admission and then dipped to 70's with HR 110. Epigastric pain
on palpation. Dark liquid stool in colostomy that was guiac pos.
ECG sinus without ischemic changes. Non contrast CT abdomen to
be done. LIJ placed. Got 4L IVF. Started on levophed and
neosynephrine. On 10L via NRB with sat of 100%. Got vanc and
zosyn. Blood and urine cultures sent. CXR did not show an
infiltrate. CVP 13-14 after 4L IBF resucitation.
Past Medical History:
- Rectal Cancer:s/p pelvic exenteration, cystectomy, formation
of
a ileal conduit, and a colostomy. Chemotherapy includes possible
5FU, FLOX + Avastin in [**12/2189**], Erbitux in [**2-/2190**] then Erbitux +
irinotecan in [**3-/2190**]
- RCC:s/p partial R.nephrectomy [**2-/2193**]
- Hypertension
- Atrial flutter, s/p cardioversion
- Asthma
- COPD
- Coronary artery disease
- Depression.
- h/o + C diff. diarrhea
- left ankle fracture 30 years ago
- macular degeneration
- tobacco use
- H/o LLL PNA in [**3-/2193**]
Social History:
-Lives at [**Location (un) 169**] [**Hospital1 1501**], reports no relatives
-Retired truck driver
-Divorced w/ no children
-20 pack yr smoking history, currently smokes 10 cigarettes/day
Family History:
-brother w/ renal cancer who died in his 60's
-brother w/ lung CA who died in his 60's
-family history of heart disease
Physical Exam:
GA: AOx3, NAD
HEENT: PERRLA. mucous membranes dry, oral mucosa clear
NECK: supple, no LAD, LIJ in place
Cards: tachycardic, 3/6 systolic murmur
Pulm: CTAB no crackles or wheezes
Abd: +BS, soft, +pain with palpation of epigastrium, +RUQ and
LUQ pain, ostomy with trace stool output, small amt urine in
urostomy pouch
Extremities: no LE edema
Skin: no lesions appreciated
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
Pertinent Results:
ADMISSION LABS from [**2194-9-15**]:
WBC-18.8*# RBC-3.51* Hgb-9.6* Hct-27.9* MCV-80* MCH-27.4
MCHC-34.5 RDW-16.5* Plt Ct-137*#
Neuts-72* Bands-25* Lymphs-1* Monos-2 Eos-0 Baso-0 Atyps-0
Metas-0 Myelos-0
Hypochr-NORMAL Anisocy-2+ Poiklo-3+ Macrocy-OCCASIONAL
Microcy-2+ Polychr-OCCASIONAL Ovalocy-2+ Schisto-OCCASIONAL
Burr-2+
PT-23.0* PTT-37.7* INR(PT)-2.2*
Fibrino-416*
Glucose-79 UreaN-43* Creat-4.1*# Na-131* K-3.4 Cl-98 HCO3-11*
AnGap-25*
BLOOD ALT-178* AST-137* AlkPhos-317* TotBili-3.6*
[**2194-9-15**] 10:16PM BLOOD Albumin-2.8* Calcium-6.3* Phos-5.5*
Mg-0.9*
CARDIAC ENZYMES:
[**2194-9-15**] 06:00PM BLOOD cTropnT-0.95*
[**2194-9-15**] 10:16PM BLOOD CK-MB-7 cTropnT-0.80*
[**2194-9-16**] 02:12AM BLOOD CK-MB-7 cTropnT-0.66*
[**2194-9-15**] 10:16PM BLOOD CK(CPK)-162
[**2194-9-16**] 02:12AM BLOOD CK(CPK)-149
URINE ANALYSIS:
[**2194-9-17**] 10:22AM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.017
[**2194-9-17**] 10:22AM URINE Blood-MOD Nitrite-POS Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
[**2194-9-17**] 10:22AM URINE RBC-25* WBC-615* Bacteri-FEW Yeast-NONE
Epi-<1
[**2194-9-17**] 10:22AM URINE WBC Clm-FEW Mucous-RARE
[**2194-9-17**] 10:22AM URINE Eos-POSITIVE
OTHER LABS:
[**2194-9-19**] 04:48PM BLOOD TSH-7.2*
MICROBIOLOGY:
[**2194-9-15**] 6:15 pm BLOOD CULTURE 4/4 BOTTLES
ESCHERICHIA COLI
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2194-9-16**] LIVER ABSCESS (1 of 2 drained)
ESCHERICHIA COLI
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
9/14,15,17,18,19,22,26/10 and [**2194-10-4**]: Negative
[**2194-9-16**] MYCOTIC BLOOD CULTURES: Neg
[**2194-9-17**] URINE CULTURES: [**2184**] CFU's GNR, no speciation
Multiple stool tests: negative Cx, negative O&P, and negative C.
diff Toxin
EBV serologies and viral load: negative
CMV viral load: negative
[**2194-9-15**] CT ABD/PELVIS w/o CONTRAST
1. Bibasilar ground-glass opacification may represent basilar
atelectasis;
however, infectious process or aspiration cannot be completely
excluded and should be considered in the correct clinical
setting.
2. Gallbladder wall is calcified placing the patient at risk for
gallbladder cancer. Thickening along the medial wall of the
gallbladder is unchanged from prior.
3. Dilated common bile duct. Hyperdense 6-mm foci in the distal
common bile duct raise concern for choledocholithiasis or soft
tissue. Recommend an ERCP/MRCP for further evaluation.
5. New hypodensities in the left lobe of the liver concerning
for
abscess/infection or metastases. These can be further evaluated
on ultrasound or MRCP.
6. Moderate perinephric stranding is slightly worse compared to
[**2194-2-27**] and is more prominent on the left versus the
right, non-specific, but could relate to acute renal failure.
Consider also correlation with
urinalysis.
7. Again noted is pre-sacral fluid collection containing air
which is slightly increased compared to [**2194-2-27**] and
shows increased air within the collection. A second walled-off
air collection noted adjacent to the larger pre-sacral fluid
collection is new since [**2194-2-27**].
8. Small bowel appears mildly dilated with no definite
transition point
identified. Findings may be due to ileus, although an early
small-bowel obstruction cannot be entirely excluded.
9. Mild perihepatic fluid and mild mesenteric stranding.
[**2194-9-16**] ERCP:
Obstruction in the lower third of the biliary tree either from
stone or a stricture. A stent was placed. Pus was noted from the
biliary tree.
Otherwise normal ercp to third part of the duodenum.
RECOMMENDATION: ERCP in 4 weeks to remove stent and obtain a
full cholangiogram.
[**2194-9-19**] RUQ ULTRASOUND: repeat ordered to assess interval change
in size of multiple liver abscesses
1. Two larger intrahepatic collections in the left lateral liver
are similar to that seen on [**2194-9-16**], with deeper segment III
lesion having more liquified appearance and more superficial
segment II lesion having more semi-solid appearance, each also
with associated few small satellite lesions. No definite new
lesion seen.
2. Small perihepatic ascites is increased compared to [**2194-9-15**].
3. Gallbladder is again noted to be rim calcified and containing
sludge.
[**2194-9-25**] CT Head: 1. Study is limited due to motion artifact,
particularly in the infratentorial region. However, no
intracranial hemorrhage or mass effect is seen in the
supratentorial region. Further followup with MR, if not
contraindicated, is recommended.
2. New, moderate sized lytic lesion in the left frontal bone
with some soft tissue component, most likely representing
metastatic lesion given the history, with less likely
possibility of infection. Rec. nuclear medicine scan for
detection of additional lesions and MR [**Name13 (STitle) 430**] for complete
assessment.
[**2194-9-27**] TTE: Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF>55%). The right
ventricular cavity is moderately dilated with normal free wall
contractility. There is a trivial/physiologic pericardial
effusion. There is an anterior space which most likely
represents a prominent fat pad. IMPRESSION: Dilated right
ventricle with normal global biventricular systolic function.
Very limited study.
[**2194-9-29**] CT Chest/Abdomen:
1. Moderate bilateral pleural effusions, increased from previous
examination, and bibasilar atelectasis. Additional probable
superimposed consolidation and changes of aspiration pneumonitis
at the left lung base.
2. Increase in perihepatic free fluid, indeterminate, but could
represent
ascites; biloma cannot be excluded. Clinical correlation is
recommended. A
pigtail catheter in a left lobe abscess has been partially
withdrawn and now side holes are located outside of the
collection. This should be advanced as this could contribute to
the accumulation of perihepatic fluid.
3. Moderate left-sided hydronephrosis with ileal conduit in
place. The
course of the ureter is not fully imaged and this is increased
compared to
[**9-15**]. Clinical correlation recommended.
4. Prior right partial nephrectomy; no definite evidence of
recurrent disease on this non-contrast CT although
retroperitoneal lymph nodes remain borderline. Continued
attention on followup imaging recommended.
5. Focal gallbladder wall thickening and punctate calcification,
which could represent porcelain gallbladder or changes of focal
adenomyomatosis. Stability since [**2189**] is reassuring.
6. Secretions filling the right lower lobe bronchus.
[**2194-10-5**] CT Abdomen/Pelvis:
1. Essentially unchanged left lobe liver abscesses.
2. Gallbladder wall thickening with calcification of the
gallbladder is
concerning. A gallbladder ultrasound may be obtained for further
evaluation if one has recently not been performed.
3. Presacral abscesses as shown interval organization, but
appears
essentially unchanged in size from the prior exam.
[**2194-10-11**] CT Abdomen/Pelvis:
IMPRESSION:
1. Limited non-contrast CT scan of the abdomen demonstrating
stable appearance of the intrahepatic catheters with residual
abscesses, with interval improvement in intrahepatic bile duct
dilation and pneumobilia.
2. Interval increase in the small amount of perihepatic ascites
as well as
bilateral moderate pleural effusions.
3. Persistence of the air-containing fluid collection in the
pelvis with
suspected communication with bowel.
Brief Hospital Course:
Mr. [**Name13 (STitle) 4027**] is a 67 yo man with history of rectal cancer and
RCC, CAD and COPD. He presented with chest pain and was
ultimately found to be in septic shock.
SEPTIC SHOCK, ASCENDING CHOLANGITIS: Grew GNR in blood which
speciated to E. coli. He was resuscitated with IVF and required
three pressors on admission (vasopressin, norepinephrine and
phenylephrine). Florid leukocytosis with bandemia and elevated
LFT's were noted on admission with evidence of dilated CBD on CT
abdomen. Emergent ERCP ([**9-16**]) was done on admission and showed
CBD stricture with frank pus. A stent was placed. He was
started vancomcyin and pip/tazo. As described below, CT also
showed liver abscesses which were drained by IR and required
repeat drainage and catheter placement given reaccumualtion.
Slowly over the course of five days, he was weaned from
pressors. RUQ ultrasound done on [**2194-9-19**] to monitor the size of
the abscesses showed they were stable in size but not
significantly improved. Repeat drainage with catheter placement
occurred on [**2194-9-24**]. He remained afebrile while off pressors.
Blood Cx grew pan-sensative E. Coli species and Abx switched to
Zosyn. Zosyn continued until changed as noted below.
LIVER ABSCESSES: Multiple hypodensities seen in the left lobe of
the liver on CT were concerning for abscesses. A
ultrasound-guided percutaneous drainage of two of the abscesses
was pursued on [**2194-9-16**] and showed frank pus (see report for
further details of anatomy; no cytology sent due to low volume
of aspirate). Blood cultures ([**4-6**] vials from admission) as well
as cultures from one of the abscesses grew pan-sensitive E coli
as noted above. Repeat drainage with catheter placement
occurred on [**2194-9-24**] and drains were left in place. They
required readjustment under IR on [**2194-9-30**]. Drains stayed in
place until [**2194-10-17**] when they were pulled even though follow-up
CT still showed residual liver abscess. Twenty-four hours after
drains pulled pt transitioned from IV zosyn to PO cipro/flagyl
per ID recs. Stayed on this regimen until [**10-22**] when Abx
switched to amoxicillin/clavulonic acid due to developing
neutropenia and concern for antibiotic toxicity as the cause. Pt
to continue these PO antibiotics to complete 4-6 weeks of
therapy. Plan for repeat Abd CT to be scheduled during follow-up
appointment in infectious disease clinic on [**2194-11-7**] with Dr.
[**Last Name (STitle) 2324**].
RESPIRATORY FAILURE: Patient was intubated on admission for his
ERCP. He remained intubated with two unsuccessful attempts at
extubation. It was felt that he likely had flash pulmonary
edema complicating his extubation attempts and needed to be
reintubated each time. He was more aggressively diuresed and a
third attempt at extubation was successful. He was weaned to 2L
nasal cannula without incident. Pt then developed a hospital
acquired pneumonia and required brief re-intubation in setting
of acute respiratory distress. Only stayed intubated for a brief
period of time and then was successfully extubated. He did not
have further respiratory issues during the hospitalization and
was quickly weaned off oxygen to room air.
ACUTE RENAL FAILURE: Mr. [**Name13 (STitle) 4027**] was anuric for ~36-48 hours
after admission, likely from dense ATN in the setting of
profound septic shock (he was on three pressors for several
days). Creatinine maxed at 5.0 with BUN 56. CVVH was started
on [**2194-9-18**] and continued until [**2194-9-20**]. Urine output slowly
increased and subsequently entered a post-ATN diuresis. His
creatinine subsequently decreased but remained elevated around
2.5-2.7. He then had another episode of elevated creatinine to
4-5 range and decreased urine output, again felt to be due to
ATN in the setting of acute GI bleed. After he was resuscitated
from this episode his creatinine slowly improved over the course
of the next two weeks until it ultimately stabilized around
1.7-1.9, slightly higher than his old baseline.
ATRIAL FIBRILLATION/AFLUTTER: He had Afib with RVR and atrial
flutter that began in setting of sepsis. He was cardioverted x
2 which only resulted in converting to sinus rhythm for a short
period of time. He was loaded with amiodarone and
rate-controlled with metoprolol. He still had episodes of
tachycardia to the 120's in atrial flutter and repeat
cardioversion was planned. However, in the setting of GI bleed
and concern over dangers of any anticoagulation, the
electrophysiology service elected to not perform either
cardioversion or flutter ablation. Recommendation was made to
stop the amiodarone and uptitrate the metoprolol which was done
over the next week. At time of discharge pt still with mildly
elevated HR 100-110s on 75mg of QID PO metoprolol tartrate.
GI BLEED and DIARRHEA: He was transferred to the floor on [**10-3**]
and had another episode of hypotension. He was resuscitated
with IV fluids and transferred back the MICU. He continued to
have profuse guaiac-positive watery diarrhea and had a few
episodes of bright red blood per rectum. GI was consulted who
planned an EGD/colonoscopy. This was done on showing gastritis,
duodenitis, and an area of anal fissure. The stomach and
intestine were attributed as the most likely sources of the
bleeding. Pt underwent an extensive work-up for causes of
infectious and non-infectious diarrhea while still in the ICU,
all of which ended up being negative including multiple samples
sent for C. diff tox. Pt continued to have large volume stool
output through his ostomy and was started on loperemide and
metamucil to reduce this output.
COAGULOPATHY: He had an elevated INR, and PTT on admission
likely related to sepsis. Fibrinogen was normal. He also had
significant reduction in platelets. His coagulopathy improved
with resolution of sepsis. He was started on coumadin for his
atrial flutter and his INR increased to 4.1. He then had BRBPR
as above and his INR was reversed with FFP and vitamin K.
Coagulation parameters normalized but the decision was made not
to further anticoagulate him acutely [**2-4**] to the GI bleed.
One-two weeks after resolution of the GI bleed pt had some
bright red blood oozing from the rectum which was brief and
self-limited. This was attributed to the anal fissures which had
been noted on colonoscopy and as a result of this second episode
of bleeding decision was made to hold even anticoagulation with
aspirin for pt's afib/aflutter until pt stable as an outpatient.
GAP METABOLIC ACIDOSIS: On admission, pt had anion gap acidosis
likely secondary to elevated lactate and renal failure. His gap
closed with treatment of underlying infection.
Neutropenia: Developed at the end of the hospitalization after
pt was started on Cipro/Metronidazole. Because of the temporal
relation to the initiation of these two medications and no other
medication addtions, neutropenia was attributed to medication
cause and antibiotics switched to augmentin.
Thrombocytopenia: Pt developed decreasing plt levels while in
the ICU. HIT work-up was negative and falling plts were deemed
[**2-4**] to PPI so this mediation was stopped and H2 blocker started
as GI bleed prophylasix. Plts levels slowly climbed back up
after PPI was stopped.
ADDITIONAL ITEMS IN NEED OF OUTPT FOLLOW-UP:
1) CALCIFIED GALLBLADDER: Noted on CT ABD. This should be
followed up as the underlying cause for the biliary stricture is
yet unidentified.
2) PRESACRAL FLUID COLLECTION: He had multiple abdominal CT
scans that showed a presacral fluid collection that was stable
in size compared to previous. This collection showed more
organization than on previous scans, but has been present since
[**2193**]. It was felt that this was likely not clinically relevant
given his improvement. However, if he were to decompensate, it
would likely need to be drained.
3) LYTIC LESION: Patient had CT head while in the MICU which
showed a new, moderate-sized lytic lesion in the left frontal
bone with some soft tissue component that was felt to represent
a metastatic lesion. He has a history of renal cell carcinoma
and colon cancer in the past and the source of this lesion was
not entirely clear.
Medications on Admission:
ALBUTEROL SULFATE [ACCUNEB] - (Prescribed by Other Provider) -
0.63 mg/3 mL Solution for Nebulization - 1 puff NEB q2 as needed
for Shortness of breath
HYDROMORPHONE - (Prescribed by Other Provider) - 2 mg Tablet -
1
Tablet(s) by mouth q4 as needed for Pain
METOPROLOL TARTRATE - (Prescribed by Other Provider) - 50 mg
Tablet - 1 Tablet(s) by mouth twice a day
PAROXETINE HCL - (Prescribed by Other Provider) - 40 mg Tablet
-
1 Tablet(s) by mouth Daily
PROCHLORPERAZINE MALEATE - (Prescribed by Other Provider) - 10
mg Tablet - 1 Tablet(s) by mouth twice a day as needed for
Nausea
RISPERIDONE - (Prescribed by Other Provider) - 0.25 mg Tablet -
1 Tablet(s) by mouth q8 as needed for psychotic symptoms
RISPERIDONE [RISPERDAL] - (Prescribed by Other Provider) - 0.25
mg Tablet - 1 Tablet(s) by mouth Daily
TRAZODONE - (Prescribed by Other Provider) - 50 mg Tablet - 0.5
(One half) Tablet(s) by mouth at bedtime as needed for Insomnia
ACETAMINOPHEN - (Prescribed by Other Provider) - 325 mg Tablet
-
2 Tablet(s) by mouth Q6 as needed for PAIN
ALUMINUM HYDROXIDE GEL - (Prescribed by Other Provider) - 600
mg/5 mL Suspension - 30 ml by mouth as needed for as neded for
stomach upset
ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - 1
Tablet(s) by mouth Daily
CYANOCOBALAMIN - (Prescribed by Other Provider) - 500 mcg
Tablet
- 1 Tablet(s) by mouth Daily
DOCUSATE SODIUM [COLACE] - (Prescribed by Other Provider) - 100
mg Capsule - 1 Capsule(s) by mouth twice a day as needed for
Constipation
ERGOCALCIFEROL (VITAMIN D2) - (Prescribed by Other Provider) -
400 unit Capsule - 2 Capsule(s) by mouth Daily
FERROUS SULFATE [FEROSUL] - (Prescribed by Other Provider) -
325
mg (65 mg Iron) Tablet - 1 Tablet(s) by mouth twice a day
MAGNESIUM HYDROXIDE [MILK OF MAGNESIA CONCENTRATED] -
(Prescribed by Other Provider) - 2,400 mg/10 mL Suspension - 15
cc by mouth PRN
MAGNESIUM OXIDE [MAG-OXIDE] - (Prescribed by Other Provider) -
400 mg Tablet - 1 Tablet(s) by mouth twice a day
METHYL SALICYLATE-MENTHOL [BENGAY ARTHRITIS FORMULA] -
(Prescribed by Other Provider) - Dosage uncertain
MULTIVITAMIN - (Prescribed by Other Provider) - Tablet - 1
Tablet(s) by mouth once a day
SODIUM BICARBONATE - (Prescribed by Other Provider) - Dosage
uncertain
Discharge Medications:
1. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 5 weeks.
2. heparin, porcine (PF) 10 unit/mL Syringe Sig: daily and prn
ML Intravenous PRN (as needed) as needed for line flush.
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. 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.
5. albuterol sulfate 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q2hr as needed for shortness of breath or
wheezing.
6. trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as
needed for sleep.
7. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: One (1)
Tablet PO once a day.
8. ergocalciferol (vitamin D2) 400 unit Tablet Sig: Two (2)
Tablet PO once a day.
9. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every six (6)
hours as needed for pain.
10. metoprolol succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO twice a day:
hold if sys BP < 90 or HR < 60.
11. paroxetine HCl 40 mg Tablet Sig: One (1) Tablet PO once a
day.
12. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for watery stools in ostomy.
13. psyllium Packet Sig: One (1) Packet PO TID (3 times a
day) as needed for loose stools in ostomy.
14. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
15. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnosis
1)Acute Cholangitis
2)E. Coli Sepsis
3)Liver Abscesses
4)Atrial Flutter
5)Acute GI Bleed
Secondary Diagnosis
1)Rectal Cancer s/p pelvic exenteration, cystectomy, formation
of
a ileal conduit, and a colostomy. Last chemo [**3-/2190**]
2)Clear cell RCC s/p partial R nephrectomy [**2-/2193**]
3)Hypertension
4)Asthma/COPD
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:
Mr. [**Name13 (STitle) 4027**], it was a pleasure caring for you during your stay.
You were admitted to the hospital with a gallbladder infection
and bacteria in your blood. You were started on antibiotics and
initially required medications to support your blood pressure
and intubation to support your breathing. A stent was placed in
your bile duct and drains were placed in two abscesses which
developed in your liver
Initially you were also found to have a fast heart rate in
atrial flutter that did not respond to shocks. You were started
on a medications to slow your heart rate. You developed a
pneumonia in the ICU and briefly required re-intubation to
support your breathing.
You had an episode of bleeding from your gut which required
blood transfusions to stabilize. You received a scope to look at
both your esophagus and stomach as well as your small intestine
and colon. Some small damaged areas were identified that may
have been where your bleeding started. Because of your GI bleed
you were not put on blood thinners for your abnormal heart
rhythm.
Because you continued to have large amounts of watery output
from your ostomy you were started on intravenous nutrition as we
were concerned you were not absorbing enough nutrients.
The Following Changes Were Made to Your Medications:
-Amoxicillin/Clavulonic Acid 875mg/125mg by mouth [**Hospital1 **] for 5
weeks (6 weeks from when your liver drains were removed)
-Metoprolol succinate 50mg tabs 3 tabs by mouth twice a day
-Famotidine 20mg by mouth once each day
-Continue the following previous home medications:
-albuterol sulfate 0.63 mg/3 mL Solution for Nebulization One
Inhalation Q2hr as needed for shortness of breath
-trazodone 50 mg Tab, 0.5 Tablet PO at bedtime as needed for
sleep
-cyanocobalamin(B12): 500 mcg Tablet One Tablet PO once daily
-ergocalciferol (vitamin D2) 400 unit, Tablet 2 Tablets PO once
a day.
-Tylenol 325 mg Tablet Two Tab PO every six hours as needed for
pain.
-Paroxetine 40mg tab by mouth once each day
-loperamide 2mg by mouth four times each day PRN watery ostomy
output
-psyllium 1 packet by mouth three times each day PRN watery
ostomy output
-miconazole nitrate 2% poweder apply to rash 4 times a day as
needed
-Camphor-menthol 0.5-0.5% lotion apply to itching area 4 times a
day as needed
You should follow up with Infectious Disease Clinic on [**2194-11-7**]
and the [**Hospital **] clinic on [**2194-11-13**] as noted below.
Followup Instructions:
Repeat CT without contrast of your abdomen will be scheduled at
your infectious disease clinic visit.
Department: INFECTIOUS DISEASE
When: FRIDAY [**2194-11-7**] at 11:30 AM
With: [**Name6 (MD) 2323**] [**Name8 (MD) 2324**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: ENDO SUITES
When: THURSDAY [**2194-11-13**] at 9:30 AM
Department: DIGESTIVE DISEASE CENTER
When: THURSDAY [**2194-11-13**] at 9:30 AM
With: [**Name6 (MD) 1948**] [**Last Name (NamePattern4) 1949**], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**]
Campus: EAST Best Parking: Main Garage
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19,940
| 154,996
|
20892
|
Discharge summary
|
report
|
Admission Date: [**2125-2-28**] Discharge Date: [**2125-3-7**]
Date of Birth: [**2061-6-15**] Sex: F
Service: MEDICINE
Allergies:
Bactrim Ds / Hurricaine / Zosyn / Glipizide / Aztreonam /
Penicillins / Vancomycin
Attending:[**First Name3 (LF) 23347**]
Chief Complaint:
cc:[**CC Contact Info 55593**]
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
HPI: 63F [**Hospital 100**] rehab resident with chronic hypoxia, secondary
to IRF and OSA, diabetes, charcot foot s/p recent hardware
removal and wound debridement presents to ED from [**Hospital **] rehab
for concern about hypoxia, confusion and left leg wound. It is
reported that she had a random oxygen saturation of 64% which
recovered to 93% on 6L. I discussed baseline with nursing staff
at HRC. Patient's baseline is 70-85% on 2-4L NC. Patient is
frequently non-compliant with her oxygen and bipap at the rehab.
Nursing staff reports that they have to constantly ask her to
wear her oxygen. Patient is semi-ambulatory at baseline. Her
recent history is significnat for a hardware removal and wound
debridement on [**2125-2-1**]. She was seen on [**2-15**] and continued on
cipro/clind and LENI was negative for clot. She was again seen
by her podiatrist on [**2-26**] and he noted that she likely needed
daptomycin for treatment of her wound (MRSA), but was not
started on this because she was not seen by her PCP.
.
In the ED patient's VS were 97.1 86 126/82 86% 4L improved to
93% on NRB. Pt had CTPA negative for PE.
.
.
ROS: + nasal congestion and cough productive of yellow sputum,
also with urinary incontinence. Denies fevers, chills,
headache, sore throat, heartburn, abdominal pain, diarrhea,
blood or mucous in stools.
Past Medical History:
- Osteomyelitis/L foot ulcer/Charcot Foot s/p admission [**4-8**]:
treated with Daptomycin x2 wks .hx MRSA [**4-/2123**] foot swab
- Acute methemoglobunemia [**2-3**] hurricaine spray
- HTN
- hyperlipidemia
- diabetes mellitus, type 2 with neuropathy, charcot foot, L
foot ulcer s/p skin graft
- diastolic CHF EF 55% ???last Echo [[**2121**] Echo with nl LV
function]
- COPD
- Severe OSA, intermittently compliant with BiPAP. [**1-8**]
note by [**Hospital1 18**] Pulmonary: severe OSA with CPAP best at pressures
of [**8-11**] cm and BiPAP at 13/9 with 2 liters of o2 needed to
prevent desats to 83%.
- IPF (CT chest [**9-6**] w/ mid lung field fibrosis, mild
honeycombing)
- h/o Lung Nodules (7 mm spiculated LUL nodules, 6mm RUL nodule)
- psoriasis
- hypothyroidism
- h/o positive PPD
- h/o Lumbar Compression fracture
- s/p partial R mastectomy [**2100**] breast ca.
- peripheral neuropathy
- depression, previous h/o hospitalization
- urge incontinence being evaluated by Urology [**2124**]
- [**2122**] persantine MIBI: Normal myocardial perfusion study; EF
73%.
.
Past [**Doctor First Name **] Hx
Charcot foot
mod rad mastectomy R breast age 37 due to cancer
2 hernia repairs as a child
Social History:
lives at [**Hospital 100**] Rehab
uses walker/wheelchair
no tobacco - quit a couple of years ago
no etoh
denies rec drugs
Sister [**Name (NI) 335**] [**Name (NI) 55586**] is HCP [**Telephone/Fax (1) 55591**]. Divorced w/ 2kids.
Family History:
Noncontributory
Physical Exam:
PE: Aging obese woman, NAD
VS: 96.1, 89HR, 144/90BP, 84% 4L.
HEENT: PERRL, EOMI, CN 2-12 intact
Neuro: 5/5 strength, Cerebellar intact
Neck: no LAD, JVP of 8cm,
Chest: Clear
Cardica: RRR no m/r/g
ABD: + BS, NTND
Ext: chronic venous statsis/vascular insufficiency changes. Left
charcot foot with open wound on heed probing deep with yellow
purulent drainage. Warmth, Swelling and erythema up 2/3 the
shin.
Pertinent Results:
[**2125-2-27**] 03:45PM PLT COUNT-343#
[**2125-2-27**] 03:45PM WBC-6.2 RBC-5.08 HGB-15.0 HCT-47.9 MCV-94
MCH-29.5 MCHC-31.3 RDW-16.4*
[**2125-2-27**] 03:45PM URINE OSMOLAL-524
[**2125-2-27**] 03:45PM URINE HOURS-RANDOM CREAT-102 SODIUM-44
POTASSIUM-57 CHLORIDE-63 TOT PROT-32 PROT/CREA-0.3* albumin-3.1
alb/CREA-30.4*
[**2125-2-27**] 03:45PM PTH-203*
[**2125-2-27**] 03:45PM CALCIUM-9.7 PHOSPHATE-3.3
[**2125-2-27**] 03:45PM estGFR-Using this
[**2125-2-27**] 03:45PM UREA N-21* CREAT-1.3* SODIUM-141
POTASSIUM-4.7 CHLORIDE-101 TOTAL CO2-30 ANION GAP-15
[**2125-2-28**] 12:30PM SED RATE-32*
[**2125-2-28**] 12:30PM PT-15.4* PTT-39.0* INR(PT)-1.4*
[**2125-2-28**] 12:30PM PLT COUNT-273
[**2125-2-28**] 12:30PM NEUTS-68.5 LYMPHS-18.5 MONOS-8.0 EOS-4.5*
BASOS-0.5
[**2125-2-28**] 12:30PM WBC-5.7 RBC-4.90 HGB-14.5 HCT-45.2 MCV-92
MCH-29.5 MCHC-32.0 RDW-16.2*
[**2125-2-28**] 12:30PM CK-MB-NotDone cTropnT-0.03*
[**2125-2-28**] 12:30PM CK(CPK)-48
[**2125-2-28**] 12:30PM GLUCOSE-102 UREA N-24* CREAT-1.4* SODIUM-141
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-32 ANION GAP-11
[**2125-2-28**] 07:30PM URINE RBC-0-2 WBC-21-50* BACTERIA-MOD
YEAST-NONE EPI-0-2 TRANS EPI-0-2
[**2125-2-28**] 07:30PM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-MOD
[**2125-2-28**] 07:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.029
[**2125-2-28**] 11:16PM LACTATE-0.8
[**2125-2-28**] 11:16PM TYPE-ART PO2-44* PCO2-56* PH-7.35 TOTAL
CO2-32* BASE XS-3
.
Chest CT [**2125-2-28**]
1. No evidence of pulmonary embolism.
2. Large main pulmonary artery again seen, suggesting pulmonary
arterial hypertension.
3. Extensive emphysematous changes are again seen, unchanged
from prior study.
4. 9-mm nodular density again seen in the right lung. Followup
imaging in [**2125-7-3**], would document 2 year stability.
5. Unchanged compression fracture of the mid thoracic vertebral
body.
6. Diffuse atherosclerotic disease again seen throughout the
aorta.
.
[**2125-3-1**]
ECHO
The left atrium is moderately dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. The saline contrast study was technically
inadequate to exclude a small PFO. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion. Suboptimal image quality - patient unable
to cooperate.
.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Compared with the report of the prior study (images unavailable
for review) of [**2121-10-30**], the LV cavity does not appear to be
dilated. The other findings are similar.
Brief Hospital Course:
Assessment/Plan: 63F with IPF, chronically hypoxic who presents
with oxygen sats near baseline.
# Hypoxia: Chest CT without acute process. Patient has
underlying hypoxia thought initially to be secondary to
idiopathic pulmonary fibrosis and OSA. Her baseline sats were
70-85% at [**Hospital6 459**]. CT was obtained here. However
the lung findings were localized to the apices supporting a
picture more consistent with chronic eosinophilic pneumonia.
The patient defered bronchoscopy. She was started on prednisone
60mg. The patient should remain on 60mg until she sees Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (pulmonology clinic) in 2 weeks. The patient will
also need a repeat CT at that time.
# Foot wound: Recently seen by [**Last Name (NamePattern1) **] who recommended
daptomycin, but it was not started at HRC. Foot obviously
infected here. Wound cultures show multidrug resistence,
complicated by patients multiple abx allergies. The patient
should continue on daptomycin. A PICC line has been placed.
The daptomycin should be continued for 9 more days. A wound vac
was placed by [**Last Name (NamePattern1) **].
# UTI: Urine culture grew Proteus. Patient was started on
ceftriaxone, which should be continued for 2 more days.
# Diabetes: Diet controlled. ISS + QID FS.
# Neuropathy: Ct neurontin, oxycodone, percocet, baclofen
# Cardiac: No known CAD. Has diastolic dysfunction.
# HTN: Not on medications at HRC
# Hypothyroidism: continued synthroid
# Depression: continued effexor, trazadone
Medications on Admission:
See chart
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. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO QID (4 times a
day).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
6. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for pain.
11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime) as needed.
13. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
14. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
15. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Chlorpheniramine Maleate 4 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed.
17. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
19. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
20. CeftriaXONE 2 gm IV Q24H
21. Daptomycin 500 mg IV Q24H
Day 1 [**3-1**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
Foot infection
Hypoxemia (chronic)
Discharge Condition:
Stable, afebrile
Discharge Instructions:
You were admitted because of low oxygen and your foot wound. The
foot wound now has a wound vaccuum in place, and your
antibiotics were changed to daptomycin, which should be
continued for 10 more days. You also had a urinary tract
infection, for which you were started on a different antibiotic
(ceftriaxone), which will be continued for 3 more days.
Please keep all of your follow-up appointments.
Please call your doctor or return to the emergency department if
you experience shortness of breath, fevers or anything else of
concern.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2125-4-4**] 10:45
Please schedule a follow-up appointment in 2 weeks with Dr.
[**Last Name (STitle) **].
[**Name6 (MD) **] [**Last Name (NamePattern4) 23348**] MD, [**MD Number(3) 23349**]
|
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|
[
[
[]
]
] |
10251, 10317
|
6905, 8464
|
374, 395
|
10405, 10424
|
3727, 6882
|
11131, 11436
|
3269, 3286
|
8524, 10228
|
10338, 10384
|
8490, 8501
|
10448, 11108
|
3301, 3708
|
304, 336
|
423, 1772
|
1794, 3007
|
3023, 3253
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,478
| 175,694
|
32267
|
Discharge summary
|
report
|
Admission Date: [**2170-11-19**] Discharge Date: [**2170-12-1**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
fevers, chills, cholangitis and gallstone pancreatitis
Major Surgical or Invasive Procedure:
[**11-19**]: ERCP with sphincterotomy and stent placement in common
[**Last Name (un) **] duct.
History of Present Illness:
The patient is a [**Age over 90 **]y man who presented to an outside hospital in
new onset rapid a-fib, ruled out for MI. While in house he
developed RUQ pain, fever, elevated LFTs and pancreatic enzymes,
as well as GNR bacteremia that was cultured as e coli for which
he was started on zosyn. A central line was placed for volume
resuscitation and monitoring purposes. He also began to develop
acute renal failure. He was transferred to [**Hospital1 18**] for management.
On admsission he denied nausea, vomiting, diarrhea, SOB, CP.
Past Medical History:
PMH:
Hypertension
Macular degeneration
Restless leg syndrome
Cataracts
Osteoarthritis
PSH:
Appendectomy [**2092**], T&A [**2092**], spinal stenosis surgery [**2165**],
laminectomy, RLL lung resection for benign lesion [**2169**].
Social History:
Lives in an [**Hospital3 **] facility call [**Location (un) **]
former pipe smoker
rare EtOH use.
Family History:
non-contributory
Physical Exam:
97.4, 110 a-fib, 177/84, 32, 93% 5L nc
A&O x 3
Mild icterus
CV:irregular, tachycardic, S1, S2
Pulm: tachypnic, CTA B
Abd: soft, non-distended, tenderness and guarding RUQ,
hypoactive bowel sounds
Extremities: no edema
Pertinent Results:
CHEST (PORTABLE AP) [**2170-11-19**] 3:41 PM
Probable bilateral pleural effusions with basilar atelectatic
change. Left subclavian catheter extends to the mid portion of
the SVC.
LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT [**2170-11-19**] 4:03 PM
IMPRESSION:
1. Mild intrahepatic duct dilation. No gallstones. The common
bile duct was not evaluated. The liver parenchyma is grossly
unremarkable. The gallbladder wall is somewhat distended with a
wall measuring 3 mm.
Transthoracic echo [**11-21**]
IMPRESSION: Mild hypokinesis of the basal to mid inferior wall.
The right ventricular function is not well seen.
ERCP [**11-19**]:
Bulging of the major papilla was noted
Cannulation of the biliary duct was performed with a
sphincterotome using a free-hand technique.
Cholangiogram showed a dilated CBD with a diameter of 1.5 cm
with small filling defects suggestive of sludge
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
Sludge and pus were extracted successfully using a 12 mm
balloon.
A 7 cm by 10 fr Cotton [**Doctor Last Name **] biliary stent was placed
successfully in the common bile duct
Admission labs
[**2170-11-19**] 02:24PM GLUCOSE-80 UREA N-35* CREAT-1.1 SODIUM-141
POTASSIUM-3.9 CHLORIDE-108 TOTAL CO2-17* ANION GAP-20
[**2170-11-19**] 02:24PM ALT(SGPT)-394* AST(SGOT)-483* LD(LDH)-383*
ALK PHOS-377* AMYLASE-1072* TOT BILI-4.1*
[**2170-11-19**] 02:24PM LIPASE-612*
[**2170-11-19**] 02:24PM ALBUMIN-2.8* CALCIUM-7.6* PHOSPHATE-3.4
MAGNESIUM-3.0*
[**2170-11-19**] 02:24PM WBC-23.8* RBC-3.38* HGB-11.2* HCT-34.5*
MCV-102* MCH-33.0* MCHC-32.3 RDW-12.4
[**2170-11-19**] 02:24PM PT-15.7* PTT-32.3 INR(PT)-1.4*
Brief Hospital Course:
The patient was admitted to [**Hospital1 18**] on [**11-19**] from [**Hospital3 628**]
for management of acute cholagnitis and gallstone pancreatitis.
He was admitted directly to the [**Hospital Ward Name 516**] ICU and taken from
there to endoscopy for ERCP. During ERCP, a sphincterotomy was
performed and a dilated common bile duct was found.Sludge and
pus were extracted successfully using a 12 mm balloon. A biliary
stent was placed successfully in the common bile.
Cholangitis/Gallstone pancreatitis:The patient was admitted with
a temperature of 97.4, a WBC count of 23.8, and alk phos 377,
amylase 1072, lipase 612 and total bili 4.1. He was taken for
ERCP on the day of admission. During ERCP, a sphincterotomy was
performed and a dilated common bile duct was found.Sludge and
pus were extracted successfully using a 12 mm balloon. A biliary
stent was placed successfully in the common bile. Following the
procedure the patient's liver enzymes fell to alk phos 135,
amylase 394, lipase 247 and total bili 0.6.
Cardiac/atrial fibrillation: Patient was admitted w/ rapid
a-fib. Heparin drip was started and then discontinued. Patient
was changed from a amiodarone drip to PO amiodarone for which he
was discharged on a taper regimen.
Respiratory: During the early part of his course the patient
was tachypnic to the low 30s respriatory rate. He was diuresed
with IV and then PO lasix with increasing daily urine out-puts
and improved respiratiory status. His O2 requirement which
required intermittent facemask and high flow nasal cannula was
titrated down to 2L nasal cannula at time of discharge.
Pre-renal acute renal failure: Patient responeded well to fluid
resuscitation and creatinine stayed between 0.9 and 1.2. IV and
then PO lasix was titrated to effect and balanced with
respiratory function. Pt was d/c'd with no diuretic.
ID: The patient was placed on zosyn on admission for the
cholangitis and as prophylaxis following ERCP. He remained on
this until being transitioned to PO bactrim which he was
discharged on.
Neuro/Pain Control:patient's pain was well controlled during
admission.
GI/Nutrition: The patient was kept NPO with intermittent sips of
clears liquids until [**11-21**] when he was advanced to clear liquids
ad lib. The following day, [**11-22**], he was advanced to a regular
diet which he tolerated. He did require encouragement to take in
adequate POs.
Dispo: The patient was discharged to the [**Location (un) 86**] Center facility
for rehabilitation.
Medications on Admission:
neurontin 400mg QHS
aspirin daily
tylenol PRN
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
treatment Inhalation Q6H (every 6 hours).
4. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime) as needed for RLS.
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): take 400mg (2 tabs) twice a day until [**2170-12-2**]. Then take
400mg once a day for 1 month. Then take 200mg (1 tab) once a
day for 2 weeks.
Disp:*100 Tablet(s)* Refills:*0*
6. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
neb treatment Inhalation Q6H (every 6 hours) as needed for
shortness of breath or wheezing.
7. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO twice a day
for 4 days.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 86**] Center for Rehab
Discharge Diagnosis:
Cholangitis
Gram Negative Rod sepsis
Gallstone pancreatitis
Atrial Fibrillation
Acute renal failure
Discharge Condition:
Good. tolerating regular diet. Pain well controlled. Vital
signs stable
Discharge Instructions:
* The amiodarone dose you are taking for you heart will be
tapered. You will be on 400mg twice a day until [**2170-12-2**], then
400mg once a day for 1 month, then 200mg once a day for 2
weeks, then stop. Your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 7842**], [**First Name3 (LF) **]
coordinate this with you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to amubulate several times per day.
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is getting worse or is changing location or moving
to your chest or back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 75436**] office at your eariliest convenience to
schedule a follow-up appointment for 2-3 weeks from now. The
number is ([**Telephone/Fax (1) 6347**].
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 7842**]
(Phone:[**Telephone/Fax (1) 8506**], . You will need lab tests as an
out-patient while you are on amiodarone. You will need LFTs,
TFTs, a chest X-ray and an EKG. Your PCP will arrange for this.
|
[
"576.1",
"995.92",
"038.40",
"427.31",
"577.0",
"574.51",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.87",
"51.85"
] |
icd9pcs
|
[
[
[]
]
] |
6894, 6960
|
3362, 5867
|
317, 415
|
7104, 7179
|
1637, 3339
|
8515, 9018
|
1366, 1384
|
5963, 6871
|
6981, 7083
|
5893, 5940
|
7203, 8492
|
1399, 1618
|
223, 279
|
443, 981
|
1003, 1235
|
1251, 1350
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,790
| 162,585
|
18577
|
Discharge summary
|
report
|
Admission Date: [**2113-8-9**] Discharge Date: [**2113-8-18**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Respiratory Distress
Major Surgical or Invasive Procedure:
R-PICC [**8-10**]--removed prior to sending to rehab
GJ Tube [**8-17**] via IR guidance-->sutures are to be removed in 10
days.
History of Present Illness:
Mr [**Known lastname **] is a 86 year-old man with afib, prostate CA, recent
non-traumatic SDH s/p Burr hole & left craniotomy [**2113-6-20**], who
presents with newly noted right sided weakness at rehab.
Pt was hospitalization one wk ago PTA ([**Date range (1) 51030**]) w/ CHF. He
underwent b/l thoracentesis, which showed transudative effusion.
He was discharged to rehab on PRN lasix. At rehab, he was
recently resumed on ASA and subcutaneous heparin. He was dx'd
with C.diff and VRE urinary tract infection, which are being
treated with PO vanco & linezolid respectively.
On the day of presentation, the pt was noted to have acute onset
of right-sided weaknessat ~12:40 pm while working with therapy
this afternoon at [**Hospital6 **]. He was noted to
have acute onset of right facial droop, pocketing food in the
right side of his mouth. He could no longer hold a cup in his
right hand, and could no longer feed himself. There was concern
that he might have "increased" right-sided neglect with the
possibility of non-specified right-sided vision loss. Vitals
there at 1 pm were: T 98, BP 124/60, P 80, RR 20, SaO2 95 RA.
The patient was brought to the [**Hospital1 18**] ED.
In the ED, a code stroke was called by the ED at 2:06 pm;
however, the code stroke was called off shortly after, when the
recent hemorrhage was determined to exclude the possibility of
thrombolysis/intervention. Prelim read on Head CT showed slight
decrease in extent of SDH; however, there was e/o some acute
bleed.
.
Once he arrived on neurology wards, he was noted to be
tachypneic (RR 30s), 02 sat on 2L ~60% (per neuro resident). He
was placed on NRB w/ improvement to 100%. Pt was given 40mg IV
lasix b/c ? acute pulm edema. ABG was 7.34/39/205. CXR was
relatively unchanged from that done in [**Name (NI) **]. Pt transferred to
MICU for further eval & tx. Labs showed increase in trop from
below assay to 0.36, though ck not elevated. Pt developed anion
gap acidosis, lactate 1.8. WBC rising 10-->17.8. Na 131-->129.
Review of Systems: Pt nods head yes to SOB, but no to pain.
Unable to provide addn'l ROS due to severe dysarthria/resp
distress.
Past Medical History:
-non-traumatic SDH s/p Burr hole ([**6-27**]) then left craniotomy
([**2113-7-21**])
- Systolic/Diastolic CHF; TTE [**7-28**] w/ mild global left
ventricular hypokinesis, LVEF = 40-45 %. Grade III/IV diastolic
dysfunction. Restrictive filling abnormality. RV moderately
dilated w/ focal hypokinesis of the apical free wall.
-Moderate MR
[**Name13 (STitle) **] pleural effusion, s/p thoracentesis, diagnosed [**Month (only) 216**]
[**2112**]
-HTN
-Hyperlipidemia
-Atrial Fibrillation, now with ventricular pacemaker
-Prostate ca presently undergoing work-up for cryotherapy
-s/p bilateral cataract surgery
-recent C.diff, started on coverage with oral vancomycin [**2113-8-5**]
-VRE UTI
Social History:
Patient is a retired architectural engineer. He is currently
residing at [**Hospital6 **] following his SDH. Patient has a
10 pack year smoking history, but quit in [**2058**].
Family History:
Father had lung cancer at age 68.
Physical Exam:
Vitals: T 98.9 F BP 138/56 P 89 RR 28 SaO2 100% on NRB
General: thin elderly man, sl uncomfortable appearing laying in
bed
HEENT: left-sided healing craniotomy scar, sclerae anicteric,
dry MM, with thrush seen on roof of mouth
Neck: mildly limited passive ROM, but no nuchal rigidity, no
bruits
Lungs: occcasional wheezes with cough, decreased breath sounds
at bases
CV: regular rate and rhythm, no MMRG
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: cool dry, no significant edema with stockings in place,
pedal pulses appreciated
Skin: no rashes
.
Neurologic Examination (per neuro note--agree w/ exam):
Mental Status:
Sleepy, inattentive, can occasionally respond appropriately to
some basic questions, though it is very difficult to understand,
given severe dysarthria, language is non-fluent and dysarthric,
following some commands appropriately cooperative with exam when
able, but appears to be neglecting right side of space
Cranial Nerves:
Optic disc margins sharp; may have homonymous hemianopsia on
right side of space, though difficult to tell. Pupils ~4 mm,
surgical, unreactive, and irregular bilaterally. Extraocular
intact vertically, but both eyes appear to be looking left, left
eye appears somewhat exotropic, both eyes crossed midline with
occulocephalics. Reports facial sensation intact bilaterally.
Has a right facial droop involving the lip and eye lid. Hearing
intact to finger rub bilaterally. Palate elevates midline.
Tongue protrudes midline, no fasciculations. Trapezii full
strength on left, 4-/5 on right.
Motor:
Normal bulk and reduced tone throughout. No tremor, no
asterixis. Cannot comply with formal testing, able to hold left
arm and leg anti-gravity for at least 10 sconds. Right arm and
leg immediately drifft down and to the right.
.
Sensation: Withdraws all 4 extremities symmetrically to noxious,
with grimace. Extinguishes right side on DSS.
.
Reflexes:
Normal reflexes on the left and brisk throughout on the right.
Right toe possibly upgoing, left toe downgoing.
.
Coordination: Left FNF without dysmetria, unable to do perform
on right. Unable to attend to make reasonable attempt to perform
HKS.
Pertinent Results:
EKG: initial ECG in ED V-paced accelerated idioventricular
rhythm, w/ stable concordant TWI in V3-6.
- Repeat ECG peri-resp distress: likely afib; more pronounced
TWI in V3-6, and inferior leads.
.
CT head, non-contrast:
No evidence of ischemia although MRI is more sensitive for acute
ischemia. Interval decrease in left subdural collection.
However, small amount of superimposed acute subdural bleeding
cannot be excluded, but there is no mass effect.
.
ECHO [**8-11**]
Conclusions
The left atrium is moderately dilated. The right atrium is
markedly dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is moderately dilated.
There is mild global left ventricular hypokinesis (LVEF = 45-50
%). No masses or thrombi are seen in the left ventricle. There
is no ventricular septal defect. Right ventricular chamber size
is normal. with normal free wall contractility. 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. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of [**2113-8-3**], RV
size is now normal and RV systolic function remains normal.
.
OSH LABS:
-Urine from [**Hospital6 **] [**8-8**]= VRE
-C diff +
.
LABS:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2113-8-11**] 12:58AM 6.7 3.18* 9.8* 28.3* 89 30.7 34.6 14.1
278
[**2113-8-10**] 06:02AM 10.2 3.21* 10.2* 29.1* 91 31.7 34.9 14.1
298
[**2113-8-9**] 10:21PM 17.8 3.68* 11.1* 32.8* 89 30.2 33.8 14.0
319
[**2113-8-9**] 02:14PM 10.5 3.71* 11.3* 33.2* 90 30.5 34.1 14.2
336
.
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2113-8-11**] 12:58AM 103 12 0.5 132* 3.6 99 25 12
[**2113-8-10**] 06:02AM 112 15 0.6 129* 3.4 96 22 14
[**2113-8-9**] 10:21PM [**Telephone/Fax (2) 51031**]* 3.5 94* 19* 20
[**2113-8-9**] 02:14PM 111 17 0.8 131* 4.1 96 26 13
.
COAGS:
PT PTT Plt Ct INR(PT)
[**2113-8-11**] 12:58AM 18.2* 35.2* 1.7
.
LFTs:
ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili
[**2113-8-11**] 12:58AM 73* 42* 170 126* 0.5
[**2113-8-9**] 02:14PM 117* 66* 244 171* 0.9
.
CE: CPK
[**2113-8-10**] 05:13PM 48
[**2113-8-10**] 06:02AM 62
[**2113-8-9**] 10:21PM 31
cTropnT
[**2113-8-10**] 05:13PM 0.18*
[**2113-8-10**] 06:02AM 0.38*
[**2113-8-9**] 10:21PM 0.36
.
Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2113-8-11**] 12:58AM 3.2* 8.5 2.0* 2.0
.
%HbA1c
[**2113-8-9**] 02:15PM 5.6
.
Phenytoin
[**2113-8-18**] 03:19AM 4.9
.
DISCHARGE LABS:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2113-8-18**] 03:19AM 7.9 3.30* 10.7* 30.3* 92 32.3* 35.2* 14.6
383
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2113-8-18**] 03:19AM 97 10 0.5 137 3.9 104 26 11
Calcium Phos Mg
[**2113-8-18**] 03:19AM 8.9 3.4 1.9
********
PEG Placement [**8-17**]
Preliminary Report !! PFI !!
Successful placement of 14-French [**Doctor Last Name 9835**] GJ tube.
.
VIDEO SWALLOW [**8-17**]
IMPRESSION: There is a moderate-to-severe oropharyngeal
dysphagia
characterized by reduced base of tongue retraction and bolus
propulsion with moderate-to-severe pharyngeal residue remained.
Episodes of penetration were noted to occur consistently after
the swallow across all consistency trial. Penetration most often
results in over aspiration after the swallow. Aspiration was
mostly silent, however, reflexive coughing did occur
consistently with penetration intermittently with aspiration.
Cued and reflexive cough were effective in clearing penetration
but unable to create gross aspirated material. This swallow
pattern corresponded to a Dysphagia Outcome Severity Scale
(DOSS) rating of level 1, not safe for POs. Per speech
therapist's recommendation, the patient should remain NPO.
Please refer to the speech therapist's note for full report,
assessment and recommendations.
.
[**2113-8-15**] HEAD CT:
IMPRESSION: Stable left hemispheric mixed-density extra-axial
fluid
collection. No new hemorrhage.
Brief Hospital Course:
Assessment and Plan:
86 year-old man with non-traumatic SDH s/p Burr hole then left
craniotomy, recently resumed on ASA and subcutaneous heparin,
atrial fibrillation s/p pacemaker, C.diff and VRE urinary tract
infection, who presented with acute onset of right-sided
weakness, and developed acute respiratory distress shortly
following arrival to [**Hospital1 **].
.
#Respiratory Distress: Transient drop in 02 sats into 60s on 2L
per neuro team; recovered sat's to high 90s on NRB. Improved in
mid-90s on RA. Suspect pt may have mucus plugged/aspirated,
particularly as he has been having difficulty clearing
secretions due to thick secretions from severe dehydration.
Other possible causes inlcude PE. However, CTA was negative for
PE. CTA actually shows some plugging of a few bronchi as well as
some atelectasis. Has remained on RA throughout MICU stay O2
sats >95%. Floor 99-100%RA. He was continued with Chest PT,
suctioned PRN. He had thick secretions and severely dry MM which
contributed to thick mucous plugs. He also received IVF
hydration. He was maintained on aspiration precuations. O2 sats
were stable >95% RA. Nebs provided prn. On a couple of occasions
required 20mg IV lasix for fluid overload. He did not require
further diuresis while on the floor. O2 sats stable >95%RA.
.
# Cardiac ischemia: Troponin haD risen from below assay to 0.36,
w/o bump in CK. EKG w/ some increase in ST-depression & T-wave
inversions in precordial (V3-6) & inferior leads. These EKG
findings may be due to non-ischemic changes, possibly cerebral T
waves or post-pacing repolarization changes. Pt now mentating
clearly and adamantly denies CP, will stop cycling CE. He was
continued on BB, ACE-I, ASA was resumed on [**8-11**]. Repeat ECHO was
done with EF unchanged, Compared with the prior study (images
reviewed) of [**2113-8-3**], RV size is now normal and RV systolic
function remains normal. He is V-paced without further incident
or EKG changes.
.
# Right sided wkness/?neglect: acute onset. [**Month (only) 116**] be post-ictal
paralysis if pt is seizing (though no clear e/o sz activity),
his dilantin level was low on admission. Also, possible that pt
has old stroke & is unmasking deficits in setting of UTI/cdiff
infections. Pt was bolus'd with dilantin 500mg IV x1 in MICU.
Most likely related to severe dehydration, hyponatremia,
infection-UTI & C-diff. Pt significanly improved on [**8-11**] with R
sided weakness resolving and prior to discharge resolved. He was
kept on TELE to monitor for SZ activity. He did not have any
seizures during this admission. His abx were continued with plan
to stop on [**8-24**] as noted below. EEG was done and per neuro did
not show seizure activity. His Hyponatremia was slowly corrected
with IVF. PT worked with pt. He was significantly decompensated
and will need physical therapy for continued
stregthening/training.
.
# Subdural Hematoma: repeat CT following respiratory event
stable from admission CT. Pt has e/o of stable hematoma, pt
denies HA, visual changes, interactive and following commands
appropriately. Per neuro there was no active bleed and no acute
stroke. He was continued on BB & ACE-I, BP goal 120-160. Per
neuro, safe to restart ASA, which was restarted on [**8-11**].
Coumadin held. He never had seizure activity, his dilantin was
not therapeutic and despite such subtherapeutic levels, he never
seized. In discussion with neurology and neurosurgery-his
dilantin was discontinued. He is to follow up with Dr. [**Last Name (STitle) 548**] as
scheduled with repeat Head CT.
.
# Hyponatremia: most likely hypovolemic process given pt's
severely dry MM & Urine specific gravity is high. His Na slowly
improved, he received gentle hydration. His hyponatremia
resolved, Tube feeds were adjusted accordingly for electrolyte
correction and free water.
.
# Cdiff: ? repeat infx. Placed NGT & started PO vanco (hold
flagyl for now as it may lower sz threshold) Continued PO vanco
x2 week course until [**8-24**].
.
# UTI: cx data from OSH indicates pt had VRE in urine sensitive
to Linezolid & nitrofurantoin. He was started on linezolid on
[**8-10**], con't linezolid for complete course on [**8-24**].
.
#. Urinary retention: Pt developed urinary retention on [**8-14**],
foley replaced. Foley was d/c'd [**8-18**] and he did void on his own.
If he continues to retain would start flomax as pt described
need to have prostate surgery at some point. He did not start
flomax while he was here.
.
# Transaminitis: reportedly noted prior to admission. His
Casodex was reportedly stopped b/c it was thought to be possible
cause. monitor; if no improvement, recheck LFTs were stable.
Did not resume casodex.
.
#.?DM: on ISS in MICU, continue to follow FS closely may be in
setting of stroke, stress response. His FS were followed closely
on the floor and were not elevated. Insulin not given. His ISS
was discontinued and his FS were within normal limits while on
tube feeds.
.
#. FEN: Followed lytes closely-avoided aggressive Na
correction, TF running, nutrition following for TF recs. Speech
& Swallow re-evaluated pt again on [**8-3**], in addition to
video swall and indicated he remained too weak to swallow and
failed his trial. Pt underwent IR guided PEG-14 French GJ tube
on [**8-17**], tolerated procedure well, without complication. PEG was
used on [**8-18**], TF were resumed. NGT was discontinued on [**8-17**].
.
# Access: R-PICC placed in MICU [**8-10**], L PIV. PICC line was
pulled on [**8-18**] prior to discharge as labs were within normal
limits and no need to follow dilantin levels.
.
# Precautions: VRE/C-DIFF/aspiration
.
# Code full, discussed with HCP (by neuro resident), daughter
[**Name (NI) 1743**] [**Name (NI) **], ([**Telephone/Fax (1) 51032**].
.
# Dispo: Rehab
Medications on Admission:
-Augmentin 500 mg [**Hospital1 **] x 7 days, started [**2113-8-7**] for 7d, unclear
indication
-Aspirin 81 mg daily
-Heparin 5000 units SQ TID
-Calcium carbonate 500 mg [**Hospital1 **]
-Citalopram 15 mg q am
-Colace 100 mg [**Hospital1 **]
-Folic acid 1 mg daily
-Ipratropium Neb q 6 hours
-Lisinopril 5 mg daily
-Metoclopramide 5 mg TID
-Metoprolol 12.5 mg [**Hospital1 **]
-Midodrine 2.5 [**Hospital1 **]
-Phenytoin 300 mg [**Hospital1 **]
-Salmeterol/fluticasone INH [**Hospital1 **]
-Albuterol INH q 4 hours prn dyspnea
-Senna 8.6 mg po BID prn constipation
-Vancomycin 125 mg QID started [**2113-8-5**] for C. diff
-Casodex, held on [**2113-8-7**] for worsening LFTs
Discharge Medications:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day).
2. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 6 days: until [**8-24**].
3. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 6 days: until [**8-24**].
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**12-21**] nebs Inhalation Q4H (every 4 hours) as
needed for dyspnea or wheezing.
8. Acetaminophen 160 mg/5 mL Solution Sig: [**4-29**] ml PO Q6H (every
6 hours) as needed for pain, fever.
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
10. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime): only if you
can't urinate.
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day): until pt ambulating
independently, sufficiently.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
-R sided weakness
-Dehydration
-Hyponatremia
-VRE-UTI
-C-diff
-Mucous Plugging
.
Secondary:
-SDH s/p burr hole evacuation
-AF s/p V-pacing
-CAD
-CHF EF 40%
-HTN
Discharge Condition:
Stable, following commands appropriately, A&Ox3, O2 sats
96-98%RA
Discharge Instructions:
You were admitted for weakness. You had a Urinary Tract
infection and C-diff diarrhea from cultures taken from your
rehab facility. Your sodium was low from dehydration. Your R
sided weakness was attributed to the above. A new stroke could
not be ruled out as you could not get an MRI to confirm. Your
subdural hematoma was stable, verified by repeat head CT prior
to your discharge.
.
If you have worsening weakness, difficulty speaking, walking,
incontinence of urine, consfusion, headaches, visual changes or
other worrisome symptoms please call your physician or go to the
emergency room.
.
You must continue to take antibiotics as directed in your
medication list.
Your coumadin was held due to concern for bleeding-do not
restart this, you were continued on aspirin.
Your dilantin was stopped per the neurosurgery team, you never
had a seizure while you were here, neurology also agreed you do
not need dilantin.
Your citalopram was held while you are on Linezolid, you may
restart your citalopram after you complete your linezolid
treatment.
Followup Instructions:
Follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 15532**]
in [**12-21**] weeks, call his office at [**Telephone/Fax (1) 51033**] for an
appointment.
.
Follow up with Dr. [**Doctor Last Name 51034**] for a follow up in 6
weeks. You also need a repeat head CT prior to your appointment
with Dr. [**Last Name (STitle) 548**]. Please call [**Telephone/Fax (1) 2992**] if you have further
questions--the appointments have been arranged already as noted:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2113-9-26**] 1:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6214**], MD Phone:[**Telephone/Fax (1) 3736**]
Date/Time:[**2113-9-26**] 2:45
.
.
Follow up with your Cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8421**] in [**12-21**]
weeks, call his office at ([**Telephone/Fax (1) 22513**] for an appointment.
Completed by:[**2113-8-18**]
|
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"729.89",
"428.0",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93",
"00.14",
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icd9pcs
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[
[
[]
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17738, 17817
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,820
| 162,299
|
5041
|
Discharge summary
|
report
|
Admission Date: [**2114-2-3**] Discharge Date: [**2114-2-15**]
Service: MEDICINE
Allergies:
Morphine
Attending:[**Doctor Last Name 1857**]
Chief Complaint:
Shortness of breath and cough x 2-3 weeks
Major Surgical or Invasive Procedure:
Cardiac catheterization [**2114-2-12**]
Left thoracentesis [**2114-2-6**]
History of Present Illness:
The patient is an 83 year-old male with H/O hypertension,
diet-controlled type II diabetes mellitus, and renal carcinoma
s/p partial right nephrectomy in [**2111**] who presents with dry
cough and shortness of breath x 2-3 weeks. Per OMR, he was seen
at PCP's office two weeks ago for cough. He was treated with
Augmentin for 10 days, but it is unclear if he took this. In
addition, at that time, he had stopped all of his medications
because he felt he was taking too many. His HR was reported at
113 at that visit- no mention of regular or irregular rhythm. He
was explained the need to continue medications.
On presentation, the patient reported dry cough and shortness of
breath x 2-3 weeks with worsening over 1 day PTA. He denied
coughing anything up, but another note in OMR said he had been
productive of yellow sputum. Per his family, he has had a
chronic non-productive cough for several years, but this has
been worsening over the past month. The patient denies fevers,
chills. He reports palpitations, nausea when coughing a lot,
wheezing (unclear for how long or whether he has a history of
wheezing), decreased appetite, swelling in legs, orthopnea.
There was no chest pain or pleuritic chest pain, vomiting,
diarrhea, myalgias, fatigue. He is unsure about weight loss.
In the ED, his vitals were T 94.5, BP 139/83, HR 125, RR 24, O2
sat 94% on RA. He was noted to be in ? SVT v. atrial flutter v.
atrial fibrillation seen on multiple EKGs. He was given
diltiazem 10 mg IV x2 and then diltiazem 30 mg PO x1. He
continued to have rapid ventricular rate and was placed on a
diltiazem drip. He was also given Levoquin and ASA. Per ED
notes, he had a bedside ultrasound placed on the heart which
showed no effusion, but uncoordinated atrial activity.
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. All of the other review
of systems were negative. Cardiac review of systems is notable
for absence of chest pain, paroxysmal nocturnal dyspnea, syncope
or presyncope.
Past Medical History:
(per OMR; pt could not confirm these except for HTN and DM).
1. Diabetes mellitus - diet controlled
2. Renal Cell Carcinoma - s/p right partial nephrectomy [**2111-1-20**]
(path showed renal cell carcinoma with both papillary and clear
cell components)
3. Hypertension
4. Benign prostatic hypertrophy
5. Testicular Microlithiasis
6. Left Eye Blindness - uses prednisilone drops in Right eye to
prevent rejection of corneal implant.
7. Palpitations
8. LUL lesion - stable on CT last checked in [**2110**], evaluated by
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
9. Supraventricular tachycardia
10. Diverticulosis - last documented on colonoscopy [**2108-11-1**].
Social History:
Quit smoking 20 years ago, still uses snuff. History of alcohol
abuse but quit 20 years ago. Moved from [**Country 3587**] 30 years ago,
? recent travel history back to [**Country 3587**]. Lives with his wife,
able to perform ADLs. Has 24 children - very involved family.
Family History:
Noncontributory.
Physical Exam:
Gen: Elderly man in NAD. Oriented x3. Mood, affect appropriate.
VS: T 97.7, BP 141/92, HR 67, RR 22, O2 sat 94% on 3L
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. Right corneal
injection present.
Neck: Supple with JVP to jaw
CV: irreg irreg, normal S1, S2. No murmurs, rubs or gallops.
Chest: Respirations were labored. Coarse breath sounds with
crackles at bilateral bases.
Abd: +BS Soft, NTND. No HSM or tenderness.
Ext: Trace edema bilaterally in lower extremities
Pulses:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
[**2114-2-2**] 04:00PM WBC-7.8 RBC-4.52* HGB-14.1 HCT-43.9 MCV-97
MCH-31.2 MCHC-32.1 RDW-13.7 PLT COUNT-145*
[**2114-2-2**] 04:00PM NEUTS-74.7* LYMPHS-17.9* MONOS-5.0 EOS-1.8
BASOS-0.7
[**2114-2-2**] 04:00PM GLUCOSE-111* UREA N-18 CREAT-1.1 SODIUM-144
POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-28 ANION GAP-13
[**2114-2-2**] 04:11PM LACTATE-1.5
[**2114-2-3**] 01:24AM TSH-1.7
[**2114-2-2**] 04:00PM CK-MB-4 cTropnT-<0.01
[**2114-2-3**] 01:24AM CK(CPK)-88 CK-MB-NotDone cTropnT-<0.01
[**2114-2-3**] 07:50AM CK(CPK)-100 CK-MB-NotDone cTropnT-<0.01
proBNP-1753*
[**2114-2-5**] ABG: pO2 48* mm Hg, pCO2 32* mm Hg, pH 7.51* units,
Calculated Total CO2 26 mEq/L, Base Excess 2 mEq/L, Oxygen
Saturation 84 %
[**2114-2-6**] 02:33AM BLOOD LD(LDH)-257*
[**2114-2-6**] 06:38PM PLEURAL WBC-110* RBC-590* Polys-8* Lymphs-50*
Monos-21* Meso-17* Macro-4*
[**2114-2-6**] 06:38PM PLEURAL TotProt-2.1 Glucose-125 LD(LDH)-78
Albumin-1.4
Discharge labs:
Glucose 89, Urea Nitrogen 27*, Creatinine 1.3* mg/dL, Sodium
141 mEq/L
Potassium 4.3 mEq/L, Chloride 100 mEq/L, bicarbonate 34*
White Blood Cells 7.9, Red Blood Cells 4.51*, Hemoglobin 13.7*
g/dL, Hematocrit 43.1 %, MCV 96 fL, MCH 30.3, MCHC 31.7 %, RDW
13.3 %, Platelet Count 316 K/uL
MICRO:
[**2-2**] BCx: STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE
SET ONLY
[**2-4**] BCx: neg x 2
[**2-5**] BCx: neg x 2
[**2-6**] pleural fluid: 1+ PMNs; no organisms on gram stain; cx
negative
[**2-6**] Pleural fuid in blood culture bottles: negative
[**2-6**] sputum: AFB neg smear & culture
[**2-7**] sputum: AFB neg smear & culture
[**2-8**] sputum: AFB neg smear & culture
ECG [**2114-2-2**] 5:35:56 PM
Atrial fibrillation with rapid ventricular response at 123 bpm.
Left axis deviation with left anterior fascicular block.
Intraventricular conduction defect. Borderline voltage criteria
for left ventricular hypertrophy. ST-T wave changes may be
related to left ventricular hypertrophy/rate or rhythm. Compared
to the previous tracing of [**2110-10-13**] atrial fibrillation is new.
[**2114-2-2**] CXR
Respiratory motion compromises the study. There is a massive
cardiomegaly again identified. There is a tortuous aorta.
Pulmonary vascularity is indistinct which may be in part due to
respiratory motion, although mild element of underlying edema
cannot be excluded. Increased density is noted in both lung
bases, particularly in the retrocardiac left lower lobe. There
is poor definition of the left hemidiaphragm. No definite right
effusion is seen. There is no large underlying pneumothorax. A
levoconcave curvature of the thoracic spine is again identified.
[**2114-2-3**] CXR (PA & lat):
Frontal and lateral views of the chest again demonstrate severe
cardiomegaly. There are bilateral pleural effusions left greater
than right and pulmonary vascular redistribution suggesting mild
failure. There is no definite infiltrate.
CXR ([**2114-2-5**]): Cardiac silhouette remains enlarged, worsening
upper zone vascular redistribution. Bilateral pleural effusions
also appear slightly larger.
ECHO ([**2114-2-5**]):
The left atrium is mildly dilated. The left atrium is elongated.
The estimated right atrial pressure is 10-20mmHg. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. There is moderate regional left
ventricular systolic dysfunction (LVEF 30-35%) with severe
hypokinesis of the basal inferolateral wall and moderate
hypokinesis of the remaining segments. There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Severe (4+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is a
moderate sized pericardial effusion. The effusion appears
circumferential. The effusion is echo dense, consistent with
blood, inflammation or other cellular elements. There are no
echocardiographic signs of tamponade. Echocardiographic signs of
tamponade may be absent in the presence of elevated right sided
pressures.
ECHO ([**2114-2-6**]):
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is moderately dilated. LV systolic function
appears depressed with inferior akinesis, inferolateral
akinesis/hypokinesis and hypokinesis elsewhere (LV ejection
fraction ?35%). Right ventricular chamber size is normal. with
normal free wall contractility. The aortic valve leaflets (3)
are mildly thickened. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. The pulmonary
artery systolic pressure could not be determined. There is a
moderate sized pericardial effusion. The effusion appears
circumferential. The pericardium appears thickened. There are no
echocardiographic signs of tamponade.
ECHO ([**2114-2-9**]):
The left atrium is moderately dilated. The right atrial pressure
is indeterminate. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is top
normal/borderline dilated. There is moderate global left
ventricular hypokinesis (LVEF = 35 %). The right ventricular
cavity is mildly dilated with borderline normal free wall
function. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis. The
aortic valve leaflets are mildly thickened. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate to severe (3+) mitral regurgitation is seen.
There is a moderate sized pericardial effusion. The effusion
appears circumferential. There are no echocardiographic signs of
tamponade. No right atrial or right ventricular diastolic
collapse is seen.
BILATERAL LOWER EXTREMITY VEINS ([**2114-2-6**]):
No evidence of acute DVT. Equivocal findings in the left
superficial femoral and popliteal veins as described above for
which short interval followup in 48 hours is recommended.
BILATERAL LOWER EXTREMITY VEINS ([**2114-2-8**]): No evidence of lower
extremity DVT.
CYTOLOGY:
[**2-6**] pleural fluid: 1+ PMLs, G stain/ culture neg, cytology neg
for malignant cells
CARDIAC CATH [**2114-2-12**]: (preliminary results)
1. Coronary angiography of this right dominant system revealed
flow limiting disease in one coronary artery and mild,
non-obstructive diseaese of 2 other coronary arteries. The LMCA
had mild plaquing. The LAD had mild luminal irregularities with
a 30% stenosis in a diffusely diseased D1 branch. The LCx had a
30% mid vessel stenosis. The RCA had an 80% distal stenosis.
2. Resting hemodynamics revealed normal right sided and
elevated left sided filling pressures with RVEDP of 9 mm Hg and
LVEDP of 20 mm Hg. PA systolic pressure was normal at 28 mm Hg.
Mean PCWP was top normal at 12 mm Hg. Systemic arterial
pressures were normal with aortic systolic pressure of 116 mm
Hg. Cardiac index was depressed at 1.93 l/min/m2.
3. Left ventriculography revealed 2+ mitral regurgitation and
LVEF=25% with global hypokinesis.
Brief Hospital Course:
The patient is an 83 year-old male with hypertension, type II
diabetes mellitus (diet-controlled), and renal carcinoma s/p
right partial nephrectomy in [**2111**] presenting with new atrial
fibrillation with rapid ventricular response and cough/dyspnea.
The patient's symptoms initially were thought to be
multifactorial with bronchitis (given quality of cough and upper
airway wheezing without fever or leukocytosis), COPD (given
extensive smoking history and history of prior cough), and
diastolic heart failure due to atrial fibrillation with rapid
ventricular rate. Pneumonia was also considered initially given
LLL rales. The patient was started on azithromycin/ ceftriaxone/
and vancomycin (given + blood culture on day of admission) for
broad coverage. The patient was also placed on respiratory
precautions given concern for TB. On [**2-5**], the patient was found
to have acute worsening of respiratory status with tachypnea,
significant wheezing, and desaturations to 80%'s despite being
on a non-rebreather. He was transferred to the ICU for further
evaluation.
Brief MICU course: Upon arrival to the ICU, echo results
returned showing moderate LV systolic dysfunction with severe
inferolateral hypokinesis and EF 30-35% (EF 55% in [**2110**]), 4+
mitral regurgitation, elevated right-sided pressures, and mild
LVH. A moderate sized echodense pericardial effusion was noted,
consistent with blood, inflammation or other cellular elements,
with no evidence of tamponade. The patient underwent diagnostic
L thoracentesis, which showed transudative properties with
cultures and cytology negative. The patient was effectively
diuresed 3 liters during MICU stay with dramatic improvement in
SOB. He was then transferred back to the floor. Remainder of
hospital course is by problem, as follows:
# Cough/ SOB: As above, the patient was initially started on
antibiotics to cover for a possible bronchitis/ pneumonia. He
completed a course of ceftriaxone and azithromycin for this.
(Vancomycin was d/c'd as GPC were felt to be contamination.) He
completed a course of prednisone x 3 days and was started on
Advair with prn levalbuterol and ipratropium nebulizers for
potential COPD component. The patient was screened for
tuberculosis with negative AFB smears x 3. Bilateral LENIs were
negative for DVTs. Once echo results returned, SOB and cough
were felt to be most likely cardiac in origin with acute
systolic and diastolic dysfunction and decompensated valvular
disease contributing. The patient was effectively diuresed
approximately >6 L over his hospital course with resolution of
symptoms and no further oxygen requirement. Upon discharge, the
patient was continued on cardiac medications, as below, as well
as Advair inhaler.
# CAD: The patient had no known CAD on admission. There was no
evidence of MI with negative cardiac biomarkers x 3 and no ST-T
wave changes suggestive of ischemia. On [**2-12**] catheterization,
the patient was found to have evidence of 1 vessel disease in
the RCA as well as diffuse plaquing. There were no interventions
done during catheterization, and there were no current
indications for CABG. The patient was continued on medical
management with ASA, ACE-I, beta-blocker, and statin therapy.
# Rhythm: The patient presented with newly diagnosed atrial
fibrillation on this admission. Etiology was felt to be due to
severe systolic as well as diastolic dysfunction and
decompensated valvular disease. The patient was started on
several agents for HR control, which were uptitrated to the
following regimen with HR in mostly 60s-70s: metoprolol XL 300
mg daily, diltiazem SR 120 mg daily (added for rate control
despite the severe LV systolic heart failure), and digoxin
(therapeutic at 0.9 on discharge). He was continued on a heparin
drip for anticoagulation for atrial fibrillation; however, upon
discharge decision was made not to pursue Coumadin therapy as
patient was felt to be a poor candidate due to history of
medication noncompliance.
# Congestive heart failure, acute, systolic and diastolic, EF
25%: As mentioned above, the patient was found to have [**3-6**]+
mitral regurgitation, pulmonary hypertension, elevated R-sided
pressures, and systolic dysfunction with severe hypokinesis of
the basal inferolateral wall and moderate hypokinesis of the
remaining segments with EF 35% on [**2-5**] echo. Cath confirmed
severe systolic LV dysfunction (global HK), mild diastolic
biventricular dysfunction, 2+ mitral regurgitation, and LVEF
25%. The patient was aggressively diuresed, as above, and was
discharged on standing dose of Lasix. He was continued on
beta-blocker, ACE-I, and CCB for BP and HR control. He was set
up with Dr. [**First Name (STitle) 437**] for further managment of heart failure as an
outpatient.
# Hypertension: The patient presented with hypertension to
160s/90s, which improved with diuresis, ACE-I, and uptitration
of metoprolol and diltiazem. BPs upon discharge were
100s-120s/50s-60s.
# Decompensated Mitral Valve Disease: [**2-5**] echo revealed 4+
mitral regurgitation of unclear etiology. The patient was
treated medically while in house with resolution of symptoms. No
plan was made for MV repair given that the patient was
asymptomatic; however, MVR may be an option in the future if
medical management fails.
# Pericardial effusion: The patient presented with an enlarged
cardiac silhouette on admission CXR, with 2/4 echo revealing
moderate sized effusion with mixed echogenic material. Effusion
was of unclear etiology - inflmammation vs infection vs
malignancy vs hemorrhagic. There were no echocardiographic signs
of tamponade, no pulsus paradoxus on exam, and no evidence of
tamponade on catheterization. There was no change in effusion
size on serial echos. Decision was made not to perform
pericardiocentesis as effusion seemed stable and the patient was
asymptomatic. Malignant etiology of effusion was considered;
however, this is less likely as pleural effusion analysis had
negative cytology.
# Ophthalomology: The patient was blind in left eye (does not
know etiology of this), and right eye had conjunctival injection
on admission. Per the patient, injection was secondary to not
using prednisiolone acetate 1% eye drops. Ophtalmology was
consulted, and they recommended to use prednisilone acetate 1%
in R eye QD to prevent rejection of corneal implant.
# Renal Cell Carcinoma: The patient has a history of RCC s/p
right partial nephrectomy in [**2111**]. Creatinine remained stable
throughout hospital course, near baseline of 1.0-1.2. The
patient is followed by urology as an outpatient with no acute
issues. As above, pleural effusion cytology was negative for
malignant cells.
# Hematuria: The patient had brief episode of hematuria upon
removal of Foley catheter, likely secondary to Foley trauma. He
was briefly kept on CBI with subsequent resolution of hematuria.
# DMII: The patient has a history of diet-controlled DM, with
recent HbA1c of 5.8%. He was continued on an ISS while inhouse,
but demonstrated good glycemic control on a diabetic diet. He
was discharged with a glucometer to check finger sticks
regularly.
# BPH: The patient was continued on outpatient finasteride.
Doxazosin was held due to low BP.
# Code: FULL (confirmed with patient and HCP - [**Name (NI) 20806**].
# COMMUNICATION: [**First Name9 (NamePattern2) 20807**] [**Known lastname 12330**] (c: [**Telephone/Fax (1) 20808**]) is the
first contact and [**Name (NI) 20806**] [**Name (NI) 12330**] (c: [**Telephone/Fax (1) 20809**]) is second
contact; daughter [**Name (NI) **] [**Name (NI) 2427**] [**Telephone/Fax (1) 20810**]. Strand Pharmacy
[**Telephone/Fax (1) 20811**], [**Last Name (un) 20812**] Pharmacy [**Telephone/Fax (2) 20813**]
The patient was discharged to home on [**2-15**] in good condition,
VSS, ambulating well, with cardiology and PCP [**Name9 (PRE) 702**] in
place. He will receive PT and VNA services at home.
Medications on Admission:
[**Doctor Last Name 1819**] ASA 81 mg daily
ASA 81 mg daily (he says he takes both of this and the [**Doctor Last Name 1819**])
Lisinopril 5 mg daily
Finasteride 5 mg qhs
Metoprolol 50 mg [**Hospital1 **]
Doxazosin 8 mg qhs
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation. Disp:*60 Capsule(s)*
Refills:*2*
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*1
Disk with Device(s)* Refills:*2*
5. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
6. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-3**]
Drops Ophthalmic Q2-4H PRN ().
7. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic DAILY (Daily).
8. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily). Disp:*30 Capsule,
Sustained Release(s)* Refills:*2*
11. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
- Atrial fibrillation
- Hypertension
- Diabetes mellitius II
- Coronary artery disease
- Congestive left heart failure, acute, systolic and diastolic
- Mitral valve regurgitation
- Benign prostatic hypertrophy
- History of renal cell carcinoma status post partial
nephrectomy
- Corneal injection s/p right corneal transplant
- Pericardial effusion
- Hematuria due to Foley catheter trauma
Discharge Condition:
Good, afebrile and VSS, ambulating well
Discharge Instructions:
You were admitted with shortness of breath that, upon further
workup, was thought to be due to heart failure. You had several
echocardiograms (ultrasounds of the heart), and a cardiac
catheterization which confirmed heart valve disease and poor
pumping function of the heart (EF ~25%).
You were started on several new medications for your heart
disease, which you should continue to take DAILY as prescribed.
These include metoprolol, diltiazem, and digoxin for heart rate
control. Please take all medications as prescribed. Please
attend all of your follow-up appointments. You should continue
to weigh yourself daily, if weight increases > 3lbs, you should
call your PCP or cardiologist. You should adhere to a 2gm sodium
diet, with free water restriction of 1.5L daily.
If you experience any chest pain, palpitations, shortness of
breath, wheezing, dizziness, swelling in the extremities, or any
other concerning symptoms please contact your PCP or go to the
ER for further evaluation.
Followup Instructions:
Please attend the following appointments. You have been set up
with a new cardiologist that specializes in heart failure.
1) Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Primary care, on Wednesday [**2114-2-21**]
at 2:00pm. Phone [**Telephone/Fax (1) 7976**]
2) Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**], Cardiology, on [**2114-3-5**] at 10:00am.
Phone [**Telephone/Fax (1) 3512**].
[**Doctor First Name **] [**First Name8 (NamePattern2) **] [**Name6 (MD) **] [**Name8 (MD) **] MD, MSC 12-339
|
[
"486",
"416.8",
"401.9",
"424.0",
"V10.52",
"250.02",
"599.7",
"423.9",
"428.41",
"600.00",
"V42.5",
"496",
"428.0",
"427.31",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"37.23",
"88.56",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
21130, 21187
|
11395, 19326
|
257, 332
|
21619, 21660
|
4254, 5203
|
22699, 23285
|
3601, 3619
|
19600, 21107
|
21208, 21598
|
19352, 19577
|
21684, 22676
|
5219, 11372
|
3634, 4235
|
176, 219
|
360, 2587
|
2609, 3296
|
3312, 3585
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,453
| 171,231
|
35672
|
Discharge summary
|
report
|
Admission Date: [**2148-4-22**] Discharge Date: [**2148-4-26**]
Date of Birth: [**2080-5-3**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
weakness, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 67M w/h/o DM II who presents with weakness,
myalgias, and diarrhea x 1 week. Pt noticed 1 week ago he had
increased difficulty transferring from couch or chair to
wheelchair. He also reports mild non-bloodly diarrhea ([**3-31**]
BMs/day). He has had poor po intake, not eating food for last
week, not hungry and only taking small amounts of water. Does
note that he has had some shortness of breath, which occurs at
rest as well as activity and has woken him from sleep this last
week. Is able to lie flat without increased SOB. He also
complains of continous hiccups since 6 am this morning, improved
slightly after drinking [**Location (un) 2452**] juice, but now worse. He denies
fever, chills, abdominal pain, nausea, vomiting. chest pain,
cough. Has no sick contacts; lives alone in apartment complex.
No smoking history although did have childhood asthma. Was
vaccinated for influenza this year. No recent hospitalizations
but does live in [**Hospital3 **] facility.
.
Regarding his diabetes, he checks his blood sugars 3-5x daily,
states he takes 70u lantus AM and another 70u PM with sliding
scale humalog at mealtimes. Does not take insulin when he is not
eating and has been taking it erratically this past week in
setting of decreased PO intake. Has not been taking humalog but
has been taking his lantus up until this AM when he was too
tired to take it. Earlier today pt finally decided he felt too
sick to continue. He states EMTs heard "something wrong" and put
him on O2.
.
On arrival to the ED, his VS were: 99.0 122 148/76 18 99% on
?O2. His EKG showed ST LAD. His CXR showed multifocal PNA. His
labs were hemolyzed but showed AG 20, Na: 123, glucose 300. He
received ceftriaxone, Azithro, 10 mg IV insulin, 1L IVF and 40
mEq KCl po. VS on transfer to the ICU were T: 97.7 ??????F, P: 117,
RR: 28, O2Flow: 2L NC
.
On arrival to the ICU, pt denies cough/sob/chest pain/ abd pain.
Has chills at rest.
.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
cough, chest pain, chest pressure, palpitations. Denies nausea,
vomiting, diarrhea, constipation, abdominal pain, frequency, or
urgency. Denies edema, rashes or skin changes.
Past Medical History:
* childhood asthma
* Hypertension
* Diabetes mellitus II - complicated by neuropathy and
retinopathy
* Anxiety
* s/p Cataract surgery
* Glaucoma
* h/o Vertigo
Social History:
Lives at [**First Name5 (NamePattern1) 553**] [**Last Name (NamePattern1) 554**] [**Hospital3 **] facility (but does not
have services). No history of smoking, occasional EtOH, no
IVDU. Used to work as a social worker
Family History:
mother with MI age 64, father with leukemia
No family history of COPD
Physical Exam:
ON ADMISSION:
Vitals: T:101.7 BP:127/63 P:110 R: 18 O2: 95%2L
General: Alert, oriented, obese no acute distress, with NC on
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no discernable JVD
Lungs: crackles bilaterally with poor air movement
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: protuberant. soft, non-tender, non-distended, bowel
sounds present and hyperactive, no rebound tenderness or
guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: strength 4/5 throughout. lower extremeties/hips everted
at rest. sensation decreased on feet but no asymetric defects.
PERRLA, EOMI.
Discharge Exam
T Afebrile BP 150s/70-80s, HR 80s, RR 20, 97% RA
GEN: NAD
Eyes: anicteric
ENT: MMMM
Lungs: Comfortable. No crackles or wheeze.
CV: RRR, no murmurs appreciated. No edema.
Abdomen soft, obese, nt, nd, nabs
PSYCH: Alert. Pleasant
NEURO: Oriented x3.
Pertinent Results:
Admission Labs:
[**2148-4-22**] 05:25PM BLOOD WBC-11.6* RBC-5.05 Hgb-14.2 Hct-42.5
MCV-84 MCH-28.1 MCHC-33.4 RDW-14.1 Plt Ct-262
[**2148-4-22**] 05:25PM BLOOD Neuts-75* Bands-1 Lymphs-13* Monos-7
Eos-0 Baso-1 Atyps-1* Metas-0 Myelos-2*
[**2148-4-22**] 08:51PM BLOOD PT-14.5* PTT-30.4 INR(PT)-1.4*
[**2148-4-22**] 05:25PM BLOOD Glucose-306* UreaN-25* Creat-1.2 Na-123*
K-4.2 Cl-84* HCO3-19* AnGap-24*
[**2148-4-22**] 08:51PM BLOOD ALT-37 AST-43* CK(CPK)-181 AlkPhos-44
TotBili-1.3
[**2148-4-22**] 08:51PM BLOOD Lipase-44
[**2148-4-22**] 08:51PM BLOOD CK-MB-3 cTropnT-<0.01
[**2148-4-23**] 11:50AM BLOOD CK-MB-3 cTropnT-<0.01
[**2148-4-22**] 08:51PM BLOOD Albumin-3.2* Calcium-7.5* Phos-1.6*
Mg-1.7
[**2148-4-22**] 10:36PM BLOOD %HbA1c-9.4* eAG-223*
[**2148-4-22**] 08:51PM BLOOD Osmolal-278
Notable studies
CXR:
IMPRESSION: New pulmonary opacities in the left lung and also
right base,
consistent with multifocal pneumonia. Followup to resolution
once treated is recommended.
Discharge/Notable Labs:
[**2148-4-25**] 07:10AM BLOOD WBC-7.1 RBC-4.48* Hgb-12.9* Hct-38.9*
MCV-87 MCH-28.8 MCHC-33.2 RDW-14.3 Plt Ct-281
[**2148-4-25**] 07:10AM BLOOD Glucose-93 UreaN-11 Creat-0.8 Na-138
K-3.8 Cl-102 HCO3-24 AnGap-16
[**2148-4-23**] 11:50AM BLOOD CK(CPK)-161
[**2148-4-24**] 07:25AM BLOOD Calcium-7.8* Phos-2.1* Mg-2.1
Studies pending on discharge:
None
Brief Hospital Course:
67 yo male with PMH of type 2 diabetes on insulin c/b neuropathy
and depression admitted with multifocal pneumonia and diabetic
ketoacidosis.
#Multifocal Pneumonia:
Patient was admitted with shortness of breath and chills and
oxygen requirement along with leukocytosis and CXR suggestive of
multifocal pneumonia. He was initially started on
vanc/cefepime/azithromycin and then narrowed to levofloxacin
with improvement in symptoms. Urine legionella Ag and
respiratory viral panel were negative. Patient was discharged to
complete a total of a 5 day course of abx with last dose
[**2148-4-27**].
He should have a follow up CXR in 6 weeks to document
resolution.
#Type 2 diabetes mellitus with diabetic ketoacidosis:
Patient was initially admitted to the MICU with DKA. He was
treated with IVF and IV insulin and his anion gap closed and
sugars were controlled. He was transferred to floor and sugars
were well controlled on his home regimen. His metformin was held
during admission and restarted on discharge. A1c was 9.
#Urinary retention:
This was felt to be due to neuropathy from diabetes exacerbated
by acute illness. He was able to void without problems prior to
discharge.
#Hyponatremia - pt presented with Na of 123 in setting of
hyperglycemia. Considered to be pseudohyponatremia in setting of
elevated blood glucose. Legionella antigen was negative as
above. Sodium normalized with IVF repletion and correction of
hyperglycemia.
#Depression: Patient was continued on home Buspar
#Hypertension:
Patient initially had all antihypertensives stopped in setting
of dehydration/DKA/low blood pressures. These were added back as
patient recovered and he was discharged on his usual home
regimen of blood pressure agents.
CONTACT: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 81154**] [**Numeric Identifier 81155**]
Pt was maintained as FULL CODE throughout course of
hospitalization.
#Disposition:
Patient was discharged back to his [**Hospital3 **] facility with
home PT. He has a previously scheduled appt with his PCP in one
week.
#Follow Up:
He should have a CXR in 6 weeks to document resolution of his
pneumonia.
Medications on Admission:
advair 100/50 mcg 1 puff q12
humalog 18u with meals
lisinopril 20mg daily
asa 81mg daily
metformin 1000bid
amlodipine 10 qd
lovastatin 40 qd
hctz 12.5 qd
neurontin 400 TID
buspirone 20mg TID
spiriva 18 mcg 1 cap daily
nevaac eyedrops one drop each eye 4 times a day 0.1%
lantus: 70-100u [**Hospital1 **]
combivent (not filled since feburary)
fluticasone
Discharge Medications:
1. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. lovastatin 40 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
4. gabapentin 400 mg Capsule Sig: One (1) Capsule PO three times
a day.
5. buspirone 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. Lantus 100 unit/mL Solution Sig: Seventy (70) units
Subcutaneous at bedtime.
8. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. MEDICATION CHANGES
1) Please take your levaquin until [**2148-4-27**]
2) Please resume your usual humalog insulin sliding scale
11. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
12. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 days: Last dose [**2148-4-27**].
Disp:*1 Tablet(s)* Refills:*0*
13. hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO
once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Diabetes
Pneumonia
Hypertension
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane). Uses wheelchair for longer distances
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
You were admitted with elevated blood sugars and pneumonia. You
were treated with insulin and IV fluids and you were started on
antibiotics for your infection. You also were tested for the flu
which was negative.
You should continue your antibiotics for the full antibiotic
course as prescribed.
You should also follow up with your PCP as noted below and as
previously scheduled.
Followup Instructions:
Name: NP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1024**]
Location: [**Hospital 81156**] [**Hospital **] HOSPITAL
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 38978**]
Phone: [**Telephone/Fax (1) **]
Appointment: Friday [**2148-5-3**] 11:00am
*This is a follow up appointment for your hospitalization. You
will be reconnected with your primary care physician after this
visit.
|
[
"995.91",
"V58.67",
"790.92",
"250.52",
"V70.7",
"401.9",
"493.90",
"788.29",
"311",
"357.2",
"276.1",
"365.9",
"250.62",
"362.01",
"250.12",
"038.9",
"486",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9250, 9308
|
5485, 7550
|
318, 324
|
9383, 9495
|
4111, 4111
|
10008, 10438
|
3049, 3121
|
8040, 9227
|
9329, 9362
|
7661, 8017
|
9602, 9985
|
3136, 3136
|
7561, 7635
|
5456, 5462
|
2303, 2613
|
263, 280
|
352, 2284
|
4127, 5442
|
3150, 4092
|
9510, 9578
|
2635, 2795
|
2811, 3033
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,964
| 195,103
|
22533
|
Discharge summary
|
report
|
Admission Date: [**2123-6-18**] Discharge Date: [**2123-6-24**]
Date of Birth: [**2078-7-31**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6114**]
Chief Complaint:
renal failure, Hypertension
Major Surgical or Invasive Procedure:
Hemodialysis
Transfused PRBC's
History of Present Illness:
Mr. [**Known lastname **] is a 44yo male with h/o uncontrolled hypertension who
p/w with
renal failure and hypertensive urgency/emergency. Patient has
been complaining
of frequent headaches around the temples for many years, onset
in the morning
or afternoon every day, improving with mutiple tablets of
motrin, which he has
been taking approximately 200mg x 6tabs qd for last 4-5 months.
Patient d/n
visual disturbances, auras, ?photosensitivity accompanying
headaches. He was
in his usual state of health until 3 weeks PTA, when he began
feeling "crappy,"
with increasing fatigue, had episodes of nausea/vomiting with
yellow emesis
following eating and drinking water, and had a metallic taste in
his mouth,
loss of appetite accompanied by weight loss of 15lbs. Patient
visited an OSH
and was found to have BP 247/135, cre 13.9 (?baseline), K+ 2.6,
hematocrit 26.
He was admitted to OSH [**6-17**] for acute renal failure, given
nitroprusside,
fenoldopam, mutiple RBC transfusions, and dialysis. Workup for
anemia revealed
retic count 7.7, LDH 626, total bili 1.0, peripheral smear
significant for
schistocytes. TTE revealed LVH with an EF of 35%. He was
transferred to [**Hospital1 18**]
ICU on [**6-18**] for further evaluation.
In 3 weeks PTA, he also reports decreased nocturia (waking
once/night vs. usual
3-4x/night) and new onset chest pain at rest that improves after
20-30 mins.
He also reports severe leg pain and SOB after walking only [**Age over 90 **]
yards now, from
being able to walk without limitation prior to onset of
symptoms. The patient
d/n visual changes, light-headedness, swelling. reports
occasional
non-productive cough, but denies fever, chills, night sweats,
CVA pain, dysuria, hematuria, abdominal pain, diarrhea.
Past Medical History:
1. Hypertension, uncontrolled
2. Chronic headaches, treated with motrin
3. s/p appendectomy
4. L shoulder dislocation
Social History:
30py smoking history, denies current EtOH use (past history of
large amounts of EtOH use stopped 12 years ago), denies IVDA.
lives in [**Location 12017**],NH is single, divorced with 2 children.
works at communications company, also paints. reports no
limitations in ADLs, IADLs.
Family History:
Mother and father both alive, mother has diabetes, father has
high blood
pressure. Reports that brother has been diagnosed with "kidney"
problems as
well.
Physical Exam:
Vitals: T , BP 170/120, p80 reg, RR, O2sats % on RA.
General: patient lying down comfortably, no acute distress,
looks stated age.
HEENT: NC/AT, no scleral icterus, PERRL, MMM, oropharynx grossly
normal,
carotid
pulses 2+ bilaterally, no bruits appreciated. no JVD
Skin: no areas of bruising or discoloration
Lymph: no LAD present
CV: RRR, normal S1, S2, S3 present, no murmurs, rubs, or
gallops.
Lungs: normal expansion, clear to auscultation without wheezes,
rhonchi, or
rales
Abdomen: normal bowel sounds, non-tender, non-distended, no
palpable masses or
bruits appreciated
Extremities: no edema/cyanosis/clubbing, 2+ radial and PT/DP
pulses.
Musculoskeletal: pain in L shoulder elicited on active motion,
5/5 strength in
upper and lower extremities. no wasting noted
Neuro: Alert and orientedx3. normal sensation to touch,
vibration,
temperature.
reports feeling well in general. chart reports papilledema
(not appreciated
on exam)
Pertinent Results:
[**2123-6-18**] 09:50PM WBC-13.7* RBC-3.85* HGB-11.5* HCT-32.0*
MCV-83 MCH-29.8 MCHC-35.8* RDW-16.3* PLT COUNT-163
[**2123-6-18**] 09:50PM PT-12.9 PTT-24.5 INR(PT)-1.1
[**2123-6-18**] 09:50PM GLUCOSE-91 UREA N-65* CREAT-8.9* SODIUM-137
POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-22 ANION GAP-19
CALCIUM-8.3* PHOSPHATE-5.9* MAGNESIUM-1.9
ALT(SGPT)-9 AST(SGOT)-17 LD(LDH)-639* ALK PHOS-50 TOT BILI-1.8*
DIR BILI-0.3 INDIR BIL-1.5
[**2123-6-18**] 09:50PM HAPTOGLOB-<20*
[**2123-6-18**] 11:42PM URINE HOURS-RANDOM CREAT-103 SODIUM-42 TOT
PROT-592 PROT/CREA-5.7*
ECG- NSR, LVH w/ strain
CXR- unremarkable
Brief Hospital Course:
1. Acute Renal [**Name (NI) 37370**] Pt was followed by the renal team. It
was felt that his renal failure was likely secondary to his
heavy NSAID use and uncontrolled hypertension. His electrolytes
were closely monitored. Only the phosphate was elevated thus he
was started on amphojel. Througout the hospital stay the patient
continued to produce good amounts of urine on his own. His
mental status was clear with no signs of volume overload. He
was started on dialysis and went a total of three times. He was
scheduled for a renal biopsy but it was cancelled for an
outpatient date as the patient had been started on aspirin for
several days.
2. Hypertension- In the ICU he was placed on a labetalol and
nitroprusside drip. He was weaned off and started on oral
metoprolol, which was switched to labetalol PO when he got to
the floor. His blood pressures remained in the 170-180's so his
labetalol was increased and amlodipine was added which got his
blood pressures down to 140-160/80-90.
3. Anemia- Felt to be secondary to the hypertensive emergency
which caused a microangiopathic hemolytic anemia. There were
concerns that the pt may have had TTP vs HUS on initial
presentation, but heme/onc team felt this was unlikely since he
did not have any thrombocytopenia and his clinical picture could
be explained by the hypertensive emergency. His HCT was stable
after the initial transfusions without any significant drops or
evidence of the hemolytic process recurring.
Medications on Admission:
Motrin 200mg 6tabs/day
Discharge Medications:
1. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Labetalol HCl 200 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
Disp:*180 Tablet(s)* Refills:*2*
3. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO QD
(once a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Aluminum Hydroxide Gel 600 mg/5 mL Suspension Sig: Thirty
(30) ML PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*QS * Refills:*2*
5. Nephrocaps 1 tab PO QD
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: ARF likely secondary to NSAID use and HTN, Hypertensive
emergency, hemolytic anemia
Secondary: HTN
Discharge Condition:
Pt. is stable and in good condition
Discharge Instructions:
Pt is advised to take his medications as advised. He will need
to go to dialysis three times a week and follow up with a
nephrologist in his home area. If he should experience any
chest pain, shortness of breath, nausea/vomiting, severe
headaches, or confusion he should go immediately to the
emergency room.
Followup Instructions:
Pt. will need to follow up with his nephrologist, Dr. [**Last Name (STitle) 58481**],
for hemodialysis, renal biopsy, and general ARF care. He should
call his nephrologist at ([**Telephone/Fax (1) 58482**] for appointment
scheduling. He is set up for dialysis at [**Location (un) **] Dialysis
([**Telephone/Fax (1) 58483**] on Mon. ([**2123-6-28**]) at 12noon. He is scheduled to
see his PCP on [**Name9 (PRE) **] at 3:15 pm, pt can call ([**Telephone/Fax (1) 58484**] if he
needs to change the time and date. His blood pressure should be
monitored and meds adjusted accordingly. His goal systolic
blood pressure is 140-160. He should have blood drawn for a
complete chemistry panel within the next week. ASpirin should
be restarted after the renal biopsy.
|
[
"283.9",
"403.01",
"584.9",
"285.9",
"E935.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
6451, 6457
|
4383, 5868
|
339, 371
|
6609, 6646
|
3755, 4360
|
7005, 7771
|
2620, 2778
|
5941, 6428
|
6478, 6588
|
5894, 5918
|
6670, 6982
|
2793, 3736
|
271, 301
|
399, 2159
|
2181, 2305
|
2321, 2604
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,393
| 117,762
|
32282+57796
|
Discharge summary
|
report+addendum
|
Admission Date: [**2149-9-27**] Discharge Date: [**2149-10-2**]
Service: SURGERY
Allergies:
Demerol / Codeine / Percocet / Darvocet-N 50 / Sulfa
(Sulfonamides)
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
85 yo female with multiple medical problems include recent
stroke,
[**Name (NI) 7792**] s/p with fall at [**Hospital3 **] facility, found down,
+LOC, doesn't recall details of fall. She is on Coumadin and
Plavix for A fib. She was transported to [**Hospital1 18**] for further care.
Past Medical History:
Type II DM
HTN
Hypothyroid
H/o TIA
Ehrlos Danlos
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.
Family History:
Family history of Ehrlos Danlos. There is no family history of
premature coronary artery disease or sudden death.
Physical Exam:
Upon exam:
Gen: In hard collar
HEENT: significant swelling and ecchymosis R face, R eye,
bleeding cut near R eye
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date..
Language: Speech fluent with good comprehension and repetition.
Cranial Nerves:
II: unable to see right eye due to swelling, L eye PERRL, 5 to
3mm.
III, IV, VI: L Extraocular movements intact, R could not assess.
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 [**6-9**] throughout. No pronator drift
Sensation: Intact to light touch, bilaterally.
Toes downgoing bilaterally
Pertinent Results:
[**2149-9-27**] 10:20PM GLUCOSE-158* UREA N-16 CREAT-0.7 SODIUM-140
POTASSIUM-3.4 CHLORIDE-99 TOTAL CO2-29 ANION GAP-15
[**2149-9-27**] 10:20PM CK(CPK)-81
[**2149-9-27**] 10:20PM CK-MB-NotDone cTropnT-<0.01
[**2149-9-27**] 10:20PM CALCIUM-8.8 PHOSPHATE-3.7 MAGNESIUM-1.5*
[**2149-9-27**] 10:20PM WBC-8.7 RBC-3.04* HGB-8.1* HCT-23.6* MCV-78*
MCH-26.7* MCHC-34.4 RDW-14.0
[**2149-9-27**] 10:20PM PLT COUNT-284
[**2149-9-27**] 10:20PM PT-14.5* PTT-26.6 INR(PT)-1.3*
Head CT scan - [**2149-9-28**]
FINDINGS: The previously noted region of high attenuation,
representing clot,
in the right lateral ventricular body is now slightly smaller,
measuring 6 x
22 mm compared to prior 5 x 29 mm. There is a small amount of
blood layering
dependently in bilateral lateral ventricular occipital horns and
atria, more
represent interval redistribution of blood, rather than true
additional
hemorrhage. There are no other foci of intra- or extra- axial
hemorrhage.
There is no edema, mass effect, or shift of normally midline
structures.
Multifocal low attenuation in the bilateral periventricular and
subcortical
white matter, unchanged, likely represent chronic small vessel
ischemic
changes.
Again is noted mucosal thickening in bilateral ethmoid air cells
and air-fluid
level in the right sphenoid sinus. The right maxillary sinus and
orbital floor fractures are not included in the field of view or
well-
depicted in the current study. There is persistent swelling in
the right
periorbital region. The known right zygomatic arch fracture is
only partially
visualized.
IMPRESSION:
1. Slight reduction in size of the right lateral ventricular
thrombus, likely
adherent to choroid plexus, with some blood in the bilateral
occipital horns
and atria, likely representing redistribution of
intraventricular hemorrhage
rather than interval progression.
2. Persistent opacification of bilateral ethmoid air cells and
air-fluid
level in the right sphenoid sinus. The known facial fractures
are not
completely visualized on the current study. Please refer to
prior report
of dedicated maxillofacial CT for details.
3. Unchanged periorbital soft tissue swelling and preseptal
thickening.
Repeat head CT scan - [**2149-9-29**]
NON-CONTRAST HEAD CT: Compared to prior exam, right
intraventricular hematoma
is minimally decreased in size. Small amount of blood is seen
layering in the
dependent portions of the lateral ventricle, unchanged. No new
focus of
hemorrhage is identified. There is no hydrocephalus, shift of
normally
midline structure or evidence of major [**Month/Day/Year 1106**] territorial
infarct. The
[**Doctor Last Name 352**]-white matter differentiation is preserved. Hypodensities in
the
periventricular and subcortical white matter reflect chronic
microvascular
ischemic change. The cavernous carotid show atherosclerotic
calcification.
Again noted are ethmoid mucosal thickeninge, air-fluid level in
the right
sphenoid sinus and complete opacification of the right maxillary
sinus. Right-
sided facial fractures are better evaluated on dedicated CT from
[**2149-9-27**].
IMPRESSION: Compared to prior exam from [**2149-9-28**], there
is minimally
decreased size of right intraventricular hematoma. Small amount
of blood
layering within the dependent portion of the ventricle is
unchanged. No new
hemorrhage is identified.
[**2149-9-27**] CT SINUS/MANDIBLE/MAXIL
FINDINGS: Marked right-sided facial swelling and preseptal
swelling has been
evident. There is a depressed fracture involving the lateral
wall of the
right maxillary sinus by approximately 3 mm. There are several
comminuted
fractures of the lateral wall as well. An inferior maxillary
sinus fracture
is also evident. Comminuted fracture involving the medial wall
of the
maxillary sinus is noted. Hemorrhage and foci of emphysema fill
the right
maxillary sinus. Hemorrhage extends in to the ethmoid sinus at
the level of
the fracture of the medial wall. A comminuted fracture also
involves the
superior wall of the maxillary sinus. The right orbit appears
intact. No
fracture of the lamina papyracea is appreciated. The left
maxillary sinus is
intact. A small amount of high-attenuation material is also
noted within the
right sphenoid sinus and may indicate extension of right-sided
facial
fractures into the level of the sphenoid sinus. An acute
fracture of the
right zygomatic arch is again noted. No left-sided facial
fractures are
identified.
IMPRESSION: Right -sided facial fractures with hemorrhage
filling the right
maxillary sinus and extending into the right ethmoid and
sphenoid sinuses.
Fractures involving all walls of the maxillary sinus, including
the inferior
orbital wall. The right globe appears otherwise intact. There is
no evidence
of muscle entrapement but right inferior rectus is thicked
indicating trauma.
Brief Hospital Course:
She was admitted to the Trauma service. Her INR was reversed in
the Emergency room and her anticoagulants were withheld.
Neurosurgery and Plastic surgery were consulted. Her injuries
were non operative. She was taken to the Trauma ICU for close
monitoring. Serial neuro exams and head CT scans were performed.
There were no new areas of intracranial hemorrhage noted on
repeat scans. It is being recommended that her anticoagulants
not be restarted.
She was eventually transferred to the regular nursing unit.
Geriatrics was also consulted given her age and mechanism of
injury. Several recommendations were made pertaining to her
medications. She has a known history of hypertension and has
been on several medications to control this. Her systolic blood
pressures have ranged between 160-170's; she was previously on
Norvasc amongst her other blood pressure medications (see
Medications at home section) and this was resumed. Her PCP, [**Last Name (NamePattern4) **].
[**Last Name (STitle) **] was contact[**Name (NI) **] and he reports that her baseline systolic
blood pressure ranges between 130-140's and has recommended to
increase the Norvasc from 2.5 mg to 5 mg.
She was noted to be delirious and it was recommended that she be
started on Zyprexa which has improved her mental status. Of
note, there have not been any behavioral issues.
Social work was consulted for patient and family emotional
support.
Medications on Admission:
Lidocaine 5% Patch 1 PTCH TD Q 24H
Chlorothiazide 500 mg PO DAILY
Meclizine 12.5 mg PO Q24H Order date: [**3-26**] @ 2301
Vytorin
Metformin 500mg [**Hospital1 **]
Levothyroxine Sodium 50 mcg PO DAILY
Lisinopril 20 mg PO DAILY
Atenolol 25mg QD
Vesacare
Allergies- Demerol / Codeine / Percocet / Darvocet-N 50
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
5. Lisinopril 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): hold for HR <130; HR <60.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Solifenacin 5 mg Tablet Sig: Two (2) Tablet PO daily ().
10. Amlodipine 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): hold fro SBP<130.
11. Hydrochlorothiazide 12.5 mg Capsule Sig: Three (3) Capsule
PO DAILY (Daily).
12. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO Q6PM: hold
for increased sedation.
14. Erythromycin 5 mg/g Ointment Sig: One (1) APPL Ophthalmic
TID (3 times a day) for 2 days: Apply OD.
15. Nevanac 0.1 % Drops, Suspension Sig: One (1) GTT Ophthalmic
TID (3 times a day): Apply OS.
16. Moxifloxacin 0.5 % Drops Sig: One (1) GTT Ophthalmic TID (3
times a day): Apply OS.
17. Omnipred 1 % Drops, Suspension Sig: One (1) GTT Ophthalmic
TID (3 times a day): Apply OS.
18. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
19. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection three times a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 5481**]
Discharge Diagnosis:
s/p Fall
Maxillary sinus fracture
Inferior orbital wall fracture
Intraventricular head bleed
Coagulopathy secondary to elevated INR
Discharge Condition:
Hemodynamically stable, pain adequately controlled
Discharge Instructions:
AVOID any anticoagulants (except for Heparin SQ) until follow up
in 2 weeks with Neurosurgery.
Followup Instructions:
Follow up in 1 week with Plastic surgery for your facial
fractures, call [**Telephone/Fax (1) 5343**] for an appointment.
Follow up next week in [**Hospital 8095**] Clinic next week, call
[**Telephone/Fax (1) 253**] for an appointment.
Follow up in 2 weeks with Dr. [**Last Name (STitle) 548**], Neurosurgery. Call
[**Telephone/Fax (1) 1669**] for an appointment. Inform the office that you will
need a repeat head CT scan for this appointment.
The following appointments were made prior to this
hospitalization:
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2149-10-14**]
11:00
Provider: [**Last Name (NamePattern5) 7224**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] Date/Time:[**2149-10-14**]
12:00
Completed by:[**2149-10-2**] Name: [**Known lastname 12392**],[**Known firstname **] Unit No: [**Numeric Identifier 12393**]
Admission Date: [**2149-9-27**] Discharge Date: [**2149-10-2**]
Date of Birth: [**2064-4-3**] Sex: F
Service: SURGERY
Allergies:
Demerol / Codeine / Percocet / Darvocet-N 50 / Sulfa
(Sulfonamides)
Attending:[**First Name3 (LF) 3524**]
Addendum:
It was recommended by Geriatrics that her Zyprexa be decreased
to 1.25 mg every evening.
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
5. Lisinopril 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): hold for HR <130; HR <60.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Solifenacin 5 mg Tablet Sig: Two (2) Tablet PO daily ().
10. Amlodipine 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): hold fro SBP<130.
11. Hydrochlorothiazide 12.5 mg Capsule Sig: Three (3) Capsule
PO DAILY (Daily).
12. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Olanzapine 2.5 mg Tablet Sig: [**2-5**] Tablet PO Q6PM: hold for
increased sedation.
14. Erythromycin 5 mg/g Ointment Sig: One (1) APPL Ophthalmic
TID (3 times a day) for 2 days: Apply OD.
15. Nevanac 0.1 % Drops, Suspension Sig: One (1) GTT Ophthalmic
TID (3 times a day): Apply OS.
16. Moxifloxacin 0.5 % Drops Sig: One (1) GTT Ophthalmic TID (3
times a day): Apply OS.
17. Omnipred 1 % Drops, Suspension Sig: One (1) GTT Ophthalmic
TID (3 times a day): Apply OS.
18. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
19. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection three times a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1267**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2207**] MD [**MD Number(1) 3525**]
Completed by:[**2149-10-2**]
|
[
"780.2",
"V45.82",
"412",
"790.92",
"294.11",
"802.8",
"250.00",
"729.89",
"V58.61",
"427.31",
"E888.9",
"756.83",
"414.01",
"801.36",
"438.89",
"293.0",
"244.9",
"401.9",
"331.0",
"E849.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
13462, 13670
|
6761, 8178
|
283, 290
|
10366, 10419
|
1918, 4155
|
10562, 11837
|
816, 931
|
11860, 13439
|
10211, 10345
|
8204, 8514
|
10443, 10539
|
946, 1098
|
235, 245
|
318, 602
|
1299, 1899
|
4164, 6738
|
1113, 1283
|
624, 674
|
690, 800
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,184
| 187,463
|
46344
|
Discharge summary
|
report
|
Admission Date: [**2113-6-19**] Discharge Date: [**2113-6-29**]
Date of Birth: [**2037-10-10**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfonamides / Penicillins / Decongestant Sinus
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
75 y/o woman with a history of moderate asthma, and recent
mediastinal mass, who presents with dyspnea and chest
discomfort.
Major Surgical or Invasive Procedure:
Mediansternotomy for excision of mediastinal mass.
History of Present Illness:
Mrs. [**Known lastname 724**] is a 75 year old woman with history of asthma,
allergies and hypertension. One week ago ([**6-15**]), she noticed a
worsening dry, non productive cough she had an xray on [**6-15**]
which did not demonstrate evidence of pneumonia. Her cough
worsened and she noticed chest tightness. She noticed that the
pain was persistent and did not flucuate with breathing. She
localized the pain to the center of her chest. Her cough and
discomfort progressed to the point that she requested that her
daughter stay with her because her condition made her feel
unsafe alone. She noted that on [**6-18**] that she had vomitted in
the setting of her cough (non bloody). She noted blurry vision,
tingling in the hands and feet, bouts of chills, an elevated
temp at 99.6, five pound weight loss (over 1 month). The night
before admission, Ms [**Known lastname 724**] had a particularly sever episode of
coughing with chest pain. She requested that her son take her to
the ER.
ROS: postive for vomiting, negative for diarrhea, diplopia
ED Course:
Vitals: t 97.5 bp 173/87 rr 20 o2 98
Ddimer: 438
CTA: negative
EKG sinus rhythm, 1st degree heart block, consistent with
baseline
Past Medical History:
Asthma diagnosed at age 50, treated at [**Hospital1 18**], previously
hospitalized, never intubated.
Allergies
GERD
Post nasal drip
Diabetes: treated a year ago with metformin, but pt experienced
nausea and stopped use.
Hypertension
Social History:
Lives alone in [**Location (un) **]. Dresses and cooks for herself. No
history of tobacco or alcohol use. Cantonese speaking woman
with a very involved family.
Family History:
No known family history of cancer
Physical Exam:
Gen: Patient was found in bed, in gown, alert and attentive, NAD
Vitals: 99.6 bp 120/70 hr 84 o2 98 3L
HEENT: normocephalic, EOMI, PERRL, no exopthalmus, moist mucous
membranes
Neck: no cervical or supraclavicular LAD, no palpable thyroid
nodules
Pulm: bilateral rhonchi right greater than left, no wheezes
apprecriated, no dullnes to percussion
Cor: heart sounds distant, normal s1 and s2 no appreciable
murmurs rubs or gallops
Abodomen: non distented, nontender, RUQ tenderness, no
involuntary guarding, no hepatosplenomegaly
Extemities: equivocal reduced vibration sense below the knees,
palable pedal and popilteal pulses
Neuro: AOx3, no fatigability of eyelids
Pertinent Results:
Labs:
WBC 5.8 Hct 34.2
Na 117 Serum Osm 260 Urine Osm 144
Glu 161
Peak Flow
Today; 200, 200, 250
Peak flow: 250 to 300
Studies:
CXR [**6-19**]: anterior mass unchanged from [**6-15**], no new opacities or
nodules
CT Chest [**6-16**]: Anterior mediastinal mass 9x6x7 well
circumscribed, non invasive, without calcification, likely
thymoma
Swallow-study [**2113-6-28**]
Mrs. [**Known lastname 724**] presents with a mild pharyngeal dysphagia at this time
primarily characterized by impaired airway closure from left
vocal cord immobility/paresis with resulting aspiration of
liquids. When a chin tuck maneuver was combined with smaller
sips
of liquids, aspiration of thin liquids was easily prevented.
However, the pt requires larger sips of thin liquids to swallow
pills. As such, I am recommending that pills be taken whole with
purees for the time being. Follow up video swallow study can be
completed in the next 2-3 months to monitor status of the pt's
dysphagia, either here as an outpatient or at rehab/other
facility.
RECOMMENDATIONS:
1. Advance to regular texture po diet with thin liquids. Pills
may be given whole with liquids.
2. Aspiration precautions, including:
a. Tuck your chin to your chest when drinking liquids.
b. Take small sips of liquids!!
3. Repeat video swallow study in the next 2-3 months to monitor
dysphagia and pending ENT intervention.
CXR: [**2113-6-26**]
Heterogeneous opacity in the right upper lung has progressed
since [**6-25**] following removal of the pleural tube. The apical
component is conceivably atelectasis or hemorrhage related to
retraction during surgery, but a more focal region in the
axillary portion of the right upper lobe developed between [**6-23**] and [**6-25**] and has grown slightly since. There is also
progressive left perihilar and basal consolidation. Overall
findings are concerning for bilateral pneumonia and/or severe
atelectasis at the left base. Small right apical pneumothorax is
new or newly apparent. There is no left pneumothorax, but there
is a small and slightly increased left pleural effusion,
following removal of the left pleural tube. Mediastinal caliber
is comparable to that on [**6-23**], but there is vascular
engorgement, and the heart is top normal size.
Brief Hospital Course:
Mediastinal Mass: Likely Thymoma
Lymphoma, teratoma, thyroid/parathyroid tumor ruled out with
history, exam, and normal tsh, pth, ionized Ca, and Phos.
Neurology evaluated for myasthenia, negative for fatigability.
Ms. [**Known lastname 724**] [**Last Name (Titles) 1834**] a resection of her anterior mediastinal mass
on [**6-23**]. For details of the procedure please see the operative
report. Of note there was a thoracic duct injury noted intraop
which was later clipped. A JP drain was left in place at the
level of the thoracic duct injury to assess for a chyle leak
postop. Two chest were left in place postoperatively as well.
Preliminary pathology at the time of the procedure was
significant for a fibrous tumor and not thymoma.
Postoperatively she was transferred extubated to the SICU. Both
chest tubes were left to suction and no air leak was noted. Her
sodium was noted to be 131 postop. She remained NPO overnight.
On POD1 her diet was advanced and her pain was controlled with a
dilaudid PCA now controlled with percocet. Both chest tubes were
removed on POD2, however the JP drain was left in place until
she was taking a significant amount of oral intake. Over the
first few postoperative days she was noted to have a
significantly hoarse voice and difficulty swallowing. ENT was
consulted out of concern for a recurrent laryngeal nerve injury.
She had an FOE exam on POD3 which confirmed an immobile left
true vocal cord. Seen by speech and swallow pathology and
cleared for regular diet with thin liquids and chin tuck. (see
report in result section).
Hyponatremia: Likely euvolemic hyponatremia due to SIADH
considering mediastinal mass. Serum osm of 260 is less
ooncentrated than normal, while Urine osm of 144 is
inappropriatedly concentrated. This is consistent with euvolemic
hyponatremia. The sodium should be corrected slowly (by half per
day). She has been getting fluid restriction to 1000 cc per day.
Her mental status has been perfect, and her sodium levels have
been improving. We are holding her HCTZ, which could have
contributed. After the procedure her her hyponatremia was
stable at around 130 and the hctz was restarted without further
lowering her sodium.
Cough/Chest pain: While originally thought to be an asthma
exacerbation an intraop bronchoscopy showed significant purulent
drainage from the right middle lobe. A BAL was positive for
MSSA which was treated with vancomycin for 3 days and then was
changed to levaquin and course was completed upon discharge from
the hospital.
UTI: A preop UA was noted to be positive and the urine culture
was positive for pansensitive E.Coli. The patient was
complaining of dysuria and hesitency. The UTI was treated with
3 days of ciprofloxacin/levofloxacin and a repeat urine culture
was negative.
Activity: The patient was seen by physical therapy and rehab was
recommended. She was discharged to rehab on [**6-29**].
Medications on Admission:
Singlair 10 mg qd
[**Doctor First Name **] 25 mg 2 puff TID
HCTZ 25 mg daily
Diovan 320mg mg daily
Ventolin 2puff TID
Atrovent 2 puff TID
Flovent 2-3 puffs prn
Serevent 50 mcg
Flonase 50 mcg
Protonix 40 mg daily
Discharge Medications:
1. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1)
Spray Nasal DAILY (Daily).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
12. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
14. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
16. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
asthma, HTN, DM, GERD, s/p TAH
Excison of mediastinal mass with pneumonia, UTI
Discharge Condition:
Deconditioned requiring rehab
Discharge Instructions:
Call Dr.[**Name (NI) **] office [**Telephone/Fax (1) 170**] if you develop increased
pain in your chest, shortness of breath, fever, chills, redness
or drainage from your incision site.
You may shower but no tub bathing or swimming for 4 weeks.
The steri-strips will fall off within 1-2 weeks.
Follow sternal precautions: no lifting or pushing greater than
10 pounds for 6 weeks and no vigorous upper extremity exercise
or work for 6 weeks.
Continue to take pain medication and stool softner.
Followup Instructions:
Call Dr.[**Doctor Last Name 4738**] office for an appointment [**Telephone/Fax (1) 170**] after
discharge from rehab.
Follow up with your PCP as needed.
You have an appointment on [**7-20**] 3:15pm with ENT Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] in the [**Last Name (un) 2577**] building, suite 6E, [**Doctor First Name **]
[**Telephone/Fax (1) 94927**]
Completed by:[**2113-7-3**]
|
[
"493.90",
"401.9",
"478.31",
"164.0",
"285.22",
"482.41",
"250.00",
"458.9",
"041.4",
"599.0",
"253.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"40.11",
"99.04",
"07.80"
] |
icd9pcs
|
[
[
[]
]
] |
9855, 9925
|
5182, 8103
|
441, 494
|
10048, 10080
|
2908, 5159
|
10624, 11039
|
2170, 2205
|
8365, 9832
|
9946, 10027
|
8129, 8342
|
10104, 10601
|
2220, 2889
|
276, 403
|
522, 1717
|
1739, 1974
|
1990, 2154
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,030
| 153,686
|
592
|
Discharge summary
|
report
|
Admission Date: [**2137-7-2**] Discharge Date: [**2137-7-9**]
Date of Birth: [**2065-8-18**] Sex: F
Service: MEDICINE
Allergies:
Adhesive Tape
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
RIJ placement
History of Present Illness:
Ms. [**Known lastname 4636**] is a 71yo paraplegic female with PMH significant
for HTN, HLD, and chronic UTI's who is being transferred to the
MICU for management of hypotension. Per her son,
the patient's home nurse noted that she had a slight temperature
this morning. Her son noted that her appetite was poor and was
also incoherent. He also noted that her catheter contained urine
that was dark and concentrated. He immediately called 911. She
was then brought to [**Hospital1 18**] ED for further work-up. There is no
report of SOB, chest pain, abdominal pain, diarrhea, or
constipation. The son was also concerned that her catheter was
not working well and needed to be changed.
In the ED, initial vitals were T 102.2 BP 115/33 AR 105 RR 18 O2
sat 94% on 3L NC. She received Vancomycin 1gm IV, Zosyn 4.5gm
IV, and Tylenol 1gm. Her blood pressure dropped to 95/43 and
given lack of improvement after receiving 3L NS, she is being
transferred to the MICU for closer monitoring.
Past Medical History:
1)Paraplegia [**1-5**] Anterior Spinal Infarct
2)Thoracic Aneurysm Repair ([**2128**])
3)Hx of LLL Collapse/PNA s/p mucous plug removal via
bronchoscopy
4)HTN
5)Hyperlipidemia
6)GERD
7)Suprapubic Catheter Placement / UTIs on Ppx Bactrim
8)Fecal Incontinence
9)Depression
Social History:
58 year tobacco history, now smoking 3 cigarettes per day,
denies EthOH, denies drug abuse. Widowed. Has 3 sons. She
lives alone in [**Hospital3 4634**].
Family History:
Son has DM
Physical Exam:
vitals T 95.8 BP 117/50 AR 65 RR 23 O2 sat 95% on 3L NC
Gen: Patient awake, responsive to commands
HEENT: MMM, PERRLA
Heart: RRR, no audible m,r,g
Lungs: CTAB, scattered crackles at posterior bases
Abdomen: Markedly distended but soft, NT, +BS
Extremities: 1+ bilateral edema, 2+ DP/PT pulses bilaterally;
large
ulcer approximately 6cm in diameter over L ischium that appears
to probe down to bone. She also has wound vac dressing in place
on left lower extremity.
Pertinent Results:
[**2137-7-2**] 07:55PM LACTATE-1.1
[**2137-7-2**] 07:57PM WBC-14.0*# RBC-4.76 HGB-12.6 HCT-38.8 MCV-82
MCH-26.4* MCHC-32.4 RDW-15.9*
[**2137-7-2**] 07:57PM CALCIUM-8.3* PHOSPHATE-3.1 MAGNESIUM-2.3
[**2137-7-2**] 07:57PM GLUCOSE-120* UREA N-12 CREAT-0.5 SODIUM-138
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-24 ANION GAP-17
[**2137-7-2**] 08:00PM URINE RBC-0 WBC-0-2 BACTERIA-MANY YEAST-NONE
EPI-0
[**2137-7-2**] 08:00PM URINE BLOOD-NEG NITRITE-POS PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-9.0*
LEUK-MOD
[**2137-7-9**] 05:52AM BLOOD WBC-8.9 RBC-4.31 Hgb-11.3* Hct-36.0
MCV-84 MCH-26.1* MCHC-31.3 RDW-15.7* Plt Ct-427
[**2137-7-5**] 06:30AM BLOOD ESR-105*
[**2137-7-7**] 06:55AM BLOOD ESR-80*
[**2137-7-9**] 05:52AM BLOOD ESR-90*
[**2137-7-9**] 05:52AM BLOOD Glucose-114* UreaN-9 Creat-0.4 Na-143
K-4.1 Cl-104 HCO3-29 AnGap-14
[**2137-7-9**] 05:52AM BLOOD Albumin-3.2* Calcium-8.5 Phos-2.8 Mg-2.5
[**2137-7-8**] 07:05AM BLOOD CRP-123.6*
[**2137-7-9**] 05:52AM BLOOD CRP-101.0*
ECG: Sinus tachycardia. Left axis deviation. Left anterior
fascicular block. Diffuse non-diagnostic repolarization
abnormalities. Compared to the previous tracing of [**2136-9-12**]
heart rate has increased. Otherwise, no major change.
[**7-2**]: KUB Single AP abdominal radiograph obtained, however,
limited as only the superior portion of the abdomen imaged. The
imaged portion is obscured by overlying pannus, however, the
underlying bowel loops show a nonspecific bowel gas pattern with
mildly air-filled distended loops of colon. No intra-abdominal
free air. Multiple left-sided rib deformities are noted.
[**7-2**]: Single AP chest radiograph compared to [**2137-2-7**] show
slightly increased interstitial lung markings, which may
represent mild edema with areas of new patchy opacity in the
right lung base and left mid lung, which may represent
atelectasis although aspiration/pneumonia would be difficult to
exclude. There is no pneumothorax or pleural effusion. The
cardiomediastinal contour is unchanged. Again seen are multiple
left-sided rib deformities.
CT Head:
IMPRESSION:
1. No acute intracranial hemorrhage.
2. Moderate opacification from fluid versus mucosal thickening
in the
maxillary sinuses, not [**Last Name (LF) 4646**], [**First Name3 (LF) **] reflect
sinusitis, and
clinical correlation is recommended.
CTA Chest [**2137-7-6**]
IMPRESSION:
1. No evidence of pulmonary embolism or aortic dissection.
2. Mild cardiac decompensation with pulmonary vascular
congestion but no
alveolar edema. Small right pleural effusion.
3. Possible small airways infection in the right middle lobe.
4. Aneurysmal descending aorta, 4 cm. Descending aortic graft in
place
without complication.
5. Enlargement of the pulmonary arteries suggesting underlying
pulmonary
artery hypertension.
[**2137-7-7**] MRI HIP
FINDINGS:
Please note that due to hardware failure, the complete sequences
could not be obtained.
There is a comminuted left proximal femur intertrochanteric
fracture, with
coxa varus orientation. There is a large amount of marrow edema
within the
proximal femur. Marrow edema and a small fracture line also
extends into the femoral neck. However, the marrow signal in the
femoral head appears normal. There is a small left hip joint
effusion. The adjacent left acetabulum appears normal. There is
a large amount of surrounding muscular edema. Also noted is
abnormal marrow signal in bilateral ischial tuberosities, left
greater than right. These areas of abnormal marrow signal are
just deep to the bilateral decubitus ulcers. In the appropriate
clinical setting, these are consistent with osteomyelitis.
The right hip appears normal. There is no evidence of right hip
fracture.
A suprapubic catheter is present. There is a large amount of
pelvic
musculature atrophy, consistent with patient's history of
quadriplegia.
There are spinal cysts which are partially visualized on the T1
images in the sacral spine. Due to lack of T2-weighted images,
these cannot be further evaluated. Differential consideration
includes Tarlov cyst.
8/3 L HIP XR: IMPRESSION:
1. Comminuted intertrochanteric fracture of the proximal left
femur.
2. Sclerosis and osseous irregularity of the left ischial
tuberosity in the region of a vacuum drain is concerning for
osteomyelitis. Correlation with the recently performed MRI is
advised.
[**7-5**] R HIP XR: Markedly limited study without definite evidence
for acute bony injury or marked infection. If there is high
clinical concern, cross-sectional imaging is recommended. Due to
the patient's large size MRI may not be possible and CT scan may
be the best alternative. (Per discussion with radiologist after
fracture seen on MR, fracture was previously visible on this
film as well, but was poor study)
Brief Hospital Course:
Ms. [**Known lastname 4636**] is a 71yo paraplegic female with PMH as listed
above who presents with transient hypotension and leukocytosis.
1)Hypotension: Patient initially found to be hypotensive with
SBP~90's despite receiving 3L NS. Her baseline SBP is between
110-120's. Upon transfer to the MICU, her BP stabilized. The
drop in her BP may have been early sepsis physiology given
fever, history of recurrent UTI's. She may also have some
underlying autonomic dysregulation given paraplegia. She was
started on Vancomycin and Zosyn given prior culture results
which grew E.coli and enterococcus. After transfer to the floor
on [**2137-7-4**] her BP remained stable SBP 110s-120s, no longer
requiring IVF.
2)Leukocytosis/fevers: Patient noted to have WBC~14.0 and
febrile on admission. Cxray was not very revealing. Her U/A was
positive for leukocytes and nitrites but no WBCs and urine cx
were negative. Plastic surgery was consulted to see patient
while she was in-house and recommended VAC dsg changes q MWF.
She continued to spike fevers until [**7-5**] on Vanc/Zosyn but
remained afebrile for the remainder of her hospital course.
Since her urine cultures and blood cultures were all negative,
we explored other etiologies for her fever. She had a CTA that
did not show a PE but did show possible PNA. She also had XRs of
her hips to look for osteomyelitis given B/L decubitus ulcers.
Initial XR was poor study. ESR was checked and was 105. MRI
showed abnormal marrow signal of B/L ischial tuberosities near
areas of decubitus ulcers c/w osteomyelitis. Zosyn was
discontinued, vancomycin was continued and Levofloxacin was
added for gram negative coverage for her osteo. She will need 6
week course (5 more weeks of antibiotics). She will also need
follow-up of inflammatory markers which trended down during
hospital stay.
3)Mental status changes: Per son, the patient was less coherent
on day of admission. This resolved rapidly with resolution of
hypotension and fever. CT head was negative.
4)Neurogenic bladder: Patient has chronic SP foley catheter
placement as a result of her paraplegia. The patient's son
reported that her foley was not working appropriately. Urology
was contact[**Name (NI) **] on floor and performed SP catheter change and
wound care was consulted for ostomy bag change around catheter.
She was also reporting increased bladder spasms since Baclofen
was originally held in MICU. Spasms resolved with restarting
Baclofen and she had decreased leaking around SP catheter after
catheter/bag change.
5)L trochanter ulcer: Patient is followed closely by plastic
surgery as an outpatient. She has a wound vac on her left lower
extremity. Wound care and plastic surgery were consulted and
changed VAC on MWF. She was continued on Zinc sulfate. When
findings of osteomyelitis were reported on MRI, plastics was
again contact[**Name (NI) **] and they did not feel that further debridement
was neccessary at that time. She will follow up in plastics
clinic. L buttock VAC dsg changes should continue qMWF.
6.) Left femur fracture: Incidentally, patient noted to have
comminuted L intertrochanteric femur fracture on MRI. She denied
any pain or h/o trauma. Imaging also commented on osteopenia.
She was started on calcium and vitamin D supplements as well as
Alendronate q week for atraumatic fracture. Ortho was consulted
and did not recommend surgery since she was non-weight bearing
on that leg and did not have pain. Could consider endocrine
workup and/or bone density scan as outpatient. She will follow
up in ortho clinic as outpatient.
7)GERD: Continued on Pantoprazole.
8)COPD: Pt reports she has "lung disease" but denies known h/o
COPD and PFTs in [**2128**] were normal. She required 3L O2 NC while
in hospital to maintain O2 sats around 94-95%. She reports that
she was intermittently on 3L O2 at home, but it was unclear who
started her home oxygen and what the original indication was.
She was continued on outpatient regimen of Advair and Combivent.
She has not seen a pulmonologist in the past, but follow up was
arranged for PFTs and an appointment was made with Dr. [**Last Name (STitle) **].
9)Depression: Outpatient regimen was initially held given mental
status. She was then re-started on Gabapentin, Nortriptyline,
and Bupropion.
10) Code: DNR/DNI
Medications on Admission:
Gabapentin 900mg PO TID
Nortriptyline 50mg PO QHS
Bupropion 100mg PO BID
Pantoprazole 40mg PO daily
Aspirin 81mg PO daily
Colace 100mg PO BID
Zinc sulfate PO daily
Hexavitamin PO daily
Advair 250-50
Combivent MDI
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO Q8H
(every 8 hours).
3. Nortriptyline 25 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
4. Bupropion 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
[**12-5**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-5**]
aerosols Inhalation four times a day as needed for shortness of
breath or wheezing.
9. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO every six (6)
hours as needed for constipation.
10. Hexavitamin Tablet Sig: One (1) Tablet PO once a day.
11. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
12. Baclofen 10 mg Tablet Sig: Four (4) Tablet PO TID (3 times a
day).
13. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 5 weeks: Do not take at the same time as
your zinc. .
Disp:*35 Tablet(s)* Refills:*0*
14. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours) for 5 weeks.
Disp:*70 * Refills:*0*
15. Sodium Hypochlorite 0.5 % Solution Sig: One (1) Appl
Miscellaneous ASDIR (AS DIRECTED).
16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
17. Saline Flush 0.9 % Syringe Sig: One (1) Injection Per NEHT
protocol: Per NEHT protocol.
Disp:*30 * Refills:*2*
18. Heparin Flush 10 unit/mL Kit Sig: One (1) Intravenous per
NEHT protocol: Per NEHT protocol.
Disp:*30 * Refills:*2*
19. Outpatient Lab Work
Please have CBC, BMP (including electrolytes and renal
function), Vancomycin trough level, ESR and CRP checked q week
on Wednesday or Thursday x 5 weeks. Fax results to Dr. [**Last Name (STitle) 1266**]
at [**Telephone/Fax (1) 4647**].
20. Home oxygen
Continue use of home oxygen. Patient previously on 3L of
supplementary oxygen at home. She should continue to use 3L of
oxygen via nasal cannula unless instructed not to by a
physician.
21. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
22. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
23. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QTHUR (every
Thursday) as needed for hip fx.
Disp:*4 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]/[**Hospital1 8**] VNA
Discharge Diagnosis:
Primary Diagnosis:
Osteomyelitis
Secondary Diagnosis
1. L proximal femur fx
2. T8 Paraplegia [**1-5**] Anterior Spinal Infarct [**2128**] surrounding
thoracic aneurysm repair
3. Thoracic Aneurysm Repair ([**2128**])
4. Hx of LLL Collapse/PNA s/p mucous plug removal via
bronchoscopy
5. HTN
6. Hyperlipidemia
7. GERD
8. Chronic Suprapubic Catheter
9. UTIs, was on Ppx Bactrim until [**5-14**]. Fecal Incontinence
11. Depression
12. ?COPD (PFTs normal [**2128**]), intermittently on 3L home O2,
Discharge Condition:
Hemodynamically stable, afebrile, normotensive
Discharge Instructions:
You were admitted to the hospital with fever, low blood
pressure, and confusion. This was most likely from an infection
of the bones in your hips. We also found that you have a
fracture of your left hip. You should not bear any weight on
this leg and should have a repeat X ray in approximately 6 weeks
to ensure that it is healing.
We made the following changes to your medications
1. We added Vancomycin 1g IV twice daily
2. We added Levofloxacin 500 mg PO daily
3. We added Calcium and Vitamin D supplements
4. We added Alendronate 75 mg PO q week
Please return to the ER or call your primary care physician if
you have fever >101, chills, shortness of breath, chest pain, or
pain in your hips.
Followup Instructions:
Please follow up with your primary care doctor Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **]. Call [**Telephone/Fax (1) 608**] if you have any questions. He will
see you at home. You should also have a repeat X ray of your
left hip to ensure continued resolution of hip fracture.
You will also need to have lab work done to follow safety labs
and inflammatory markers. This will be drawn by nurses in your
home.
Please follow up with Dr. [**First Name4 (NamePattern1) 4648**] [**Last Name (NamePattern1) **] in Pulmonary clinic. You
have an appointment on Wednesday [**8-7**] at 8am. Please
arrive at 7:30am to complete paperwork and have pulmonary
function tests prior to your visit. Call [**Telephone/Fax (1) 612**] if you
have any questions or need to reschedule.
Please follow up with Dr. [**First Name (STitle) **] in plastic surgery/wound care
clinic on Friday [**7-19**] at 1:30pm. Call [**Telephone/Fax (1) 4649**] if you
have any questions or need to reschedule.
Please follow up with Dr. [**Last Name (STitle) **] in orthopedics clinic on
Thursday [**8-15**] at 10:00am. Call [**Telephone/Fax (1) 1228**] if you
have any questions or need to reschedule.
|
[
"596.54",
"707.09",
"E879.6",
"996.31",
"787.6",
"272.4",
"348.30",
"909.3",
"530.81",
"733.14",
"730.25",
"596.8",
"311",
"401.9",
"E878.8",
"496",
"V13.02",
"344.1",
"707.03",
"V12.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14287, 14358
|
7096, 11403
|
284, 299
|
14895, 14944
|
2307, 4381
|
15692, 16888
|
1794, 1806
|
11667, 14264
|
14379, 14379
|
11429, 11644
|
14968, 15669
|
1821, 2288
|
233, 246
|
327, 1310
|
4390, 7073
|
14398, 14874
|
1332, 1604
|
1620, 1778
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,971
| 192,709
|
51453
|
Discharge summary
|
report
|
Admission Date: [**2200-12-21**] Discharge Date: [**2200-12-24**]
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 11040**]
Chief Complaint:
Bright red blood per G-tube
Major Surgical or Invasive Procedure:
None
History of Present Illness:
82 yo F with h/o parkinson's, mechanical fall c recent SDH,
aspiration pneumonia and recent UGI bleed presents to OSH ED
from [**Hospital1 **] with bright red blood per G-tube x 1 day. HCT on
presentation to ED was 24 down from 27 yesterday. At OSH ED,
vitals revealed T 97.8 P 85 BP 121/49. Hct was 29 on admission
to [**Hospital1 18**] s/p 2U prbc at OSH. Lavage via PEG was not performed
at OSH, but performed at [**Hospital1 18**] and cleared after just over 1L
lavage.
.
Recent [**11-19**] scope via G-tube revealed 1cm antral ulcer and
erosive esophagitis. She was started on a PPI during her recent
hospitalization at [**Hospital1 2025**].
.
The patient's recent complicated medical course began on
[**2200-11-10**] when she fell at home and was taken to [**Hospital1 2025**] where she
was found to have SDH. She was observed without complication
and d/c to [**Hospital **] Rehab where she again fell. She was readmitted to
[**Hospital1 2025**] on [**2200-11-15**] s/p fall and in the setting of fever and AMS.
She was found to have LLL infiltrate on CXR and began a course
of cefepime and vanco for [**Company 191**] pneumonia. On [**11-18**], she developed
UGI with hct drop from 32 to 25. In preparation for
EGD/colonoscopy, she aspirated and required intubation.
Subsequent extubation was c/b stridor and she was reintubated
and eventually underwent tracheostomy and PEG placement (found
to be aspirating on speech and swallow study). She was
transferred to [**Hospital1 **] for additional vent rehab, PT/OT on
[**2200-12-12**].
Past Medical History:
1. Parkinson's
2. ACA aneurysm [**2195**], s/p repair
3. Subdural hematoma
3. s/p VP shunt
4. GI Bleed
5. Atrial fibrillation with RVR
6. HIT
7. Aspiration pneumonia
8. s/p trach and PEG
9. HTN
10. Glabrata fungemia
Social History:
She has been living with her daughters since her aneurysm repair
in [**2195**] until her recent fall in late [**2200-10-15**] when she
had been living at [**Hospital **] rehab. She was never a tobacco smoker and
consumed EtOH rarely.
Family History:
Noncontributory
Physical Exam:
Vitals: T 97.2 ax. BP 125/48 HR 68 RR 12 O2 sat 100% (AC Vt 400
RR 12 FiO2 0.40 PEEP 3.0)
Gen: Somnolent, arounsable to voice. Follows
HEENT: PERRL, MMM
Neck: No JVD appreciated, supple
Cardiac: RRR, no mrg appreciated
Resp: clear anteriorly
Abdomen: Soft, +BS, NT, Maroon colored blood from G-tube
Ext: No c/c/e
Neuro: Responsive to name. Follows commands by physical
instruction (nonverbal given Mandarin speaking and daughters not
present for initial eval)
Pertinent Results:
[**11-19**] Echocardiogram performed at [**Hospital1 2025**] with LVEF approx 70%.
.
EKG from OSH: NSR with rate of 75. LAD. Q in III and aVF. Nml
intervals. No acute ST, T wave changes.
.
[**2200-12-21**] 05:24PM BLOOD Type-ART pO2-125* pCO2-46* pH-7.45
calTCO2-33* Base XS-7
[**2200-12-22**] 05:02AM BLOOD Cortsol-15.8
[**2200-12-21**] 02:01PM BLOOD TSH-2.7
[**2200-12-21**] 02:01PM BLOOD Calcium-7.0* Phos-2.8 Mg-2.5
[**2200-12-24**] 05:29AM BLOOD Calcium-8.7 Phos-4.2 Mg-2.2
[**2200-12-21**] 02:01PM BLOOD CK-MB-7 cTropnT-0.78*
[**2200-12-21**] 10:02PM BLOOD CK-MB-7 cTropnT-0.81*
[**2200-12-22**] 05:02AM BLOOD CK-MB-8 cTropnT-0.79*
[**2200-12-21**] 02:01PM BLOOD CK(CPK)-83
[**2200-12-21**] 10:02PM BLOOD CK(CPK)-69
[**2200-12-22**] 05:02AM BLOOD CK(CPK)-70
[**2200-12-21**] 02:01PM BLOOD Glucose-94 UreaN-61* Creat-0.9 Na-130*
K-4.0 Cl-92* HCO3-31 AnGap-11
[**2200-12-24**] 05:29AM BLOOD Glucose-140* UreaN-30* Creat-0.8 Na-139
K-3.5 Cl-101 HCO3-30 AnGap-12
[**2200-12-22**] 05:02AM BLOOD PT-12.1 PTT-31.8 INR(PT)-1.0
[**2200-12-22**] 05:02AM BLOOD Neuts-82* Bands-9* Lymphs-6* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2200-12-24**] 05:29AM BLOOD Neuts-PND Lymphs-PND Monos-PND Eos-PND
Baso-PND
[**2200-12-21**] 01:29PM BLOOD WBC-13.4* RBC-3.41* Hgb-10.4* Hct-29.4*
MCV-86 MCH-30.5 MCHC-35.4* RDW-14.4 Plt Ct-303
[**2200-12-22**] 05:02AM BLOOD WBC-12.2* RBC-3.80* Hgb-11.4* Hct-33.4*
MCV-88 MCH-30.1 MCHC-34.2 RDW-14.8 Plt Ct-303
[**2200-12-23**] 02:16AM BLOOD WBC-11.4* RBC-3.65* Hgb-11.1* Hct-32.1*
MCV-88 MCH-30.5 MCHC-34.7 RDW-14.6 Plt Ct-301
[**2200-12-24**] 05:29AM BLOOD WBC-15.7* RBC-3.90* Hgb-11.8* Hct-34.1*
MCV-87 MCH-30.2 MCHC-34.6 RDW-14.5 Plt Ct-295
.
UA and urine cultures pending.
.
Sputum culture pending.
Brief Hospital Course:
82 yo F with h/o Parkinson's, SDH, HTN, aspiration pneumonia,
and UGI bleed in [**11-19**] presents to OSH with BRB per G-tube.
.
# GIB: Prior to transfer from OSH ED she received 2U prbc and
her hct bumped from 24 to 29.4. She was recently scoped at the
time of her G-tube placement at [**Hospital1 2025**] and she was found to have
erosive esophagitis and antral ulcers; she was discharged to
rehab on 30mg [**Hospital1 **] lansoprazole. She was evaluated by GI at
[**Hospital1 18**] who lavaged her G-tube which cleared after approximately 1
L of lavage. She received 1U prbcs at [**Hospital1 18**] and her hct again
responded appropriately and she had no other gross evidence of
active bleed. SBP was originally 80s-100s on admission, but
with IVFs and 1U prbcs, her BP improved to her baseline where it
has remained (130s systolic). Because her hct and HDs remained
stable and she has known probable sources as described above, GI
opted not to pursue further evaluation with endoscopy. She was
continued on [**Hospital1 **] PPI and sucralfate was started. H. pylori
studies were sent and these will need to be followed up as she
may require treatment if positive. Hct on [**2200-12-24**] was 34.1.
.
# Hypotension: Likely [**1-16**] to GIB and holding of tube feeds in
this setting. She was, however, not tachycardic, but it was
unclear when she received her last dose of beta blocker. She is
currently being treated with vancomycin for pneumonia, but she
was not febrile. Her WBC count was elevated with a left shift,
but her hypotension was responsive to fluids and it was not
thought [**1-16**] to infection. Sputum cultures were sent and will
need to be followed up. We did not broaden antibiotic coverage
as she was clinically stable following IV hydration. She was
restarted on her beta blocker, ACEI, and lasix.
.
# Hypoxic respiratory failure: [**1-16**] to aspiration pneumonia,
requiring trach placement at OSH. She arrived on AC vent
settings, but was weaned to trach mask alone (as she had been at
[**Hospital1 **]). Speech and swallow fitted her with Passey Muir valve
which she used while here. She will be discharged with her PMV
and, thus, this should be continued at rehab.
.
# Hyponatremia: Na+ 130 on admission to [**Hospital1 18**] thought to
represent hypovolemic hyponatremia. It normalized with IV
hydration. Prior to normalization, cortisol and TSH were
checked; both of which were normal.
.
# Pneumonia: Please see above for respiratory status. She was
continued on vancomycin (documentation on transfer from OSH
ED/rehab states she is to complete course on [**2200-12-29**]). Cultures
were resent and should be followed up.
.
# Leukocytosis: Her WBC count rose to 15 on discharge from 11
the day prior without a clear source of infection. She was
afebrile and normotensive. Levofloxacin was added to vancomycin
on [**2200-12-24**] to treat for tracheobronchitis (7 day course) [**1-16**] to
mild increase in upper airway secretion production. Urine and
sputum cultures should be followed up by rehab staff.
.
# Elevated troponin: Her troponin was elevated to 0.80, but
remained stable there x3. CKs were flat. She denied any
symptoms of chest pain. EKG did reveal Qs in III and aVF, but
these are not new per outside records. She had a normal echo in
[**Month (only) 1096**] at [**Hospital1 2025**] and did not appear to be in failure to suggest
the elevation (and higher than would be expected). Creatinine
was normal and BUN was elevated, but this was in the setting of
her GIB, so renal failure did not appear to be the etiology
either.
.
# Atrial fibrillation: She was in NSR throughout her stay at
[**Hospital1 18**]. She was restarted on her metoprolol as above. She had
not been anticoagulated previously in the setting of her SDH and
GIB. This can be readdressed as an outpatient as she improves
clinically, but is not currently a good anticoagulation
candidate.
.
# HTN: Pt. with h/o HTN with baseline SBPs 130s-150s, but was
hypotensive to high 80s-low 100s on admission which was
responsive to fluids. Her pressures improved to 130s-140s
systolic and her antihypertensive meds were restarted which she
tolerated well.
.
# Parkinson's: She was continued on sinemet.
.
# Dementia: She was continued on namenda.
.
# SDH: Occipital bleed, neuro exam and imaging during last
hospitalization at [**Hospital1 2025**] stable per records and her neurologic
exam remained stable while here. She does have symmetric [**3-19**]
grip strength and [**3-19**] b/l dorsi and plantar flexion.
.
# FEN: Her TFs were held in the setting of GIB, but were
restarted prior to discharge. Erythromycin was started as a
motility [**Doctor Last Name 360**] and she has been tolerating TFs without high
residuals.
.
# Proph: She was continued on [**Hospital1 **] PPI and pneumoboots were used
for DVT prophylaxis.
.
# Code: FULL
.
# Communication: [**First Name5 (NamePattern1) **] [**Known lastname 106677**] (daughter) [**Telephone/Fax (3) 106678**]; other daughter [**Telephone/Fax (1) 106679**]
Medications on Admission:
1. Albuterol nebs q4hours
2. Alendronate 70mg qSunday
3. Bunesonide Respules 0.5mg/2mL nebs q12hours
4. Calcium carbonate 250mg tid
5. Captopril 12.5mg tid
6. Carbidopa/levodopa 25/100 tid
7. Erythromycin 250mg tid (for GI motility in setting of high
residuals with tube feeds)
8. Fondaparinux 2.5mg SC qdaily
9. Furosemide 40mg via G tube tid
10. Lansoprazole 30mg via G tube [**Hospital1 **]
11. Memantine 5mg qhs
12. Metoprolol 25mg tid
13. MVI
14. Vancomycin 1g q36hours (to complete course [**2200-12-29**])
15. Vitamin D 400U daily
Discharge Medications:
1. Carbidopa-Levodopa 25-100 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO
TID (3 times a day).
2. Memantine 5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO qhs ().
3. Polyvinyl Alcohol 1.4 % Drops [**Month/Day/Year **]: 1-2 Drops Ophthalmic PRN
(as needed).
4. Metoprolol Tartrate 25 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q8H
(every 8 hours).
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
6. Sucralfate 1 g Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day): Please deliver separately from other medications. thank
you.
7. Captopril 12.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times
a day).
8. Furosemide 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
9. Vancomycin in Dextrose 1 g/200 mL Piggyback [**Last Name (STitle) **]: One (1) gram
Intravenous Q 24H (Every 24 Hours): To complete course on
[**2200-12-29**].
10. Calcium 500 500 mg Tablet [**Date Range **]: One (1) Tablet PO three times
a day.
11. Vitamin D 400 unit Tablet [**Date Range **]: One (1) Tablet PO once a day.
12. Multivitamin Liquid [**Date Range **]: One (1) PO once a day.
13. Alendronate 70 mg Tablet [**Date Range **]: One (1) Tablet PO once a week:
on Sunday.
14. Erythromycin 250 mg Tablet [**Date Range **]: One (1) Tablet PO three
times a day: If patient having high tube feed residuals. For GI
motility.
15. Levofloxacin 500 mg Tablet [**Date Range **]: One (1) Tablet PO QD () for
7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
1. Upper GI bleed
2. Pneumonia
3. Elevated troponin
4. Hyponatremia
5. Parkinson's disease
6. Dementia
Discharge Condition:
Stable with stable hematocrit and hemodynamics.
Discharge Instructions:
Please call your doctor or return to the emergency room if you
experience any blood via your G-tube, if you develop focal
numbness/tingling/weakness/headache/changes in vision,
fever/chills, worsening sputum or any other symptoms that
concern you.
.
Please continue taking medications as prescribed.
Followup Instructions:
Please follow up with your primary care doctor as suggested by
your rehab physician.
|
[
"332.0",
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"486",
"294.8",
"531.40",
"285.1",
"585.9",
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icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
11863, 11942
|
4626, 9687
|
253, 259
|
12098, 12148
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2861, 4603
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|
2346, 2363
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10275, 11840
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2378, 2842
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186, 215
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287, 1837
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1859, 2077
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2093, 2330
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,202
| 106,481
|
30383
|
Discharge summary
|
report
|
Admission Date: [**2144-11-21**] Discharge Date: [**2144-12-7**]
Date of Birth: [**2090-7-16**] Sex: M
Service: MEDICINE
Allergies:
Cefepime / Cipro
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Fever, shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
54-year-old gentleman with a history of AML. He is day 508
post-transplant complicated by chronic graft-versus-host disease
manifesting as skin, liver involvement and edema. Pt was most
recently admitted for right leg cellulitis; discharged [**11-4**]
with chronic levofloxacin that per records finished on [**11-19**].
Today the patient describes waking up this AM with chills and
malaise. He reports not being able to get warm; the wife called
the onc fellow on call took his temp-- 99.6. As the day
progressed, his temperature increase and he came to the ER.
.
In addition to the fever, the patient has been having
siginificant fatigue and increased cough with sputum. This
afternoon he also developed severe headache (as is typical with
his acute illness), feeling very weak, acute onset of shortness
of breath and pleuritic chest pain. Of note, his lower
extremities have been more swollen recently, but he has recently
noticed that his L>R has been swollen since yesterday, but
previously the right was more swollen than the left.
.
On presentation to the ER, initial vitals were T 101, HR 104, RR
18 02 95% RA. While in the ED, he became more hypoxic and
required a NRB to keep sats above 93%. He also became
hypotensive to BPs of 80s/50s. His BP was fluid responsive and
the patient received a total of 3L. Additionally, he was seen by
onc who recommended Vancomycin, Zosyn. He also received
azithromycin. CTA was done for pleuritic CP that showed a
subsegmental PE, thus he was started on heparin gtt and given
dilaudid for pain.
.
On arrival to the floor, the patient is feeling well, but feels
fatigued. As well he has a persistent bifrontal headache with
photophobia.
.
ROS: + photophobia, + bilateral chest pressure (chronic)
hyperesthesia. + sick contacts (daughter who lives with him has
had fever and sore throat) Denies dizziness or lightheadedness,
syncope or presyncope. He has had no dysuria, constipation,
melena, hematochezia, diarrhea. He has no blurry vision, neck
stiffness.
Past Medical History:
-AML-M7 ([**3-23**]) [Diagnosed with AML in 04/[**2142**]. Admitted
[**2143-6-24**] for matched unrelated allogenic transplant with
busulfan and
cyclophosphamide as his conditioning regimen. AB0 mismatch and
requiring periodic blood transfusions. Underwent bone marrow
aspirate and biopsy most recently on [**2143-9-2**] which showed
markedly hypercellular bone marrow with opacity of
erythroblasts. Cytogenetics were normal. FISH was normal.
Chimerism testing showed them to be 100% donor. ]
-Hyperlipidemia, HTN
-Nephrolithiasis, lithotrypsy and previous nephrostomy tube
and emergent surgery to repair ureteral damage
-Basal cell carcinoma, resected
-Multiple back surgeries: Lumbar L5-S1 surgery x 3, and cervical
spine fusion (bone graft, no hardware)
- Chronic numbness, neuropathic pain
-Pericardial effusion s/p [**3-23**] drainage
- C5/C6 and C6/C7 secondary to herniation of nucleus pulposus,
s/p
Anterior cervical discectomy and fusion C5-6 and C6-7
Social History:
Mr. [**Known lastname 47367**] lives in [**Location 14840**] with his wife and has three
children, used to work as a [**Company 22957**] technician, but recently was
"forced" to retire. Smoked a pack per day
of cigarettes for many years, but does not currently smoke. He
drinks alcohol socially. He does not use drugs. Walks with
walker and has a cat.
Family History:
Mother died suddenly in her 70s. Father died of unknown cancer
with tumors visible across body. One sister has thyroid cancer.
One brother has diabetes and kidney stones. One sister has
[**Name (NI) 5895**].
Physical Exam:
Tmax: 37.2 ??????C (99 ??????F)
Tcurrent: 37.2 ??????C (99 ??????F)
HR: 71 (71 - 86) bpm
BP: 100/64(73) {100/64(73) - 122/78(88)} mmHg
RR: 12 (11 - 13) insp/min
SpO2: 98%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 105 kg (admission): 105 kg
Height: 72 Inch
General Appearance: Well nourished, No acute distress, Sleepy
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, neck supple, JVP 10 cm
Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : , Crackles : in the left lower base)
Abdominal: Soft, Bowel sounds present, Tender: RUQ and
epigastrium
Extremities: Right: 1+, Left: 1+
Skin: Warm, Rash: Hands, erythema of upper abdomen
Neurologic: Follows simple commands, Responds to: Not assessed,
Oriented (to): x3, Movement: Purposeful, Tone: Normal
Pertinent Results:
Heme:
[**2144-11-21**] 03:00PM WBC-6.0 RBC-3.18* HGB-12.6* HCT-36.3*
MCV-114* MCH-39.5* MCHC-34.7 RDW-17.6*
[**2144-11-21**] 03:00PM NEUTS-85.1* LYMPHS-6.9* MONOS-6.8 EOS-0.8
BASOS-0.3
[**2144-11-21**] 03:00PM PT-14.1* PTT-25.6 INR(PT)-1.2*
Chemistries:
[**2144-11-21**] 03:00PM GLUCOSE-135* UREA N-14 CREAT-1.3* SODIUM-139
POTASSIUM-4.8 CHLORIDE-99 TOTAL CO2-33* ANION GAP-12
[**2144-11-21**] 03:00PM ALT(SGPT)-23 AST(SGOT)-32 ALK PHOS-279* TOT
BILI-0.4
[**2144-11-21**] 03:00PM LIPASE-12
Cultures:
[**2144-11-21**] Blood: No growth
[**2144-11-21**] Urine: < 10,000
[**2144-11-22**] Sputum: contamination
IMAGING:
UPRIGHT AP VIEW OF THE ABDOMEN: No free air is seen under the
diaphragms.
Relative gasless abdomen is present with no air-fluid levels
identified.
Stool and air is seen within the descending colon and sigmoid
colon. No soft tissue calcifications are identified.
IMPRESSION: No air-fluid levels or free intra-abdominal air
identified.
Relative paucity of gas within the abdomen.
UPRIGHT AP VIEW OF THE CHEST: The right PICC has been removed.
Cervical
fusion hardware is present. Cardiac, mediastinal and hilar
contours are
unchanged and within normal limits. The lungs are clear. There
is no
pulmonary vascular congestion. No pleural effusions or
pneumothorax. Osseous structures are unremarkable.
IMPRESSION: No acute cardiopulmonary abnormality.
.
[**2144-11-21**] CTA:
1. Left lower lobe segmental pulmonary embolism.
2. Wedge-shaped peripheral consolidation in the superior segment
of the right lower lobe. Differential considerations include
infectious or inflammatory processes; atelectasis is less
likely.
3. Thoracic vertebral compression fracture, unchanged in
comparison to
[**2144-9-10**].
.
Portable TTE (Complete) Done [**2144-11-23**] at 10:26:48 AM
The left atrium is dilated. Left ventricular wall thicknesses
and cavity size are normal. Left ventricular systolic function
is hyperdynamic (EF>75%). There is no left ventricular outflow
obstruction at rest or with Valsalva. 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 appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2144-6-8**], LV
function appears hyperdynamic on the current study. The other
findings are similar.
.
BILAT LOWER EXT VEINS Study Date of [**2144-11-23**] 5:05 PM
IMPRESSION: No DVT in the bilateral lower extremities.
.
CHEST (PORTABLE AP) Study Date of [**2144-11-25**] 5:10 AM
IMPRESSION:
1. Worsening right lower lobe opacity over the period of last
five days most likely representing a worsening infectious
process.
2. Given the presence of pulmonary embolism in left lower lobe
the worsening left lower lobe opacity might represent infarction
as well as atelectasis or infection, determination based on the
chest radiograph cannot be made.
.
CHEST (PORTABLE AP) Study Date of [**2144-11-27**] 4:53 AM
Portable AP chest radiograph was compared to [**2144-11-26**].
There is a slightly improved aeration of lung bases due to
resolution of
atelectasis. Cardiomediastinal silhouette is stable. No
appreciable pleural effusion is seen.
.
[**2144-12-4**] CXR: FINDINGS: Comparison study [**12-3**], there is no
interval change. The two vague bilateral upper lobe opacities
are again seen. These could represent areas related to pulmonary
emboli.
.
[**2144-12-7**] CT chest w/o contrast:
1. Findings are most consistent with cryptogenic organizing
pneumonia, although a component of viral pneumonia is possible.
2. Stable centrilobular emphysema.
3. Multilevel compression fractures are similar to [**2144-11-21**].
Brief Hospital Course:
54 yo M with AML s/p allo-BMT with chronic GVHD of liver, skin
now with fever and pulmonary embolism.
.
Fever/RSV: The patient was admitted to the MICU for inital
hypotension, PE, Acute renal insufficency and increased oxygen
requirement. The patient reported recent sick contacts and due
to his respiratory complaints, a pulmonary process was the most
consistant site of infection. He was treated with Vancomycin and
Zosyn in the ED and this therapy was continued throughout his
ICU course. He was hypotensive in the ED (SBP to 80's), but this
resolved with IV fluids and was felt to be consistant with
pre-septic physiology. Cultures were obtained. Nasal swab was
positive for RSV, sputum with gram positive cocci and yeast.
The patient was treated with Synagist/palivizumab in two
7.5mg/kg doses for RSV. The patient remained febrile over the
first 4 days of hospitalization but defervessed by hospital day
5. He was transferred to the BMT service on ICU Day 6. On the
floor patient was treated with scheduled abuterol and ipatropium
nebs and his supplemental oxygen was weaned down to 2L/min.
Patient's shortness of breath resolved. However, his hypoxia
persisted. Patient was seen by the Pulmonary and physical
therapy. It appears that the RSV infection is primarily an upper
respiratory tract infection as there is no evidence of RSV
pneumonia. There was some concern that his hypoxia may represent
an element of GVHD of the lung so his prednisone dose was
increased to 40mg. He had slight improvement with increased
steroids and was tapered to 30mg at the time of discharge. His
steroid dose will continued to be tapered in the outpatient
setting. He is recommended to continue use of supplemental
oxygen after discharge to maintain oxygen saturations greater
than 94%.
.
PE: LLL pulmonary embolism was identified on CTA. Pt was
started on [**Hospital1 **] lovenox. On the day of discharge he was started
on coumadin 2mg po and instructed to follow up in two days to
have his INR monitored. He is to continue lovenox injections at
the reduced dose of 80 mg [**Hospital1 **] until his INR becomes therapeutic.
.
Chronic Health Issues:
GHVD: The patient was maintained in his home regimen of
cyclosporin and prednisone. A RUQ ultrasound was performed to
assess pt's chronic complaint of RUQ tenderness. Ultrasound was
without evidence of acute processes consistent with this pain.
Liver function tests were monitored throughout hospitalization.
AML: The patient was maintained in his home regimen of
cyclophosphamide, ACV, Bactrim and Voriconazole
Lower Extremity Edema: Has been an issue for several months.
Increased over his initial hospital course due to fluid
resusitation. He underwent gentle diuresis with lasix with
moderate improvement. An Echo was performed which showed
hyperdynamic LVEF. Pt was restarted on home lasix 20 mg po
prior to discharge.
Diabetes: Continued outpatient dose of NPH, lispro ss.
Avascular necrosis of hips bilateral: Outpatient pain regimen
continued.
Obstructive Sleep Apnea: The was given CPAP for his OSA. He
did not tolerate the face mask or nasal mask. He refused to use
CPAP for the remainder of his hospitalizaiton. He is scheduled
for an outpatient appointment with a sleep clinic in [**Month (only) 404**] to
introduce him to CPAP.
Medications on Admission:
Medications:
acyclovir 400mg TID
cyclosporine 50mg [**Hospital1 **]
Valium 5mg daily prn muscle spasm
folic acid 1mg daily
Lasix 20mg daily
Neurontin 300mg QHS
Insulin Lispro per sliding scale, NPH 12units [**Hospital1 **]
levofloxacin 500mg daily - until f/u with Dr. [**Last Name (STitle) 724**]
metoprolol 50mg [**Hospital1 **]
cxycodone 5mg 1-2 tabs Q4-6hr prn pain
OxyContin 20mg Q12hr
Protonix 40mg daily
prednisone 10mg daily
Actonel 35mg weekly
Androgel 50mg to torso daily
Bactrm SS one tab daily
voriconozole 200mg [**Hospital1 **]
Discharge Medications:
1. Supplemental oxygen
Please provide supplemental oxygen and necessary equipment.
Start at 2L/minute oxygen via nasal cannula and titrate oxygen
up to maintain oxygen saturations of greater than 94%.
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Testosterone 5 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
5. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
7. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
8. Cyclosporine Modified 25 mg Capsule Sig: Two (2) Capsule PO
Q12H (every 12 hours).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
11. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
14. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as
needed for pain.
15. Diazepam 5 mg Tablet Sig: One (1) Tablet PO BID PRN () as
needed for muscle spasm.
16. Insulin
Please resume home insulin regimen:
NPH 12 units [**Hospital1 **]
Lispo per sliding scale
17. Actonel 35 mg Tablet Sig: One (1) Tablet PO once a week.
18. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
Disp:*1 inhaler* Refills:*0*
19. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
twice a day for 15 days.
Disp:*15 days supply* Refills:*0*
20. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Community VNA
Discharge Diagnosis:
Respiratory Syncytial Virus (RSV)
Pulmonary Embolism
Chronic Graft Versus Host Disease
Obstructive Sleep Apnea
h/o Acute Myelogenous Leukemia s/p BMT [**2142**]
Discharge Condition:
Stable; Pt requires supplemental oxygen with ambulation. He is
tolerating po diet and medications well.
Discharge Instructions:
You were admitted to the hospital for fever, low blood pressure,
and difficulty breathing. You were found to have a blood clot
in your left lung as well as an upper respiratory tract
infection with a virus called RSV. You were admitted to the ICU
until you were stabilized. Once you blood pressure returned to
[**Location 213**] and your fever resolved you were transferred to the floor
where you were closely monitored. Your shortness of breath
improved. However, you still required supplemental oxygen to
maintain adequate oxygen levels.
.
The following changes were made to your medications:
1) START Lovenox SC injections 80mg twice a day
2) START Albuterol inhaler 2 puffs every 4 hours as needed for
shortness of breath
3) START Warfarin (Coumadin) 3mg by mouth daily
4) STOP levofloxacin (levoquin)
5) INCREASE prednisone to 30 mg by mouth daily
.
.
Please continue taking all other home medications as previously
prescribed.
.
Please contact your physician or return to the hospital if you
experience fever, chills, chest pain, worsening cough, increased
difficulty breathing or any other symptom that is concerning to
you.
Followup Instructions:
Please follow up with [**First Name8 (NamePattern2) 3235**] [**Last Name (NamePattern1) 3236**] in [**Hospital 3242**] clinic on Wednesday
[**2144-12-9**] at 10:30 am.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9574**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3241**]
Date/Time:[**2144-12-9**] 10:30
|
[
"996.85",
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"205.01",
"733.90",
"279.52",
"733.42",
"V58.67",
"415.19",
"327.23",
"782.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14728, 14772
|
8853, 12161
|
305, 311
|
14977, 15084
|
4944, 8830
|
16268, 16607
|
3713, 3922
|
12754, 14705
|
14793, 14956
|
12187, 12731
|
15108, 16245
|
3937, 4925
|
239, 267
|
339, 2342
|
2364, 3327
|
3343, 3697
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,669
| 115,633
|
18662
|
Discharge summary
|
report
|
Admission Date: [**2124-8-14**] Discharge Date: [**2124-8-29**]
Date of Birth: [**2051-7-31**] Sex: M
Service: Vascular Surgery
CHIEF COMPLAINT: Right iliac artery aneurysm.
HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old
male with four days of history of right upper quadrant pain.
He denied nausea or vomiting. The pain was worse with
eating. There was no change in bowel activity. He also
reported positive pain in the right calf after walking a
couple of miles, also in the right buttock and right thigh
area. Comorbidities include hypercholesterolemia,
questionable diabetes, status post back surgery, and
hypertension.
PHYSICAL EXAMINATION: The patient was afebrile, pulse 55,
blood pressure 199/87, breathing at a rate of 16, 98% oxygen
saturation on room air. The patient was a tanned portly man
in no apparent distress. Heart rate was regular. Lungs were
clear to auscultation bilaterally. Abdomen was round with
right upper quadrant and right midabdominal tenderness.
Carotid examination revealed no bruits. There was no
pulsatile mass in the abdomen. All lower extremity pulses
were 2+ including femoral, popliteal, dorsalis pedis and
posterior tibial pulses bilaterally. The patient was noted
to have a small umbilical hernia, no inguinal hernias noted.
On rectal examination no masses were palpated. The patient
was guaiac negative.
LABORATORY DATA: On admission the laboratory studies were
all within normal limits. EKG revealed normal sinus rhythm.
CT of the abdomen showed a 4.5 cm right iliac artery aneurysm
without extravasation. Left common iliac was 2.7 cm.
HOSPITAL COURSE: Post admission the patient received regular
preoperative work-up including appropriate laboratory
studies, chest x-ray, EKG, and in addition the patient
received cardiology clearance, as well as a right upper
quadrant ultrasound to rule out cholelithiasis and
cholecystitis. After a positive stress test the patient
received cardiac catheterization on [**2124-8-16**]. Upon pulling
out of the sheath post cardiac catheterization, the patient
experienced a vagal episode where his heart rate dropped to
the 30s and blood pressure to systolic of 59. The patient
received two amps of atropine as well as dopamine started at
20 cc per hour. Blood pressure increased to 111/63. The
patient was also fluid resuscitated with three liters of
normal saline. Cardiac catheterization analysis revealed a
mild two-vessel coronary artery disease as well as a mild
left ventricular systolic and diastolic dysfunction.
Ejection fraction was 51%.
Once the patient received clearance for the operating room,
the patient was taken for aortobifemoral bypass on [**2124-8-18**].
For a detailed account of surgery, please see the operative
report.
Postoperatively the patient experienced abdominal distention
as well as abdominal discomfort. KUB obtained on
postoperative day number five revealed dilated loops of
bowel, both small intestine and colon, positive air in the
rectum. The picture was consistent with postoperative ileus
as opposed to obstruction of some sort. The patient at that
time received nasogastric tube put to low continuous wall
suction with good results. Distention went down as well as
the patient's discomfort. Repeat KUB on [**2124-8-25**] revealed
resolution of dilated loops.
The patient was started on TPN on [**2124-8-27**] due to prolonged
course of n.p.o. In the early AM of [**2124-8-28**] the patient's
nasogastric tube was discontinued with no resulting nausea,
vomiting, or distention. The patient was started on a
regular diet on [**2124-8-28**] starting with clears in the AM,
general diet in the evening. On [**2124-8-28**] the patient's
staples were discontinued. Steri-Strips were applied. The
patient is stable on discharge.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES: Right iliac artery aneurysm status post
aortobifemoral bypass.
DISCHARGE MEDICATIONS:
1. Metamucil.
2. Lipitor 40 mg p.o. q. day.
3. Aspirin 81 mg p.o. q. day.
4. Clorazepate 7.5 mg p.o. q. day.
5. Atenolol 50 mg p.o. q. day.
6. Tricor 160 mg p.o. q. day.
7. Verapamil 240 mg p.o. q. day.
8. Ultram p.r.n.
FOLLOW-UP PLANS: The patient will follow up with Dr.
[**Last Name (STitle) **] in vascular surgery clinic at [**Hospital1 346**] in one to two weeks.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**]
Dictated By:[**Name8 (MD) 7190**]
MEDQUIST36
D: [**2124-8-28**] 11:34
T: [**2124-8-28**] 11:53
JOB#: [**Job Number 51204**]
|
[
"553.1",
"401.9",
"414.01",
"560.1",
"442.2",
"272.0",
"458.2",
"997.4",
"413.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"37.22",
"99.15",
"38.93",
"88.55",
"38.46"
] |
icd9pcs
|
[
[
[]
]
] |
3867, 3931
|
3954, 4175
|
1650, 3845
|
686, 1632
|
4193, 4597
|
167, 197
|
226, 663
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,280
| 106,466
|
48045
|
Discharge summary
|
report
|
Admission Date: [**2105-12-22**] Discharge Date: [**2106-1-13**]
Date of Birth: [**2052-8-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1162**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
intubation
PICC line placement
History of Present Illness:
Mr. [**Known lastname **] is a 53yo quadriplegic male ([**3-13**] motorcycle accident 6
years ago) with h/o frequent UTIs who presented to the ED after
his VNA found him hypotensive this morning with BP 50/30. He
stated he was in his usual state of health (other than a recent
UTI for which he took 10 days of bactrim, ending 5 days prior to
this admission) until a few days ago. He reported feeling
general fatigue/malaise/nausea, with mild abdominal and back
pain (difficult to discuss ascertain given altered sensation).
He also reported mild dizziness when he got out of bed on the
morning of admission. As above, Mr. [**Known lastname **] is dependent on
intermittent urinary catheterization due to his paralysis and
has had frequent UTIs ([**6-14**] in the past year; the last being [**3-13**]
klebsiella pneumoniae resistant to bactrim, cipro,
nitrofurantoin).
In the ED his initial BP was 60's/40's with HR of 64, improving
with IVF to 70's/30's, and finally 80's after 4L IVF bolus. In
the ED a Precept catheter was placed, he was given empiric
ceftriaxone and vancomycin and was started on Levophed after his
CVP>8. SVO2 70
Past Medical History:
- quadriplegia and TBI [**3-13**] MVA several years ago
- h/o DVT's (1 year ago)
- autonomic dysfunction: frequent swings of blood pressure
associated with not having BMs
- urinary retnsion requiring straight cath: frequent UTI's (most
recent due to Klebsiella resistant to ciproflox and
nitrofurantoin)
- chronic cystitis (?cystoscopy at [**Hospital1 2025**] with bladder irritation)
Social History:
Former computer and real-estate executive. Retired wealthy at
age 42 and traveled the country riding his motorcycle and
unfortunately had his accident while on a trip to [**State **]. Has 4
children; now lives with his wife and 2 of his kids at home with
daily VNA. He drinks 5+ shots of gin per day (no h/o
withdrawal); no smoking.
Family History:
mother with cancer, grandmother with [**Name2 (NI) **]
Physical Exam:
T 100.6 BP 116/67 HR 83 CVP6 RR 22 95% on RA
Gen: quadriplegic male, non-toxic appearing, no distress
CV: RRR no m/r/g
Pulm: Lungs CTAB
Abd: S/ND/NT +BS
Flank: no flank TTP
Extremities: mild edema
Pertinent Results:
[**2105-12-22**] 10:45AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-MOD
[**2105-12-22**] 10:45AM URINE RBC-[**4-13**]* WBC->50 BACTERIA-MANY
YEAST-NONE EPI-[**7-19**]
[**2105-12-22**] 10:45AM PT-17.9* PTT-32.9 INR(PT)-1.7*
[**2105-12-22**] 10:45AM WBC-15.7*# RBC-3.34* HGB-10.9* HCT-31.8*
MCV-95 MCH-32.6* MCHC-34.3 RDW-13.4
[**2105-12-22**] 10:45AM NEUTS-73* BANDS-18* LYMPHS-5* MONOS-3 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2105-12-22**] 10:45AM ALT(SGPT)-26 AST(SGOT)-70* LD(LDH)-282* ALK
PHOS-85 AMYLASE-31 TOT BILI-0.5
[**2105-12-22**] 10:45AM LIPASE-21
[**2105-12-22**] 10:45AM ALBUMIN-3.4 CALCIUM-7.8* PHOSPHATE-2.3*
MAGNESIUM-1.4*
[**2105-12-22**] 10:45AM GLUCOSE-71 UREA N-25* CREAT-2.6*# SODIUM-127*
POTASSIUM-4.1 CHLORIDE-89* TOTAL CO2-28 ANION GAP-14
[**2105-12-22**] 10:51AM LACTATE-2.9*
[**2105-12-22**] 12:49PM LACTATE-1.7
[**2105-12-22**] 03:18PM LACTATE-1.4
[**2105-12-22**] 05:33PM LACTATE-1.2
[**2105-12-22**] 06:32PM LACTATE-1.2
[**2105-12-22**] 10:25PM LACTATE-1.0
.
CHEST (PORTABLE AP) [**2105-12-22**] 10:38 AM
IMPRESSION:
No acute intrathoracic process.
.
RENAL U.S. [**2105-12-23**] 9:47 AM
IMPRESSION: Normal renal ultrasound.
.
ECHO [**2105-12-24**]
IMPRESSION: Moderate left ventricular systolic dysfunction with
focal basal to mid hypokinesis and apical sparing, which could
be most consistent with stress induced cardiomyopathy
(reverse-Takostubo type), although multivessel CAD cannot be
ruled out.
.
PORTABLE ABDOMEN [**2105-12-26**] 9:04 AM
IMPRESSION: Dilated colonic bowel loops. Assessment for free air
limited. The findings likely represent a colonic ileus, however,
early distal colonic obstruction is not definitively excluded.
Followup is recommended. Findings were discussed with the
covering resident at the time of dictation on [**2105-12-26**] at 12:15
p.m.
.
[**2105-12-28**] 9:02 PM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
IMPRESSION:
1. Bilateral basilar consolidation, effusion, and atelectasis,
concerning for multifocal pneumonia.
2. Diffuse fatty infiltration of the liver.
3. No perinephric abscess or evidence of other acute
intra-abdominal pathology.
.
CHEST (PORTABLE AP) [**2105-12-28**] 5:14 AM
IMPRESSION: AP chest compared to [**12-24**] through 18:
Moderately severe pulmonary edema has worsened since [**12-27**]
accompanied by increasing moderate right pleural effusion. There
is also markedly asymmetric pulmonary consolidation strongly
suggestive of pneumonia or pulmonary hemorrhage worsened
particularly in the right upper lobe. Heart size top normal. ET
tube and nasogastric tube in standard placements. Right jugular
line ends in the lower SVC. Findings were discussed by telephone
with Dr. [**Last Name (STitle) **] to report these findings at the time of
dictation.
.
ECHO [**2105-12-28**]
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. There is no aortic valve stenosis. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is a trivial/physiologic pericardial
effusion.
Compared with the prior study (images reviewed) of [**2105-12-24**],
LVEF is now normal.
.
LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT [**2105-12-31**] 2:16 PM
The liver is unremarkable in appearance without focal or
textural abnormalities. No intrahepatic biliary dilatation is
seen. The common bile duct is prominent measuring 9 mm in
greatest diameter in its proximal portion. It is tapering
smoothly distally, and its appearance is stable compared to CT
of [**2105-12-28**]. No common bile duct stones are seen. The
gallbladder is normal. There is no cholelithiasis or evidence of
cholecystitis. There is no gallbladder sludge. The main portal
vein is patent. The pancreas appears unremarkable. There is no
ascites.
IMPRESSION:
No evidence of cholecystitis, cholelithiasis, or sludge.
AEROBIC BOTTLE (Final [**2105-12-28**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2105-12-25**]):
REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 101327**] @ 0052 ON [**2105-12-23**].
ESCHERICHIA COLI. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ =>16 R
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- =>16 R
[**2105-12-22**] 10:45 am URINE Site: CLEAN CATCH
**FINAL REPORT [**2105-12-24**]**
URINE CULTURE (Final [**2105-12-24**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ =>16 R
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 2 S
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
Hospital Course: Mr. [**Known lastname **] is a 53 yo gentleman with
quadriplegia and chronic urinary tract infections presenting
with hypotension, required intubation on [**12-24**] for respiratory
distress with hypoxia.
.
#. Respiratory Failure: Mr. [**Known lastname **] mental status progressively
deteriorated over the first 24 hours of his stay. He developed
respiratory distress in the setting of multiple fluid boluses
given to reach goal hemodynamics in sepsis, and also in the
setting of a witnessed aspiration. His chest xray showed
increasing pulmonary edema and his ECHO showed left ventricular
defect as described above. He was intubated. Attempts at
weening were complicated by polymicrobial ventilator-assisted
pneumonia, notably MRSA cultured on [**12-26**], for which he was
given courses of multiple antibiotics as below. He was also
found to have a right-sided pleural effusion (though there was
not enough by bedside U/S to do a bedside tap with culture). The
patient was successfully extubated and weaned off of
supplemental oxygen with normal saturation on room air at the
time of discharge.
2. Urosepsis: likely cause of his presenting septic shock and
hypotension as he had BCx and UCx growing out e coli sensitive
to antibiotic treatment started empirically upon admission. He
rapidly improved from his original septic presentation and his
white count normalized before rising again as below. No
perinephric abscess by CT per wet read. He finished a total of
12 days of Cipro for his urosepsis on [**1-3**].
3. PNA: MRSA growing in sputum culture although now showing
polymicrobial infection concerning for GNR and anaerobes. There
were consolidations in lung bases per abdominal CT. His PNA
antibiotic coverage included vanc, ceftriaxone, zosyn, and
cipro. He received gram negative coverage with ceftriaxone (for
UTI), though no lab evidence of GNR. Ceftriaxone dc'ed to start
Zosyn as patient was in respiratory distress with high fevers
and worsening rhonchi, but zosyn was discontinued when no GNRs
grew out on culture. He received a 12 day cipro course for
urosepsis and gram negative PNA coverage. He also received a 14
day vancomycin course for MRSA PNA.
4. C. diff: Mr. [**Known lastname **] was found to be c diff positive and had
colonic distension observed by abd film in the setting of a
profound ileus complicated by his quadriplegia. Repeat CT showed
gas filled 7cm colon without thickened wall on wet read. He was
covered with po vanc and IV flagyl (while his bowels were not
moving). His oxybutinin was discontinued for fear that it could
exacerbate his ileus. His abdominal distension improved with
treatment and his ileus resolved. Second stool culture for
cdiff was negative on [**12-31**].
5. Mental status changes: he was acutely delirious several days
into his ICU stay and the differential included infection as
well as etoh withdrawal. These findings resolved upon transfer
to the floor.
6. Hx of DVT: coumadin was initially held for supertherapeutic
INR up to 13 (likely from interraction with Cipro). He was also
given FFP and vit K, after which his INR became subtherapeutic.
Further history revealed that IVC was filter placed
prophylactically after his accident roughly 5-6 years ago, but
then he developed a DVT and was found to be positive for
antiphosolipds Ab's per PCP. [**Name10 (NameIs) **] was started on lovenox for
anticoagulation and then restarted on coumadin. He was
discharged with an INR of 2.5 on a reduced coumadin dose of 2.5.
VNA was set up for the patient to have his INR rechecked on
[**1-15**] with the results sent to his PCP.
7. Quadriplegia: has home regimen of baclofen, valium, etc and
wellbutrin for autonomic disorder, and very detailed bowel
regimen.
Medications on Admission:
1. Ascorbic Acid 500 mg po bid
2. Baclofen 20mg po QAM, 30mg po Q noon, 20mg po Q 4pm, 30mg po
Q 8pm
3. Bupropion SR 200mg PO QAM
4. Bupropion 100 mg SR po Q 4PM
5. Diazepam 10 mg PO QAM ?prn
6. Ditropan XL 20 mg po q AM, 10mg po Q 4pm.
7. Dulcolax 10 mg PR once a day.
8. oxycontin 15mg po q4-6hrs prn pain.
9. Omeprazole 20 mg po daily.
10. Pantoprazole 40 mg po daily.
11. Senna 2 tabs po qhs.
12. Tamsulosin 0.4 mg PO HS
13. Nitroglycerin 2 % Ointment Sig: One (1) application
Transdermal once a day as needed for dysreflexia.
14. Furosemide 40 mg po daily
15. Paroxetine HCl 50 mg PO DAILY
16. Coumadin 5mg
Discharge Medications:
1. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
2. Bupropion 100 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO QAM (once a day (in the morning)).
3. Bupropion 100 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q4PM ().
4. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for autonomic dysreflexia.
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Baclofen 10 mg Tablet Sig: Three (3) Tablet PO BID (2 times a
day).
7. Nitroglycerin 2 % Ointment Sig: One (1) Transdermal DAILY
(Daily) as needed for autonomic dysreflexia.
8. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
12. Dulcolax 10 mg Suppository Sig: One (1) Rectal once a day.
13. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
14. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
Discharge Disposition:
Home With Service
Facility:
Care group home care
Discharge Diagnosis:
urosepsis
quadroplegia
ventilator assoicated pneumonia
autonomic dysreflexia
Etoh withdrawal
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the ICU with hypotension and were found to
have urosepsis. Your hospitalization was complicated by
respiratory failure requiring intubation and you developed a
pneumonia while on the respirator. You have completed your
antibiotic regimens and repeat cultures show no evidence of
infection. You were also observed to undergo Etoh withdrawal
while hospitalized. You should refrain from Etoh use in the
future. You should return to ther ER or call your PCP if you
develop fevers, chills, rigors, abdominal pain or new symptoms.
Followup Instructions:
You will need to follow up with your PCP, [**Last Name (NamePattern4) **].[**Doctor Last Name **] in [**2-10**]
weeks. His number is [**Telephone/Fax (1) 49716**].
If you would like to transfer your urology and neurology care
over to the [**Hospital1 18**], you can call the below numbers and schedule
an appointment:
neurology: [**Telephone/Fax (1) 44**]
urology: [**Telephone/Fax (1) 164**]
The VNA will need to come to your house on [**1-15**] to have your INR
checked with results sent to your PCP.
|
[
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"008.45",
"482.41",
"599.0",
"285.9",
"V12.51",
"344.00",
"995.92",
"275.3",
"518.81",
"291.81",
"584.9",
"560.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.72",
"96.56",
"96.04",
"99.15",
"33.22",
"96.6",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
14264, 14316
|
8555, 8555
|
328, 361
|
14453, 14462
|
2587, 8532
|
15061, 15570
|
2299, 2355
|
12981, 14241
|
14337, 14432
|
12344, 12958
|
8572, 12318
|
14486, 15038
|
2370, 2568
|
277, 290
|
389, 1525
|
1547, 1933
|
1949, 2283
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,925
| 161,653
|
8589
|
Discharge summary
|
report
|
Admission Date: [**2139-9-7**] Discharge Date: [**2139-9-10**]
Date of Birth: [**2092-11-1**] Sex: F
Service: MEDICINE
Allergies:
Epinephrine / Ciprofloxacin / Vicodin
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
diabetic ketoacidosis, hypertensive urgency
Major Surgical or Invasive Procedure:
None
History of Present Illness:
.
The patient is a 46 year old female with DM-1 x 35 years
complicated by Diabetic Nephropathy, Neuropathy who was recently
started on HD 1 month ago for ESRD [**2-27**] Diabetic Nephropathy. The
patient was recently admitted to [**Hospital1 18**] from [**2139-7-25**] to [**2139-8-8**]
for treatment of pyelonephritis (Ucxs unrevealing) with
initiation of HD during this hosptalization.
.
The patient now presents to the E.D. with symptoms of
nausea/vomiting x 1 day with associated profound fatigue and
myalgias. She reports feeling warm with Tmx at home 99.8 and
subjective chills as well as myalgias/arthralgias. She reports
cough that has been ongoing for one month, generally
non-productive, but reports otherwise no localizing symptoms.
She denies chest pain, dyspnea, URI like symptoms, abdominal
pain, diarrhea, dysuria, urinary frequency. She does produce
urine. The patient reports she has not missed any doses of her
insulin but has decreased her home BP meds given feeling
lightheaed after HD sessions.
.
ED Course: In the ED the patient was found to have elevated
blood glucose of 420 with AG of 26 and K=6.3. The patient was
given 10U Regular insulin x 1 as well as 1L NS with improvement
of AG to 12. The patient was additionally treated for
hypertensive urgency with SBP in 220s with Lopressor and
Nitropaste. She was noted to be very agitated, requiring 4mg
Ativan (serum tox negative, Utox pending). The patient was
transferred to the floor for ongoing management.
.
Past Medical History:
HTN
DM1 last A1c 8.4 [**8-30**] c/b neuropathy and nephropathy
CKD, stage2-3-- baseline creatinine 1.6-2.0-- secondary to DM,
with signif microalbuminuria
Anemia-- thought secondary to CKD baseline around 30, has had
smear reviewed in [**2133**] with normocystic, normochromic anemia, nl
SPEP [**5-/2137**], negative work up in [**5-/2132**]
Hypothyroidism
hyperlipidemia
axonal peripheral neuropathy with some demyelinating features
anxiety
Hx of myeloid sarcoma with skin biopsy
chronic eosinophilia
Social History:
1 yr tobacco use 25yrs ago, no etoh or other drugs. The patient
lives with her [**Last Name (un) 30131**] in [**Hospital1 3597**], MA. Previously employed as a
secretary, not working currently [**2-27**] illness.
Family History:
Father with pericarditis, mother adopted, no hx of colon cancers
or DM
Physical Exam:
.
Vitals: Tc- 99.4 BP-122/60, HR - 103, RR-18, 02-96% RA
FS: 222, 275, 257, 243, 259
.
General: Patient is a tired appearing middle aged female,
chronically ill, but pleasant in NAD
HEENT: NCAT, EOMI. OP: MM do not appear very dry. No sinus
tenderness
Neck: Supple, JVP at base of neck, relatively flat
Chest: CTA anterior and posterior without rales, rhonchi or
wheezes
Cor: Regular, tachycardic. III/VI early systolic murmur
throughout precordium, loudest at LSB.
Back: No CVAT
Abdomen: Soft, non-tender, non-distended. + BS
Ext: No cyanosis, clubbing, edema
.
.
Pertinent Results:
Labs: see below
.
[**2139-9-8**] 05:46AM ABG: 7.30 36 92 18
.
WBC: 10.0
Hct: 42.9 <- BL near 31
Plt: 285
.
Microbiology:
.
Blood Cultures:
[**2139-9-7**] - x 2 pending
[**2139-9-8**] - x 1 pending
.
UA/Urine Cultures:
[**2138-9-9**] - mixed bacterial flora (>=3 colony types, consistent
with skin and /or genital contamination.)
.
Imaging:
[**2139-9-7**] - Chest Pa/Lat
1. No evidence of new or residual pneumonia.
2. Interval placement of right IJ dialysis catheter, no
pneumothorax.
.
ECG: 93, sinus. nml axis, nml interval. No acute St/TW changes
Brief Hospital Course:
.
On arrival to the floor it was questioned if patient should be
in ICU given elevated AG, although difficult to interpret in
setting of ESRD, due for HD. The patient was given 8U Lantus as
well as 3U Humalog for FS=273 (8 units Humalog in total on
floor) However patient's bicarb decreased through the night from
25 -> 16 with increase in AG from 12 to 21 with large Acetone
detectable in serum. Given this, the patient is now transferred
to ICU for ongoing management of DKA.
.
#. DKA: No obvious precipitant by history or exam. Patient
reports medications compliance. Zofran and reglan were given
PRN nausea. DKA resolved with insulin drip, and anion gap
closed within 24 hours of ICU admission. Pt was able to
transition back to usual subcutaneous insulin once she was able
to take po nutrition with resolution of nausea and vomiting.
Labile blood glucose overnight after insulin drip stopped but
thought to be secondary to altered PO diet; also glucose at home
levels are somewhat labile as an outpatient. On the morning of
discharge, the patient received glargine 10 units as [**First Name8 (NamePattern2) **] [**Last Name (un) **]
consult recommendatins and continued sliding scale insulin ACHS.
Her fingersticks glucose was stable throughout the day. [**Last Name (un) **]
recs followed patient while in ICU and agree patient stable to
discharge home. The patient was instructed to resume home
insulin regimen and also to follow-up with her endocrinologist.
Patient also instructed to resume carbohydrate counting: 1
unit/20 g carbs, correctin factor.
.
#. Hypertensive Urgency: Etiology not clear, again patient
reports good outpatient compliance. Hypertensin controlled in
ICU on outpatient regimen. Continue outpatient BP regimen.
Patient due for HD T/R/S.
.
#. ESRD: Secondary to Diabetic Nephropathy, patient receives HD
at [**Hospital1 **] [**Location (un) 1121**] HD with Dr. [**First Name (STitle) **]. Patient had HD beside
in ICU; final HD was on morning of discharge home. Resume T/R/S
schedule as per outpatient regimen. Continue Cinacalcet,
Nephrocaps.
.
#. Depression: Clinically stable during hospital stay.
Continued Lexapro in ICU and patient to continue Lexapro as an
outpatient.
.
#. Hypothyroidism - Levothyroxine continued as an inpatient.
TSH slightly low, free T4 normal. Patient instructed to follow
up with her PCP as an outpatient regarding synthroid dosing.
.
#. Anemia - Anemia of Chronic Disease, Hct 10 points above
baseline on admission, expected drop with volume resuscitation.
Stable upon discharge with hematocrit of 35.0.
.
#. Hyperlipidemia - Continued Zetia per outpatient regimen while
in ICU and will resume Zetia as outpatient.
.
#. Pancreatic Uncinate mass - Seen on recent CT ([**2139-8-19**],
previous hospitalization). Small, cystic, septated lesion in
the region of the uncinate process of the pancreas that was not
present on the prior study from [**2132**]. Differential diagnosis
includes intraductal papillary mucinous neoplasm or a small
cystic neoplasm. Patient instructed to have full outpatient
evaluation of mass.
.
#. PPx: Activity ad-lib, no PPI indicated or given while in ICU.
.
#. Access: PIV to be dc'ed at discharge, Tunneled HD catheter
.
#. Dispostion: Discharge to home as patient clinically well.
Medications on Admission:
1. Escitalopram 10 mg po daily
2. Amlodipine 10 mg po daily
3. Levothyroxine 75 mcg po daily
4. Zetia 10 mg po daily
5. Ferrous Sulfate 325 mg [**Hospital1 **]
6. Labetalol 100 mg PO qHS, 50mg Qam
7. Clonidine 0.1 mg Tablet PO BID
9. B Complex-Vitamin C-Folic Acid 1 mg daily
10. Cinacalcet 30 mg po daily
11. Insulin Glargine 8 units QHS, HSS with carb counting during
day
.
Allergies:
Cipro - Swelling
Vicodin - Hallucinations
Contrast Dye - Renal failure
.
Discharge Medications:
1. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Labetalol 100 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
7. Labetalol 100 mg Tablet Sig: 0.5 Tablet PO QAM (once a day
(in the morning)).
8. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Nephrocaps 1 mg Capsule Oral
11. Insulin Glargine 100 unit/mL Solution Sig: One (1) 7
Subcutaneous at bedtime.
12. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: One (1)
2 Subcutaneous q AM.
13. Carbohydrate Counting 1 U/20 g carbs, correction factor.
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic ketoacidosis, hypertensive urgency
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted to the hospital with elevated blood glucose
levels and also elevated blood pressure. You were in diabetic
ketoacidosis which resolved with an insulin drip within 24 hours
of ICU admission. Your blood pressure normalized once you were
given your home blood pressure medications. You were
transitioned back to usual subcutaneous insulin once you were
able to take nutrition by mouth.
Followup Instructions:
1. Please follow-up with Dr. [**First Name (STitle) **] for hemodialysis at [**Hospital1 **]
[**Location (un) 1121**] and resume outpatient Tuesday/Thursday/Saturday
schedule.
2. Please follow-up with your endocrinologist in several days
for continued managment of your diabetes.
3. Please follow-up with your primary care doctor regarding mass
seen in pancreas (uncinate mass) for full workup. PCP:
[**Name10 (NameIs) 30128**],[**First Name8 (NamePattern2) 30129**] [**Name12 (NameIs) **] [**Telephone/Fax (1) 30130**]
.
Also you are scheduled for the following appointment as below:
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 17785**],MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2139-9-21**] 2:05
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 2833**]
Date/Time:[**2139-9-25**] 9:00
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2139-11-9**]
8:40
|
[
"250.53",
"585.6",
"272.4",
"250.43",
"285.21",
"577.9",
"362.01",
"250.13",
"583.81",
"244.9",
"250.63",
"357.2",
"403.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
8620, 8626
|
3888, 7171
|
341, 347
|
8713, 8722
|
3310, 3865
|
9172, 10219
|
2637, 2710
|
7682, 8597
|
8647, 8692
|
7197, 7659
|
8746, 9149
|
2725, 3291
|
258, 303
|
375, 1863
|
1885, 2389
|
2405, 2621
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,745
| 104,239
|
43118
|
Discharge summary
|
report
|
Admission Date: [**2180-1-8**] Discharge Date: [**2180-1-10**]
Service: MEDICINE
Allergies:
Meclofenamate Sodium
Attending:[**Last Name (NamePattern1) 7539**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
84yo F admitted on [**2180-1-8**] for progressively worsening dyspnea x
1 week felt to be a CHF exacerbation +/- NSTEMI developed
dizziness tonight and, per tele, became bradycardic w/ complete
heart block. She then became unresponsive w/ PEA arrest. She was
intubated w/o event (ABG 7.44/44/431/31) and received
epinephrine x2, atropine x2, and bicarb x1 with establishment of
a palpable pulse. By rhythm strip, then appeared to be in sinus
tach. BP stable w/ SBP in 150s. R femoral line was placed for
central access. 12 lead EKG was obtained and revealed ST
elevations in aVR and V1-V3 with reciprocal ST depressions in V5
and V6. Repeat EKGs revealed persistence of ST elevations and
plans were made to take her to cath. Stat CXR revealed
improvement in her pleural effusions from earlier today, but
still w/ persistent hilar fullness. Labs were drawn and were
pending at time of cath.
.
For PMH, she has known CAD s/p PCI to Lcx in [**2163**] (at the time,
was found to have 2VD), CHF, HTN, DM type II, and COPD. Per her
[**Hospital Unit Name 196**] admission note by Dr. [**Last Name (STitle) 11315**], she began developing SOB 1
week ago. She would have SOB ("gasping for air") mostly with
walking [**9-17**] feet. These episodes lasted 15 min and resolved
with deep breathing. These episodes became more frequent over
the last few days. She normally sleeps with the head of her bed
elevated, but the night prior to admission she awoke gasping for
air at 1:30 am. The episode resolved on its own and she went
back to sleep. In the morning, she was again SOB when speaking
and her family called 911.
.
ROS + for angina recently (had not had it for several yrs) ->
described as bilateral shoulder discomfort ("squeezing") w/o
radiation. Associated w/ SOB, relieved w/ NTG. + LLE, unchanged.
No medication noncompliance or dietary indiscretion.
.
Per ED trip sheet/OSH records, pt was 90% on RA on arrival, 98%
on NRB. At OSH given ASA, NTP 1", lasix 80 mg IV, heparin bolus
and morphine (for anxiety). Was transferred to our ED where her
VS were
T 98, HR 63, BP 144/53, RR 18, sats of 100% NRB. On exam, she
had rales bilaterally and 2+ pitting edema. Labs were notable
for elevated BNP and trop 0.77. EKG with NSR, rate 63, ST dep 1
mm in I, avL, V5-V6, no ST segment elevation. TWI in I, avL, V4,
flat TW in V5-V6. She was admitted to the [**Hospital Unit Name 196**] service for CHF
exacerbationWas transferred up to the floor where she appeared
to do well overnight. She received 2 additional doses of IV
lasix, with net I/O of -500cc. On exam this AM, was SOB at rest
sitting 90 degrees upright in a chair.
.
Past Medical History:
1. CAD
Cath [**12/2163**]: done for postitive ETT
a. Limited angiography of the left coronary artery
demonstrated moderate disease of the LAD with stenoses of the
proximal and mid artery. The circumflex artery had a total
occlusion
after the takeoff of a large first OM. The distal circumflex and
OM2
filled by retrograde left to left collaterals.
b. Resting hemodynamics were normal.
c. Successful PTCA of the totally occluded mid-LCX
2. CHF
3. COPD - on home O2 of 3L
4. HTN
5. DM2 on insulin
6. Hypothyroidism
7. Sleep apnea on CPAP
8. bilateral TKR
9. Hearing loss with hearing aid
10. Basal and squamous cell skin cancer s/p resection
11. Mastectomy for ?benign breast tumor
Social History:
(per admit note) Lives with grandson in [**Name (NI) 15289**],
performs all ADLs, quit smoking 35 years ago (unable to quantify
how much), occ ETOH
Family History:
NC
Physical Exam:
On admission to CCU:
.
VS - T 99.8, BP 107/61, HR 90-100, RR 18, sats 100% by vent
Vent: AC FiO2 100%, Tv 500 (set), Tv 530 (actual), PEEP 5, RR 14
Gen: Sedated, intubated
HEENT: Sclera anicteric
Neck: Supple, JVP
CV: RR, NL S1, S2, no m/r/g appreciated.
Lungs: Vented BS anteriorly. No crackles/wheezes.
Abd: Soft, obese, NT/ND, + BS, no masses.
Ext: Bilateral LE 2+ edema up 1/3 of shins, +chronic venous
stasis changes
.
Pertinent Results:
Labs on admission:
[**2180-1-8**] 06:00PM BLOOD WBC-9.4 RBC-3.64* Hgb-9.6* Hct-29.2*
MCV-80* MCH-26.5* MCHC-32.9 RDW-15.7* Plt Ct-300
[**2180-1-8**] 06:00PM BLOOD Neuts-80.7* Lymphs-15.4* Monos-3.5
Eos-0.2 Baso-0.2
[**2180-1-8**] 06:00PM BLOOD PT-14.9* PTT-88.6* INR(PT)-1.3*
[**2180-1-8**] 06:00PM BLOOD Glucose-84 UreaN-44* Creat-1.4* Na-141
K-4.6 Cl-100 HCO3-31 AnGap-15
[**2180-1-8**] 06:00PM BLOOD CK(CPK)-101
[**2180-1-8**] 06:00PM BLOOD CK-MB-6 proBNP-7327*
[**2180-1-8**] 06:00PM BLOOD cTropnT-0.77*
[**2180-1-8**] 11:36PM BLOOD CK(CPK)-98
[**2180-1-8**] 11:36PM BLOOD CK-MB-NotDone
[**2180-1-8**] 11:36PM BLOOD cTropnT-0.66*
.
Labs on discharge:
[**2180-1-9**] 05:30AM BLOOD CK(CPK)-113
[**2180-1-9**] 05:30AM BLOOD CK-MB-8 cTropnT-0.57*
[**2180-1-9**] 05:30AM BLOOD calTIBC-241* Ferritn-145 TRF-185*
[**2180-1-9**] 05:30AM BLOOD TSH-1.1
[**2180-1-9**] 10:43PM BLOOD Type-ART pO2-431* pCO2-44 pH-7.44
calHCO3-31* Base XS-5
[**2180-1-8**] 06:16PM BLOOD Glucose-80 K-4.7 calHCO3-36*
[**2180-1-9**] 10:43PM BLOOD Lactate-7.3* K-4.3
[**2180-1-9**] 11:55PM BLOOD WBC-13.3* RBC-3.43* Hgb-9.2* Hct-27.3*
MCV-80* MCH-26.8* MCHC-33.7 RDW-15.9* Plt Ct-332
[**2180-1-9**] 11:55PM BLOOD Neuts-90.0* Bands-0 Lymphs-7.1* Monos-2.7
Eos-0.2 Baso-0.1
[**2180-1-9**] 11:55PM BLOOD PT-14.3* PTT-52.9* INR(PT)-1.3*
[**2180-1-9**] 11:55PM BLOOD Glucose-142* UreaN-51* Creat-1.4* Na-141
K-4.4 Cl-99 HCO3-31 AnGap-15
[**2180-1-9**] 11:55PM BLOOD ALT-22 AST-50* LD(LDH)-319* CK(CPK)-313*
AlkPhos-140* TotBili-0.3
[**2180-1-9**] 11:55PM BLOOD CK-MB-30* MB Indx-9.6* cTropnT-0.78*
.
Imaging:
CXR [**2180-1-10**]: PA and lateral views of the chest. Pulmonary edema
and bilateral pleural effusions are present, obscuring the
cardiac contours. Mediastinal contours are within normal limits.
There is no pneumothorax. Degenerative changes are noted in the
thoracic spine. IMPRESSION: Congestive heart failure with
bilateral pleural effusions.
Brief Hospital Course:
Mrs. [**Known lastname 30119**] is an 84yo F admitted on [**2180-1-8**] for progressively
worsening dyspnea x 1 week felt to be a CHF exacerbation +/-
NSTEMI developed dizziness tonight and, per tele, became
bradycardic w/ complete heart block. She then became
unresponsive w/ PEA arrest. She was intubated w/o event (ABG
7.44/44/431/31) and received epinephrine x2, atropine x2, and
bicarb x1 with establishment of a palpable pulse. By rhythm
strip, then appeared to be in sinus tach. BP stable w/ SBP in
150s. R femoral line was placed for central access. 12 lead EKG
was obtained and revealed ST elevations in aVR and V1-V3 with
reciprocal ST depressions in V5 and V6. Repeat EKGs revealed
persistence of ST elevations and plans were made to take her to
cath. Stat CXR revealed improvement in her pleural effusions
from earlier today, but still showed persistent hilar fullness.
Labs were drawn and showed elevated cardiac enzymes. Her family
was contact[**Name (NI) **] and made aware of need for urgent cardiac cath,
and with her EKG changes, the likely possibility of left main
disease with probable need for CABG. Pt is a poor surgical
candidate currently and with this in mind, and with the
knowledge of the patient's wishes, the family did not want to
proceed with cardiac catheterization. Ms. [**Known lastname 92959**] family said
that the patient did not want to intubated, so they decided to
extubate her and to continue with medical management, knowing
that she may not survive once extubated. She was given morphine
to help with her tachypnea and apparent dyspnea. Thirty minutes
after being extubated, Mrs. [**Known lastname 30119**] passed away from
respiratory failure.
Medications on Admission:
isosorbine mononitrate
naproxen 375 mg [**Hospital1 **]
levoxyl 150 mcg qd
metroprolol 125 mg [**Hospital1 **]
lasix 80 mg qd
insulin 54 u NPH/44 u NPH pm
ecotrin
quinine sulfate 260 mg qhs
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
STEMI
Cardiopulmonary arrest
Respiratory failure
Discharge Condition:
Expired
Discharge Instructions:
Not applicable
Followup Instructions:
Not applicable
|
[
"V58.67",
"496",
"244.9",
"250.00",
"410.71",
"V45.82",
"401.9",
"428.0",
"V43.65",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"99.60"
] |
icd9pcs
|
[
[
[]
]
] |
8157, 8166
|
6196, 7887
|
239, 251
|
8258, 8267
|
4250, 4255
|
8330, 8347
|
3785, 3789
|
8128, 8134
|
8187, 8237
|
7913, 8105
|
8291, 8307
|
3804, 4231
|
196, 201
|
4905, 6173
|
279, 2900
|
4269, 4886
|
2922, 3604
|
3620, 3769
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,830
| 114,740
|
9370
|
Discharge summary
|
report
|
Admission Date: [**2192-2-5**] Discharge Date: [**2192-2-9**]
Date of Birth: [**2154-5-4**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
Upper GI bleed
Major Surgical or Invasive Procedure:
EGD [**2-5**]: Large adherent blood clot was seen in the fundus, that
was expansile and enlarging slowly. Varices at the mid esophagus
Normal mucosa in the duodenum
Blood in the fundus and feeding gastric varices noted
(injection)
Otherwise normal EGD to third part of the duodenum
EGD [**2-6**]: Clotted blood in the fundus
Otherwise normal EGD to third part of the duodenum
History of Present Illness:
This is a 37 yo female from [**Country 4194**] with known hx of
schistosomias complicated by [**Country 32004**] hypertension and esophageal
varices, s/p splenectomy, 3 months post-partum who presented
with melena and hematemesis. Her last endoscopy was in [**Month (only) **]
[**2191**] revealing two cords of grade 2 varices and two cords of
grade 1 varices in the distal esophagus. She is currently on
Labetalol 100 mg b.i.d and on omeprazole 40mg [**Hospital1 **]. During her
last GI visit in early [**2192-1-7**], she was noted to have
epigastric pain [**4-15**] which was worse at night while laying down.
Her Omeprazole was then increased to [**Hospital1 **]. She was also found to
have significant iron deficiency and her iron supplemmentation
was increased to 3 x a day. She states that she started to feel
nauseous the day PTA in the afternoon and was feeling dizzy when
she stood up. She woke up at around 3 AM and had a dark black
stool. She then felt nauseas, lightheaded, feeling as she would
faint.
.
In the ED, her vitals were: HR 105, SBP 110s. She had one
episode of large amount of hematemesis, Guaiac +. NG tube was
placed and now draining coffee ground fluid/dark blood. She was
started on PPI and octreotide. Given 1 L of IV fluids, typed and
crossed for 2 units. Her Hct was 27. GI was notified.
.
On the floor, she was comfortable and denied having any c/o at
this time. Her NG tube is draining dark red fluid with clots.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies constipation or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
OBHx:one prior missed abortion requiring a D&C and a therapeutic
abortion.
GynHx: one prior missed abortion
requiring a D&C and a therapeutic abortion.
PMHx:
- schistosomiasis-induced [**Hospital1 32004**] hypertension complicated by
recurrent upper GI bleeds from esophageal varices. In [**2189**], she
underwent vessel banding. She has also had a splenectomy in
[**Country 4194**] in [**2178**]. Her last upper GI bleed was possibly in
[**2190-9-7**], although there was no evidence of bleed on endoscopy. At
that time she received 2 units of blood. At her most recent
type
and screen, she was found to have Anti-C and Anti-S antibody.
Her
most recent endoscopy on [**2191-1-25**] revealed grade [**1-8**]
varices. She was taking Propranolol 20 mg twice a day prior to
pregancy but in light of the pregnancy Propranolol was changed
to
Labetolol. She had a liver biopsy in [**2188-6-6**] that showed no
significant [**Year (4 digits) 32004**] inflammation and rare mild lobular
inflammation. There was no definite cirrhosis seen but there was
focal bridging and fibrosis noted.
PSHx: Splenectomy, D&C
Social History:
Patient moved to the United States from [**Country 4194**] approximately six
years ago. She lives in [**Location 583**] with her sister. She works as
a house cleaner. She reports no alcohol or tobacco use or
illicit drug use.
Family History:
She has one uncle who is status post splenectomy for unclear
reasons.
Physical Exam:
Admission Physical Exam
Vitals: T: 98.5, HR 107, BP 98/72, RR 19, O2 sat 98% on RA
General: Alert, oriented, pale female in 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: tachy, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, mildly distended and tender at epigastric area, +
hyperactive BS, no rebound tenderness or guarding, no
organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Chest X-Ray [**2-5**]: Pulmonary vasculature is mildly engorged but
there is no edema. Heart size is normal. No pleural effusion. ET
tube ends at the upper margin of the clavicles, no less than 43
mm from the carina. Nasogastric tube ends in a mildly distended
stomach. No pneumothorax.
RUQ U/S Doppler [**2-6**]:
1. Heterogenous hepatic echotexture without focal mass.
2. Patent hepatic vasculature with normal directional flow.
[**2192-2-5**] 08:23PM HCT-30.4*
[**2192-2-5**] 04:00AM PT-13.0 PTT-22.7 INR(PT)-1.1
[**2192-2-5**] 04:00AM PLT COUNT-168
[**2192-2-5**] 04:00AM NEUTS-71.9* LYMPHS-23.8 MONOS-3.3 EOS-0.3
BASOS-0.5
[**2192-2-5**] 04:00AM WBC-8.7# RBC-3.19* HGB-9.0* HCT-27.5* MCV-86
MCH-28.1 MCHC-32.6 RDW-15.2
[**2192-2-5**] 04:00AM ALBUMIN-3.9
[**2192-2-5**] 04:00AM ALT(SGPT)-22 AST(SGOT)-24 ALK PHOS-68 TOT
BILI-0.1
[**2192-2-5**] 04:00AM estGFR-Using this
[**2192-2-5**] 04:00AM GLUCOSE-121* UREA N-35* CREAT-0.7 SODIUM-137
POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-22 ANION GAP-13
[**2192-2-5**] 04:21AM HGB-9.2* calcHCT-28
[**2192-2-5**] 05:08AM URINE RBC-[**3-10**]* WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0-2
[**2192-2-5**] 05:08AM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR
[**2192-2-5**] 05:08AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.026
[**2192-2-5**] 05:08AM URINE UCG-NEGATIVE
[**2192-2-5**] 05:08AM URINE HOURS-RANDOM
[**2192-2-5**] 05:08AM URINE HOURS-RANDOM
[**2192-2-5**] 06:45AM HCT-23.8*
[**2192-2-5**] 10:16AM HCT-26.6*
[**2192-2-5**] 03:47PM FIBRINOGE-167#
[**2192-2-5**] 03:47PM FIBRINOGE-167#
[**2192-2-5**] 03:47PM FDP-0-10
[**2192-2-5**] 03:47PM PLT COUNT-122*
[**2192-2-5**] 03:47PM PLT COUNT-122*
[**2192-2-5**] 03:47PM HCT-32.4*
[**2192-2-5**] 03:47PM HCT-32.4*
[**2192-2-5**] 05:21PM freeCa-1.03*
[**2192-2-5**] 05:21PM freeCa-1.03*
[**2192-2-5**] 05:21PM TYPE-[**Last Name (un) **] PH-7.31* COMMENTS-GREEN TOP
Brief Hospital Course:
37 yo female with hx of schistosomis complicated by [**Last Name (un) 32004**]
hytertension with esophageal varices who presents with
hematemesis and melena.
.
# UPPER GI BLEED: Pt with hx of esophageal varices grade 2 with
prior hx of variceal bleed. This is secondary to schistosomiasis
leading [**Last Name (un) 32004**] hypertension. She was receiving labetalol 100mg
[**Hospital1 **] and omeprazole 40mg [**Hospital1 **]. She was switched from propanolol to
labetolol due to her recent pregnancy. Her HCT at admission was
27 with her last Hct in [**Month (only) **] of 36(her baseline Hct has ranged
from mid 20s to mid 30s in the last few months). Her Hct
decreased from 27->23.8 within 3 hours. She was noted to have
dark blood in NG tube and had blood clots with her NG lavage.
She received 4 units of PRBC's and was for intubated for EGD.
EGD showed a large adherent blood clot in the fundus, that was
expansile and enlarging slowly. She was extubated the following
day after second EGD which revealed a clot in the fundus but no
active bleed. She was placed on an Octreotite drip for 72 hours
and continued on Ceftriaxone 1gm IV Q 24 for ppx for 5 days. Her
Hematoctit was stable in the unit and transferred to the floor.
On the floor, her Hct remained stable with no further episodes
of hemetemesis. She was continued on PO PPI which will be
continued as an outpatient. She will need f/u endoscopy as an
outpatient.
.
# Schistosomiasis: treated in [**2178**], leading to liver fibrosis
and [**Year (4 digits) 32004**] hypertension. S/p splenectomy [**2178**]. As per records,
she had pneumovax [**2181**]. She does not have cirrhosis as per liver
bx in [**2188**] and is not at increase risk for HCC. She is followed
by Dr. [**Last Name (STitle) 497**]
.
# Anemia: Hx of [**Doctor First Name **] with last iron level at 14, currently on
iron 325mg TID. This is likely due to recent pregnancy, and
possible GI bleed. For now transfuse for acute bleed as noted
above and continue iron once tolerating PO. No colonoscopy in
our system. She will follow with GI as outpatient.
.
# Communication:
Sister, [**Name (NI) 32010**] [**Name (NI) **] (HCP) [**Telephone/Fax (1) 32011**]
Husband, [**Name (NI) 32012**] [**Name (NI) **], [**Telephone/Fax (1) 32013**]
.
# Code: Full (discussed with patient)
Medications on Admission:
-Labetalol 100 mg twice a day
-omeprazole 40 mg [**Hospital1 **]
-ferrous sulfate 325, one 3 x a day
Discharge Medications:
1. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
2. propranolol 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
3. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO three times a day.
Discharge Disposition:
Home
Discharge Diagnosis:
melena, hematemesis
esophageal varices
Schistosomiasis - dx [**2178**], s/p splenectomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to [**Hospital1 69**] for
blood in your stools and vomit. You were treated with
medications and you underwent a procedure called endoscopy to
visualize your GI tract. Your symptoms are likely secondary to
schistosomiasis infection. You will need a follow-up endoscopy
in 1 week.
The following changes were made to your medications:
STOP Labetalol 100 mg twice a day
START Propranolol 20 mg twice a day
Followup Instructions:
The following appointments have been made for you:
EGD with Dr. [**Last Name (STitle) 497**] next Tuesday [**2-14**] -
Please arrive at 7:30am in preparation for the procedure at
8:30am.
You need to go to the [**Hospital Ward Name 1950**] Building [**Location (un) **] ([**Street Address(2) 32014**]).
Department: [**Hospital3 249**]
When: FRIDAY [**2192-2-17**] at 11:10 AM
With: Dr. [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 1520**]
Location: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Address: [**Location (un) 830**] [**Location (un) 86**], [**Numeric Identifier 718**] SC [**Hospital Ward Name 23**]
Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
This appointment is with a hospital-based doctor as part of your
transition from the hospital back to your primary care provider.
[**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor
in follow up.
Department: DIGESTIVE DISEASE CENTER
When: TUESDAY [**2192-3-20**] at 8:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**]
Campus: EAST Best Parking: Main Garage
|
[
"456.1",
"139.8",
"456.21",
"280.0",
"572.3",
"578.0",
"578.1",
"571.8",
"456.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"45.13",
"43.41",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
9450, 9456
|
6659, 8969
|
315, 693
|
9588, 9588
|
4654, 6636
|
10186, 11594
|
3985, 4057
|
9121, 9427
|
9477, 9567
|
8995, 9098
|
9738, 10163
|
4072, 4635
|
2189, 2592
|
261, 277
|
721, 2170
|
9603, 9714
|
2614, 3722
|
3738, 3969
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,364
| 110,563
|
45342
|
Discharge summary
|
report
|
Admission Date: [**2187-1-31**] Discharge Date: [**2187-2-1**]
Date of Birth: [**2115-5-20**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
difficulty extubating after PVI
Major Surgical or Invasive Procedure:
Pulmonary vein isolation
Intubation
Extubation
Placement and removal of arterial line
History of Present Illness:
(Patient intubated, history from OMR and wife): 71 yo M with
atrial fibrillation, s/p PVI and flutter ablation on [**2186-11-21**],
s/p redo PVI today, now in sinus rhythm but still intubated.
.
Patient has a long history of atrial fibrillation (see below).
He came in today for a scheduled redo-PVI, after which he was
initially extubated. He complained of shortness of breath and
had poor mental status due to sedation. ABG at the time on CPAP
was 7.18/69/79 but then improved to 7.34/38/182 after
re-intubation. He received 2x 10 mg IV lasix. CXR at the time
was suggestive vascular congestion. He was thus transferred to
the CCU for weaning of sedation and ventillation.
.
In terms of patient's cardiac history, he has had hypertension
for the past 20 years. He developed atrial fibrillation 10 years
ago, which initially paroxysmal, but progressed to continous
since [**4-29**]. He was evaluated in [**8-29**] by Dr. [**Last Name (STitle) **] and started
on amiodarone
.
He had a PVI here on [**2186-11-21**], with isolationof all 4 pulmonary
veins with extensive lines in the left atrium, mitral isthmus,
coronary sinus, and also the right atrial isthmus. He organized
into slow regular atrial tachycardia and then was cardioverted
into sinus rhythm. At follow-up on [**2186-12-25**], his EKG showed
narrow-complex tachycardia at 128 bmp. Subsequently, he
underwent several cardioversions at [**Hospital3 **] but
reverted to A fib. His Amiodarone was cut down to 200mg qd in
[**Month (only) 1096**] and admitted to redo PVI.
.
ROS: Per wife, increased SOB and fatigue. No palpitations,
syncope, or orthopnea. Has had an URI over the past week with
cough and scant yellow phlegm but no fever. ROS otherweise
negative.
Past Medical History:
Hypertension
Afib s/p PVI [**11-29**] and prior cardioversions
Anxiety
? Hepatitis with mononucleosis as a teen
Ulcers/gastritis/PUD on Vioxx
s/p EGD with cautery of ulcer
shoulder surgery bilaterally
Right Knee surgery
BPH (patient had mild hematuria for several days after foley
insertion for PVI)
(-) TIA (-) CVA (+) GIB (-) sleep apnea (not diagnosed
but pt suspects he has)
Social History:
Retired, lives with wife and has 3 grown children. Never smoked
or used recreational drugs. Drinks wine occasionally.
Family History:
No family history of CAD, MIs, sudden death
Physical Exam:
ON ADMISSION:
GENERAL: Intubated, sedated, in no distress
HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
NECK: JVP difficult to assess
CARDIAC: Regular rhythm, rate 80, normal S1/S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: ET tube in place. On A/C support. Unlabored, no accessory
muscle use. No obvious wheezes. Scattered crackles.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 2+ edema up to mid-calf bilaterally.
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+
.
ON DISCHARGE:
GENERAL: extubated, speaking in full sentences, NAD
HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
NECK: JVP difficult to assess
CARDIAC: Regular rhythm, rate 80, normal S1/S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: ET tube in place. On A/C support. Unlabored, no accessory
muscle use. No obvious wheezes. Scattered crackles.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 2+ edema up to mid-calf bilaterally.
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:
ADMISSION LABS:
[**2187-1-31**] 07:05AM BLOOD WBC-5.4 RBC-5.19 Hgb-16.8 Hct-46.5 MCV-90
MCH-32.4* MCHC-36.1* RDW-14.5 Plt Ct-149*
[**2187-1-31**] 07:05AM BLOOD PT-24.0* INR(PT)-2.3*
[**2187-1-31**] 07:05AM BLOOD Glucose-135* UreaN-12 Creat-0.9 Na-134
K-3.8 Cl-98 HCO3-26 AnGap-14
[**2187-1-31**] 07:07PM BLOOD Calcium-8.1* Phos-3.8 Mg-1.6
[**2187-1-31**] 07:07PM BLOOD Triglyc-113
[**2187-1-31**] 03:21PM BLOOD Type-ART Rates-12/ Tidal V-550 PEEP-5
pO2-122* pCO2-43 pH-7.32* calTCO2-23 Base XS--3 -ASSIST/CON
Intubat-INTUBATED
[**2187-1-31**] 03:21PM BLOOD freeCa-1.02*
[**2187-1-31**] 05:05PM BLOOD Hgb-14.0 calcHCT-42
.
DISCHARGE LABS:
[**2187-2-1**] 04:00AM BLOOD WBC-10.7 RBC-4.29* Hgb-13.9* Hct-39.9*
MCV-93 MCH-32.3* MCHC-34.7 RDW-14.7 Plt Ct-193
[**2187-2-1**] 04:00AM BLOOD PT-29.5* PTT-32.7 INR(PT)-2.9*
[**2187-2-1**] 04:00AM BLOOD Glucose-181* UreaN-17 Creat-1.1 Na-133
K-4.8 Cl-100 HCO3-23 AnGap-15
[**2187-2-1**] 04:00AM BLOOD Calcium-8.4 Phos-4.4 Mg-1.8
ABG [**2-1**]: 7.42/37/136
.
STUDIES:
TEE [**1-31**]:
LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo
contrast or thrombus in the LA/LAA or the RA/RAA. Good (>20
cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Overall normal LVEF (>55%).
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No
masses or vegetations on aortic valve.
MITRAL VALVE: Normal mitral valve leaflets. No mass or
vegetation on mitral valve. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PERICARDIUM: Trivial/physiologic 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 monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**]
throughout the procedure. The patient was monitored by a nurse
in [**Last Name (Titles) 9833**] throughout the procedure. The patient was under
general anesthesia throughout the procedure. No glycopyrrolate
was administered. No TEE related complications. Results were
reviewed with the Cardiology Fellow involved with the patient's
care.
Conclusions
The left atrium is moderately dilated. No spontaneous echo
contrast or thrombus is seen in the body of the left atrium/left
atrial appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Overall left ventricular systolic function is normal
(LVEF>55%). 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 leaflets are structurally normal. No mass or
vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. Trivial/physiologic pericardial effusion.
IMPRESSION: No intracardiac thrombus. Preserved left ventricular
function. No significant valvular regurgitation.
.
CXR [**1-31**]:
Overlying defibrillator pads limit this evaluation and there are
low lung
volumes. Endotracheal tube is appropriately positioned. There is
vascular
crowding likely secondary to the low lung volumes, although an
element of
vascular congestion cannot be entirely excluded. A retrocardiac
opacity may represent atelectasis.
.
CXR [**2-1**]:
FINDINGS: A previously placed nasogastric tube has been removed
in the
interval. Moderate cardiomegaly without evidence of pulmonary
edema. No
pleural effusions. No focal parenchymal opacity suggesting
pneumonia.
Moderate tortuosity of the thoracic aorta.
Brief Hospital Course:
71 yo M with atrial fibrillation, s/p PVI and flutter ablation
[**11-29**] and subsequent conversion, s/p PVI redo on [**1-31**]
complicated by respiratory failure.
.
# Atrial fibrillation: Pt underwent PVI on [**1-31**]. This is the
second PVI the patient has had here. He is also s/p multiple
cardioversions, as well as failed trials of Norpace and
Dronedarone in the past, and currently on amiodarone. TEE was
done pre-procedurally showing no thrombus. Following the PVI,
he remained in sinus rhythm with HR in the 70-90s overnight, and
MAPs>60 (breifly requiring neo). He was continued on amiodarone
200mg daily, as well as his home coumadin regimen (remained
therapeutic overnight), and was discharged on his home regimen.
He was also discharged on a prophylactic antibiotic regimen of
keflex 500mg QID x5 days post-procedurally.
.
# Respiratory distress: Patient developed shortness of breath
after extubation in the EP lab and had one ABG which showed
hypoxemia. He was re-intubated as a result and restarted on
phenylephrine for pressure support. On transfer to CCU he was on
A/C, PEEP of 5, and FiO2 of 100%, on propofol gtt. Likely
etiology included large body habitus, sedation for procedure,
and also an underlying URI that started about a week ago. CXR
from the EP lab was of poor quality but did show signs of fluid
overload which resolved on subsequent X-ray after 40mg IV lasix.
His respiratory status and oxygenation improved markedly and he
was extuabated early in the morning following his procedure
without complication.
.
# Anxiety: Patient has anxiety at baseline and this might have
played a role in the difficult extubation. As he is was weaned
off sedation, he was controlled with prn ativan without
complication.
.
# GERD/gastritis: Continued on home regimen of omeprazole 20 mg
po daily.
.
# Hypertension: Not currently on any antihypertensives. He was
weaned off neo, and his BPs remained stable.
.
# Gout: Renal function was intact with Cr of 0.9 the morning of
discharge. He was continued on home regimen of colchicine and
allopurinol.
.
# BPH: Continued home regimen of tamsulosin 0.4 mg daily. Of
note, pt with difficulty voiding on day of discharge likely
secondary to not receiving his tamsulosin the night before. He
did receive it the morning of discharge and subsequently voided
later in the afternoon.
.
# CAD prevention: Patient does not have documented CAD, though
he is on primary prevention with Aspirin and atorvastatin, which
was continued.
Medications on Admission:
ALLOPURINOL 300 mg daily
AMIODARONE 200 mg daily
ATORVASTATIN 10 mg daily
COLCHICINE 0.6 mg Tablet - 2 tabs daily
OMEPRAZOLE 20 mg daily
TAMSULOSIN [FLOMAX] 0.4 mg daily
WARFARIN 7mg M/W/F, 6mg all other days
ASPIRIN 81 mg daily
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
3. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. colchicine 0.6 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
7. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
8. warfarin 5 mg Tablet Sig: One (1) Tablet PO (MON, WED, FRI):
Please take one 5 mg tablet and one 2 mg tablet for a total of 7
mg on Mondays/Wednesdays/
Fridays. .
Disp:*12 Tablet(s)* Refills:*2*
9. warfarin 2 mg Tablet Sig: One (1) Tablet PO (MON, WED, FRI):
Please take one 5 mg tablet and one 2 mg tablet for a total of 7
mg on Mondays/Wednesdays/ Fridays.
Disp:*12 Tablet(s)* Refills:*2*
10. warfarin 6 mg Tablet Sig: One (1) Tablet PO
(SUN,SAT,[**Last Name (LF) **],[**First Name3 (LF) **]).
Disp:*16 Tablet(s)* Refills:*2*
11. Keflex 500 mg Capsule Sig: One (1) Capsule PO every six (6)
hours for 5 days: Please take from [**2187-2-1**] through [**2187-2-5**] for a
total of 5 days. .
Disp:*20 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Atrial fibrillation
Gout
Anxiety
Benign prostatic hyperplasia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 6608**], you were admitted to the Cardiac ICU at the [**Hospital1 1535**] because after the procedure to
help stop your atrail fibrillation, you had difficulty coming
out of sedation and breathing on your own. We were able to take
you off of the breathing machine by the morning. Your heart
rhythm was regular after the proceudre, and your blood pressure
stable.
.
We did not make any changes to you medications. However, you
should take keflex (antibiotic) as directed below
.
You should follow-up with your cardiologist Dr. [**Last Name (STitle) **] at the
time listed below.
Followup Instructions:
Department: CARDIOLOGY, DR [**Last Name (STitle) **]
When: THURSDAY [**2187-3-8**] at 4:40 PM
|
[
"600.00",
"535.50",
"518.81",
"300.00",
"427.31",
"V12.71",
"274.9",
"530.81",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.27",
"96.04",
"37.34",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
12098, 12104
|
7760, 10254
|
335, 423
|
12210, 12210
|
4157, 4157
|
12987, 13084
|
2740, 2785
|
10534, 12075
|
12125, 12189
|
10280, 10511
|
12361, 12964
|
4795, 7737
|
2800, 2800
|
3479, 4138
|
264, 297
|
451, 2177
|
4173, 4779
|
2814, 3465
|
12225, 12337
|
2199, 2589
|
2605, 2724
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,898
| 102,786
|
36473
|
Discharge summary
|
report
|
Admission Date: [**2169-4-18**] Discharge Date: [**2169-4-20**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Dyspnea, AAA
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known lastname 15674**] is an 85 year old male with hypothyroidism, COPD,
former smoker, who presents with chest/abdominal pain and
dyspnea. He was in his usual state of health until 2 days ago
when he developed mild dyspnea, worse on exertion. He also
complained of mild cough at that time. This was accompanied by
intermittent chest and back pain of unknown duration, with assoc
nausea, but no radiation of the pain, HA, or true abd pain. He
denies any fever/[**Last Name (LF) **], [**First Name3 (LF) **], leg pain, swelling orthopnea. He
endorses normal Bms, urination, and appetite. He otherwise
denies dizziness, focal numbness or weakness. At [**Hospital1 **] [**Location (un) 620**]
patient he was mildly hypertensive and diaphoretic, and had an
EKG which was unremarkable for ischemia. He underwent CT Abd
which demonstrated a 4.2-4.5 cm infrarenal AAA with thrombus.
No evidence of dissection or bleed. Lungs with emphysematous
changes, no evidence of infection, PE, or edema. He was
transferred here for further evaluation.
In the ED, T97.6, BP 121/76, HR 79, RR 17, 99%RA. The patient
was maintained on nitro gtt with BP mostly in the 150s-160s
systolic range. The patient was given ASA 81mg, Lopressor 50mg
PO x1, zofran x2, as well as nebulizers with good effect.
Cardiac enzymes were negative.
ROS: As per above, otherwise negative
Past Medical History:
COPD
Hypothyroidism
h/o colon CA s/p colectomy (unsure which side)
Prostatectomy
Hemmorhoid surgery
s/p cataract surgery
Social History:
Former smoker 1ppd x35yrs. Quit 10yrs ago. Seldom EtOH. No
recreational drug use. Works part time at Stop & Shop
Family History:
Non-contributory
Physical Exam:
VS: T 97.2, HR 61, BP 163/92, RR 12, 98% 2L
Gen: lying in bed, comfortable, NAD
HEENT: EOMI, anicteric sclera, MM dry, OP clear, right-sided
ptosis
Neck: supple, no carotid bruits
Heart: distant heart sounds, no m/r/g
Lungs: Decreased breath sounds throughout with poor air
movement. Diffuse expiratory wheeze
Abd: obese with midline surgical scar. + BS no rebound or
guarding. No bruits appreciated
Ext: warm well perfused
Skin: no rash
Neuro: CN II-XII intact
Pertinent Results:
Admission Labs:
[**2169-4-18**] 10:48AM BLOOD WBC-17.2* RBC-4.17* Hgb-12.6* Hct-37.8*
MCV-91 MCH-30.1 MCHC-33.2 RDW-14.0 Plt Ct-307
[**2169-4-18**] 10:48AM BLOOD Neuts-90.3* Lymphs-5.1* Monos-3.3 Eos-1.0
Baso-0.2
[**2169-4-18**] 10:48AM BLOOD PT-13.8* PTT-26.9 INR(PT)-1.2*
[**2169-4-18**] 10:48AM BLOOD Glucose-132* UreaN-17 Creat-1.2 Na-142
K-4.1 Cl-107 HCO3-27
[**2169-4-18**] 10:48AM BLOOD ALT-15 AST-19 CK(CPK)-121 AlkPhos-73
TotBili-0.4
[**2169-4-18**] 10:48AM BLOOD Lipase-32
[**2169-4-18**] 10:48AM BLOOD CK-MB-5
[**2169-4-18**] 10:48AM BLOOD cTropnT-<0.01
[**2169-4-18**] 10:48AM BLOOD Albumin-3.9 Calcium-8.4 Phos-2.4* Mg-2.1
[**2169-4-18**] 11:12AM BLOOD Glucose-129* Lactate-2.0 Na-144 K-4.4
Cl-103 calHCO3-28
[**2169-4-19**] 03:53AM BLOOD Triglyc-113 HDL-32 CHOL/HD-4.7 LDLcalc-96
[**2169-4-18**] 12:05PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.015
[**2169-4-18**] 12:05PM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2169-4-18**] 12:05PM URINE RBC-[**6-14**]* WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0
Studies:
[**2169-4-18**] ECG - Baseline artifact. Sinus rhythm. Premature atrial
contraction. No previous tracing available for comparison.
[**2169-4-18**] ECG - Sinus rhythm. Compared to tracing #1 the premature
atrial contraction and artifact are both absent.
[**2169-4-18**] Portable CXR - FINDINGS: No definite focal consolidation
is noted. There is diffuse fine reticular interstitial pattern
of unknown chronicity. This, however, is not consistent with an
edema-like picture. There is marked tortuosity of the thoracic
aorta. The cardiac silhouette is otherwise normal in size. There
is discoid atelectasis in both lung bases, particularly the
right. No definite effusion or pneumothorax is noted. The
visualized osseous structures are unremarkable.
IMPRESSION: No definite acute pulmonary process.
Brief Hospital Course:
Mr. [**Known lastname 15674**] is a 85 year old male with COPD, hypothyroidism, and
a former smoker, who presented with dyspnea and chest/back pain,
and found to have an infrarenal AAA with thrombus.
# Dyspnea/Chest Pain/COPD: The patient's symptoms were
associated with exertion. He has a history of COPD and his exam
was notable for poor air flow and wheezing. EKG and enzymes were
unremarkable for cardiac ischemia. Chest x-ray was without
evidence of infection or edema. CT at [**Hospital1 **] [**Location (un) 620**] showed
emphysema and no obvious PE. Ultimately, it was felt that his
symptoms were related to a mild COPD exacerbation and he was
started on albuterol and ipratropium nebs as well as advair.
Given his hemodynamic stability, he was transfered from the MICU
to the medical floor. There he was started on a short steroid
burst with azithromycin as he was noted to desat to 85% on room
air with walking. The patient's PCP's office was called an no
records of his baseline oxygen sats could be obtained. The
following day, the patient's wheezing was still present, though
improved, and his oxygen level only dropped to 93% with
ambulation. He was discharge with instructions to complete a
short course of steroids and azithromycin to prevent return of
his symptoms. He was instructed to continue to use advair and
albuterol inhaler as needed. Home VNA was arranged to check on
the patient and to ensure that he was using his inhalers
properly as he had difficulty with them initially in the
hospital.
# Infrarenal abdominal aortic aneurysm: The patient remained
clinically asymptomatic and without any signs of rupture.
Vascular surgery was consulted and recommended blood pressure
control to SBP < 140 (the patient was hypertensive and requiring
a nitro drip initially on arrival), aspirin, and statin. As the
patient's LDL was less than 100, statin therapy was deferred for
consideration as an outpatient. Follow-up with Dr. [**Last Name (STitle) **]
was scheduled for 6 months following discharge.
# Hypertension: The patient was transitioned from a nitro gtt to
lisinopril. His SBP remained predominantly in the 120s-130s.
He was instructed regarding the importance of taking this
medication, checking his blood pressure, and that the dose may
need to be titrated up by his PCP.
# Hypothyroidism: The patient was continued on his home
levothyroxine dose.
Medications on Admission:
Levothyroxine 75mcg daily
Proair hfa inhaler 2 puffs prn
Discharge Medications:
1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Albuterol 90 mcg/Actuation Aerosol Sig: [**1-6**] Inhalation every
four (4) hours as needed for shortness of breath or wheezing.
4. 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*
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
6. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
7. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary Diagnoses:
1. Chronic obstructive pulmonary disease exacerbation
2. Abdominal aortic aneurysm
Discharge Condition:
Vital signs stable. Afebrile. Ambulatory O2 sat 93% on room
air.
Discharge Instructions:
You were admitted to the hospital for evaluation of shortness of
breath, chest pain, and back pain. You likely had a COPD
exacerbation and are being treated with a short course of
steroids, antibiotics, and inhalers. It is important that you
take these medications as prescribed to prevent recurrence of
symptoms.
You were also found to have an enlarged aorta. You blood
pressure was also mildly elevated and you were started on a new
medication, Lisinopril, to decrease your blood pressure and help
prevent further enlargement of your aorta. You should also take
a baby aspirin. It is important that you follow-up with your
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3142**], regarding this.
The following changes have been made to your medications.
1. Start taking Lisinopril 5 mg daily for your blood pressure.
2. Start taking Aspirin 81 mg daily for your heart and blood
vessels.
3. Use the advair diskus inhaler twice a day for your lungs; you
may continue to use your Proair (albuterol) inhaler as needed
for shortness of breath.
4. Take prednisone 40 mg daily through [**4-23**] for your lungs.
5. Take azithromycin 250 mg daily through [**4-23**] for your lungs.
Please call Dr. [**Last Name (STitle) 3142**] or return to the hospital if you have
worsening shortness of breath, fevers, worsening back or chest
pain, or other concerning symptoms.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 3142**] within the next two weeks.
His office phone number is [**Telephone/Fax (1) 19980**].
You have a follow-up appointment with the Vascular Surgeon Dr.
[**Last Name (STitle) **] regarding your aortic aneurysm on [**2169-10-19**] at 10:00
am. His office phone number is [**Telephone/Fax (1) 1237**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
|
[
"244.9",
"491.21",
"441.4",
"401.1",
"V10.05"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7766, 7815
|
4415, 6810
|
274, 282
|
7961, 8030
|
2491, 2491
|
9476, 9959
|
1973, 1991
|
6918, 7743
|
7836, 7940
|
6836, 6895
|
8054, 9453
|
2006, 2472
|
222, 236
|
310, 1679
|
2507, 4392
|
1701, 1823
|
1839, 1957
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,015
| 157,324
|
48782
|
Discharge summary
|
report
|
Admission Date: [**2154-3-24**] Discharge Date: [**2154-3-26**]
Date of Birth: [**2079-1-1**] Sex: F
Service: MEDICINE
Allergies:
Latex / Amoxicillin / Percocet / Propoxyphene
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Pt. pulled out PICC line at NH
Major Surgical or Invasive Procedure:
None
History of Present Illness:
75 y/o female with COPD, OSA, T2DM, HTN, CHF EF 40%, frequent
UTIs, CAD, and CKD who presents with altered mental status in
the setting of receiving Ativan in the ED. Patient was recently
admitted to the [**Hospital Unit Name 153**] for respiratory failure in the setting of a
pneumonia/COPD flare, as well as an ESBL UTI, and was discharged
yesterday to rehab to complete a course of
piperacillin-tazobactam. In the interim, she self-discontinued
her PICC line and was brought back to the ED to have it
replaced. She had a chest CT performed in the ED, prior to which
she received 1 mg of Ativan at 9 am in the morning. It appears
that patient refused the CT scan despite much convincing and
started pulling off her leads, and was subsequently given 1 mg
Ativan prior to the CT scan. She was then noted by RN notes to
be "sleeping" until her admission 3 hours later to 11R, where
she was noted to be obtunded. She was given two doses of
flumazenil, to which she had response for approximately 15
seconds before falling asleep again. She was also noted to be
hypoglycemic to 53 as well as hypothermic to 90.3 orally.
Past Medical History:
COPD
T2DM on insulin
HTN
CHF (EF 40%)
CAD
CKD (baseline creatinine 1.8-2.1)
OSA
OA
Depression
Gout
Hyperlipidemia
GERD
[**2154-1-5**]: I&D/VAC L leg, Ex Fix LLE, splint R leg
[**2154-1-8**]: I&D, closure, ex-fix adjustment LLE; ORIF R distal
tibia
Difficult to wean vent after above recent surgeries
Social History:
Lives in nursing home. Denies smoking or alcohol. No illicit
drug use. Patient is Spanish speaking only, from [**Name (NI) 5976**], husband
passed away after their move to the United States.
Family History:
Non-contributory.
Physical Exam:
Vitals: T90.3 (orally)HR 62 BP 198/98 RR 18 O2 sat 98% room air
General: Chronically ill appearing obese female. Opens eyes to
sternal rub. Does not open eyes to voice.
Neck: Thick. Unable to assess JVD.
CV: RRR. Distant heart sounds.
Pulm: Clear to ascultation anteriorly.
Abd: Obese. Soft, nontender. Normoactive bowel sounds.
Ext: WWP. Left tibia externally fixated. 2+pulses.
Skin: +Candidal intertrigo.
Neuro: PERRL. Grimaces to sternal rub. Toes downgoing
bilaterally. Reflexes symmetric bilaterally.
Pertinent Results:
[**2154-3-24**] 02:00AM PT-13.3 PTT-29.4 INR(PT)-1.1
[**2154-3-24**] 02:00AM PLT COUNT-88*
[**2154-3-24**] 02:00AM NEUTS-87.9* LYMPHS-8.8* MONOS-2.7 EOS-0.2
BASOS-0.4
[**2154-3-24**] 02:00AM WBC-5.1 RBC-3.46* HGB-10.7* HCT-31.2* MCV-90
MCH-31.0 MCHC-34.3 RDW-15.7*
[**2154-3-24**] 02:00AM TSH-0.57
[**2154-3-24**] 02:00AM GLUCOSE-139* UREA N-75* CREAT-2.1*
SODIUM-146* POTASSIUM-4.6 CHLORIDE-120* TOTAL CO2-16* ANION
GAP-15
[**2154-3-24**] 03:15PM LACTATE-0.8
[**2154-3-24**] 03:15PM TYPE-ART PO2-85 PCO2-35 PH-7.34* TOTAL
CO2-20* BASE XS--5
[**2154-3-24**] 06:45PM freeCa-1.38*
[**2154-3-24**] 06:45PM GLUCOSE-95 LACTATE-1.0 NA+-146 K+-4.2
CL--120* TCO2-18*
[**2154-3-24**] 06:45PM TYPE-ART TEMP-33.8 RATES-/18 O2-100 PO2-317*
PCO2-26* PH-7.44 TOTAL CO2-18* BASE XS--4 AADO2-363 REQ O2-66
INTUBATED-NOT INTUBA
[**2154-3-24**] 08:44PM ETHANOL-NEG bnzodzpn-NEG barbitrt-NEG
tricyclic-NEG
[**2154-3-24**] 08:44PM CALCIUM-10.0 PHOSPHATE-4.0 MAGNESIUM-2.2
[**2154-3-24**] 08:44PM CK-MB-6 cTropnT-0.03*
[**2154-3-24**] 08:44PM ALT(SGPT)-22 AST(SGOT)-27 CK(CPK)-84 ALK
PHOS-43 TOT BILI-0.4
[**2154-3-24**] 08:44PM GLUCOSE-75 UREA N-70* CREAT-1.9* SODIUM-148*
POTASSIUM-4.4 CHLORIDE-119* TOTAL CO2-20* ANION GAP-13
[**2154-3-24**] 10:00PM URINE HOURS-RANDOM SODIUM-82 POTASSIUM-23
CHLORIDE-78
Brief Hospital Course:
# Altered mental status: likely due to sedation in ED. Reversed
transiently with flumazenil. Observed in ICU for one night, pt.
became more alert and to baseline over a period of approximately
12 hours.
.
#. Hypothermia. Resolved with resolution of sedation
.
#. UTI. Patient with ESBL Klebsiella UTI. Had originally been on
Zosyn; changed to meropenem for planned 14 day course. Pt. has
documented pcn allergy, however, had no reaction evident to
zosyn, and none seen to meropenem. PCP aware, and will monitor
at NH.
.
#. COPD. Stable. Continued nebs, advair, tiotroprium, and
prednisone taper as originally written from prior admission.
.
#. CHF - chronic, systolic. Patient with evidence of regional
hypokinesis c/w CAD at prior echo, with EF 40%. Restarted ACE
inhibitor, euvolemic. Cont. nitrate, BB, ASA.
.
#. Hypertension. Patient BP control suboptimal. Restarted ACE
inhibitor.
.
#. Chronic renal insufficiency, CKD stage III:. Cr. to baseline.
Restarted ACE inhibitor, but continued to hold diuretics given
Cr. at baseline without diuresis and pt. appeared euvolemic.
.
#. Thrombocytopenia. Stable.
.
#. Diabetes mellitus. Lantus reduced given diminished intake.
Continued HISS.
.
#. S/P ORIF. Orthopedics follow up 2/28.
.
# Access. PICC replaced
Medications on Admission:
Heparin SC
Bisacodyl 10 mg po qd
Allopurinol 100 mg qod
Calcitriol 0.25 mcg qd
Citalopram 20 mg qd
Simvastatin 40 mg qd
Miconazole 2% powder topically [**Hospital1 **]
Aspirin 81 mg qd
Metoprolol 100 mg tid
Omeprazole 20 mg qd
Prednisone 40 mg qd taper
Tioptropium inhaler
Albuterol inhaler
Nystatin 5 mg po qid
Polysaccaride iron coplex
Docusate prn
Advair 1 puff [**Hospital1 **]
Imdur 60 mg qd
Pip-Tazo 2.25 mg q8 hr (start [**3-22**])
Lantus 50u qam, 45u qpm
Discharge Medications:
1. Meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg
Intravenous Q12H (every 12 hours) for 14 days.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
6. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
13. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation Q6H (every 6 hours) as needed.
14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
15. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
16. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) inhallation Inhalation [**Hospital1 **] (2 times a day).
17. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
18. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
19. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 days. Tablet(s)
20. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days: following one day at 20 mg dose.
21. Insulin Glargine 100 unit/mL Solution Sig: 35 units Q am
insulin and 30 Units Q pm insulin Units, insulin Subcutaneous
twice a day.
22. Insulin Lispro 100 unit/mL Solution Sig: as directed by
sliding scale (attached) Units, insulin Subcutaneous QACHS.
23. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
24. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
PICC line self d/c'd
Over sedated by lorazepam in ED with resultant unresponsiveness,
hypothermia - monitored in ICU overnight, and then back to
baseline
Discharge Condition:
Stable
Discharge Instructions:
Take all medications as prescribed.
Return to the [**Hospital1 18**] Emergency Department for:
Fever
Shortness of breath
Followup Instructions:
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2154-4-11**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2154-4-11**] 10:20
|
[
"403.90",
"E879.8",
"311",
"428.22",
"428.0",
"041.3",
"E849.7",
"496",
"274.9",
"530.81",
"E939.4",
"327.23",
"780.97",
"996.1",
"276.2",
"585.3",
"599.0",
"287.5",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8062, 8158
|
3944, 3954
|
336, 343
|
8357, 8366
|
2601, 3921
|
8537, 8806
|
2038, 2057
|
5726, 8039
|
8179, 8336
|
5238, 5703
|
8390, 8514
|
2072, 2582
|
266, 298
|
371, 1490
|
3969, 5212
|
1512, 1813
|
1829, 2022
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,735
| 199,929
|
26597
|
Discharge summary
|
report
|
Admission Date: [**2200-10-3**] Discharge Date: [**2200-10-13**]
Date of Birth: [**2160-2-16**] Sex: M
Service: MEDICINE
Allergies:
Sulfasalazine / Tape [**12-22**]"X10YD / Lactose / Optiray 350
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
sepsis
Major Surgical or Invasive Procedure:
PICC
History of Present Illness:
40M s/p liver transplant 4 months ago on Rapamune and Cellcept
transferred by ambulance from [**Hospital Ward Name **] after becoming
unresponsive. Patient had been called from home after routine
labs drawn 5 days prior to hyponatremia with sodium of 122.
[**Name (NI) **] mother states that he had an episode of staring into
space yesterday. Today, prior to having labs drawn, the patient
crumpled to the ground and became unresponsive. Fingerstick
170s.
.
On arrival to ED, patient is unresponsive and rigid. Afebrile,
no outright seizure activity but eyes are deviated. Tachycardic
and normotensive. Reportedly was rigid for periods of time mixed
in with delerium. Rigidity and mental status improved after
Ativan.
.
He had an LP and was given vanc, ceftriaxone, acyclovir,
ampicillin, 2LNS. A head CT showed no acute intracranial
process. CXR was negative. He was seen by neurology who
recommened EEG. Also seen by liver and transplant surgery.
.
On arrival to the ICU, he is shivering and reports feeling
unwell since switched from the tacro to rapammune. He states
that since this change, he has had chills, mouth sores and
worsening diarrhea.
Past Medical History:
1. Ulcerative colitis s/p subtotal colectomy [**2196**] with chronic
diarrhea
2. Primary sclerosing cholangitis, liver cirrhosis complicated
by
cirrhosis, ascites, and varices s/p banding
3. Esophageal varices s/p banding
PSH: ABO incomaptible liver transplant [**2200-4-18**]
Exploratory laparotomy, takedown jejunojejunostomy and liver
biopsy [**2200-4-27**]
Social History:
He is single and heterosexual; He is currently not working and
is on disability. He lives at home with parents. No alcohol or
drugs.
Family History:
His father has [**Name (NI) 4522**] disease. There is no known family history
of colon cancer. He does not smoke cigarettes or use NSAIDs. He
is not certain whether stress makes his condition worse. Both
parents are well. He has no siblings.
Physical Exam:
Vitals: 99.3, 97.5, 119/75, 86, 17, 98RA
General:AAOx3 in NAD, not making eye contact. Answering
questions appropriately. Very flat affect
HEENT: PEERLA, MMM, no lymphadenopathy, temporal wasting
Heart: RRR, no MRG appreciated
Lungs: CTAB
Abdomen: Thin, tympanitic but no shifting dullness, multiple
light colored striae, and scars are well healed. +BS, nontender,
nondistended, no rebound or gurading
Extremities: No peripheral edema, 2+DP pulses biltareally
Neurological: AA0x3, no asterixis. CN II-XII intact, strenght
[**4-24**] bilaterally UE and LE.
Pertinent Results:
Admission labs:
[**2200-10-3**] 10:30AM BLOOD WBC-6.1 RBC-3.80* Hgb-12.1* Hct-34.1*
MCV-90# MCH-31.9 MCHC-35.5* RDW-14.2 Plt Ct-453*
[**2200-10-3**] 10:30AM BLOOD Neuts-47* Bands-10* Lymphs-31 Monos-12*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2200-10-3**] 10:30AM BLOOD Glucose-172* UreaN-59* Creat-3.1* Na-124*
K-3.7 Cl-80* HCO3-16* AnGap-32*
[**2200-10-3**] 10:30AM BLOOD ALT-28 AST-63* AlkPhos-136* TotBili-0.3
DirBili-0.1 IndBili-0.2
[**2200-10-3**] 10:30AM BLOOD Calcium-9.5 Phos-3.8 Mg-2.7*
[**2200-10-3**] 10:39AM BLOOD Lactate-7.0* Na-122* K-3.5
[**2200-10-3**] 01:43PM BLOOD Lactate-2.5*
[**2200-10-3**] 01:00PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* Polys-5
Lymphs-80 Monos-15
[**2200-10-3**] 01:00PM10/16 Stool O&P, viral Cx: pending
[**10-5**] Stool C. diff: negative
[**10-5**] Blood Cx: pending
[**10-5**] CMV VL: pending
[**10-4**] Blood Cx: pending
[**10-3**] Stool Cx/C. diff: negative
[**10-3**] Urine Cx: no growth
[**10-3**] CSF: coag neg Staph --> then no growth
ACINETOBACTER SP.. UNABLE TO IDENTIFY FURTHER.
FINAL SENSITIVITIES. sensitivity testing performed by
Microscan.
Cefepime >16 MCG/ML.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
TETRACYCLINE AND MEROPENEM SENSITIVITY TESTING
REQUESTED BY DR.
[**Last Name (STitle) **] ([**Numeric Identifier 59053**]) [**2200-10-8**].
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ACINETOBACTER SP.
|
AMPICILLIN/SULBACTAM-- =>32 R
CEFEPIME-------------- R
CEFTAZIDIME----------- =>32 R
CIPROFLOXACIN--------- <=0.5 S
GENTAMICIN------------ 2 S
LEVOFLOXACIN---------- <=1 S
MEROPENEM------------- =>16 R
PIPERACILLIN/TAZO----- S
TETRACYCLINE---------- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=2 S
[**10-3**] Stool studies:NO MICROSPORIDIUM SEEN. NO CYCLOSPORA SEEN.
NO SALMONELLA OR SHIGELLA FOUND. NO CAMPYLOBACTER FOUND. Feces
negative for C.difficile toxin A & B by EIA. NO OVA AND
PARASITES SEEN. NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
CXR [**2200-10-3**]: IMPRESSION: No acute findings in the chest.
CT head [**2200-10-3**]: No evidence of acute intracranial
abnormalities.
RUQ U/S [**2200-10-3**]: 1. Patent hepatic vasculature.
2. Focal ring-down artifact in 1 or 2 bile ducts in the left
lobe of the
liver, may be due to pneumobilia vs artifact.
3. 1.3 x 1.3 x 1.1 cm echogenic focus in the peripheral right
lobe of the
liver, likely segment VII, not identified previously. Suggest
further
evaluation with MRI.
MRI Abdomen [**2200-10-5**]: 1. Discrete patchy parenchymal abnormality
in segment VI of the liver peripherally concerning for focal
area of inflammation or infection. No liquefaction or collection
identified in this region. Attention to this region on follow-up
is recommended to evaluate for evolving abscess.2. Intraluminal
splenic vein thrombus with extension of clot into the SMV-portal
vein confluence, new since prior imaging. 3. Septated minimally
complex 5mm cyst in the upper pole of the right kidney.
MRI Brain [**2200-10-8**]: 1. No evidence of intracranial
infection/abscess, as questioned clinically. 2. Decreased
conspicuity of T1 hyperintensities with the bilateral basal
ganglia previously seen on [**2200-5-1**].
Brief Hospital Course:
40 yo M s/p Liver transplant (cadaveric) in [**3-/2200**] for PSC
cirrhosis, and UC s/p colectomy who presented with diarrhea in
the setting of elevated rapamycin levels and was septic with GNR
and found to have a splenic-portal vein junction thrombus on
MRI.
.
#ACINETOBACTER sepsis- patient was admited and fond to have
sepsis, and +GNR bacteremia. He was started on daptomycin,
cefepmine and flagyl. After this was speciated and found to be
enterobacter with known sensitivies including resistance to
cefepime he was switched to cipro/flagyl and bactrim (treatment
dose). Infectious disease was consulted who recommended a MRI
given that he presented with concern for seizure and the
affinity of enterobacter for the brain. MRI showed no areas
concerning for infection. He also had an area within his liver
which was concerning for a possible liver abscess and therefore
he was continued on the flagyl for broader coverage. Per
infectious disease consult, Pt will be discharged with cipro
500mg po bid and Bactrim DS [**Hospital1 **] until [**11-1**], after which he
will resume his previous dose of Bactrim SS daily.
.
# Diarrhea: Patient had diarrhea on admission with negative
stool studies since then, including C. diff. He had a small
bowel enteroscopy on [**10-5**]; a Schatzki's ring was found in the
lower third of the esophagus. Protruding Lesions 2 cords of
grade I varices were seen in the lower third of the esophagus.
The varices were not bleeding. Pt also had sigmoidoscopy on
[**10-5**]; A few punched out ulcers with stigmata of recent bleeding
in the rectum (biopsy). No evidence of surrounding colitis was
noted. Otherwise normal sigmoidoscopy to splenic flexure. His
final biopsy showed chronic severely active colitis with
ulceration. No granulomata or dysplasia identified. CMV
negative. An anti TTG IgA (to rule out sprue) was still pending
on discharge but serum total IgA is low at 17. However, low
suspicion of sprue given high vitamin B12 and folate levels
inconsistent with malabsorption. His diarrhea / blood stool were
therefore attributed to a UC flare, and Pt's symptoms improved
w/ [**Hospital1 **] mesalamine enemas and PRN immodium, which were both
continued on discharge.
#Thrombus- patient was found to have a thrombus in splenic vein
/ portal vein junction on MRI. He was anticoagluated initially
with a heparin gtt, and ultimately switched to coumadin. This is
important so that he does not have a clot that breaks off and
block blood flow in his liver. Bridging with enoxaparin was
considered but patient states that he absolutely will not "do
needles." Pt was discharged with warfarin 3mg po daily and close
follow-up in transplant clinic, where he already has twice
weekly lab draws. He should have repeat imaging in 3 months to
document resolution of his thrombus, followed by 3 more months
of anticoagulation and then stop.
#S/p Liver transplant- Patient had elevated rapamycin levels on
admission and associated diarrhea. His sirolimus was held until
it was back in the therapeutic range and then restarted at
1mg/day. He was continued on his cellcept, bactrim and
valgancyclovir while here. His sirolimus level was low at 4.9 on
day of discharge, so it was increased back to 2mg/day on
discharge.
# hyponatremia - This was likely due to decreased po intake and
diarrhea and corrected readily with rehydration, and had
resolved after a couple of days inpatient, and was normal at the
time of discharge.
# ? seizure - He was followed by neurology. Based on history it
was eventually felt likely that his presentation represented
true seizure acitvity. He had no further suspicious episodes.
# Nutrition/ Function- patient with decrease po intake and
temporal wasting on exam. He was seen by nutrition who felt that
he would benefit from tube feedings. He had an NJ tube placed on
EGD, with fixing by IR. He tolerated his tube feeds without
problems and was counseled on foods to eat to improve his
nutritional state. He was monitored for signs of refeeding
syndrome and his phos was repleted during this time. Pt was set
up with tube feeds delivered to his home on day of discharge.
TRANSITIONAL ISSUES:
-Pt will need repeat Hct within 1 wk to ensure bleeding is
controlled.
-Pt will need regular INR checks at his biweekly draws. He
should continue anticoagulation with goal 2.5 and have repeat
imaging in 3 months to document resolution of his thrombus,
followed by 3 more months of anticoagulation and then stop.
Medications on Admission:
- ERGOCALCIFEROL (VITAMIN D2) - (Prescribed by Other Provider) -
50,000 unit Capsule - 1 Capsule(s) by mouth twice per week
- MYCOPHENOLATE MOFETIL - 500 mg Tablet - 2 Tablet(s) by mouth
twice a day
- SIROLIMUS [RAPAMUNE] - (Dose adjustment - no new Rx) - 1 mg
Tablet -2 Tablet(s) by mouth once a day
- SODIUM POLYSTYRENE SULFONATE [KAYEXALATE] - Powder - 4 tsp
Powder(s) by mouth once a day as needed for for high potassium
level Transplant Center will call you if you need to take
- SULFAMETHOXAZOLE-TRIMETHOPRIM - 400 mg-80 mg Tablet - 1
Tablet(s) by mouth DAILY (Daily)
- TRIAMCINOLONE ACETONIDE - 0.1 % Paste - apply to affected
areas twice a day
- VALGANCICLOVIR [VALCYTE] - (Dose adjustment - no new Rx) - 450
mg Tablet - 1 Tablet(s) by mouth DAILY (Daily)
- CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 600 + D(3)] -
(Prescribed by Other Provider; Dose adjustment - no new Rx) -
600 mg-400 unit Tablet - one Tablet(s) by mouth twice a day
- LYSINE - 600 mg Tablet - 1 Tablet(s) by mouth twice a day
Discharge Medications:
1. Tube feeds
sig: Isosource 1.5 or equivalent at 60ml/hr via pump and
supplies
refills: 3
2. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO twice per week.
3. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
twice a day.
4. sirolimus 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. sodium polystyrene sulfonate Powder Sig: Four (4) tsp PO
once a day as needed for high potassium: Transplant Center will
call you if you need to take this medication.
6. triamcinolone acetonide 0.1 % Ointment Sig: apply to affected
areas Topical twice a day.
7. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO once a
day.
8. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit
Capsule Sig: One (1) Capsule PO twice a day.
9. lysine 600 mg Tablet Sig: One (1) Tablet PO twice a day.
10. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): Take through [**2200-11-1**].
Disp:*38 Tablet(s)* Refills:*0*
11. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: Two (2)
Tablet PO BID (2 times a day): Take through [**2200-11-1**] then start
taking 1 single strength tablet daily as before.
Disp:*76 Tablet(s)* Refills:*0*
12. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO once a day: Start taking this on [**2200-11-2**].
13. mesalamine 4 gram/60 mL Enema Sig: One (1) enema Rectal [**Hospital1 **]
(2 times a day).
Disp:*60 enema* Refills:*0*
14. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
Disp:*60 Capsule(s)* Refills:*0*
15. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM: Dosing will be managed by [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **] in the transplant
center.
Disp:*30 Tablet(s)* Refills:*2*
16. Outpatient Lab Work
Please check CBC, chem 10, and INR twice weekly and fax results
to [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **] in the Transplant Center. Fax: ([**Telephone/Fax (1) 12146**].
Discharge Disposition:
Home With Service
Facility:
[**First Name5 (NamePattern1) 5871**] [**Last Name (NamePattern1) 269**]
Discharge Diagnosis:
Primary: Enterobacter sepsis, splenic vein thrombosis,
ulcerative colitis flare, malnutrition, hyponatremia
Secondary: S/p liver transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 13029**],
.
It was a pleasure caring for you while you were here at [**Hospital1 18**].
You were admitted because you were found unconscious. This was
likely from electrolyte abnormalities in your blood which have
been corrected. You were also found to have a bacterial
infection in your blood which we are treating with antibiotics.
.
You were found to have a blood clot in one of the vessels near
your liver. We are treating this with a blood thinner called
warfarin (Coumadin) which you will need to take for at least the
next few months. This medication requires regular blood tests
which will be managed by [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **] in the transplant center.
.
You were found to be very malnourished. We placed a feeding tube
through your nose to give you a sufficient level of nutrients
and calories. You will continue with the tube feeds at home but
should eat as well.
.
Prior to your admission you were having a lot of diarrhea. We
performed a flexible sigmoidoscopy and endoscopy which showed
several ulcers in your rectum and inflammation consistent with
your ulcerative colitis. We are treating this with mesalamine
enemas and the diarrhea is improving.
.
We made the following changes to your medications:
- START Bactrim (sulfamethoxazole-trimethoprim) 2 double
strength tablets twice daily through [**2200-11-1**]. On [**2200-11-2**] start
taking Bactrim 1 single strength tablet daily as you were
before.
- START Ciprofloxacin 500mg twice daily through [**2200-11-1**]
- START Mesalamine enemas twice daily
- START Loperamide (Immodium) four times daily as needed for
diarrhea
- START Warfarin (Coumadin) 3mg daily. You will have twice
weekly blood draws and [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **] will tell you when to adjust
the dose.
Followup Instructions:
Department: TRANSPLANT
When: WEDNESDAY [**2200-10-22**] at 9:40 AM
With: TRANSPLANT [**Hospital 1389**] CLINIC [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST
Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2200-10-14**]
|
[
"780.39",
"787.91",
"263.9",
"556.8",
"787.20",
"V42.7",
"530.3",
"038.49",
"995.91",
"456.1",
"572.1",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"45.13",
"48.24",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
14120, 14223
|
6573, 10712
|
332, 338
|
14407, 14407
|
2906, 2906
|
16438, 16729
|
2071, 2314
|
12097, 14097
|
14244, 14386
|
11072, 12074
|
14558, 15820
|
2329, 2887
|
10733, 11046
|
15849, 16415
|
286, 294
|
366, 1518
|
2922, 6550
|
14422, 14534
|
1540, 1903
|
1919, 2055
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,879
| 143,965
|
54678
|
Discharge summary
|
report
|
Admission Date: [**2178-8-12**] Discharge Date: [**2178-8-18**]
Date of Birth: [**2104-3-12**] Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 23497**]
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
[**2178-8-12**] Lumbar puncture in ED
History of Present Illness:
74 y.o male w/ unknown pmhx presenting with altered mental
status. Found down today in his home covered in feces on the
floor for unknown amount of time. He cannot provide much history
but reportedely said to EMS he was hiding from people trying to
get him for around 10-20 minutes, Complained of generalized pain
in ED but otherwise denies fever, chills, chest pain, dyspnea,
cough, abdominal pain, dysuria. Poor historian.
.
Initial vitals in the ED was 97.8 104 180/100 12 95% RA. The
patient recieved a LP and was given IV 50mg benadryl, IV 20m
Famotidine, Lorazepam 2mg IV X 3, MethylPREDNISolone Sodium Succ
125mg,Vancomycin 1gram IV , Ceftriaxone 1 gram IV, Thiamine
100mg IV. 4 liters of IV NS.
.
He was noted to have generalized urticarial rash and was given
meds per above in the ED around 1PM and is currently resolving.
He was also noted to be alert, but altered and [**Doctor Last Name **] more than
10 on CIWA and given IV ativan a total of 5mg at 1PM, 3PM and
approx. 6PM.
On arrival to the MICU,he unresponsive, and does not respond to
painful stimuli. Vitals were 99.1, P-85, 94% RA, and
134/62.Physical exam obtained per below.
.
Review of systems:
Could not be obtained given patient's mental status.
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
Osteoarthritis of bilateral knees and ankles
Tophaceous gout on bilateral hands
Social History:
cab driver. states cab company is his family and lists his work
number as emergency contact. drinks 6 drinks of etoh per day.
Divorced. Lives alone.
Family History:
NC
Physical Exam:
ADMISSION EXAM:
Vitals: 99.1, P-85, 94% RA, and 134/62
General:Not Alert, oriented X 0,unresponsive to painful stimuli
and sternal rub.
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear,
at times has rotational nystagmus b/l which then later stops and
gaze remains unfixed, pupils 1mm sluggishly responsive to light
b/l.
Neck: supple, JVP not elevated, no LAD.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley -[**Location (un) 2452**] urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema.Fungus on toenails. Back stage 2 ulcer on sacrum, back is
erythematous in the upper back. Severe groin erythematous urine
rash, b/l.
Neuro: Flacid extremities, does not withdraw to pain. Reflexes
could not be illicitied, babinski upgoing b/l with whole limb
flexion to stimuli.
DISCHARGE EXAM:
Vitals: 98.2, P-66 136/57 RR20 94% RA,
General:A&Ox3, NAD, pleasant
HEENT: Sclera anicteric, EOMI, PERRL, oropharynx clear, MMM
Neck: supple, JVP not elevated, no LAD.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, mild rales to L base
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no organomegaly
GU: no foley
Ext: warm, well-perfused, 2+ pulses, no clubbing, cyanosis or
edema. Fungus on toenails. Back dressing c/d/i, stage 2 ulcer on
sacrum dressing c/d/i, back is erythematous in the upper back.
Urticarial plaques resolved. Tophaceous subcutaneous nodules on
hands and L knee, non-tender, no appreciable warmth.
Neuro: A&O x3, sensation and CNII-XII grossly intact, gait
deferred.
Pertinent Results:
ADMISSION LABS:
[**2178-8-12**] 11:45AM BLOOD WBC-21.3* RBC-5.94 Hgb-14.2 Hct-43.3
MCV-73* MCH-23.9* MCHC-32.7 RDW-14.7 Plt Ct-248
[**2178-8-12**] 11:45AM BLOOD Neuts-86.4* Lymphs-8.3* Monos-4.5 Eos-0.3
Baso-0.4
[**2178-8-12**] 11:45AM BLOOD PT-14.1* PTT-28.6 INR(PT)-1.3*
[**2178-8-12**] 11:45AM BLOOD Glucose-122* UreaN-26* Creat-1.1 Na-133
K-4.4 Cl-96 HCO3-19* AnGap-22*
[**2178-8-12**] 11:45AM BLOOD ALT-51* AST-103* CK(CPK)-2152* AlkPhos-73
TotBili-1.4
[**2178-8-12**] 11:45AM BLOOD Lipase-11
[**2178-8-12**] 11:45AM BLOOD cTropnT-<0.01
[**2178-8-12**] 11:45AM BLOOD Albumin-3.6 Calcium-9.2 Phos-2.7 Mg-2.0
[**2178-8-12**] 11:45AM BLOOD Osmolal-282
[**2178-8-12**] 08:03PM BLOOD TSH-1.3
[**2178-8-12**] 11:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2178-8-12**] 08:23PM BLOOD Type-[**Last Name (un) **] FiO2-4 pO2-48* pCO2-38 pH-7.36
calTCO2-22 Base XS--3 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**]
[**2178-8-12**] 12:35PM BLOOD Lactate-3.4*
[**2178-8-12**] 04:11PM BLOOD Lactate-2.3*
[**2178-8-12**] 05:20PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-29* Polys-6
Lymphs-20 Monos-74
[**2178-8-12**] 05:20PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-1350*
Polys-34 Lymphs-32 Monos-34
.
On discharge:
[**2178-8-18**] 05:30AM BLOOD WBC-11.6* RBC-4.52* Hgb-10.9* Hct-34.0*
MCV-75* MCH-24.1* MCHC-32.1 RDW-14.3 Plt Ct-255
[**2178-8-18**] 05:30AM BLOOD PT-14.3* PTT-27.2 INR(PT)-1.3*
[**2178-8-18**] 05:30AM BLOOD Glucose-109* UreaN-22* Creat-0.8 Na-138
K-4.0 Cl-103 HCO3-29 AnGap-10
[**2178-8-18**] 05:30AM BLOOD ALT-69* AST-39 AlkPhos-77 TotBili-0.4
[**2178-8-18**] 05:30AM BLOOD Calcium-8.2* Phos-4.0 Mg-1.9
Microbiology:
[**2178-8-12**] Blood cx- no growth final
[**2178-8-12**] CSF cx-no growth final
[**2178-8-16**] blood cx- pending
.
Neuro:
[**2178-8-13**] Continuous EEG
OBJECT: FOUND UNCONSCIOUS. MONITOR FOR SEIZURES FROM [**9-14**]. THERE WERE NO PUSHBUTTON ACTIVATIONS.
.
FINDINGS:
CONTINUOUS EEG RECORDING: Began at 11:21 on the morning of [**8-13**] and
continued until 7 the next morning. Throughout the recording, it
showed a
very low voltage background with no areas of prominent focal
slowing or any clearly epileptiform features.
SPIKE DETECTION PROGRAMS: Showed muscle and other artifact, but
there were no
clearly epileptiform features.
SEIZURE DETECTION PROGRAMS: Showed no electrographic seizures.
PUSHBUTTON ACTIVATIONS: There were none.
SLEEP: No normal waking or sleep patterns were evident.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: This telemetry captured no pushbutton activations.
It showed a
slow, encephalopathic background throughout. The faster, beta
frequency
activity suggested some sedating medication effect. There were
no clearly
epileptiform features. There were no electrographic seizures.
IMAGES:
[**2178-8-13**] MRI Head
TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired
through the
head with before and after administration of IV gadolinium.
Diffusion-weighted images and ADC maps were also obtained.
FINDINGS: There is a very faint punctate DWI-hyperintense focus
in the right
putamen (9:15), with mildly pseudo-normalized ADC-hypointensity
(8:15),
representing a tiny subacute infarction. There is no
corresponding FLAIR
signal abnormality. A old lacunar infarct is noted in the left
cerebellum
(3:5). There is a solitary tiny focus GRE-hypointensity in the
right medulla,
representing old microhemorrahge (6:8).
The lateral ventricles and sulci are moderately prominent, with
disproportionally prominent third and fourth ventricles and
temporal [**Month/Day/Year **].
There is no shift of normally midline structures. While this
could represent
age-related atrophy, the ventricular morphology suggests
possibility of
communicating hydrocephalus.
Scattered foci of T2/FLAIR hyperintensity in the subcortical
white matter,
likely represent chronic microvascular ischemic disease.
Periventricular
white matter T2/FLAIR hyperintensity with the appearance of
"capping" of the
frontal and occipital [**Last Name (LF) **], [**First Name3 (LF) **] also be seen in communicating
hydrocephalus.
The [**Doctor Last Name 352**]-white matter differentiation is otherwise preserved.
Major vascular
flow voids are present. There is no abnormal enhancement.
There is minimal
ethmoidal mucosal thickening, and trace fluid in the right
mastoid air cells.
The remaining visualized paranasal sinuses and mastoid air cells
are clear.
IMPRESSION:
1. Tiny subacute right putaminal infarct, with minimal FLAIR
signal
abnormality.
2. Disproportionally prominent third and fourth ventricles, with
prominent
temporal [**Doctor Last Name **], and appearanc of "capping"
T2-/FLAIR-hyperintensity in
periventricular white matter. While non-specific, this
constellation of
findings raises the possibility of communicating hydrocephalus,
which should
be correlated clinically.
[**2178-8-12**] PELVIS AP: No acute fracture. Mild degenerative changes
of the hip.
[**2178-8-12**] CT HEAD:
IMPRESSION:
1. No acute intracranial process.
2. Age-related involutional changes and chronic small vessel
ischemic
disease.
3. Periapical lucency in upper right maxillary tooth. Correlate
clinically.
[**2178-8-12**] CT C-SPINE:
FINDINGS: The study is slightly limited by motion artifact.
Within these
limitations, there is no acute fracture or traumatic
malalignment. There are
degenerative changes at multiple levels, most prominent at C5-6
where there is
disc space narrowing. Anterior osteophytes are present at
multiple levels.
There is calcification of the ligamentum flavum (602B:28) at the
level of C4.
The outline of the thecal sac is preserved. There is no
prevertebral soft
tissue swelling and the remainder of the soft tissues are
unremarkable.
IMPRESSION: No acute fracture or malalignment. Multilevel
degenerative
changes as outlined above.
Brief Hospital Course:
74 y.o male w/ unknown past medical history presenting with
altered mental status.
#Altered mental status: unknown baseline mental status. No frank
seizure-like activity observed on field or in the ED.
Electrolytes were normal with no evidence of liver failure,
arguing against metabolic causes. Serum tox including alcohol
was negative. LP in the ED negative for meningitis so
antibiotics were stopped. CT head negative for bleed. Recieved
50mg IV benadryl and 5mg IV ativan over 8 hours in the ED which
could be the cause of unresponsiveness on arrival to MICU. Not
hypercarbic or hypoxic. Also considered illicit drug abuse,
alcohol withdrawal/intoxication. CNS event was concerning given
potential rotational nystagmus but was ruled out by head CT and
MRI. No epileptiform activity found on continous EEG. He stated
that he remembered coming to the ED and lying on the ground
because people were after him, he might have been
"hallucinating." Endorsed drinking 6 beers per night for past
week. Neurology consulted and recommended high dose IV thiamine
for 3 days as empiric treatment of Wernicke's encephalopathy.
After 3 day course of IV thiamine, pt was continued on PO
thiamine. B12 and Folate levels were normal. RPR was checked
which was negative.
Neurology did not have further recommendations after
unremarkable imaging and EEG and pt's mental status improved
throughout course to baseline. There was a transient period of
delirium on [**7-29**] where pt endorsed visual hallucinations.
Delirium was improved with CIWA protocol diazepam over 24 hours
and with improved sleep (improved with Trazodone). He had been
CIWA negative for 24 hours before discharge.
#Anion gap metabolic acidosis: This was likely secondary to
dehyration/mild lactic acidosis which correlated clinically. Pt
received 3 Liters of NS in the ED and another liter in MICU.
There were no osmolol gap to suggest other ingestions. Gap
closed with IVF and remained stable throughout course.
#Leukocytosis: Pt initially treated for presumed meningitis in
the ED but had negative LP. Resp status remained stable as well
as hemodynamically stable. Stopped abx due to low suspicion for
infection, with reasoning that elevated WBC count was probably
due to hemoconcentration vs allergic reaction given rash on
admission. WBC trended down while pt remained afebrile.
Ultimately trended down again when started treatment for PNA as
below.
# Aspiration pneumonia: Did have cough productive of sputum and
a repeat CXR on [**8-16**] showed new consolidation. Sputum cx
nonconclusive as they were contaminated specimens. During brief
period of hallucinations from [**Date range (1) 19037**], pt was started on
antibiotics to treat possible pneumonia. Pt started on
ceftriaxone and vancomycin on [**8-16**] and was transitioned to
levofloxacin on [**8-17**] and pt's cough and lung exam improved. Pt
is to complete a total of 7 days of antibiotics, end date: [**8-22**].
#Elevated CK: Most likely in the setting of being down for
unknown period of time. Hydrated per above and CK trended down.
No evidence of acute kidney injury, though moderate blood seen
on UA with only 4 RBC. Pt also had persistent mild transaminitis
throughout hospitalization which could be related to resolving
rhabdomyolysis vs. alcohol use.
#Hypertension (HTN): Pt received on medical floor from MICU with
SBP in 160s without being on antihypertensives. Pt denies formal
history of HTN and was not on medications preadmission. Pt was
started on metoprolol tartrate 12.5mg [**Hospital1 **] on [**8-14**] and BP
persistently elevated on [**8-15**] and thus metoprolol increased to
25mg [**Hospital1 **].
#Transaminitis: Pt was not complaining of abdominal pain and so
less likely acute process (acute cholecystitis, hepatitis or
pancreatitis). Pt did have elevated CK, and rhabdomyolysis could
have increased liver enzymes. With pt's h/o substance abuse, his
high risk behavior puts him at risk for hepatitis. Elevated LFTs
be chronic due to alcohol abuse or NASH given pt is obese,
levels were not high enough to be shock liver. AST and ALT
remained elevated persistently but trended down.
#Substance, EtOH abuse: Pt initially equired CIWA benzodiazepine
for CIWA >10, but upon coming to medical floor from MICU, was
without agitation or signs of withdrawal. Social work consulted
and pt admitted to drinking 4 beers a day at home (lives alone)
and named his friend as healthcare proxy. Social work looked
into establishing home services for pt. Pt was continued on PO
thiamine after 3 days of IV thiamine and was supplemented with
folate via multivitamin. Patient was given information about
acquiring a cell phone for medical purposes by social work. He
was also encouraged to set up a homemaker for himself after he
is discharged from the rehab. He told social work that he would
do both of these things.
#Elevated INR: INR persistently elevated and was possibly
related to liver dysfunction vs chronic liver disease with
superimposed malnutrition. Pt had no issues with bleeding.
#Urticarial rash- Pt noted to have rash which was diffuse and
urticarial in the ED. Significant improvement by the time pt got
to MICU status post IV steroids, benadryl and famotidine in ED.
No signs of mucous involvement or ulcerations to suggest severe
drug rash and no signs of cellulitis. Rash remained as stable
erythematous plaques on all extremities without dermatographism.
No etiology of rash was found. Rash was resolved upon discharge.
#Sacral ulcer, shoulder abrasions: Pt was found down for at
least 3 days and most likely developed skin tears and pressure
ulcer due to being unconscious for some time. Wound consult
obtained and recommended: Commercial wound cleanser or normal
saline to irrigate/cleanse all open wounds. Pat the tissue dry
with dry gauze. Apply Mepilex to 2 shoulder wounds and sacral
ulcer. Change dressing Q3D. Pt's wounds remained stable without
signs of infection throughout course.
# Onychomycosis, tinea pedis: Severe onychomycosis on exam.
Obtained podiatry consult- recommended ketoconazole to feet, and
no indication for debridement. Pt is follow-up with podiatry in
clinic.
#Loose maxillary tooth: L sided loose maxillary denture. Pt does
not have an established dentist and will need to work on this at
rehab facility.
TRANSITIONAL ISSUES:
- Pt is to complete a 7 day course of levofloxacin for
aspiration pneumonia (Day 1=[**8-16**], end=[**8-22**]).
-Pt is to follow up in podiatry clinic as outpatient
([**Telephone/Fax (1) 111813**])
-Pt is to follow-up with an outpatient physician to discuss
alcohol abuse, monitor LFTs, and manage HTN and osteoarthritic
pain.
-Pt is to have referral to psychiatry as outpatient by newly
established PCP
[**Name10 (NameIs) 30412**] is to have physical and occupational therapy at rehab
facility in order to regain lower extremity strength and to
escalate autonomy in order to fulfill ADL/iADLs.
-Given pt does not have a home phone, pt is to call [**Hospital **] before leaving rehab facility to set up appointment
with primary care physician [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 2010**].
Medications on Admission:
Ibuprofen PRN osteoarthritic pain in knees and ankles
Discharge Medications:
1. Acetaminophen 325 mg PO Q6H:PRN pain
do not exceed 4g per day
2. Ibuprofen 400 mg PO Q6H:PRN pain
3. Ketoconazole 2% 1 Appl TP [**Hospital1 **]
to feet
4. Levofloxacin 750 mg PO Q24H Duration: 4 Days
day 1=[**2178-8-16**]
5. Metoprolol Tartrate 25 mg PO BID
hold for HR<60, BP<100
6. Miconazole Powder 2% 1 Appl TP TID:PRN antifungal
7. Multivitamins 1 TAB PO DAILY
8. Thiamine 100 mg PO DAILY
9. traZODONE 25 mg PO HS:PRN insomnia
10. FoLIC Acid 1 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Altered mental status
Alcohol abuse
Secondary:
Osteoarthritis
Gout
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you at the [**Hospital1 18**].
You were admitted to the hospital for altered mental status
after finding you unconscious in your apartment. It appears that
you were missing from work and may have been on the floor of
your home for at least 3 days. Your mental status improved with
fluids and you were able to admit that you were drinking alcohol
every night during the week leading up to your admission.
Neurology team followed you and judging by the images of your
brain, there were no acute emergencies that needed to be acted
on. You should follow-up with a physician as an outpatient to
manage your arthritis, gout and most importantly, your alcohol
use.
You will need to establish a primary care physician once you
leave the rehab facility and also will need a dentist to manage
your loose dentition. Lastly, you should see a podiatrist as an
outpatient.
Followup Instructions:
Please discuss your medical issues with the physician at your
rehab facility. You will need to establish a primary care
physician and dentist before transitioning from the facility
back to your home.
Your information was given to the [**Hospital1 18**] primary care clinic
(called [**Hospital3 **]), but they cannot call you to set
up an appointment because you do not have a phone. IT IS VERY
IMPORTANT FOR YOU TO GET A PHONE FOR YOUR MEDICAL CARE. When
you are leaving the rehab facility, you should call [**Hospital **] to make a new patient appointment. The phone number
is: [**Telephone/Fax (1) 2010**].
Also please schedule a follow-up appt with podiatry (foot
specialist) clinic by calling [**Telephone/Fax (1) 111813**].
|
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64,904
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46902
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Discharge summary
|
report
|
Admission Date: [**2131-8-23**] Discharge Date: [**2131-9-3**]
Date of Birth: [**2066-7-17**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
initially AMS, nausea, abdominal pain
Major Surgical or Invasive Procedure:
[**2131-8-28**] ex lap, transverse colectomy and colostomy with
Hartmann's pauch
History of Present Illness:
65 yo lady h/o liver transplant [**2125**], HTN, chronic renal
insufficiency s/p left hip repair [**2131-8-15**] who was discharged
from here on [**2131-8-20**]. She was transferred here on [**7-/2431**] from
[**Hospital 745**] Health Care Center rehab facility for AMS and nausea.
Patient's daughter had called to report that she is returning to
[**Hospital1 18**] b/c of persisted leg pain, confusion.
.
In ED, vitals 98.5 100 105/66 18 94% RA. Patient treated with
good pain relief with Vicodin.
.
On transfer to floor, vitals 96.6 100 139/78 18 98% RA. History
obtained from daughter. [**Name (NI) **] s/p liver transplant [**2125**], s/p
left intertrochanteric hip fracture [**8-15**] with left hip Dynamic
hip screw placement and subsequent discharge to rehab on [**8-20**].
At the time of discharge, patient reported by daughter to be
near baseline mental status. At rehab, reported to have received
combination of different pain medications including Morphine and
Vicodin. Daughter reports poor functioning on Tuesday to today,
such as not being able to recognize daughter at times, calling
for food on her cell phone three times in a row. Her functioning
is reported to vary throughout the day.
.
Over her hospital stay, patient continued to be nauseous,
developed abdominal pain and on HD 6, west 1 surgery was
consulted on [**2131-8-27**].
Past Medical History:
- HTN
- Liver transplant in [**2125**] for HCV acquired from blood
transfusions following an abortion (acquired liver is hepatitis
B positive)
- Hep C (acquired Hep C after blood transfusion in setting of
abortion. Her most recent HCV viral load is 5,000,000 copies per
patient)
- Hep B (per patient her transplanted liver came from a donor
who had been exposed to hepatitis B)
- Chronic kidney disease (peak Cr=3.2)
Social History:
Patient is from [**Location (un) 86**], but currently resides in [**State 108**]. She
was spending time in [**Hospital3 **] with her husband visiting her
children. She denies alcohol or tobacco use. She never smoked.
Family History:
Patient denies family history of malignancy or cardiac
conditions.
Physical Exam:
gen: pleasant lady, WA/WD, NAD, no signs of encepahalopathy
HEENT: PERRL, EOMI
CV: RRR, nl S1, S2
pulm: CTA b/l
abd: NBS, minimaly tender, non-distended
- midabdominal incision - sutures in place, the openings between
the sutures packed with [**Last Name (un) **], no erythema, no edema, no
discharge, no sign of infection
- colostomy bag in place to the right of the incision, the bowl
red color, viable
extremities: R/L TP/ DT - palpable, minimal edema
neuro: no confusion, AAQ x3, no signs of encephalopathy, yet
patient seems a little bit different today
CN II - XII grossly intact
Pertinent Results:
----------
CHEST (PORTABLE AP) Study Date of [**2131-8-23**] 2:01 PM
IMPRESSION: No definite consolidation. Small left pleural
effusion with
associated atelectasis.
----------
HIP UNILAT MIN 2 VIEWS LEFT Study Date of [**2131-8-23**] 2:34 PM
IMPRESSION: Stable post-surgical changes.
----------
CT HEAD W/O CONTRAST Study Date of [**2131-8-23**] 2:46 PM
IMPRESSION: No intracranial hemorrhage. MR is more sensitive in
detection of
acute stroke.
----------
VIDEO OROPHARYNGEAL SWALLOW Study Date of [**2131-8-24**] 1:28 PM
IMPRESSION: Aspiration of thin liquid; delayed swallowing of
pill.
----------
CT ABDOMEN/PELVIS W/O CONTRAST Study Date of [**2131-8-27**] 8:56 PM
IMPRESSION:
1. Large left abdominal air-fluid collection. The origin of this
collection
is not definitively identified, although it is likely due to
perforation given the presence of air. This may arise from the
distal duodenum/proximal
jejunum, with which it appears contigiuous, or the colon There
is mestenteric inflammatory stranding adjacent to the left
colon. (Note: this was found to be colon perf at surgery).
2. Calcified splenic artery aneurysm.
------------
CXR [**2131-8-28**]
The NG tube tip is in the stomach. The right internal jugular
line tip is at
the level of mid SVC. There is no pneumothorax or apical
hematoma. The
cardiomediastinal silhouette is stable. The lungs are lower
which might
exaggerate the appearance of the bibasal areas of atelectasis.
There is no
appreciable pleural effusion.
------------
[**2131-8-23**] - urine culture - no growth
[**2131-8-24**] - blood culture - no growth
[**2131-8-25**] - C. diff culture - negative
[**2131-8-28**] - blood culture - pending
[**2131-8-28**] - MRSA screen - negative
ADMISSION: [**2131-8-23**]
LACTATE-0.8
AMMONIA-15
GLUCOSE-120* UREA N-24* CREAT-2.2* SODIUM-137 POTASSIUM-2.9*
CHLORIDE-110* TOTAL CO2-16* ANION GAP-14
ALT(SGPT)-6 AST(SGOT)-12 ALK PHOS-84 TOT BILI-0.4
VIT B12-382 FOLATE-8.9
TSH-2.3
WBC-7.0 RBC-3.29* HGB-8.8* HCT-26.6* MCV-81* MCH-26.9* MCHC-33.2
RDW-15.6*
NEUTS-84* BANDS-3 LYMPHS-7* MONOS-6 EOS-0 BASOS-0 ATYPS-0
METAS-0 MYELOS-0
HYPOCHROM-OCCASIONAL ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
OVALOCYT-OCCASIONAL BURR-OCCASIONAL TEARDROP-OCCASIONAL
PLT SMR-NORMAL PLT COUNT-239
DISCHARGE:
[**2131-9-2**] 04:52AM BLOOD WBC-5.1 RBC-3.22* Hgb-8.9* Hct-27.7*
MCV-86 MCH-27.7 MCHC-32.3 RDW-15.2 Plt Ct-201
[**2131-8-28**] 09:01AM BLOOD Neuts-63 Bands-26* Lymphs-3* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-4* Myelos-0 NRBC-1*
[**2131-9-2**] 04:52AM BLOOD Plt Ct-201
[**2131-9-2**] 04:52AM BLOOD PT-12.6 INR(PT)-1.1
[**2131-9-3**] 04:57AM BLOOD Glucose-93 UreaN-13 Creat-1.8* Na-141
K-3.3 Cl-114* HCO3-19* AnGap-11
[**2131-9-1**] 04:35AM BLOOD ALT-8 AST-19 AlkPhos-149* TotBili-0.4
[**2131-9-3**] 04:57AM BLOOD Calcium-7.7* Phos-2.3* Mg-1.3*
[**2131-9-3**] 04:57AM BLOOD tacroFK-5.4
Brief Hospital Course:
65 yo lady h/o liver transplant [**2125**], HTN, chronic renal
insufficiency s/p left hip repair [**2131-8-15**] discharged [**2131-8-20**]
transferred from [**Hospital 745**] Health Care Center rehab facility for
AMS, nausea.
# AMS. Patient's AMS improved through initial course of
hospitalization. Etiology included drug-induced delirium
(different combinations of pain medications, change of
environment at rehab) vs hepatic encephalopathy (liver
transplant), infection (s/p UTI). Less likely chronic dementia
(husband has concerns that she may be developing dementia).
Patient improved s/p removal of morphine for pain control. UA
negative and stool culture negative for c. diff. Lactulose
discontinued [**2131-8-27**], when surgery was consulted and patient
was taken to OR with perforated transverse colon.
.
# Dysphagia. Patient's dysphagia on admission improved
throughout initial course of hospitalization; repeat speech and
swallow evaluation on [**2131-8-27**] showed improved function and
diet was advanced. Etiology likely secondary to AMS.
.
# Hypernatremia. Hypernatremic to 154 on [**2131-8-27**] thought
likely due to poor POR intake with thick liquids. Plan was to
correct to 144 mEq/L at a rate of -0.5 mEq/L/hr over 20 hours
correcting for insensible loss of 500 cc/day and adjusting for
other fluid intake using D5W. Na has been within normal range
since [**8-29**].
.
# Pain. Pain control was stable off of Morphine. Patient
tolerated pain well on Acetaminophen 325-650 mg PO/NG Q6H:PRN
pain and OxycoDONE Liquid 2.5 mg PO/NG Q6H:PRN pain.
.
# UTI. UA showed moderate bacterial, nitrite/leuk negative on
admission, an improvement from [**2131-8-14**] dipstick with postive
nitrite and large leuk. Urinary frequency and suprapubic
tenderness concerning for recurring UTI, however patient denied
urinary complaints and said that this was unlike her episode a
few weeks prior. Treatment deferred and urine cx on admission
subsequently negative.
.
# Tachycardia. Also noted on previous admission with baseline
around 100s. Though likely [**3-5**] pain, anxiety. Patient's hr
returned to [**Location 213**] after the operation.
.
# Anemia. Patient's hematocrit has ranged between 27 and 33
throughout the admission. Patient did not recieve any blood
transfusions intra operatively, but got 2 units of PRBCs after
admission to ICU.
.
# s/p Liver transplant in [**2125**] in [**State **]. Stable and
continued on hepsera, cellcept, and rapamune, which were
continued throughout her admission.
.
# Hypokalemia. Potassium initially low between 2.7 and 3.2
between [**8-23**] and [**8-27**]. Electrolytes were repleted PRN. Etiology
likely secondary to CKD. On [**8-27**] potassium normalized to 3.3 and
remained withing nomral range, yet on the lower end for the
remainer of the hosiptalization.
.
# CKD. Stable throughout admission and medications remained
renally dosed. CRT 2.2 on admission and 1.8 on discharge. It
decreased with hydration.
.
# Acidosis. Also noted on previous discharge and which time
patient was started on sodium bicarb for acidosis thought likely
secondary to chronic renal failure. [**Month (only) 116**] have been worsened by
continued diarrhea from lactulose. The sodium was discontinued
post-op when patient experienced diabetes insipidus and has been
held for the rest of admission. It is also held at dicharge and
it is up to the discretion of pt's outpatient nephrologist to
initiate it. Lactulose was also help post-operatively as patient
s/p colectomy with colostomy.
.
antibiotic coverage - cipro / flagyl until [**8-28**], then switched
to vanco/ meropenem
.
Patient was transfered from medicine service to surgery on [**8-27**]
when an evaluation of abdominal pain revealed perforation of
transverse colon, via the CT scan which showed air. Patient was
taken to the OR emergently and transverse colectomy with
Hartmann's pouch was performed by Dr. [**Last Name (STitle) 816**]. Patient was
transfered to ICU post-operatively.
POD 1 - Cellcept was held, pt recieved 2 units of PRBCs, she was
initially on neo-synephrine for blood pressure support. She
revieced appropriate fluid resucitation with LRs.
POD 2 - Patient likely developed central vs. nephrogenic
diabetes insipidus. She was treated with DDAVP, free water
deficit was replaced, blood pressure support. Pt was started on
clears and NG tube was pulled out.
POD 3 - Patient was transferred to floor. Her diet was advanced
to clears and regular as tolerated. DI resolved and fluid
replacement was stopped. The abdominal wound was packed once or
twice a day with [**Last Name (un) **] between the sutures. There was no
infection, edema, erythema surrounding the wound.
POD 4 - PCA was discontinued and oral pain control was
initiated. Patient was advanced to and tolerated regular diet.
Rehab screen and PT consult as well as stoma teaching were
initaited.
POD 5 - Continued regular diet, ambulation, oral pain control,
wound care and teaching. Started lovenox.
POD 6 - POD 7 - Continued regular diet, ambulation, oral pain
control, wound care and teaching, waited for rehab placement.
POD 8 - Patient continues to be afebrile, with stable vital
signs, able to tolerate PO diet and ambulates well. She denies
any nausea, pain, subjective fever, constipation, diarrhea.
# Communication:
- Patient's daughter: [**Name (NI) **] ([**Telephone/Fax (1) 99492**], cell)
- [**Name (NI) **] husband: [**Name (NI) **] ([**Telephone/Fax (1) 99493**], cell)
Medications on Admission:
1. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
2. Sirolimus 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Adefovir 10 mg Tablet Sig: One (1) Tablet PO daily ().
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
7. Enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg
Subcutaneous Q24H (every 24 hours): for four weeks ([**8-15**]) per orthopedics.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): please take this standing while on narcotics to
avoid constipation.
9. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day):
please take this standing while on narcotics to avoid
constipation.
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. Morphine 15 mg Tablet Sig: One (1) Tablet PO q6h PRN as
needed for breakthrough pain: please hold for oversedation.
12. Promethazine 25 mg/mL Solution Sig: One (1) mL Injection q6h
PRN as needed for nausea.
13. Outpatient Lab Work
Please check Potassium and bicarb daily until repleted.
14. Paroxetine HCl 20 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
15. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
16. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
17. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Discharge Medications:
1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
2. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet 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. Paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg
Subcutaneous Q24H (every 24 hours): until [**2131-9-12**] per Ortho.
6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO prn every 4
hours if needed for pain as needed for pain.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
9. Adefovir 10 mg Tablet Sig: One (1) Tablet PO daily ().
10. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous Q48H (every 48 hours) for 1 days: discontinue
[**9-4**].
11. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours) for 1 days: discontinue [**9-4**].
12. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
13. do not resume lactulose without checking with Hepatology
first
14. Calcium Carbonate 500 mg Capsule Sig: One (1) Capsule PO
once a day.
15. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
s/p liver transplant in [**2125**]
transverse colon perforation on this admission
Discharge Condition:
stable
Discharge Instructions:
Please call Dr.[**Name (NI) 1381**] office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, increased abdominal pain/distension or
incision redness/bleeding/drainage
No heavy lifting
Followup Instructions:
Follow up with your surgeon, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] [**Telephone/Fax (5) 99494**]
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 99495**], [**Location (un) **] on [**2131-9-13**] at 10:00
Specialty: Ortho
Phone: [**Telephone/Fax (1) 1228**]
Date/Time: [**2131-9-6**]; 8:20am
Special Instructions: Please obtain ORTHO XRAY at this time
prior to your appointment with [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP.
Specialty: Ortho
Provider: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], [**MD Number(3) 4383**]: [**Telephone/Fax (1) 1228**]
Date/Time: [**2131-9-6**]; 8:40am
Specialty: Hepatology
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 3688**] [**Name8 (MD) **], MD
Phone: [**Telephone/Fax (1) 673**]
Date/Time: [**2131-9-7**]; 1:20pm
Completed by:[**2131-9-3**]
|
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57,051
| 110,518
|
38755
|
Discharge summary
|
report
|
Admission Date: [**2105-7-19**] Discharge Date: [**2105-7-22**]
Date of Birth: [**2031-10-4**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Neomycin Sulfate / Neomycin
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
73 year old woman with past medical history significant for CKD
and diastolic heart failure was transferred to [**Hospital1 18**] from
[**Hospital 882**] hospital with severe respiratory distress due to
hypoxia. Patient has been a resident at [**Hospital 100**] Rehab since her
discharge from [**Hospital1 18**] on [**2105-6-3**]. During this admission she
was found to have narrow complex tachycardia and anemia. She has
had several admissions to [**Hospital 882**] hospital since that time with
a notable admission for c.diff colitis in early [**Month (only) **].
.
On day of admission, patient presented to [**Hospital1 882**] from [**Hospital 100**]
Rehab with cough, hypoxia, and shortness of breath that evolved
acutely over two hours prior to presentation to [**Hospital1 882**].
Patient was given Ceftazidime, 80mg IV Lasix, nitro paste, and
morphine prior to transfer to [**Hospital1 18**] ED.
.
Upon presentation to the ED vitals were: T 98.8, HR 81, BP
170/87, RR 30, O2Sat 70% on NRB. After confirming code status
with proxy (DNR/DNI) patient was placed on BiPAP with O2Sats
coming up to mid 90s. Patient the given levofloxacin IV and
admitted to MICU.
.
Pt has no complaints at this time and would like to leave the
hospital. She complains of no shortness of breath, no chest
pain, no abdominal pain, and no headache. She is -2.6 L total
and -1.5 L over the last 24 hours.
.
ROS: no fever, chills, night sweats, headache, sinus tenderness,
rhinorrhea, congestion, cough, wheezing, chest pain, chest
pressure, palpitations, weakness, nausea, vomiting, diarrhea,
constipation, abdominal pain, dysuria, frequency, urgency
Past Medical History:
1) Chronic kidney disease
2) Alcoholic cirrhosis
3) Diastolic CHF
4) Cervical malignancy (reported from last hospitalization)
5) Severe c.diff pancolitis (Diagnosed [**2105-6-9**] and still on
oral vanco treatment until [**2105-7-25**])
6) Atrial flutter
7) h/o retinal vein occlusion
8) Ocular hypertension
9) Glaucoma
10) Cataract extraction
Social History:
Lives alone. Daughter recently passed away from drugs/etoh. Has
six children and is one of 16 herself.
- Tobacco: Former. Quit in [**2070**].
- Alcohol: History of alcoholism and hospitalized at the [**Hospital1 86076**] in the [**2065**]. Sober since then.
- Illicits: None
Family History:
Mom died of unknown cancer. Daughter died of drugs and alcohol.
Physical Exam:
Vitals - T: 96.8 BP: 112/46 HR: 72 RR: 24 02 sat: 92% on 4L NC
GENERAL: NAD, AAOx3
HEENT: sclera anicteric, PERRL, EOMI, MMM
NECK: no LAD, supple, +JVD
CARDIAC: RRR, S1/S2, no M/R/G
LUNG: light wheezes bilaterally, crackles present on both sides,
worse at bases
ABDOMEN: soft NT/ND, +BS
EXT: pitting edema evident at ankles
NEURO: AAOx3
DERM: no rash present
Exam upon discharge shows decreased crackles and wheezes and
less pitting edema on [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**].
Pertinent Results:
[**2105-7-19**] 07:07PM BLOOD WBC-13.2* RBC-3.54* Hgb-10.7*# Hct-33.4*#
MCV-94# MCH-30.1# MCHC-31.9# RDW-20.2* Plt Ct-502*
[**2105-7-19**] 07:07PM BLOOD PT-12.2 PTT-24.8 INR(PT)-1.0
[**2105-7-19**] 07:07PM BLOOD Glucose-113* UreaN-21* Creat-1.3* Na-141
K-4.4 Cl-104 HCO3-21* AnGap-20
[**2105-7-19**] 07:07PM BLOOD cTropnT-0.04*
[**2105-7-19**] 07:08PM BLOOD Lactate-2.4*
[**2105-7-21**] 05:30AM BLOOD WBC-8.5 RBC-2.94* Hgb-8.3* Hct-26.7*
MCV-91 MCH-28.4 MCHC-31.1 RDW-20.0* Plt Ct-436
[**2105-7-20**] 03:17AM BLOOD Glucose-87 UreaN-21* Creat-1.4* Na-139
K-4.5 Cl-101 HCO3-23 AnGap-20
[**2105-7-20**] 07:42PM BLOOD Glucose-100 UreaN-23* Creat-1.5* Na-139
K-3.8 Cl-100 HCO3-26 AnGap-17
[**2105-7-20**] 03:17AM BLOOD cTropnT-0.05*
[**2105-7-20**] 3:17 am URINE
[**2105-7-22**] 06:30AM BLOOD Glucose-87 UreaN-24* Creat-1.3* Na-142
K-4.0 Cl-104 HCO3-26 AnGap-16
**FINAL REPORT [**2105-7-20**]**
Legionella Urinary Antigen (Final [**2105-7-20**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 86080**] F 73 [**2031-10-4**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2105-7-20**] 2:43
AM
[**Last Name (LF) **],[**First Name3 (LF) **] R. MED MICU [**2105-7-20**] 2:43 AM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 86081**]
Reason: Interval change?
[**Hospital 93**] MEDICAL CONDITION:
73 year old woman with likely CHF and pneumonia
REASON FOR THIS EXAMINATION:
Interval change?
Final Report
CHEST RADIOGRAPH
INDICATION: Chronic heart failure, pneumonia, assessment of
interval change.
COMPARISON: [**2105-7-19**].
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Minimal tendency to increasing consolidation at both
lung bases, as
manifested by slight decrease in extent of the previously
visible air
bronchograms. The lung volumes, however, are smaller than on the
previous
image. In the ventilated parts of the lung parenchyma, the
extent of the
pre-existing opacity is unchanged.
Brief Hospital Course:
#.Hypoxia: Pt presented to [**Hospital1 18**] on [**7-19**] with respiratory
distress and decreased O2 sats. Patient was given Ceftazidime,
80mg IV Lasix, nitro paste, and morphine prior to transfer to
[**Hospital1 18**] ED. Once at [**Hospital1 18**], she was placed on BiPAP with O2Sats
coming up to mid 90s. She was started on broad coverage with
cefepime and levofloxacin for presumed healthcare-associated
pneumonia. CXR was taken and showed both findings suggestive of
pulmonary edema and opacity probably representing atelectasis or
pleural effusion, but could not rule out infectious processes.
It was decided to continue antibiotic regimen. Overnight, pt
showed improving oxygen saturation, good urine output, and was
taken off BiPap in the early morning. It is unclear whether she
suffered flash pulm edema from a supraventricular tachycardia or
infectious etiology, but pt had not produced sputum, and
remained afebrile throughout ICU course. On [**7-20**], pt was
transferred to the general medicine floor on 4L NC, with sats in
the low 90s. Pt did not feel short of breath at this time, and
for the remainder of her hospital course. Lasix was provided IV
upon arrival to the floor, and was switched to PO home dose of
Lasix on [**7-21**]. It was presumed that her hypoxia was due to
pulmonary edema from the patient's CHF. On the evening of [**7-21**],
pt was able to discontinue O2 and did well until discharge on
[**7-22**], without SOB.
.
#.Diastolic CHF: pt was found to be fluid overloaded on
admission, and pt was given 80 mg IV Lasix twice while in the
ICU. She was -2L when transferred to the floor, with a slight
rise in Cr. Lasix was held on the night of [**7-20**], due to this.
In the afternoon of [**7-21**], Cr approached baseline, pt was
switched to PO home dose of Lasix (20 mg qdaily) and continued
to diurese. Upon discharge, pt was approximately negative
3.5-4L. Pt was continued on metoprolol while in the hospital,
but was not on spironolactone. Home doses of Lasix, metoprolol
and spironolactone should be continued upon discharge, as
written.
.
#.C. difficile pancolitis: pt came to the hospital on PO
Vancomycin for C. diff pancolitis, and was originally due to
finish this regimen on [**7-25**]. Due to patient being discharged on
PO levofloxacin for possible HAP, we lengthened this regimen to
avoid relapse to be finished on [**7-31**]. Pt did not complain of
abdominal pain or diarrhea during admission.
.
#.Tachycardia: pt's tachycardia was controlled during
hospitalization with home doses of metoprolol and amiodarone, to
be continued as written.
.
#.Chronic kidney disease: pt's Cr showed a small increase during
diuresis for fluid overload, but normalized according upon
titrating down the dose.
.
#.Glaucoma: home doses of medications were continued throughout
hospital course, and should be continued upon discharge as
written.
Medications on Admission:
1) traZODONE 25 mg PO/NG HS:PRN insomnia
2) Albuterol 0.083% Neb Soln 1 NEB IH Q6H
3) Magnesium Oxide 400 mg PO/NG TID
4) Lidocaine 5% Patch 1 PTCH TD DAILY
5) Ipratropium Bromide Neb 1 NEB IH Q6H
6) Ferrous Sulfate 325 mg PO DAILY
7) Vitamin D 1000 UNIT PO/NG DAILY
8) Calcium Carbonate 650 mg PO/NG [**Hospital1 **]
9) Artificial Tears 1-2 DROP BOTH EYES PRN dry eyes
10) Amiodarone 200 mg PO/NG DAILY
11) Acetaminophen 325-650 mg PO/NG Q6H:PRN pain
12) Furosemide 20 mg daily
13) Spironolactone 12.5 mg PO/NG DAILY
14) Omeprazole 20 mg PO BID
15) Metoprolol Succinate XL 100 mg PO DAILY
16) Oxycodone 5 mg [**Hospital1 **]
17) Vancomycin 250 mg PO QID
Discharge Medications:
1. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
3. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Daily weights
5. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-24**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
10. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
12. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 10 days.
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
15. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Nitroglycerin 2 % Ointment Sig: One (1) Transdermal Q6H
(every 6 hours) as needed for High BP.
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
18. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
19. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 4 days.
20. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO once a day.
21. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Hypoxia, Congestive heart failure
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
It was a pleasure to take care of you at the [**Hospital1 18**]. You came
for further evaluation of shortness of breath and low oxygen in
your blood. Tests showed that you had congestive heart failure.
You were treated with diuretics (water pills) and your shortness
of breath improved. You were treated with antibiotics for
possible pneumonia and for C. difficile colitis. It is
important that you continue to take all of your medications.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
The following changes were added to your medications:
Added levofloxacin
Followup Instructions:
Name: [**Last Name (LF) 38274**],[**First Name3 (LF) **] X.
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 19604**]
Phone: [**Telephone/Fax (1) 3530**]
Appointment: Tuesday [**2105-7-28**] 4:40pm
Please allow extra time to get to your appointment due to
construction in the garage. Thanks.
|
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[
[]
]
] |
11119, 11185
|
5664, 8559
|
322, 328
|
11262, 11262
|
3274, 4959
|
12074, 12424
|
2668, 2733
|
9264, 11096
|
4999, 5047
|
11206, 11241
|
8585, 9241
|
11440, 12051
|
2748, 3255
|
263, 284
|
5079, 5641
|
356, 1992
|
11277, 11416
|
2014, 2359
|
2375, 2652
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,136
| 149,711
|
9059
|
Discharge summary
|
report
|
Admission Date: [**2132-7-27**] Discharge Date: [**2132-8-1**]
Date of Birth: [**2065-10-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Fever, neutropenia and hypotension
Major Surgical or Invasive Procedure:
Transfused 2 units PRBC's
Bone Marrow Biopsy
History of Present Illness:
This is a 66 year old female with a history of CLL s/p treatment
with Campath in [**10/2131**], history of recurrent c.diff colitis in
[**5-10**], recent hospitalization for PCP pneumonia in [**6-10**]
complicated by readmission for aseptic meningitis thought to be
related to bactrim and treated with steroids who presents with
fevers. She notes that she had been in her usual state of
health since her last discharge on [**2132-7-10**]. She has been taking
her temperature almost daily given her recent hospitalizations
for infections. Today she noted that her temperature was 102.2.
She called her oncologist who then recommended that she come to
the hospital. She denies chills and nightsweats. Also denies
SOB, nausea, vomitting, chest pain, diarrhea, neck stiffness,
headaches or photophobia.
.
In ED T 99.8 (Tmax 102, given tylenol 1 gm) HR 133 BP 133/79 RR
16 97% RA. CBC notable for WBC 5200 with 4% bands, clean u/a,
cxr without infiltrate, LP benign (1WBC, neg gram stain), CT
head negative, lactate wnl. She was initially signed out for
admission to the oncology service, when she transiently dropped
her SBP to 86. She was given 3 L IVF, started empirically on
vancomycin and cefepime, and was given dexamethasone 10 mg. Her
SBP remained in the 100s at the time of transfer to the MICU.
.
On the floor, she feels comfortable and denied any complaints
other than concern regarding her new fever.
Past Medical History:
Oncologic Hx:
She completed two cycles of R-CVP back in [**7-/2130**] as part of her
initial treatment for CLL. She did not have a significant
response to treatment though her white count did normalize after
treatment. However, the patient remained with a predominance of
lymphocytes. She continued to have bulky lymphadenopathy both
above and below the diaphragm following this treatment, did have
slight interval decrease overall with the exception of a slight
increase in the size of her lymph nodes in the right
supraclavicular chain. She has remained with massive
splenomegaly. She had an extended hospitalization in [**8-/2130**] for
further workup for fever and night sweats. Her disease status
was reassessed with a bone marrow biopsy, which confirmed her
known history of CLL. She also had a lymph node biopsy of the
right supraclavicular node in order to rule out transformation
of her disease, which was also consistent with CLL without any
evidence of transformation. However, there was note of caseating
granuloma concerning for TB. She did have a PPD placed, which
was positive. Of note, she also developed a rash in this
setting, which eventually resolved. However, it was thought to
be related to TB, noted to be granuloma annulare on biopsy.
Ultimately, it was felt that she had extrapulmonary TB. She was
ultimately started on TB medication regimen with rifampin, INH,
ethambutol, and pyrazinamide. The patient was started on that at
the time of discharge from hospital on [**2130-8-18**]. At that
point, she was still having high fevers. After a few days of
being on this regimen, her high fevers improved. Of note, due to
a poor tolerability with anorexia, nausea, weight loss, and
fatigue, we switched her regimen. The ethambutol and
pyrazinamide were discontinued on [**2130-8-28**] and moxifloxacin
was added. She completed a six-month course of her TB medicines,
which she completed back in 02/[**2131**]. The patient refused to take
the medications any longer. She then had a slowly rising white
blood count over the past couple of months. Also has had a
depressed platelet count. Her CT scans have overall been stable,
but remained with persistent bulky disease above and below the
diaphragm with massive splenomegaly. Our recommendation had been
to proceed with a fludarabine-based regimen given her bulky
disease, but until recently the patient refused any treatment
and we had been monitoring her off treatment. She noted at the
beginning of [**2-/2131**] of her plans to go to [**Country 27587**] in [**Month (only) 116**] for
five or six months. As a result, she agreed to receive treatment
with FCR regimen, which she began on [**2131-2-14**]. The goal of
this was to cytoreduce her disease before she leaves for
[**Country 27587**]. The plan is to try to get two cycles in with time to
recover prior to her departure.
.
PAST MEDICAL HISTORY:
====================
1. CLL. Please refer to OMR note [**2131-4-4**] for extensive details.
2. Extrapulmonary TB diagnosed [**8-8**], now s/p 6 months of
therapy with rifampin, INH, and moxifloxacin.
3. Hypothyroidism
4. OA
5. Status post ERCP with sphincterotomy for gallstone
pancreatitis and cholangitis, [**4-10**]
6. Status post cholecystectomy [**2132-5-8**]
7. History of C. difficile
Social History:
From [**Country 27587**] lives with daughter, husband and [**Name2 (NI) 12496**],
retired, [**1-6**] ppd x 45 years quit 3 years ago, denies EtOH,
denies drugs.
Family History:
Non-contributory
Physical Exam:
Gen: Well appearing adult female, no acute distress.
HEENT: PERRL, EOMI. MMM. Conjunctiva well pigmented.
Neck: Supple
Chest: CTA b/l, no w/r/r
Cor: Normal S1, S2. RRR. [**2-8**] murmur non-radiating left upper
sternal border
Abdomen: Soft, mild lower quadrant tenderness. No R/G.
Non-distended. +BS.
Extremity: Warm, without edema. 2+ DP pulses bilat.
Neuro: Alert and oriented. CN 2-12 intact. Motor strength intact
in all extremities. Sensation intact grossly.
Pertinent Results:
[**2132-7-27**] 03:35PM BLOOD WBC-5.2 RBC-3.11* Hgb-9.1* Hct-27.0*
MCV-87 MCH-29.4 MCHC-33.7 RDW-16.2* Plt Ct-109*
[**2132-7-28**] 04:03AM BLOOD WBC-2.1*# RBC-2.38* Hgb-7.0* Hct-20.5*
MCV-86 MCH-29.7 MCHC-34.3 RDW-16.9* Plt Ct-68*
[**2132-7-29**] 04:29AM BLOOD WBC-2.7* RBC-2.86* Hgb-8.4* Hct-23.6*
MCV-83 MCH-29.3 MCHC-35.5* RDW-16.4* Plt Ct-74*
[**2132-7-27**] 03:35PM BLOOD Neuts-16* Bands-4 Lymphs-78* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2132-7-28**] 04:03AM BLOOD Neuts-15* Bands-0 Lymphs-79* Monos-5
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2132-7-29**] 04:29AM BLOOD Neuts-26.6* Bands-0 Lymphs-68.2*
Monos-2.8 Eos-2.0 Baso-0.4
[**2132-7-28**] 08:00AM BLOOD I-HOS-AVAILABLE
[**2132-7-29**] 04:29AM BLOOD Hypochr-1+ Anisocy-OCCASIONAL Poiklo-1+
Macrocy-NORMAL Microcy-OCCASIONAL Polychr-NORMAL Ovalocy-1+
Schisto-OCCASIONAL Tear Dr[**Last Name (STitle) 833**]
[**2132-7-27**] 03:35PM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-1+ Polychr-NORMAL Ovalocy-2+ Tear Dr[**Last Name (STitle) **]1+
Bite-OCCASIONAL
[**2132-7-29**] 04:29AM BLOOD PT-11.8 PTT-24.7 INR(PT)-1.0
[**2132-7-29**] 04:29AM BLOOD FDP-0-10
[**2132-7-29**] 04:29AM BLOOD Fibrino-243
[**2132-7-29**] 04:29AM BLOOD [**Doctor Last Name 17012**]-NEGATIVE
[**2132-7-29**] 04:29AM BLOOD Glucose-123* UreaN-24* Creat-0.6 Na-138
K-4.0 Cl-111* HCO3-18* AnGap-13
[**2132-7-27**] 03:35PM BLOOD Glucose-106* UreaN-33* Creat-1.0 Na-132*
K-5.2* Cl-100 HCO3-24 AnGap-13
[**2132-7-28**] 04:03AM BLOOD Glucose-216* UreaN-22* Creat-0.7 Na-137
K-4.6 Cl-111* HCO3-17* AnGap-14
[**2132-7-27**] 03:35PM BLOOD ALT-32 AST-24 CK(CPK)-10* AlkPhos-110
TotBili-1.2
[**2132-7-29**] 04:29AM BLOOD TotBili-0.9
[**2132-7-28**] 08:00PM BLOOD LD(LDH)-219 TotBili-0.9
[**2132-7-27**] 03:35PM BLOOD Lipase-81*
[**2132-7-29**] 04:29AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.9
[**2132-7-28**] 04:03AM BLOOD Calcium-8.1* Phos-3.6 Mg-2.0
[**2132-7-27**] 03:35PM BLOOD Calcium-8.6 Phos-3.4 Mg-1.8
[**2132-7-28**] 08:00PM BLOOD Folate-14.1 Hapto-<20*
[**2132-7-29**] 04:29AM BLOOD Hapto-<20*
[**2132-7-28**] 05:20AM BLOOD Cortsol-18.0
[**2132-7-27**] 03:42PM BLOOD Lactate-1.1
[**2132-7-27**] 04:45PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
[**2132-7-27**] 04:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2132-7-27**] 08:06PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 Polys-0
Lymphs-100 Monos-0
[**2132-7-27**] 08:06PM CEREBROSPINAL FLUID (CSF) TotProt-37 Glucose-38
Blood Cultures: Pending
CSF Culture [**2132-7-27**]: No growth, prelim
Urin Culture7/26/09: No growth, final
Brief Hospital Course:
This is a 66 year old female with history of CLL with multiple
recent hospitalizations for infections here with a fever,
neutropenia and transient hypotension.
# Transient hypotension: Patient met SIRS criteria with fever
and tachycardia, without clear source for infection and stable
blood pressures, after administration of 3L NS in the ED, and
with a normal lactate. During her [**Hospital Unit Name 153**] course she never had
clear localizing symptoms and no known previous indwelling line
or hardware, that could explain her fever. She was empirically
treated for febrile neutropenia (WBC range from 2.1-3.3) with
cefepime and vancomycin. Blood cultures, CSF cultures and Urine
cultures drawn have been negative to date. Her recent steroid
use and the abrupt discontinuation of this drug may have
contributed to her hypotensive episode, but her [**Last Name (un) 104**] stimulation
was appropriate, pre ACTH cortisol level 0.9, 18 post ACTH
stimulation. She remained hemodynamically stable throughout the
rest of her [**Hospital Unit Name 153**] stay. All cultures were negative for growth
from admission. On the evening of [**7-29**], she spiked a temp to
103 and became tachycardic to 130s. She was bolused with IVF
without any significant change in HR. She maintained sats on RA
and BP remained stable while heart rates trended down overnight
with tylenol. Additional cultures were obtained and hct was
stable at 24-25. The patient was continued oh her antibiotics
and was stable and afebrile upon transfer to 7F. Her pressures
were stable and her neutropenia resovled.
#Acute anemia: Pt??????s hct dropped from 27 on admission to 20.5 on
the night of [**7-28**]. She was transfused 2 units PRBC??????s and did
not have an appropriate response as her Hct only increased to
24.5. On [**7-29**] her Hct decreased to 23.6. No obvious source of
bleeding was found. Hemolysis, as a cause, was pursued.
Hemolysis laboratories(Haptoglobin <20, Tbili 0.9, LDH 219,
[**Doctor Last Name 17012**] body negative, Coombs test pending) have been negative to
date. Decresed production as a possible explanation was also in
the differential diagnosis. Parvo virus PCR was ordered and is
pending result, and a folate level was normal.
.
# Heart Murmur: No prior documentation of heart murmur was
found but a prior ECHO in [**2131**] showed 1+ TR/MR. [**Name14 (STitle) **] was done
which resulted in no vegetations seen and MR was improved from
previous study. Cultures have been negative to date, but in a
pt with fever, endocarditis was on differential. Given negative
cultures to date and no vegetations on [**Name14 (STitle) **], Vancomycin was dc'd
on [**7-29**].
.
# Tachycardia: Patient presented w/ sinus tach to 130s and this
initially resolved after administration of IVF. However, on [**7-29**]
her HR spiked into 130s with fever to 103 and did not respond to
bolused IVF. Pt remained hemodynamically stable without any
evidence of hypoxia or SOB. HR trended down spontaneously with
fever resolution.
.
# Hyponatremia: Patient had a Na of 132 on admission which
quickly resolved after administration of IVF (138 on [**7-29**]).
Hypovolemia was likely the cause of this hyponatremia. But as
noted above adrenal insufficiency also on differential, although
her [**Last Name (un) 104**] stim was appropriate.
.
# CLL: Patient has a p53 mutation and is s/p multiple rounds of
chemo (last Campath [**10-9**], previously fludarabine-based therapy
CVP, CHOP) with continued bulky lymphadenopathy and
splenomegaly. Prophylaxis with fluconazole, vancomycin PO and
atovaquone were continued. She is followed by Dr. [**Last Name (STitle) **].
Medications on Admission:
Levothyroxine 137 mcg daily
Omeprazole 20 mg qd
Vancomycin 250 mg Capsule daily
Bactrim DS 2 tabs q6h
Folic acid 1mg daily
Fluconazole 100mg
1. Atovaquone 750 mg/5 mL Suspension Sig: Two (2) teaspoons PO
once a day.
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) once a day.
4. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO once a
day.
5. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
6. Dexamethasone 2 mg Tablet Sig: one daily.
7. Vancomycin 250mg daily.
Discharge Medications:
1. Atovaquone 750 mg/5 mL Suspension Sig: Two (2) PO DAILY
(Daily).
2. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
5. Folic Acid 1 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
8. Vancocin 250 mg Capsule Sig: One (1) Capsule PO once a day.
9. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO twice a
month.
Discharge Disposition:
Home
Discharge Diagnosis:
Lymphoma
Pneumonia
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with fevers and low blood pressure. You were
given antibiotics and your fevers resolved. You were given
fluids and your blood pressure improved.
.
You were prescribed an antibiotic. Please take your home
medications as before.
.
Please attend your follow up appointments. They are listed
below.
.
Please contact your oncologist or present to the emergency
department if you experience fevers, dizziness, loss of
consciousness, cough, shortness of [**Last Name (STitle) 1440**] or any other symptoms
that you find concerning.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2132-8-7**] 1:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9574**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3241**]
Date/Time:[**2132-8-7**] 1:00
|
[
"995.90",
"283.9",
"785.0",
"244.9",
"276.52",
"204.10",
"276.1",
"780.60",
"284.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"41.31",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
13484, 13490
|
8487, 12150
|
350, 396
|
13553, 13562
|
5847, 8464
|
14153, 14473
|
5329, 5347
|
12754, 13461
|
13511, 13532
|
12176, 12731
|
13586, 14130
|
5362, 5828
|
276, 312
|
424, 1844
|
4741, 5135
|
5151, 5313
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,415
| 162,957
|
21581
|
Discharge summary
|
report
|
Admission Date: [**2199-3-19**] Discharge Date: [**2199-4-3**]
Date of Birth: [**2144-6-14**] Sex: F
Service: MEDICINE
Allergies:
Antipsychotic Drug / Antidepressant Combinations O.U. Classif
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
transferred to MICU for hypoxemia and GIB
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
53-year-old female with a history of hepatitis C diagnosed about
10 years ago, depression and anxiety presented to ED [**3-19**] with
confusion and recent falls. Pt was unable to give a history and
cries to questions, so the history was taken from notes. She
recently established her care at [**Hospital1 18**] in [**3-20**]. She has had
multiple admissions in the past at an OSH for decompensation of
her cirrhosis and encephalopathy. She now lives in a nursing
home [**1-17**] psych issues. She intially presented from [**Location (un) **]
North with increased lethargy, slurred speech, confusion,
feeling of lightheadedness with standing, low grade temp to
99.7. She also had 2 falls on [**2199-3-18**]. At baseline she is alert
and oriented, and independent with all ADLs with activity. She
was unable to give a review of systems. She was found to be
guaiac negative in the ED.
Past Medical History:
PAST MEDICAL HISTORY:
Major Depressive Disorder
anxiety
diabetes TYPE 2
hypothyroid
fibroids
hepatitis C genotype 1 with VL 1.9 million
COPD
GERD
Social History:
She reports smoking 2 cigarettes per day. She denies any IV drug
use or any alcohol use, although she has a history of alcohol
abuse in the past, but she reports she has not had any alcohol
for the past 6 years.
Family History:
Significant for mother who had coronary artery disease and
diabetes.
Physical Exam:
Tm 99.5, Tc 99.5, BP 113/66 P 110, R 30, 73% 2L, 88% NRB
Gen: blood dripping from nose and mouth, unresponsive
HEENT: aniceric, 7-8 mm pupils, PERRL, OP with blood.
Neck: JVP 8-9 cm
CV: RRR, nl s1, s2, no m/g/r
Lungs: decreased breath sounds at bases
Abd: BS+, soft, NT, ND, ? palpable liver edge 1 fingerbreadth
below rib cage
Back: no CVA tenderness
Ext: no edema
Skin: no rash
Pertinent Results:
An EGD on [**2198-5-9**], revealed grade 2 esophageal varices.
The patient had an abdominal ultrasound performed on [**2198-5-9**], which revealed:
1. Heterogeneous liver consistent with cirrhosis but no focal
liver lesions.
2. Splenomegaly.
.
[**3-19**] Abd U/S: Extremely limited [**1-17**] pt being uncooperative. No
main portal vein thrombosis. No appreciable ascites.
.
[**3-19**] CT head: No acute intracranial hemorrhage.
.
[**3-19**] CXR: Mild congestive heart failure with cardiomegaly. Left
lower lobe opacity indicating pneumonia vs. atelectasis.
.
[**2199-3-19**] 03:21PM K+-4.3
[**2199-3-19**] 03:00PM LD(LDH)-226 DIR BILI-1.1*
[**2199-3-19**] 03:00PM IRON-131
[**2199-3-19**] 03:00PM calTIBC-354 VIT B12-1269* FOLATE-7.3
HAPTOGLOB-<20* FERRITIN-59 TRF-272
[**2199-3-19**] 03:00PM TSH-23*
[**2199-3-19**] 02:30PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.020
[**2199-3-19**] 02:30PM URINE BLOOD-TR NITRITE-POS PROTEIN-NEG
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
[**2199-3-19**] 02:30PM URINE RBC-[**2-17**]* WBC->50 BACTERIA-MANY
YEAST-NONE EPI-0-2
[**2199-3-19**] 01:30PM LACTATE-1.2
[**2199-3-19**] 01:20PM GLUCOSE-52* UREA N-28* CREAT-1.2* SODIUM-138
POTASSIUM-5.1 CHLORIDE-106 TOTAL CO2-17* ANION GAP-20
[**2199-3-19**] 01:20PM ALT(SGPT)-35 AST(SGOT)-109* ALK PHOS-70
AMYLASE-14 TOT BILI-2.1*
[**2199-3-19**] 01:20PM LIPASE-25
[**2199-3-19**] 01:20PM AMMONIA-113*
[**2199-3-19**] 01:20PM WBC-8.2 RBC-3.77* HGB-11.8* HCT-34.0* MCV-90
MCH-31.1 MCHC-34.5 RDW-16.2*
[**2199-3-19**] 01:20PM NEUTS-75.0* LYMPHS-15.8* MONOS-6.6 EOS-2.1
BASOS-0.7
[**2199-3-19**] 01:20PM ANISOCYT-1+
[**2199-3-19**] 01:20PM PLT COUNT-68*
Brief Hospital Course:
53 F with PMH Hep C cirrhosis (diagnosed 10 years ago),
depression/anxiety, presenting with hypoxic respiratory failure,
confusion, recent falls, UTI, pna, GIB (esophageal varices vs.
nasopharynx), passed away in the MICU.
Events leading up to MICU admission:
On [**3-19**], she had a traumatic NGT placement in ED. On [**3-20**] an NGT
placement was attempted to give lactulose as MS [**First Name (Titles) **] [**Last Name (Titles) 56843**]d. Pt had OGT placed and she was not GIB then.
Lactulose was given through OGT. O2 sats dropped to almost 73%
on 2L NC with bleeding around the nose and mouth with ?
hematemesis/aspiration. Pt was placed on NRB satting at 88%,
with HR 110, RR 32, BP 110/64. Coarse resp sounds heard but no
heart sounds were heard although she had a good pulse. Code blue
was called anesthesia intubated the patient and she was
transferred to the MICU.
# Altered mental status:
The patient was admitted to the MICU in altered mental status
and after code blue. She had an extensive history of severe hep
C cirrhosis and encephalopathy. Given this substrate, UTI and
possible LLL pneumonia, this would likely explain her decline in
mental status. Her UTI and pna were treated with Zosyn and Vanc.
Her cirrhosis care included rifaximin, lactulose to attain [**2-16**]
BMs per day. Liver team was following. TSH on admission was 23,
and levothyroxine was increased to 150 mcg per day after
adjusting thyroid function labs for sick euthyroid. Her
psychiatry medications were held inhouse. After her vital signs
had stabilized, she was started on ritalin to help with a
possible depressive component (the patient had an extensive
psychiatric history).
Although her vitals, lytes, acid-base status, oxygenation status
were all recovered to baseline, she never woke up and regained
normal mental status again. She was made CMO and passed away
shortly after withdrawing care.
# Hypoxic respiratory failure:
Her hypoxemia was likely due to MRSA aspiration pneumonia. She
was very short of breath on 15L rebreather and 5L nc with sats
89-95%. She was intubated on PS 10/5 Fi02 100% Rate 26, and was
started on ARDS ventilation [**2198-3-21**]. She was aggressively
diuresed, improved in respiratory status, moved to CPAP w/ PS
support and was tolerating it well. She completed a 10 day
course on Vancomycin and Zosyn on [**2200-3-28**], with one sputum cx
positive for MRSA.
Differential for her hypoxia was aspiration pneumonia,
hepatopulmonary syndrome, pulmonary AVMs, aspiration, pulmonary
edema from CHF exacerbation. She had TTE with bubble study to
assess for shunt for workup for hepatopulmonary syndrome, and
TTE showed LVEF 55%, small secundum ASD with bidirectional flow.
Decision was made not to perform perfusion scan of brain and
kidneys (using technetium-microalbumin) to assess for pulmonary
AVMs, since etiology of hypoxia was most likely aspiration.
# Sepsis from UTI and pneumonia:
Etiology was likely secondary to sepsis from both UTI and LLL
PNA. UTI grew pan sensitive Ecoli. She was aggressively
resuscitated with IVF and was on levophed and vasopressin for a
few days before she was weaned with stable vitals. She failed
her [**Last Name (un) 104**] stim test and was started on hydrocort and fludrocort.
Her WBC increased from 25 to 31 before she had been started on
steroids. Her pancreatic enzymes were elevated. Differential
included fungemia, Cdiff, leukemoid reaction, line infection,
cholangitis, sinusitis, malignancy. US Abdomen with Doppler
showed no bile duct dilation (0.62 cm) from gallstone or sludge
obstruction, and pt was s/p CCY. Fungal blood culture was
negative. Stool was negative for Cdiff x4, and toxin A was
negative. Due to patient's tenuous clinical status, concern for
anticoagulation, baseline clinical status, LP was not performed.
She was started on Flagyl for presumptive Cdiff although
multiple testing was negative. Ceftriaxone was stopped after 1
day for lack of source. For possible line infection, her line
was re-sited from LSC to RSC [**3-31**]. At this point, she had
already completed a 10 day course of Vanco/Zosyn.
# GIB (nasopharyngeal vs esophageal):
NG lavage performed was clear, patient had possible esophageal
GIB with a 7 point Hct drop from baseline 42 from [**5-20**], but Hct
was stable during this admission. Her last EGD showed grade 2
esophageal varices. PPI IV BID was continued and GI consult was
following. On admission, her stool was brown and guaiac
negative. Iron, B12, and folate studies were normal. Hemolysis
labs were negative.
#. Hep C cirrhosis:
The patient had a history of multiple admissions for
encephalopathy. Her total bilirubin was 2.1, which was stable
from [**5-20**]. Her coags and LFTs were monitored with minimal change
during admission.
# ARF with gap and non-gap acidosis:
Her acidosis (HCO3 13) was likely secondary to diarrhea,
iatrogenic from NS, and from ATN. She had metabolic acidosis
with respiratory compensation and delta/delta < 1. She was
changed to LR boluses with improving bicarb. Aldactone, lasix,
HCTZ were held. Her Cr was elevated but normalized over her
admission.
# Cardiac:
For her ischemia issues, she had a troponin leak to 1.9. TTE was
done and showed EF 30% (previously normal EF) with global
hypokinesis. She was started on low dose hydralazine for
afterload reduction (was frequently held due to hypotension) and
patient remained hemodynamically stable. She was in NSR during
her admission.
Medications on Admission:
Medications at NH:
Triamterene/HCTZ 37.5/25 QD
Lasix 20 mg QD
ASA 81 mg QD
Rifaximin
Aldactone 100 mg QD
Zoloft 200 mg QD
Buproprion 75 mg [**Hospital1 **]
Carafate 1 gm [**Hospital1 **]
Protonix 40 QD
Glipizide 2.5 QD
Oxybutynin 5 mg [**Hospital1 **]
Colace 100 TID
Synthroid 125 mcg QD
Ambien 10 mg QHS
MVT with minerals 1 QD
Lactulose 30 ml QID
Risperdal 1 mg QHS
ASA 325 Q6 PRN
Robitussin PRN
Ativan 0.25 mg QHS PRN
.
Medications on transfer:
Albuterol nebs
Heparin SQ
Insulin SS
Lactulose 30 QID
levothyroxine 125 mcg
levoflox 250 IV qd
atvan 0.25 mg PO qhs
protonix 40 IV Bid
rifamixin 400 TID
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired.
Discharge Condition:
Expired.
Discharge Instructions:
Expired.
Followup Instructions:
Expired.
Completed by:[**2201-2-25**]
|
[
"305.1",
"287.5",
"785.52",
"518.81",
"428.0",
"255.4",
"285.29",
"486",
"745.5",
"507.0",
"070.44",
"286.7",
"530.81",
"577.1",
"041.4",
"250.00",
"784.7",
"571.5",
"410.71",
"599.0",
"933.1",
"414.8",
"244.9",
"496",
"584.9",
"V15.88",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"98.14",
"96.6",
"93.90",
"38.93",
"96.04",
"54.91",
"96.72",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
10023, 10032
|
3922, 4812
|
362, 374
|
10084, 10094
|
2190, 2576
|
10151, 10190
|
1702, 1773
|
10053, 10063
|
9398, 9820
|
10118, 10128
|
1788, 2171
|
280, 324
|
402, 1285
|
2585, 3899
|
4827, 9372
|
9845, 10000
|
1329, 1455
|
1471, 1686
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,697
| 187,079
|
41081
|
Discharge summary
|
report
|
Admission Date: [**2114-2-9**] Discharge Date: [**2114-2-15**]
Date of Birth: [**2038-2-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Allerest
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Heartburn
Major Surgical or Invasive Procedure:
[**2114-2-9**] Aortic valve replacement (23mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Epic porcine
valve)
coronary artery bypass graft x4 (left internal mammary artery >
left anterior descending, Saphenous vein graft > RAMUS > Y graft
saphenous vein graft > diagonal, Saphenous vein graft > obtuse
marginal)
History of Present Illness:
75 year old male with known aortic stenosis, followed by
echocardiogram for several years. Recently has been having
"heartburn" and pressure discomfort on exertion, which lasts
approximately 10-15 minutes and is relieved with rest.
Additionally, mean gradient across aortic valve is increasing.
He is referred for surgical evaluation.
Past Medical History:
Aortic stenosis
Hypertension
Hyperlipidemia
Gastric esophageal reflux disease
Subdural hematoma s/p fall [**2110**]
Obstructive sleep apnea
s/p Total Hip Replacment [**2098**]
s/p arthroscopic left knee [**2108**]
s/p shoulder surgery [**2093**]
s/p rotator cuff [**2094**]
s/p cholecystectomy
Social History:
Lives with: significant other
Occupation: sales for water testing company
Tobacco: quit 42 years ago
Family History:
Non-contributory
Physical Exam:
Pulse: 77 Resp: 16 O2 sat: 98%
B/P Right: Left: 120/69
Height: 5'9" Weight: 200 lb
General: NAD
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 2/6 SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema- none
Varicosities: None [x]
Neuro: Grossly intact x
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit no bruits
Pertinent Results:
[**2114-2-9**] Echo: Pre CPB: No spontaneous echo contrast or thrombus
is seen in the body of the left atrium or left atrial appendage.
No atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. 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 ascending
aorta is mildly dilated. There are simple atheroma in the aortic
arch. There are simple atheroma in the descending thoracic
aorta. There are three aortic valve leaflets. The aortic valve
leaflets are severely thickened/deformed. There is moderate
aortic valve stenosis (valve area 1.0-1.2cm2). Trace aortic
regurgitation is seen. There is no mitral valve prolapse.
Physiologic mitral regurgitation is seen (within normal limits).
Post CPB: There is preserved biventricular systolic
function.Thre is a well seated, well functioning bioprosthesis
in the aortic position. There is no AI visuailzed. Remaining
study is unchanged from prebypass.
[**2-14**] CXR: The patient is status post median sternotomy and
coronary artery bypass surgery. Cardiomediastinal contours are
similar in appearance compared to prior postoperative
radiographs allowing for patient rotation. Pulmonary vascularity
is normal. Slight worsening in degree of atelectasis in the left
lower lobe with persistent elevation of left hemidiaphragm and
small left pleural effusion. Small right pleural effusion is
either new or increased from prior study (previous exam did not
have a lateral radiograph, limiting comparison). No visible
pneumothorax. Calcified pleural plaque is incidentally noted.
[**2114-2-9**] 12:56PM BLOOD WBC-14.4*# RBC-3.36*# Hgb-11.0*#
Hct-31.0*# MCV-92 MCH-32.8* MCHC-35.6* RDW-13.3 Plt Ct-116*
[**2114-2-13**] 08:44AM BLOOD WBC-9.1 RBC-3.37* Hgb-10.8* Hct-30.6*
MCV-91 MCH-32.2* MCHC-35.4* RDW-14.4 Plt Ct-102*#
[**2114-2-9**] 12:56PM BLOOD PT-14.4* PTT-42.0* INR(PT)-1.2*
[**2114-2-14**] 04:25AM BLOOD PT-14.3* INR(PT)-1.2*
[**2114-2-9**] 01:53PM BLOOD UreaN-25* Creat-1.0 Na-139 K-4.3 Cl-110*
HCO3-23 AnGap-10
[**2114-2-13**] 08:44AM BLOOD Glucose-113* UreaN-32* Creat-1.0 Na-137
K-4.0 Cl-101 HCO3-28 AnGap-12
[**2114-2-14**] 04:25AM BLOOD UreaN-31* Creat-1.0 Na-136 K-3.9 Cl-101
[**2114-2-9**] 08:08PM BLOOD Mg-3.1*
[**2114-2-14**] 04:25AM BLOOD Mg-2.2
Brief Hospital Course:
Mr. [**Known lastname 89564**] was Admitted same day as surgery and underwent aortic
valve replacement and coronary artery bypass graft surgery, see
operative report for further details. He was transferred to the
intensive care unit for post operative management. In the first
twenty four hours he was weaned from sedation, awoke and was
extubated without complications. He continued to progress
except some confusion and narcotics were discontinued and he was
placed on Tylenol which was effective for pain. He additionally
went into rapid atrial fibrillation then junctional rhythm with
hypotension treated with fluids and pacing. Electrophysiology
was consulted for arrhythmia, all beta blockers were stopped and
he continued in atrial fibrillation, rate controlled 70-90's.
He continued to progress and was started on Coumadin for atrial
fibrillation. He was transferred to the floor for the remainder
of his care. He was restarted on Lopressor and amiodarone bolus
150 mg once with conversion to sinus rhythm. He continued in
sinus rhythm and EP reevaluation felt he was stable with beta
blockers but thought no further amiodarone due to sinus node
dysfunction. Epicardial wires removed and Coumadin was
continued. He was ready for discharge to rehab ([**Hospital1 **] [**Location (un) 1110**])
on post operative day five. He should remain on continuous
telemetry while in rehab. All appropriate medications and
follow-up appointments were given.
Medications on Admission:
lisinopril 40mg daily
simvastatin 40mg daily
asa 81mg daily
metoprolol 12.5mg daily
omeprazole 40mg daily
Celebrex 200mg prn
Tylenol arthritis prn
MVI daily
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for fever/pain. Tablet(s)
2. Outpatient Lab Work
Labs: PT/INR for Coumadin ?????? indication atrial fibrillation
Goal INR 2-2.5
First draw [**2-16**]
Rehab physician to dose coumadin based on INR while at rehab
then please contact [**Name (NI) **] heart center coumadin clinic phone
[**Telephone/Fax (1) 6256**] fax [**Telephone/Fax (1) 31080**] - and they will follow as
outpatient
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. aspirin, buffered 81 mg Tablet Sig: One (1) Tablet PO once a
day.
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
7. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): please do not titrate due to sinus node
dysfunction as per EP attending .
8. warfarin 1 mg Tablet Sig: One (1) Tablet PO ONCE (Once):
please give 1 mg on [**2-15**] and check INR [**2-16**] for further dosing -
goal INR 2.0-2.5 for atrial fibrillation - please titrate slowly
- received 1mg on [**2-14**] INR 1.2.
9. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
11. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day.
12. Outpatient Lab Work
please check chem 7 to evaluate electrolytes [**2-16**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
Aortic stenosis s/p AVR
Coronary artery disease s/p CABG
Atrial fibrillation
Hypertension
Hyperlipidemia
Gastroesophageal reflux disease
Obstructive sleep apnea (no mask at home)
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with walker, needs more assistance in am due to
arthritis
Incisional pain managed with tylenol prn
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, ecchymosis, no erythema or drainage.
Edema +1 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**]
**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) **] at MWHC [**Telephone/Fax (1) 6256**] [**3-1**] at 9 am
Cardiologist: Dr [**Last Name (STitle) 4610**] [**Telephone/Fax (1) 6256**] [**3-8**] at 9am
Please call to schedule appointments with your
Primary Care Dr [**Doctor Last Name 27303**] in [**2-20**] weeks [**Telephone/Fax (1) 85121**]
**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 [**2-16**]
Rehab physician to dose coumadin based on INR while at rehab
then please contact [**Name (NI) **] heart center coumadin clinic phone
[**Telephone/Fax (1) 6256**] fax [**Telephone/Fax (1) 31080**] - and they will follow as
outpatient
Please titrate up coumadin slowly - history of subdural hematoma
from fall in past
Completed by:[**2114-2-15**]
|
[
"427.81",
"427.31",
"293.9",
"426.3",
"276.69",
"272.4",
"530.81",
"327.23",
"424.1",
"414.01",
"458.29",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"39.61",
"36.15",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
7677, 7760
|
4513, 5976
|
284, 618
|
7983, 8273
|
2099, 2970
|
9113, 10102
|
1433, 1451
|
6183, 7654
|
7781, 7962
|
6002, 6160
|
8297, 9090
|
1466, 2080
|
235, 246
|
646, 982
|
1004, 1299
|
1315, 1417
|
2980, 4490
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,361
| 197,330
|
7762
|
Discharge summary
|
report
|
Admission Date: [**2189-12-16**] Discharge Date: [**2189-12-25**]
Date of Birth: [**2142-8-18**] Sex: M
Service: [**Company 191**]
HISTORY OF PRESENT ILLNESS: The patient is a 47 year old
male with a history of HIV (CD4 count was 393; viral load,
undetectable on [**10-3**]). He presented to his Primary Care
Physician's office with a two to three day history of
nonproductive cough, chills and disorientation. The patient
was seen in the Clinic on [**2189-12-14**], initially and
treated with Biaxin for a pneumonia. The patient did not
improve on Biaxin. The patient reports a nonproductive
cough, subjective fevers and shortness of breath. The
patient denies hemoptysis, nausea, vomiting and abdominal
pain, diarrhea, headache or neck stiffness. He reports no
photophobia or visual changes.
In the Emergency Department, the patient had an oxygen
saturation of 80 percent on room air which improved to 94
percent on 100 percent nonrebreather at a rate of 20. An
arterial blood gases on the 100 percent rebreather was
7.28/60/102 and the chest x-ray revealed right sided
opacities in the right upper, right middle and right lower
lungs. The patient was hemodynamically stable. The patient
did not tolerate a trial of BiPAP in the Emergency
Department. The patient was given Vancomycin, Ceftriaxone,
Levofloxacin, nebulizer treatments x 3 and 3 liters normal
saline. The patient was admitted to the MICU for further
monitoring.
An echocardiogram in the Emergency Department was obtained
for increased jugular venous pressure which was negative for
any pericardial effusion.
PAST MEDICAL HISTORY:
1. HIV diagnosed in [**2183**].
2. Hepatitis C, status post 48 weeks of Interferon
treatment.
3. Hepatitis B.
4. Exposure to tuberculosis.
5. Depression.
SOCIAL HISTORY: The patient reports a history of intravenous
drug use and is currently on Methadone maintenance. The
patient has not used intravenous drugs for greater than ten
years. The patient denies any other drug use. The patient
also has a history of incarceration. The patient is
unmarried with no children. The patient reports a one to two
pack per day smoking history. The patient currently lives
with his mother.
MEDICATIONS:
1. Methadone 20 mg p.o. q day.
2. Klonopin one tab p.o. q d.
3. Combivir one tab p.o. b.i.d.
4. Crixivan one tab p.o. b.i.d.
5. Biaxin 500 mg p.o. b.i.d.
ALLERGIES: There are no known drug allergies.
PHYSICAL EXAMINATION: Physical examination on admission:
Temperature, 98; blood pressure, 117/69; heart rate, 88;
respiratory rate, 18; oxygen saturation, 99 percent on 100
percent nonrebreather, 94 percent on 50 percent. In general,
the patient was in moderate respiratory distress, cachectic.
Head, eyes, ears, nose and throat: Pupils were equally
reactive to light with scleral icterus. Neck was positive
for shotty cervical lymphadenopathy and a jugular venous
pulse of 11 cm. Neck was noted to be supple. Lungs revealed
coarse breath sounds bilaterally with poor air movement,
prolonged I:E ratio. There are no wheezes, no dullness to
percussion. Cardiac exam was notable for tachycardia. There
were no murmurs. Abdomen was soft, nontender, nondistended
with bowel sounds. Extremities, no clubbing, cyanosis or
edema. Neurological examination, the patient was alert and
oriented x 3. Cranial nerves II through XII are intact.
Five out of five motor strength with deep tendon reflexes +2
in all four extremities. The sensation was intact.
LABORATORY: Laboratory data on admission: White count was
10.8. Hematocrit, 33.5; platelets, 130; MCV, 122.
Differential is 84 percent neutrophils with 11 percent bands,
4 percent lymphocytes and 1 percent monos. The chem 7 was
all within normal limits. Of note, the creatinine was 1.2.
Liver enzymes on admission were notable for an AST of 148;
ALT, 54; alk phos, 168; amylase, 31; total bili, 4; lipase,
7; LDH, 435; albumin 2.7. An arterial blood gas on admission
is noted in the HISTORY OF PRESENT ILLNESS. A urinalysis was
negative.
A chest x-ray revealed dense consolidation of the right
upper, middle and lower lobes with air bronchograms. An
echocardiogram revealed an ejection fraction of 60% without
pericardial effusion.
Serum toxicology was negative. Urine toxicology was positive
for benzodiazepines, Methadone and opiates.
The patient is a 47 year old male with HIV, hepatitis C,
hepatitis B and history of tuberculosis exposure,
incarceration, who presented with cough, shortness of breath,
chills, fevers and increased white count with bandemia. The
patient was admitted to the Intensive Care Unit for further
monitoring of his respiratory status.
HOSPITAL COURSE:
1. Pneumonia - The patient was initially on Levofloxacin and
Ceftriaxone for the purpose of community acquired pneumonia.
On hospital day #2, the patient was also started on
Vancomycin given a gram stain sputum positive for Methicillin
resistant Staphylococcus aureus. Subsequently, Levofloxacin
and Ceftriaxone were discontinued. Urinary Legionella
antigen was negative. The patient was also ruled out for
tuberculosis with acid fast bacilli negative x 3. Induced
sputum for PCP was also negative.
At the time of discharge, the patient remains on day #9 of
#14 of Vancomycin therapy.
The patient's oxygenation status remained stable on the night
of admission. On hospital day #2, the patient was
transferred to the Floor where he continued to require oxygen
supplementation via nasal cannula. The patient maintained
saturations greater than 94% throughout the admission,
however on hospital day #7 the patient had an episode of
acute desaturation with a decrease in O2 saturation to 68% on
room air. The patient was given nebulizer treatments and
pulmonary toilet with expiration of thick secretions and
improvement in saturations to 94% on a 70% mask. However the
patient throughout the morning continued to remain lethargic
and tachypneic and increased respiratory rate at 24. He was
placed on 100 percent nonrebreather and a blood gas at this
time revealed a pH of 7.24/CO2 95%/O2 139. It was thought at
this time that the patient was experiencing acute respiratory
distress secondary to narcotics, specifically his 90 mg dose
of Methadone. The patient was given a 0.4 mg dose of Narcan
and the patient was noted to be more arousable.
A repeat gas was notable for a pH of 7.4/61/79 on six liters.
However, throughout the morning, the patient intermittently
was found to be lethargic and required three more doses of
Narcan. After the fourth total dose of the morning, the
patient continued to have a stable respiratory status with
the last gas revealing 7.44/57/58 on six liters of nasal
cannula. The patient had no further episodes of desaturation
throughout the remainder of the hospital stay.
Upon discharge, the patient continues to require six liters
of nasal cannula in order to maintaine oxygen saturations
greater than 92%.
2. Human immunodeficiency: Initially upon admission the
patient's anti-retroviral of medications were held secondary
to poor p.o. intake. HAART therapy was resumed on hospital
day #2 as the patient tolerated p.o.'s. Current regimen was
continued throughout the remainder of the hospital stay.
3. Increased liver function tests: Given increased liver
function tests, the patient had a right upper quadrant
ultrasound that showed dilation of both the extra and intra
hepatic ducts. No stones or sludge. The impression was that
this may be consistent with HIV cholangiopathy and
recommended further evaluation as needed. LFTs were followed
for several days after procedure and noticed to be down
trending throughout the remainder of the hospital stay.
4. Thrombocytopenia: On the day of admission, the patient's
platelets were noted to be 130,000. Throughout the hospital
stay, the patient had a decrease of his platelets to a nadir
of 565. Hospital day #7 showed no evidence of bleeding or
purpura. Heparin induced thrombocytopenia antibody was sent
and remains pending at this time. All Heparin flushes and
subcutaneous Heparin were discontinued at this time. The
patient had an increase in platelet levels throughout the
remainder of the hospital stay. Platelets are 115 on date of
discharge.
5. Anemia - Upon admission, the patient had a hematocrit
level of 33.5. Throughout the hospital stay, the patient's
hematocrit level trended downwards and remains stable at
approximately 29. However, after receiving his PICC line, it
was noted that his hematocrit levels had dropped even further
with a few readings measuring about 22%. However, peripheral
hematocrit levels drawn at this time, not off of the PICC
line, revealed a hematocrit level of 26.5. Multiple stool
guaiacs were negative and hemolysis sites were negative. The
patient hematocrit was 26 on the date of discharge and the
patient was hemodynamically stable. No blood transfusions
were given.
6. Intravenous drug use - The patient's Methadone dose was
initially held secondary to poor p.o. intake. The patient
was then reintroduced to Methadone initially at grams of 70
mg then increased to 80 then increased to 90 mg. However of
note, the course is complicated by respiratory failure
believed secondary to Methadone dosage for which the patient
required several doses of Narcan. The patient's respiratory
status remained stable after receiving the doses of
additional Narcan. The patient was then restarted on his
Methadone therapy, however, at a decreased dose of 50 mg.
The patient shows no evidence of any signs of withdrawal at
the time of discharge. The patient should be continued on
lower dose of Methadone maintenance therapy. If patient
shows signs of acute narcotic withdrawal, the patient may be
given an additional 10 mg dose of Methadone as needed with
careful monitoring of his respiratory status.
7. The patient received a PICC line for administration of
antibiotics.
DISCHARGE CONDITION:
DISCHARGE STATUS: To short term rehabilitation.
DISCHARGE DIAGNOSIS:
1. Pneumonia/Methicillin resistant Staphylococcus aureus.
2. HIV.
3. Thrombocytopenia.
4. Anemia.
5. Hypercarbic respiratory failure.
DISCHARGE MEDICATIONS:
1. Vancomycin 1 gram intravenous q 12 hours, last day is
[**2189-12-30**].
2. Adenovir 800 mg p.o. q 8 hours.
3. Combivere one tab b.i.d.
4. Methadone 50 mg p.o. q d with additional 10 mg prn.
DISCHARGE PLANS: The patient is to follow with Dr. [**Last Name (STitle) **]
on [**2189-12-30**], at 3:00 p.m.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2667**], M.D. [**MD Number(1) 2668**]
Dictated By:[**First Name3 (LF) 28139**]
MEDQUIST36
D: [**2189-12-25**] 15:15
T: [**2189-12-25**] 16:03
JOB#: [**Job Number 12311**]
|
[
"518.81",
"042",
"E935.1",
"573.1",
"287.5",
"070.32",
"482.41",
"070.54",
"305.50"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
9955, 10005
|
10189, 10772
|
10026, 10166
|
4693, 9933
|
2463, 2484
|
177, 1606
|
3542, 4676
|
1628, 1788
|
1805, 2440
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,618
| 186,957
|
34561
|
Discharge summary
|
report
|
Admission Date: [**2198-7-18**] Discharge Date: [**2198-7-20**]
Date of Birth: [**2144-3-19**] Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
fall, hit head
Major Surgical or Invasive Procedure:
cerebral angiogram
History of Present Illness:
54M who got up this morning and and was standing in the
bathroom to urinate, when he felt light-headed and fell and hit
his head. He did lose consciousness, and his wife found him face
down on the ground. He awoke with a mild headache, but no other
symptoms on his way to [**Hospital **] Hospital, where a head CT was
read
as SAH and SDH, and was sent to [**Hospital1 18**]. He denies other
complaints
or focal deficits, except for some left reproducible chest wall
pain. Hx is significant for a recent hospitalization for
babesiosis, which was treated. ECG in the ED has shown A Fib, no
RVR, but this is a new finding for him.
Past Medical History:
none except for recent babesiosis
Social History:
Self-employed lawyer, married with 2 kids. no smoking, or
alcohol.
Family History:
non-contibutory
Physical Exam:
O: BP: 130/90 HR:72 R18 O2Sats 99%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL 5 to 3 bilaterally, EOMs intact.
Neck: Supple
Extrem: Warm and well-perfused, mild stable cramping in R leg.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**1-22**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
II: Pupils equally round and reactive to light, 5 to 3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**3-26**] throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Reflexes: Pa
Right 2
Left 2
Pertinent Results:
[**2198-7-18**] 09:50AM GLUCOSE-114* UREA N-16 CREAT-0.9 SODIUM-140
POTASSIUM-4.4 CHLORIDE-106 TOTAL CO2-28 ANION GAP-10
[**2198-7-18**] 09:50AM WBC-13.2* RBC-5.11 HGB-15.8 HCT-43.0 MCV-84
MCH-30.9 MCHC-36.7* RDW-16.3*
[**2198-7-18**] 09:50AM NEUTS-91.0* LYMPHS-5.3* MONOS-2.7 EOS-0.8
BASOS-0.2
[**2198-7-18**] 09:50AM PLT COUNT-183
Brief Hospital Course:
Pt was admitted to the SICU from the ED after a head CT showed
subarachnoid hemorrhage along the tentorium and extends along
the gyri of the cerebellum and into the basal cisterns, along
with subcentimeter left frontal subgaleal hematoma and
associated soft tissue swelling. He was to undergo a CTA of head
to r/o aneurysm or further bleed, which showed intracranial
vertebral/internal carotid arteries and their major branches are
patent without evidence of stenosis, occlusion, or aneurysm
formation. He was watched in the SICU and loaded with dilantin.
He was also seen by cardiology for his new onset A Fib. He had
an ECHO that showed no structural abnormalities and normal EF.
He was started on metoprolol.
On [**7-20**], he underwent a cerebral angiogram which was also
normal. He was stable on telemetry and laid flat for several
hours until he was deemed stable enough to go home. He walked
around on tele and was in sinus rhythm on D/C. He will follow-up
with Dr. [**First Name (STitle) **] and Dr. [**Last Name (STitle) **] in 4 weeks. He will re-start
ASA 325 one week from the bleed.
Medications on Admission:
ASA 81
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H:PRN as
needed.
Disp:*30 Tablet(s)* Refills:*0*
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 7 days.
Disp:*21 Capsule(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
subarachnoid hemorrhage
Discharge Condition:
neurologically stable
Discharge Instructions:
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room
Followup Instructions:
Follow-up with Dr. [**First Name (STitle) **] (Neurosurg) in 4 weeks. Call the
office to make an appointment [**Telephone/Fax (1) 1669**].
Follow-up with Dr. [**Last Name (STitle) **] (Cardiology) in 4 weeks.
[**Telephone/Fax (1) 62**] [**8-22**] @1pm.
Completed by:[**2198-7-20**]
|
[
"852.02",
"E885.9",
"780.2",
"427.31",
"852.22",
"432.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
4429, 4435
|
2709, 3809
|
289, 310
|
4503, 4527
|
2344, 2686
|
6189, 6472
|
1127, 1144
|
3867, 4406
|
4456, 4482
|
3835, 3844
|
4551, 5248
|
5274, 6166
|
1159, 1372
|
235, 251
|
338, 968
|
1665, 2325
|
1387, 1649
|
990, 1026
|
1042, 1111
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,719
| 123,663
|
54096+59571
|
Discharge summary
|
report+addendum
|
Admission Date: [**2101-5-3**] Discharge Date: [**2101-5-9**]
Date of Birth: [**2032-12-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2101-5-5**] 1. Urgent off-pump coronary artery bypass graft x3; left
internal mammary artery to left anterior descending artery and
saphenous vein grafts to diagonal and distal right coronary
arteries.
[**2101-5-3**] Cardiac cath
History of Present Illness:
68 year old male with report of band like pain across his ribs,
first noted last [**Month (only) **]. This has occurred when doing
activities associated with lifting, lasts a few seconds as is
not associated with any other symptoms. He notes there has been
an increase in frequency over the past month. He states seeing
his PCP who referred him to Dr [**Last Name (STitle) 1911**] for an ETT which was
done last week. On [**5-1**] he felt the onset of rib discomfort at
bedtime. This waxed and waned all night. He woke [**5-2**] with
persistent discomfort. He presented to [**Location (un) **] for evaluation.
He ruled of for MI by EKG and troponins. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**5-5**] reported
positive for anterior wall perfusion defect. He was transferred
to [**Hospital1 18**] for cardiac catheterization today. He was found to have
coronary artery disease and is now being referred to cardiac
surgery for revascularization.
Past Medical History:
s/p CVA (no residual) [**2093**]
Hypertension
Hyperlipidemia
Diabetes type 2
COPD (pt states he does not have COPD- in [**Location (un) 68596**] records)
Chronic Back pain s/p MVA at age 16
Carpal tunnel
Right knee surgery
Social History:
Race:Caucasian
Last Dental Exam: < 1 year ago
Lives with:significant other
Contact:[**Name (NI) **] [**Last Name (NamePattern1) 1007**] Phone# [**Telephone/Fax (1) 110878**]
Occupation:Retired truck driver
Cigarettes: Smoked no [] yes [x] quit in [**2055**]
Other Tobacco use:Active pipe smoker, started in [**2055**]
ETOH: 3-4 beers/night
Illicit drug use:denies
Family History:
Premature coronary artery disease- Mother had valve replacement
in her late 60's
Physical Exam:
Pulse:52 Resp:18 O2 sat:100/RA
B/P Right:155/73 Left:132/69
Height:5'7" Weight:186 lbs
General:
Skin: intact [x]
HEENT: EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x]
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [-]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: p Left: p
DP Right: p Left: p
PT [**Name (NI) 167**]: p Left: p
Radial Right: p Left: p
Carotid Bruit Right: none Left: none
Pertinent Results:
[**2101-5-3**] Cardiac cath: 1. Selective coronary angiography of this
right dominant system demonstrated two vessel coronary artery
disease. The LMCA had no significant stenoses. The LAD had a
sub-total occlusion at the origin and a 70% stenosis mid-vessel
at D2. The LCX had no significant
stenoses. The RCA had a 60-70% stenosis mid-vessel. 2. Limited
resting hemodynamics revealed normotension.
.
[**2101-5-4**] Carotid U/S: Right ICA <40% stenosis. Left ICA <40
stenosis.
.
[**2101-5-4**] Echo: The left atrium is mildly dilated. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Doppler parameters are
indeterminate for left ventricular diastolic function. 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. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened.
Physiologic mitral regurgitation is seen (within normal limits).
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
IMPRESSION: Normal regional and global biventricular systolic
function. Mild aortic regurgitation.
[**2101-5-9**] 05:20AM BLOOD WBC-3.9* RBC-2.50* Hgb-7.7* Hct-24.0*
MCV-96 MCH-31.0 MCHC-32.2 RDW-14.3 Plt Ct-159
[**2101-5-3**] 03:35PM BLOOD WBC-3.4* RBC-3.80* Hgb-11.6* Hct-36.4*
MCV-96 MCH-30.6 MCHC-32.0 RDW-14.5 Plt Ct-141*
[**2101-5-9**] 05:20AM BLOOD PT-25.4* INR(PT)-2.4*
[**2101-5-3**] 03:35PM BLOOD PT-27.7* PTT-150* INR(PT)-2.7*
[**2101-5-9**] 05:20AM BLOOD Glucose-124* UreaN-14 Creat-1.1 Na-137
K-3.9 Cl-100 HCO3-31 AnGap-10
[**2101-5-3**] 03:35PM BLOOD Glucose-112* UreaN-11 Creat-0.8 Na-136
K-3.7 Cl-103 HCO3-26 AnGap-11
Brief Hospital Course:
As mentioned in the HPI, MR. [**Name14 (STitle) 110879**] was transferred to [**Hospital1 18**] for
cardiac cath. Cath revealed severe two vessel coronary artery
disease. He was referred for bypass surgery and underwent
pre-operative work-up. On [**2101-5-5**] he was brought to the
operating room where he underwent an off-pump coronary artery
bypass graft x 3. Please see operative note for surgical
details. Following surgery he was transferred to the CIVCU for
invasive monitoring in stable condition. Later this day he was
weaned from sedation, awoke neurologically intact and extubated.
On post-op day one he was started on beta-blockers and diuretics
and gently diuresed towards his pre-op weight. Later this day he
was transferred to the step-down floor for further care. Chest
tubes and epicardial pacing wires were removed per protocol. His
coumadin was restarted for his CVA history.Since Mr.[**Name14 (STitle) 110880**] is on
Coumadin, per Dr.[**First Name (STitle) **], no need for Plavix s/p OPCAB. He had
urinary retention requiring foley replacement. He worked with
physical therapy for strength and mobility. He continued to make
steady progress and was discharged to Applevalley Skilled
Nursing in [**Location (un) **] on POD #4. All follow up appointments were
advised.
Medications on Admission:
ALBUTEROL SULFATE 90 mcg HFA Aerosol Inhaler 1-2 puffs inh every
four hours as needed for shortness of breath or wheezing
CELEBREX 200 mg [**Hospital1 **]
ZETIA 10 mg Daily
ACTOS 45 mg Daily
PROPRANOLOL 10 mg Daily
WARFARIN 5 mg Daily
Crestor 10mg Daily
Discharge Medications:
1. pantoprazole 40 mg [**Hospital1 8426**], Delayed Release (E.C.) Sig: One
(1) [**Hospital1 8426**], Delayed Release (E.C.) PO Q24H (every 24 hours).
2. rosuvastatin 20 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY
(Daily).
3. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily) as needed for nicotine withdrawal.
4. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing.
5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. acetaminophen 325 mg [**Hospital1 8426**] Sig: Two (2) [**Hospital1 8426**] PO Q4H (every
4 hours) as needed for pain, fever.
8. aspirin 81 mg [**Hospital1 8426**], Delayed Release (E.C.) Sig: One (1)
[**Hospital1 8426**], Delayed Release (E.C.) PO DAILY (Daily).
9. thiamine HCl 100 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY
(Daily).
10. folic acid 1 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY (Daily).
11. metoprolol tartrate 25 mg [**Hospital1 8426**] Sig: 0.5 [**Hospital1 8426**] PO BID (2
times a day).
12. furosemide 20 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO BID (2 times
a day).
13. potassium chloride 10 mEq [**Hospital1 8426**] Extended Release Sig: Two
(2) [**Hospital1 8426**] Extended Release PO Q12H (every 12 hours).
14. ezetimibe 10 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY (Daily).
15. pioglitazone 15 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY
(Daily).
16. warfarin 1 mg [**Hospital1 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] DAILY (Daily).
17. warfarin 5 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO ONCE (Once) for
1 doses.
18. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): per Sliding Scale.
19. tramadol 50 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO Q4H (every 4
hours) as needed for pain.
Disp:*40 [**Last Name (Titles) 8426**](s)* Refills:*0*
20. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
21. nitrofurantoin monohyd/m-cryst 100 mg Capsule Sig: One (1)
Capsule PO Q12H (every 12 hours) for 5 days: for UTI. Please dc
on [**2101-5-13**].
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 25576**] Center
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 3
Past medical history:
s/p CVA (no residual) [**2093**]
Hypertension
Hyperlipidemia
Diabetes type 2
COPD (pt states he does not have COPD- in [**Location (un) 68596**] records)
Chronic Back pain s/p MVA at age 16
Carpal tunnel
Right knee surgery
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
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 will be contact[**Name (NI) **] to arrange the following appointments:
Surgeon: Dr. [**First Name (STitle) **] #[**Telephone/Fax (1) 170**]
Cardiologist: Dr. [**Last Name (STitle) 1911**] [**Telephone/Fax (1) 62**]
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 17029**] [**Telephone/Fax (1) 17030**] in [**4-28**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication CVA
Goal INR 2.0-3.0
First draw :[**2101-5-10**]
Results to phone fax: PCP [**Last Name (NamePattern4) **].[**Last Name (STitle) 17029**] Fax: [**Telephone/Fax (1) 62884**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2101-5-9**] Name: [**Known lastname 18164**],[**Known firstname **] Unit No: [**Numeric Identifier 18165**]
Admission Date: [**2101-5-3**] Discharge Date: [**2101-5-9**]
Date of Birth: [**2032-12-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 265**]
Addendum:
68M s/p OP CABG x3(LIMA-LAD,SVG-Diag,SVG-dRCA)[**5-5**]
discharged to rehabilitation at Apple [**Hospital 18166**] Rehab Ctr on
[**2101-5-9**].
Discharge medications included sliding scale insulin with
regular insulin. He was covered with Humalog insulin sliding
scale while here at [**Hospital1 8**] and should be covered with Humalog
sliding scale at rehabilitation as well.
Discharge Medications should be:
1. pantoprazole 40 mg [**Hospital1 7115**], Delayed Release (E.C.) Sig: One
(1) [**Hospital1 7115**], Delayed Release (E.C.) PO Q24H (every 24 hours).
2. rosuvastatin 20 mg [**Hospital1 7115**] Sig: One (1) [**Hospital1 7115**] PO DAILY
(Daily).
3. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily) as needed for nicotine withdrawal.
4. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing.
5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
7. acetaminophen 325 mg [**Hospital1 7115**] Sig: Two (2) [**Hospital1 7115**] PO Q4H (every
4 hours) as needed for pain, fever.
8. aspirin 81 mg [**Hospital1 7115**], Delayed Release (E.C.) Sig: One (1)
[**Hospital1 7115**], Delayed Release (E.C.) PO DAILY (Daily).
9. thiamine HCl 100 mg [**Hospital1 7115**] Sig: One (1) [**Hospital1 7115**] PO DAILY
(Daily).
10. folic acid 1 mg [**Hospital1 7115**] Sig: One (1) [**Hospital1 7115**] PO DAILY (Daily).
11. metoprolol tartrate 25 mg [**Hospital1 7115**] Sig: 0.5 [**Hospital1 7115**] PO BID (2
times a day).
12. furosemide 20 mg [**Hospital1 7115**] Sig: One (1) [**Hospital1 7115**] PO BID (2 times
a day).
13. potassium chloride 10 mEq [**Hospital1 7115**] Extended Release Sig: Two
(2) [**Hospital1 7115**] Extended Release PO Q12H (every 12 hours).
14. ezetimibe 10 mg [**Hospital1 7115**] Sig: One (1) [**Hospital1 7115**] PO DAILY (Daily).
15. pioglitazone 15 mg [**Hospital1 7115**] Sig: One (1) [**Hospital1 7115**] PO DAILY
(Daily).
16. warfarin 1 mg [**Hospital1 7115**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 7115**] [**Last Name (Titles) **] DAILY (Daily).
17. warfarin 5 mg [**Last Name (Titles) 7115**] Sig: One (1) [**Last Name (Titles) 7115**] PO ONCE (Once) for
1 doses.
18. insulin Humalog 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): per Sliding Scale.
19. tramadol 50 mg [**Last Name (Titles) 7115**] Sig: One (1) [**Last Name (Titles) 7115**] PO Q4H (every 4
hours) as needed for pain. Disp:*40 [**Last Name (Titles) 7115**](s)* Refills:*0*
20. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
21. nitrofurantoin monohyd/m-cryst 100 mg Capsule Sig: One (1)
Capsule PO Q12H (every 12 hours) for 5 days: for UTI. Please dc
on [**2101-5-13**].
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Center
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2101-5-9**]
|
[
"496",
"V58.67",
"724.2",
"599.0",
"401.9",
"788.20",
"414.01",
"411.1",
"V58.61",
"272.4",
"V12.54",
"250.00",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.22",
"36.12",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
14567, 14740
|
4715, 6005
|
319, 553
|
9241, 9467
|
2873, 4692
|
10390, 14544
|
2192, 2274
|
6309, 8810
|
8913, 8974
|
6031, 6286
|
9491, 10367
|
2289, 2854
|
269, 281
|
581, 1549
|
8996, 9220
|
1811, 2176
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,188
| 107,115
|
5734
|
Discharge summary
|
report
|
Admission Date: [**2125-3-11**] Discharge Date: [**2125-3-19**]
Date of Birth: [**2067-10-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
fever, mental status changes, headache
Major Surgical or Invasive Procedure:
endotracheal intubation, mechanical ventilation, lumbar puncture
lumbar puncture
History of Present Illness:
57 yo M with PMHX of nonischemic CM, CRI, anemia [**1-4**] plasma cell
dysplasia who presents today from OSH with fever and mental
status changes and transferred from OSH.
.
Unable to obtain hx from patient. History obtained from OSH
records and his girlfriend.
.
Per the girlfriend who is his HCP, yesterday at 9am he was
coherent and conversing normally. He became confused transiently
while going to the donut store and didn't remember the day of
the week. However, he was conversing normally. He then around
11am was in the bathroom and came out short of breath and in
abdominal pain, throwing up "coffee material". He was sitting on
a chair bent over secondary to pain. He also complainted of a
terrible headache and light was bothering him. He also had a
stomach ache at the same time. Her girlfriend waited for about
1/2 hour and then called the ambulance yesterday around 1pm and
he was taken to [**Location (un) **] ED.
.
At [**Location (un) **], his initial vitals were noted to be 101.0, 59,
157/71, 15, 98% on RA. His initial complaints to the OSH ED per
their records were abdominal pain [**7-12**] and vomiting with
questionable blood in vomit. Head CT was showed right
mastoiditis but no ICH. CXR showed multifocal PNA and slightly
increased effusions from [**3-10**], cardiomegaly. CT abdomen with
po/IV contrast showed bilateral lower lobe infiltrates, CHF.
Also showed an inflammatory process in left posterior pararenal
space with mild sigmoid diverticulosis without diverticulitis.
His labs were remarkable for WBC 28.9 and BUN 40/cr 1.4 and BNP
1870. He also grew gram positive cocci [**3-6**] blood cultures -
alpha hemolytic strep. He was given ceftriaxone 2g IV x 1,
azithromycin 500 mg IV x 1, vancomycin 1g IV x 1, hydrocortisone
100 mg IV x 1. Ativan 1mg IV x 1 for agitation. and then
transferred here for further care.
.
Of note, he was d/c'd from [**Hospital1 2177**] on [**2-21**] for new diagnoses of
nonischemic dilated CM and kappa light chain gammopathy/plasma
cell dyscrasia - monoclonal. He had a renal and BM bx this
admission which are pending, had a SPEP/UPEP, and flow cytometry
confirming these diagnoses and started on prednisone for concern
of a vasculitic process.
Past Medical History:
1. Nonischemic dilated CM - EF 47%
2. CRI
3. light chain gammopathy/plasma cell dyscrasia - monoclonal via
SPEP/UPEP - had renal bx/BM bx
4. Anemia with baseline hct 28
5. Alcohol abuse - while back
6. HTN
7. MVA with trauma to the right leg with back flap to right
anterior calf. Also with right radial artery to right leg. On
chronic narcotics including methadone and percocet
8. Hyperlipidemia
Social History:
No EtOH since [**2116**], but heavy use prior. No cigarettes.
Occasional cigars. Motorcycle driver. On disability s/p MVA. Had
worked in the iron industry and as a carpenter.
Family History:
Mother with CHF. No premature CAD/sudden death.
Physical Exam:
98.3, 101, 137/98, 16, 97% on 2LNC
GEN- lying in bed at 30 degrees extremely agitated, moving all 4
extremities, keeping eyes shut majority of time, not following
any commands
Neck - stiff but unclear if not cooperating and pushing back or
truly stiff
Chest- bilateral crackles R>L
Abd- soft, NT/ND, +BS
Ext- no edema, right leg skin grafts
Neuro - PERRL 3->2 mm, neck stiff, not following any commands,
moving all 4 extremities, withdrawing to pain, bilateral upgoing
toes, hard to assess reflexes as trying to kick physicians and
nurses
rectal - OSH - black, guiac positive
Pertinent Results:
ADMISSION LABS;
ABG on arrival 7.50/33/66
CBC: WBC 28.9 w/ 17% bands, 81% neutrophils, hct 38.5, plt 445
Chem 7 latest 137, 4.3, 101, 26, 30, 1.3, 178. alb 2.1. AST 14,
ALT 24, alk P 146, lipase 95.
BUN 40/cr 1.4 and BNP 1870.
.
CXR showed multifocal PNA (LUL, RLL, ?RML) and slightly
increased effusions from [**3-10**], cardiomegaly.
.
EKG - LAD, sinus tachy @ 120, nl intervals, LVH,
.
CT abdomen with po/IV contrast showed bilateral lower lobe
infiltrates, CHF. Also showed an inflammatory process in left
posterior pararenal space with mild sigmoid diverticulosis
without diverticulitis. (of note, last CT at [**Hospital1 2177**] with pararenal
hematoma after biopsy, lung bases pneumonitis)
.
CT head at OSH: possible R mastoiditis, otherwise unremarkabel
awith no intracranial mass or hemorrhage
ABG - 7.55/32/79 at OSH on RA -> 7.51/34/73 few hrs later ->
7.55/29/69 this AM
.
UA large blood, 100 protein, neg nitrites/LE
.
Influenza test negative.
.
CK 5, Trop I 0.25 ((0.1-1.5 - borderline on OSH labs)
.
TTE:
1.The left atrium is mildly dilated. The left atrium is
elongated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. There is severe global
left ventricular hypokinesis with inferior wall akinesis.
Overall left ventricular systolic function is severely
depressed. [Intrinsic left ventricular systolic function is
likely more depressed given the severity of valvular
regurgitation.]
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic root is mildly dilated.
5. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. No masses or vegetations are seen on the
aortic valve. No aortic regurgitation seen.
6.The mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. Moderate (2+) mitral
regurgitation is seen.
7.There is a trivial/physiologic pericardial effusion.
IMPRESSION: Compared with the findings of the prior study
(images reviewed) of [**2124-12-29**], the LV function has decreased
substantially with now global hypokinesis with inferior wall
akinesis. There is no echocardiographic evidence of endocarditis
seen.
.
MR CONTRAST GADOLIN [**2125-3-16**] 6:24 PM
MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN
Reason: Evaluate for mastoiditis, mass lesion, possible
vasculitis/a
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
57 year old man with possible mastoiditis, recently dx'd with
bacterial meningitis, continues to have mild confusion. Is
currently getting worked up at OSH for vasculitis.
REASON FOR THIS EXAMINATION:
Evaluate for mastoiditis, mass lesion, possible
vasculitis/amyloid
CONTRAINDICATIONS for IV CONTRAST: None.
EXAM: MRI brain.
CLINICAL INFORMATION: Patient with possible mastoiditis with
bacterial meningitis continues to have mild confusion, for
further evaluation.
TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and
diffusion axial images of the brain were obtained before
gadolinium. T1 sagittal, axial and coronal images were obtained
following the administration of gadolinium. There are no prior
similar examinations for comparison.
FINDINGS: Diffusion images demonstrate no evidence of slow
diffusion to indicate acute infarct. There is evidence of slow
diffusion within the posterior portion of both lateral
ventricles as well as in the fourth ventricle and cisterna magna
indicative of cellular debris possibly related to meningitis.
Following gadolinium administration subtle meningeal enhancement
is seen. Meningeal enhancement is predominantly seen along the
superior aspect of the right petrous temporal bone. There are
soft tissue changes within the right mastoid air cells which
could be related to the history of mastoiditis. No evidence of
cerebritis is seen in the right temporal lobe or cerebellum.
There is moderate ventriculomegaly which indicates a
communicating hydrocephalus. No evidence of periventricular
edema is seen.
IMPRESSION:
1. Increased signal within the posterior portion of both lateral
ventricles, fourth ventricle and cisterna magna indicative of
cellular debris possibly related to history of meningitis. 2. No
evidence of cerebritis or acute infarct. 3. Right mastoid soft
tissue changes and subtle meningeal enhancement along the right
petrous temporal bone could be related to mastoiditis. 4.
Moderate ventriculomegaly indicative of communicating
hydrocephalus. No evidence of periventricular edema.
Brief Hospital Course:
Mr. [**Known lastname 22873**] is a 57 yo M with non-ischemic CM and other medical
problems who presented from [**Hospital3 **] with fevers,
altered mental status/agitation, and report of headache,
photophobia and confusion at home.
[**Hospital Unit Name 13533**]:
The patient was transferred here from an outside hospital
after approximately 24 hours there. At the OSH blood cultures
were drawn and the patient was started empirically on meningitis
doses of ceftriaxone, although LP was not performed. Head CT
there showed only R sided possible mastoiditis. CXR showed
multifocal bilateral pneumonia, however the patient was recently
treated for pneumonia at [**Hospital1 2177**] and it is cunclear what his CXR
looked like at that time. Upon arrival here it was immediately
clear that the patient was so agitated he would not tolerate LP.
He was therefore intubated for sedation to attempt LP. The
patient was empirically started on vancomycin, ampicillin,
ceftriaxone and acyclovir. LP was not able to be obtained by
several teams over two days and was finally obtained via
fluoroscopy by interventional radiology. After OSH blood
cultures revealed strep pneumonia, dexamethasone was started for
a planned total of 16 doses. CSF was consistent with bacterial
meningitis, despite the patient being on antibiotics for
approximately three days. We stopped empiric ampicillin and
continued acyclovir only until HSV PCR was negative. The
patient continued on IV ceftriaxone and vancomycin, had a PICC
placed and was transferred to the floor.
Echo performed while in the ICU showed EF 20% and new global
and inferior hypopkinesis. The patient has a known history of
nonischemic cardiomyopathy with last echo in [**Month (only) **] showing EF
of 35-40% and a clean catheterization at that time. We continued
hte patien's home blood pressure medications, but decreased his
lisinopril to 40mg po qday, and continued his home lasix.
The patient is being worked up as an outpatient at [**Hospital1 2177**] for
possible vasculitis versus intrinsic renal disease with renal
biopsy results pending. He is on prednisone 40mg po qday as an
outpatient for this possible vasculitis and therefore will be
maintained on this dose. He is also being worked up at [**Hospital1 2177**] for
likely plasma cell dyscrasia with light chain gammopathy.
.
General Medicine Course:
Pt was stable throughout course. He continued to complain of
difficulty with hearing, but ENT was consulted and felt that
this was not acute. ID was consulted to assist in defining
treatment course for meningitis and pneumonia. An HIV test was
done given multiple infections over past few months.
Medications on Admission:
methadone 20 tid, ferrous sulfate 325 qd, metoprolol XL 50 mg po
qd, lasix 20 po qd, lisinopril 60 qd, percocet 1 tab q4h prn,
prednisone 40 qd, kcl 20 meq po qd
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. 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*
3. Methadone 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
4. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Penicillin G Potassium 20,000,000 unit Recon Soln Sig: 4 MU
Recon Solns Injection Q4H (every 4 hours) for 5 days.
Disp:*QS Recon Soln(s)* Refills:*0*
6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily): while on prednisone.
Disp:*30 Tablet(s)* Refills:*2*
7. PICC Care
PICC care per protocol
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a
day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 486**]
Discharge Diagnosis:
Meningitis
Pneumonia
Discharge Condition:
Sstable
Discharge Instructions:
Continue your antibiotics as directed.
Followup Instructions:
Follow up with your primary care doctor at the appointment
[**2125-3-29**].
.
Follow up with your kidney doctor, Dr. [**First Name (STitle) **] as planned - [**2125-3-28**]
at 11am.
.
Follow up with cardiologist Dr. [**Last Name (STitle) 11493**] [**2125-3-20**] at 2:15.
.
Dr. [**Last Name (STitle) 6955**] will refer you to a hematologist/oncologist to help
you with your bone [**Last Name 15482**] problem.
.
Follow up with Infectious Disease Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] TAN
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2125-4-13**] 10:00 at [**Hospital1 771**].
.
Completed by:[**2125-3-26**]
|
[
"585.9",
"425.4",
"273.9",
"272.4",
"790.7",
"482.41",
"401.9",
"320.2",
"584.9",
"428.0",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"03.31",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
12209, 12259
|
8504, 11183
|
354, 437
|
12324, 12334
|
3972, 6381
|
12421, 13064
|
3307, 3356
|
11395, 12186
|
6418, 6590
|
12280, 12303
|
11209, 11372
|
12358, 12398
|
3371, 3953
|
276, 316
|
6619, 8481
|
465, 2676
|
2698, 3097
|
3113, 3291
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,841
| 178,579
|
49947
|
Discharge summary
|
report
|
Admission Date: [**2187-1-15**] Discharge Date: [**2187-1-17**]
Date of Birth: [**2120-5-31**] Sex: M
Service: CCU
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 104311**] is a 66 year-old
gentleman with a long standing history of diabetes, end stage
renal disease and an extensive coronary artery disease who
presents to the hospital with shortness of breath. He has
been in his usual state of health until five days ago when he
had acute onset of shortness of breath that progressively
worsened. He denies any chest pain, fevers or chills, or any
other associated symptoms. He is admitted to the [**Hospital Unit Name 196**]
Service on [**2187-1-15**] and there is shortness of breath was
improved with hemodialysis, but ruled in for a non Q wave
myocardial infarction with a troponin if 13, normal CK.
He went to the catheterization laboratory this afternoon for
intervention. In the cardiac catheterization laboratory he
was noted to have three vessel disease with occlusion of two
saphenous vein, with occlusion of his venous graft, which is
new from 8/[**2184**]. His EF was noted to be only 15%. This is
his left ventricular ejection fraction. His left internal
mammary coronary artery to left anterior descending coronary
artery was patent with extensive collateral left and right.
His left circumflex and right coronary artery were diffusely
diseased. The left circumflex was difficult to intervene upon
due to difficulty engaging the vessel, but ultimately
received a stent. During the procedure the patient had
several episodes of ventricular tachycardia that was
responsive to cardiac massage on at least one instance. He
was started on Dopamine drip at the cardiac catheterization
laboratory at the end of the procedure for a systolic blood
pressure in the low 80s. The patient arrived in the Coronary
Care Unit hemodynamically stable, tachycardic to 110 and
sedated.
PAST MEDICAL HISTORY: 1. Diabetes type 2 insulin dependent.
2. End stage renal disease on hemodialysis, with placement
of an AV fistula in the right forearm in [**2186-6-11**]. 3.
Hypertension. 4. Coronary artery disease, status post
myocardial infarction and coronary artery bypass graft in
[**2185-6-11**], (left internal mammary coronary artery to left
anterior descending coronary artery, saphenous vein graft to
posterior descending coronary artery, saphenous vein graft to
obtuse marginal) as well as implantation of an AICD in [**2185-7-12**] for syncope and runs of nonsustained ventricular
tachycardia. 5. History of central line infection times two
as described previously. 6. Cholecystectomy. 7.
Appendectomy. 8. Status post left fourth metatarsal
debridement in [**2186-3-12**].
MEDICATIONS: Zestril 20 mg Tuesdays, Thursdays, Saturday and
Sunday. NPH sliding scale, Lipitor 5 mg po q.d., Lopresor
12.5 mg Tuesdays, Thursday, Saturday and Sunday. Nephrocaps
one tab po q.d., Neurontin 200 mg po q.d., Phos-Lo three tabs
po t.i.d., Renagel 800 mg po t.i.d., Avandia 8 mg po q.h.s.,
Quinine 325 mg q.h.s. and q noon on days of hemodialysis.
Aspirin 325 mg q.d., Plavix 75 mg q.d. A heparin drip was
started on the cardiac catheterization laboratory. Protonix
40 mg q.d.
FAMILY HISTORY: Father had a cerebrovascular accident at the
age of 69. He also had diabetes.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He is a less then one pack per day smoking
history for at least thirty five years. He quit fifteen
years ago. He denies any alcohol use. He is divorced. He
lives with his mother. [**Name (NI) **] is a retired salesman.
PHYSICAL EXAMINATION: His blood pressure is 88/48 on 5 mg of
Dopamine. Pulse 118. Respiratory rate 16. Sating 91% on 5
liters nasal cannula. In general, he was sedated. He
appears comfortable. He is an obese elderly man. HEENT
pupils are equal, round and reactive to light. Sclera
anicteric. Oropharynx clear. Respiratory clear to
auscultation bilaterally. Cardiovascular regular rate and
rhythm. No murmurs, rubs or gallops. Abdomen soft and
benign. Extremities good peripheral pulses. Right groin
sheath in place.
LABORATORY: White blood cell count 8.3, hematocrit 34.9,
platelets 213. Chem 7 sodium 140, potassium 3.7, chloride
96, bicarb 27, BUN 52, creatinine 9.3, glucose 97, PT 13, PTT
33, INR 1.3. Arterial blood gas, pH was 7.50, PCO2 34, PAO2
was 84, CK 98, troponin 13.4, bilirubin 3.7, calcium 9.1,
phos 4.9, mag 1.9, B-12 [**2137**]. Electrocardiogram revealed
normal sinus rhythm at a rate of 114, first degree AV block,
normal axis, right bundle branch block, lateral ST
depressions. Chest x-ray revealed an interval increase in
cardiac shadow with a small pleural effusion suggestive of
congestive heart failure. No infiltrates were identified.
PA pressures on catheterization were 45/30. His pulmonary
capillary wedge pressure was 25 to 30.
HOSPITAL COURSE: The patient did fine until early the next
morning where he developed progressive shortness of breath.
Arterial blood gases was obtained, which revealed that the
patient was severely acidotic. A chem 7 later on revealed
that ............... metabolic. As respiratory therapy was
called to intubate the patient emergently, the patient became
apneic and pulseless. His electroencephalogram tracing on
the defibrillator revealed that the patient was in
ventricular tachycardia, which transformed into ventricular
fibrillation. A code was called and the patient was
immediately defibrillated with no conversion from VF. CPR
was initiated and the patient was given pharmacotherapy
according to standard HCL protocol with no success in
improving the patient's condition. After over thirty minutes
of trying to aggressively resuscitate the patient he was
pronounced dead at 7:00 a.m. on [**2187-1-17**]. The patient's family
was notified and they declined an autopsy.
CONDITION ON DISCHARGE: Deceased.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Type 2 diabetes.
3. End stage renal disease on hemodialysis.
4. Hypertension.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5467**], M.D. [**MD Number(1) 5468**]
Dictated By:[**Last Name (NamePattern1) 7690**]
MEDQUIST36
D: [**2187-1-26**] 21:14
T: [**2187-1-30**] 13:13
JOB#: [**Job Number **]
|
[
"250.40",
"585",
"428.0",
"250.60",
"583.81",
"414.02",
"414.01",
"357.2",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"36.01",
"36.06",
"88.53",
"88.55",
"99.20",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
3271, 3389
|
5957, 6328
|
4932, 5900
|
3654, 4914
|
150, 172
|
201, 1954
|
1977, 3254
|
3406, 3631
|
5925, 5936
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,678
| 187,633
|
19887
|
Discharge summary
|
report
|
Admission Date: [**2192-5-23**] Discharge Date: [**2192-5-29**]
Service: CARDIOTHORACIC
Allergies:
Codeine / Percocet / Lisinopril
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Mmitral valve repair (26mm CG future annuloplasty ring) [**2192-5-23**]
Past Medical History:
Mitral Regurgitation, Atrial fibrillation, Hypertension,
Hyperlipidemia, Osteoarthritis, Osteopenia, Gastroesophageal
Reflux Disease, Rectal polyp s/p partial resection [**3-16**],
Diverticulosis, CHF with preserved EF on ECHO [**4-5**], cervical and
lumbar spondylosis
PSH: s/p right total knee replacement [**2188**]. [**Doctor Last Name 15568**]-NWH, s/p
cholecystectomy in [**2145**], s/p appendectomy in [**2145**], s/p
cataracts, s/p bilateral carpal tunnel release
Social History:
The patient lives at home, she is independent in her ADLs. She
has 3 daughters. Widowed. Retired executive secretary who was
also a sales representative for Nestle. No smoking. Occasional
alcohol.
Family History:
Non Contributory
Physical Exam:
VS: 71 116/68
Gen: NAD
Skin: Unremarkable
HEENT: EOMI, PERRL, NCAT
Neck: Supple, FROM, -JVD
Chest: CTAB -w/r/r
Heart: RRR 4/6 SEM
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused, trace edema
Neuro: A&O x 3, MAE, Non-focal
Pertinent Results:
[**5-23**] Echo: PRE CPB Suboptimal study due to heart rotation likely
due to left atrial enlargement. 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. Left ventricular wall thicknesses
and cavity size are normal. Regional left ventricular wall
motion is normal. Overall left ventricular systolic function is
mildly depressed (LVEF= 45-50 %). [Intrinsic left ventricular
systolic function is likely more depressed given the severity of
valvular regurgitation.] Right ventricular chamber size and free
wall motion are normal. There are simple atheroma in the aortic
arch. The descending thoracic aorta is mildly dilated. There are
complex (>4mm) atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild to moderate ([**11-30**]+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is partial mitral leaflet flail that appears to
be limited to the P3 scallop though there may be some slight
involvement of P2. An eccentric, anteriorly directed jet of
moderate to severe (3+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is a
trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) **] was
notified in person of the results in the operating room at the
time of the study. POST CPB Normal right ventricular systolic
function. The left ventricle displays mild to moderate global
hypokinesis with an ejection fraction of about 40%. There is a
mitral valve annuloplasty ring in situ. It appears well seated.
The mitral valve is s/p repair. Mitral regurgitation is not
appreciated. The peak gradient through the mitral valve is about
7 mm Hg with a mean gradient of 3.5 mm Hg at a cardiac output of
4 liters/minute. The thoracic aorta appears intact.
Brief Hospital Course:
Ms. [**Known lastname **] was a same day admit after undergoing pre-operative
work-up prior to admission. On [**5-23**] she was brought to the
operating room where she underwent a Mitral Valve Repair. Please
see operative report for surgical details. Following surgery she
was transferred to the CVICU in stable condition for invasive
monitoring. Within 24 hours she was weaned from sedation, awoke
neurologically intact and extubated. On post-op day one chest
x-ray revealed right apical pneumothorax therefore a chest tube
remained in place. Beta blockers and diuretics were initiated
and she was gently diuresed towards her pre-op weight. On
post-op day two she was transferred to the telemetry floor for
further care. Pneumothorax remained small and stable and chest
tube was dc'd. She was restarted on coumadin for chronic atrial
fibrillation. She did well postoperatively and was ready for
discharge to rehab on POD # 6.
Medications on Admission:
Diltiazem 240mg qd, Lasix 20mg qd, Prilosec 20mg qd, Zocor 80mg
qd, Trazadone 50mg prn, Valsartan 80mg qd
Discharge Medications:
1. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day).
8. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed.
9. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO ONCE (Once) for
1 doses: check INR [**5-30**].
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
Mitral Regurgitation s/p Mitral Valve Repair
PMH: Hypertension, Gastroesophageal Reflux Disease,
Hyperlipidemia, Atrial Fibrillation, Rectal polyps,
Osteoarthritis, Osteopenia
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**Last Name (STitle) 311**] in 2 week ([**Telephone/Fax (1) 3070**]) please call for appointment
Dr [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] in 2 weeks please call for appointment
Completed by:[**2192-5-29**]
|
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"721.0",
"530.81",
"715.90",
"V58.61",
"733.90",
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"272.4",
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"401.9",
"721.3",
"424.0",
"429.5",
"599.0",
"512.1",
"110.5",
"V43.65"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.12",
"39.61",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
5300, 5377
|
3309, 4237
|
265, 338
|
5596, 5602
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1336, 3286
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5398, 5575
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5626, 6090
|
1096, 1317
|
206, 227
|
360, 833
|
849, 1047
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,460
| 161,772
|
51261
|
Discharge summary
|
report
|
Admission Date: [**2144-3-13**] Discharge Date: [**2144-4-10**]
Date of Birth: [**2095-4-26**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
Confusion and hypotension.
Major Surgical or Invasive Procedure:
Intubation
Tunneled Dialysis Line in right
PICC placement in L X2
HD non-tunneled catheter placed in RIJ
HD catheter exchange over wire in RIJ
History of Present Illness:
Mrs. [**Known lastname **] is a 48 year old woman with a history of alcoholic
cirrhosis s/p two transplants in [**2136**], then in [**2137**] who
presented with acute altered mental status on [**2144-3-10**]. Per
husband, patient had an unwitnessed fall on Wed, found on snow
by neighbors. This was followed by AMS on Thursday, with ED
visit on Friday complaining of "pain everywhere", some nausea,
and headache.
.
In the ED, initial vs were: 97.8 85/60 88 18 96%RA. Patient
was given 4L of NS, but pressures did not improve. She was then
given levofed for hypotension via a fem line that was placed. Pt
was intubated with TV 400 Rate 14/5 PEEP, 100% FIO2. Pt was
given calcium gluconate 1gm and 10 units of insulin regular for
hyperkalemia with QRS widening and peaked t-waves. Patient was
given 3 amps sodium bicarb in 1L D5W for low bicarb per renal.
Was given 10 mg of albuterol neb, and 1mg IV ativan for groin
line placement as pt was extremely agitated. Patient was also
given 10mg IV decadron. Pt was also given 100mcg of neo. Last
set of vitals were 95 93/53 100% on above vent settings. She
was also given versed and fentanyl gtt. She was also given cipro
400 IV for UTI and rocuronium 25 for intubation and propofol
100mg IV ONCE for intubation.
.
On the floor, the patient remains intubated and sedated, unable
to follow commands.
Past Medical History:
- ETOH cirrhosis s/p OTL [**2137-12-7**], s/p OTL [**2136-6-4**]
- renal insufficiency (due to cyclosporine: baseline cr 1.4)
- hemochromatosis
- HTN
- CAD s/p MI
- asthma
- h/o cyclosporine toxicity
- history of antiphospholipid syndrome with myopathy and
neuropathy
Social History:
Smokes [**4-3**] pack per day. drinks etoh rarely [**2-2**] glass wine a
week. Denies other illicit drug use including cocaine,
marijuana. Lives with husband.
Family History:
father with [**Name2 (NI) 499**] ca and dvt.
Physical Exam:
ADMISSION EXAM
General: Intubated, sedated, no acute distress, moves all 4
extremities by command
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Marked echymoses seen on arms.
Discharge Physical Exam:
T: AF/T max 99.4 HR 82 P 94/59 (range 80's-110's/50's) RR18 96%
on RA. BS 90-110.s
Gen: NAD, Alert and Oriented x 3.
HEENT: MMM, oropharynx clear, poor dentition
Neck: Supple
Lungs: CTA-bilaterally.
CV: Normal S1 and S2 no S3 or S4. No systolic murmur
appreciated.
Abd: Ecchymosis across lover abdomen. Soft, NT, ND. + BS. No
rebound or guarding
GU: No feloy
Ext: Warm, no cyanosis or edema.
Pertinent Results:
ADMISSION LABS:
[**2144-3-13**] 07:30PM BLOOD WBC-11.7*# RBC-3.15* Hgb-10.7* Hct-31.6*
MCV-100* MCH-34.0* MCHC-33.8 RDW-16.5* Plt Ct-251
[**2144-3-13**] 07:30PM BLOOD Neuts-90.5* Lymphs-6.1* Monos-3.1 Eos-0.1
Baso-0.2
[**2144-3-13**] 07:30PM BLOOD PT-13.0 PTT-30.6 [**Year/Month/Day 263**](PT)-1.1
[**2144-3-13**] 07:30PM BLOOD Glucose-85 UreaN-131* Creat-6.5*# Na-120*
K-8.3* Cl-84* HCO3-10* AnGap-34*
[**2144-3-13**] 07:30PM BLOOD ALT-77* AST-180* AlkPhos-209* TotBili-0.6
[**2144-3-13**] 07:30PM BLOOD Albumin-3.7 Calcium-6.5* Phos-12.6*#
Mg-2.2
[**2144-3-13**] 07:30PM BLOOD Osmolal-310
[**2144-3-14**] 05:05AM BLOOD Cortsol-48.7*
[**2144-3-13**] 07:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-POS
[**2144-3-13**] 07:37PM BLOOD Lactate-1.7 K-7.7*
[**2144-3-14**] 10:39PM BLOOD ETHYLENE GLYCOL- <10 ( ref <10)
ALCOHOL PROFILE
Test Result Reference
Range/Units
ALCOHOL, METHYL (B) NONE DETECTED NONE DETECTED
mg/dL
Reportable Limit: 5 mg/dL
Test Result Reference
Range/Units
ALCOHOL, ETHYL (B) NONE DETECTED NONE DETECTED
mg/dL
100 mg/dL = 0.100 g%(g/dL)
Reportable Limit: 10 mg/dL
Test Result Reference
Range/Units
ALCOHOL, ETHYL (B) NONE DETECTED NONE DETECTED
g/dL(%)
Reportable limit: 0.010 g/dL
Test Result Reference
Range/Units
ACETONE (B) 22 H NONE DETECTED
mg/dL
Verified by repeat analysis.
Reportable Limit: 5 mg/dL
Test Result Reference
Range/Units
ALCOHOL, ISOPROPYL (B) NONE DETECTED NONE DETECTED
mg/dL
Reportable Limit: 5 mg/dL
[**2144-3-13**] 07:30PM URINE Color-Amber Appear-Hazy Sp [**Last Name (un) **]-1.017
[**2144-3-13**] 07:30PM URINE Blood-LG Nitrite-NEG Protein-150
Glucose-TR Ketone-15 Bilirub-SM Urobiln-NEG pH-5.0 Leuks-SM
[**2144-3-13**] 07:30PM URINE RBC-[**12-20**]* WBC-21-50* Bacteri-MOD
Yeast-NONE Epi-[**4-4**] TransE-0-2
[**2144-3-13**] 11:00PM URINE Hours-RANDOM Creat-144 Na-19 K-59 Cl-18
[**2144-3-13**] 11:00PM URINE Osmolal-306
[**2144-3-13**] 11:00PM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
.
OTHER PERTINENT LABS:
[**2144-3-19**] 04:28AM BLOOD WBC-18.7* RBC-3.43* Hgb-11.3* Hct-33.0*
MCV-96 MCH-33.1* MCHC-34.4 RDW-18.4* Plt Ct-205
[**2144-3-20**] 05:02AM BLOOD PT-18.4* PTT-46.5* [**Month/Day/Year 263**](PT)-1.7*
[**2144-3-15**] 07:32PM BLOOD CK-MB-155* MB Indx-14.2* cTropnT-4.55*
[**2144-3-16**] 03:11AM BLOOD CK-MB-150* MB Indx-17.7* cTropnT-4.44*
[**2144-3-16**] 08:40AM BLOOD CK-MB-111* MB Indx-19.9* cTropnT-3.95*
[**2144-3-16**] 05:15PM BLOOD CK-MB-61* MB Indx-22.4* cTropnT-2.97*
[**2144-3-17**] 02:23AM BLOOD CK-MB-37* MB Indx-23.1* cTropnT-2.71*
[**2144-3-19**] 04:28AM BLOOD CK-MB-23* MB Indx-15.2* cTropnT-3.73*
[**2144-3-19**] 01:53PM BLOOD CK-MB-13* MB Indx-14.3* cTropnT-6.38*
[**2144-3-20**] 05:02AM BLOOD CK-MB-11* cTropnT-7.73*
[**2144-3-20**] 08:33AM BLOOD CK-MB-10 MB Indx-16.1* cTropnT-7.54*
[**2144-3-25**] 05:15AM BLOOD calTIBC-125* Hapto-193 Ferritn-927*
TRF-96*
[**2144-3-24**] 04:30AM BLOOD %HbA1c-5.7 eAG-117
[**2144-3-24**] 04:30AM BLOOD Triglyc-111 HDL-21 CHOL/HD-4.7 LDLcalc-56
[**2144-3-13**] 07:35PM BLOOD Ammonia-184*
[**2144-3-18**] 04:16AM BLOOD Ammonia-15
[**2144-3-24**] 04:30AM BLOOD TSH-2.9
[**2144-3-14**] 09:02PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE IgM HAV-NEGATIVE
[**2144-3-14**] 08:13PM BLOOD ANCA-NEGATIVE B
[**2144-3-14**] 08:13PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2144-3-14**] 05:00PM BLOOD C3-84* C4-24
[**2144-3-14**] 09:02PM BLOOD HCV Ab-NEGATIVE
[**2144-3-15**] 01:05AM BLOOD Glucose-134* Lactate-4.3* Na-125* K-3.5
Cl-86*
.
ECG Study Date of [**2144-3-13**] 7:35:04 PM
Baseline artifact makes P wave interpretation difficult. Sinus
rhythm.
Non-specific intraventricular conduction delay. Consider left
anterior
fascicular block. Tall peaked T waves in the inferior and
lateral leads.
Consider hyperkalemia or ischemia. Poor R wave progression.
Compared to the
previous tracing of [**2143-1-5**] bradycardia is absent. The QRS
complex is wider
with tall peaked T waves suggesting the possibility of
hyerkalemia.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
80 [**Telephone/Fax (3) 106360**]/461 73 -50 80
.
Sinus rhythm with a ventricular premature beat. Non-specific
lateral
T wave flattening. Compared to tracing #3 ventricular rate is
faster.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
96 134 94 366/429 68 29 71
.
ECG Study Date of [**2144-3-19**]
Possible atrial flutter with uncontrolled ventricular response.
Diffuse
minimal ST segment depressions in the anterolateral leads.
Compared to
tracing #1 the patient is no longer in normal sinus rhythm.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
151 0 82 310/469 0 51 -132
.
ECG Study Date of [**2144-3-21**] 2:45:56 AM
Probable atrial flutter with 2:1 A-V conduction. Diffuse ST-T
wave
abnormalities. Compared to the previous tracing of [**2144-3-19**]
probably no
significant change, except rhythm is now more regular.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
163 0 90 244/424 0 57 -79
.
ECG Study Date of [**2144-3-24**]
Normal sinus rhythm. Left atrial abnormality. Compared to the
previous tracing of [**2144-3-21**] atrial flutter is no longer
appreciated. The diffuse ST-T wave abnormalities have resolved.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
99 108 88 368/436 63 47 66
.
IMAGING:
CT HEAD W/O CONTRAST Study Date of [**2144-3-13**]
FINDINGS: Evaluation is slightly limited given slight motion
artifact.
However, there is no acute intracranial hemorrhage, large areas
of edema, or
mass effect. There is preservation of normal [**Doctor Last Name 352**]-white matter
differentiation. Ventricles and sulci are normal in size and
configuration.
There is no fracture. There is calcification of the carotid
siphons
bilaterally. Soft tissues of the orbits are within normal
limits.
Calcification is again noted in the right upper eyelid, which
was present in
[**2138-4-1**]. The paranasal sinuses and left mastoid air cells
are clear.
There is partial opacification of the right mastoid air cells.
IMPRESSION: Evaluation is slightly limited by motion artifact.
However, no
evidence of acute intracranial hemorrhage.
.
CT C-SPINE W/O CONTRAST Study Date of [**2144-3-13**]
FINDINGS: There is no fracture. Alignment is maintained. Please
note that
evaluation is slightly limited due to motion artifact.
Prevertebral soft
tissues are within normal limits. Soft tissue structures of the
neck are
within normal limits. CT does not provide intrathecal detail
comparable to
that of MRI. There is dense calcification of the carotid bulbs
bilaterally.
A 3-mm nodule at the left lung apex (2:67).
IMPRESSION:
1) No fracture. Alignment maintained.
2) 3-mm pulmonary nodule at the left lung apex. Dedicated chest
CT is
recommended for further evaluation. At the time of this
dictation, patient is
ordered for a CT torso, as which time the lungs can be further
evaluated and
surveillance schedule established.
.
CHEST (PA & LAT) Study Date of [**2144-3-13**]
FINDINGS: Lung volumes are mildly diminished. No consolidation
or edema is
evident. The mediastinum is unremarkable. The cardiac silhouette
is within
normal limits for size. No effusion or pneumothorax is noted.
The osseous
structures are unremarkable.
IMPRESSION: No acute pulmonary process.
.
CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Study Date
of [**2144-3-14**]
CT CHEST WITHOUT IV CONTRAST: There is dependent subsegmental
atelectasis at
the bilateral lung bases. There is no focal consolidation.
Emphysematous
changes are noted diffusely. There is no pleural effusion or
pneumothorax.
Heart size is normal without pericardial effusion. There is mild
atherosclerotic calcification of the aortic arch and branch
vessels. The great
vessels are otherwise unremarkable. There is no axillary,
mediastinal, or
hilar lymphadenopathy meeting CT criteria for pathologic
enlargement.
Endotracheal and orogastric tubes are noted in situ.
CT ABDOMEN WITHOUT IV CONTRAST: Evaluation of the abdominal
organs is limited
without IV contrast. Within this limitation, there is geographic
hypodensity
within segments V and VIII of the liver with some capsular
retraction that
most likely represents fibrosis, but poorly evaluated on this
single-phase CT.
There is trace ascites. The gallbladder is surgically absent.
There is fatty
atrophy of the pancreas. The spleen has markedely decreased in
size and
demonstrates multiple calcifications. Bilateral adrenal glands
are normal.
The kidneys appear atrophic. A 2 mm nonobstructing stone is
noted in the the
right kidney. There is hydronephrosis or hydroureter. The aorta
is of normal
caliber throughout with atherosclerotic disease. There is a
stent that is
related to the celiac axis but it is not evaluated on this
noncontrast study.
The non-opacified stomach and intra-abdominal loops of small and
large bowel
are unremarkable. No mesenteric or retroperitoneal
lymphadenopathy meeting CT
criteria for pathologic enlargment is noted.
CT PELVIS WITHOUT IV CONTRAST: The urinary bladder is collapsed
around a
Foley catheter. The distal ureters, uterus, adnexa, sigmoid
[**Date Range 499**], and rectum
are unremarkable. There is no free fluid in the pelvis. No
pelvic or
inguinal lymphadenopathy is noted. Right femoral catheter is
noted in situ.
BONE WINDOWS: No suspicious lytic or sclerotic osseous lesion is
identified.
Old right rib fracture is noted on the sagittal view only.
IMPRESSION:
1. No acute intra-abdominal or pelvic abnormality to explain the
patient's
symptoms.
2. Poorly evaluated geographic hypodensity in the right lobe of
the liver
with capsular retraction is likely fibrosis; vascular problem as
the
underlying cause can not be assessed on this study.
3. Trace ascites.
.
DUPLEX DOPP ABD/PEL Study Date of [**2144-3-14**]
The liver demonstrates diffusely increased echogenicity. There
are no focal
liver lesions. There is no intra- or extra-hepatic biliary
dilatation with
the common bile duct measuring up to 4 mm.
DOPPLER EXAMINATION: The left, middle and right hepatic veins
are patent.
The IVC is patent. The main portal vein and its major branches
including the
left portal, right anterior and posterior portal branches are
patent with
appropriate directions of flow and Doppler waveforms.
IMPRESSION:
1. Echogenic liver compatible with diffuse fatty deposition.
Other forms of
liver disease including more significant liver disease such as
advanced
hepatic cirrhosis/fibrosis cannot be excluded on this
examination.
2. Patent hepatic vasculature with no evidence of Budd-Chiari
syndrome.
3. No biliary dilation.
.
[**2144-3-16**] TTE
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded (?hypokinesis of the
basal anterior septum) Right ventricular chamber size is normal.
with borderline normal free wall function. The aortic valve
leaflets (?#) appear structurally normal with good leaflet
excursion. Mild to moderate ([**2-2**]+) aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. Moderate (2+)
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2142-1-2**],
global left ventricular systolic function is less vigorous, and
the severity of aortic regurgitation, mitral regurgitation, and
tricuspid regurgitation have slightly increased.
.
CHEST (PORTABLE AP) Study Date of [**2144-3-21**]
Interstitial abnormality always has been a problem in the left
lung, and has not cleared. Given the relatively extensive
involvement of the left lung, I think is probably residual
asymmetric edema rather than pneumonia, although has not changed
appreciably since [**3-18**]. Previous right lower lobe
atelectasis is improved. At least a small left pleural effusion
is present. Tip of the ET tube is nearly at the carina and
needs to be withdrawn 4 cm. Right jugular dual-channel dialysis
catheter ends in the mid SVC and a left PICC line in the upper
right atrium approximately 2 cm below the estimated location of
the cavoatrial junction. Nasogastric tube ends in the stomach.
Heart size normal. No pneumothorax. Dr. [**Last Name (STitle) **] was paged.
.
[**Last Name (un) **] DUP EXTEXT BIL (MAP/DVT) Study Date of [**2144-3-26**]
The subclavian veins present patent with normal flow.
On the right side, the right cephalic vein is thrombosed from
the distal
portion of the upper arm to the level of the antecubital fossa.
The proximal portion of this vessel is patent and compressible
with diameters ranging between 0.12 and 0.21 cm.
The right basilic vein is patent and compressible with diameters
ranging
between 0.1 and 0.53 cm. On the left side, the left cephalic
vein is thrombosed and noncompressible from the distal segment
of the upper arm to the level of the antecubital fossa. The
proximal segment of the vessel was patent and compressible with
diameters ranging between 0.29 and 0.35 cm.
The left basilic vein is patent and compressible with diameters
ranging
between 0.15 and 0.34 cm. The brachial arteries present patent
and single bilaterally, presenting with triphasic Doppler
waveforms.
COMPARISON: None available.
IMPRESSION: Noncompressible cephalic veins from the level of the
distal
portion of the upper arm to the antecubital fossa bilaterally.
Patent basilic veins bilaterally with diameters as described
above.
Single brachial arteries bilaterally, with triphasic Doppler
waveforms.
Pertient Imaging Since MICU discharge:
.
CLINICAL INDICATION: 48-year-old with ATN to assess for
hydronephrosis.
.
Both kidneys are slightly small, but symmetrical in size
measuring 9.6 cm in length on the right and 9.7 cm on the left.
There is diffuse increase in cortical echogenicity throughout
both kidneys. There are no signs of
hydronephrosis or renal stones, nor are any masses seen. Limited
views of the bladder are unremarkable.
.
CONCLUSION: Slightly small and hyperechoic kidneys suggesting
some form of
diffuse parenchymal disease. No signs of obstruction.
.
LIVER/GALLBLADDER US
FINDINGS:
No free fluid seen. The liver shows no focal or textural
abnormalities.
There is a tortuous course of the hepatic artery along the
medial margin of the right hepatic lobe in keeping with the
previously demonstrated post
transplant anatomy, this is also seen on the prior CT of
[**2143-1-5**]. A vascular stent is also seen in this region.
The common duct is not dilated. Both right and left kidneys are
normal without hydronephrosis or stones. The pancreas and spleen
are unremarkable. There is a small peripancreatic node measuring
1.2 cm, which has also been present since [**2143-1-1**]. The
portal vein is patent with normal hepatopetal flow. A full
Doppler study was not performed as this was done on [**2143-3-14**].
.
IMPRESSION:
1. No ascites. No spot was marked for paracentesis.
2. Unchanged appearance of the transplanted liver.
.
The study and the report were reviewed by the staff radiologist.
.
Lower Extremity Dopplers:
INDICATION: 48-year-old woman with alcohol cirrhosis with fever
of unknown
origin. Assess for clot.
.
BILATERAL LOWER EXTREMITY ULTRASOUND: [**Doctor Last Name **]-scale and Doppler
son[**Name (NI) 1417**] of
bilateral common femoral, superficial femoral, and popliteal
veins show normal blood flow, compressibility, and augmentation.
The bilateral calf veins show normal flow.
.
IMPRESSION: No evidence of DVT in bilateral lower extremities.
.
Non-Contrast CT:
INDICATION: 48-year-old female with orthotopic liver
transplantation with
left upper lobe pneumonia. Question abscess.
.
TECHNIQUE: Multiple axial images were obtained of the chest from
thoracic
inlet through the upper abdomen without contrast. Coronal and
sagittal images are reformatted and reviewed. Elevated
creatinine precluded administration of contrast.
Comparison is made with chest CT, [**2144-3-14**].
.
FINDINGS: There is coalescent consolidation in the anterior
segment of left upper lobe with no evidence of cavitation to
suggest abscess. Additionally, there are multifocal areas of
ground-glass and more nodular parenchymal opacity seen in the
right middle, right lower and left lower lobes. There are
diffuse emphysematous changes. There are bilateral pleural
effusions, larger on the left.
.
There is no mediastinal lymphadenopathy. No large hilar mass on
this
non-contrast examination.
.
Since the prior chest CT, there has been interval development of
diffuse
calcification involving the anterior wall of the left ventricle,
portions of the interventricular septum and papillary muscles.
The apex and inferior and free walls appear uninvolved. The
distribution of this finding is consistent with LAD territory
infarction. The rapid development of calcification is somewhat
atypical given the relatively normal appearance of the
myocardium on the comparison examination from [**2144-3-14**]. There
is no pericardial effusion.
.
Imaged portions of upper abdomen are stable with a small amount
of pneumobilia (2:54) as has been seen in the past.
.
IMPRESSION:
.
1. Multifocal areas of consolidation bilaterally with more
confluent
consolidation in the anterior segment of left upper lobe. No
evidence of
cavitation to suggest abscess formation. The findings are most
consistent
with multifocal pneumonia with associated bilateral pleural
effusions.
.
2. There has been interval development of diffuse calcification
involving the anterior wall of left ventricle, portions of the
interventricular septum and papillary muscles. The distribution
is consistent with LAD infarction with the rapid development of
calcification being somewhat atypical.
.
VQ SCAN
RADIOPHARMACEUTICAL DATA:
8.5 mCi Tc-[**Age over 90 **]m MAA ([**2144-4-6**]);
39.6 mCi Tc-99m DTPA Aerosol ([**2144-4-6**]);
HISTORY: 48 year old female with multifocal pneumonia and
shortness of breath. Evaluate for pulmonary embolus.
.
Ventilation images obtained with Tc-[**Age over 90 **]m aerosol in 8 views
demonstrate
obstructive airways disease with central clumping of
radiotracer. There are large ventilation defects in a
non-segmental distribution, especially in the lung apices.
.
Perfusion images in the same 8 views show large areas of
perfusion defects in a non-segmental distribution, especially in
the lung apices.
.
Chest CT demonstrates multifocal pneumonia and left greater than
right pleural effusions.
.
The above findings are consistent with a low probability of PE.
.
IMPRESSION: Matched perfusion and ventilation defects consistent
with a low probability of PE, especially in the setting of
multifocal pneumonia and pleural effusions.
.
ECHO:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 55-60%). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. There is no
aortic valve stenosis. Mild to moderate ([**2-2**]+) aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild to
moderate ([**2-2**]+) mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
Compared with the findings of the prior study (images reviewed)
of [**2144-3-16**], no major change.
.
Brief Hospital Course:
48 year old woman with a history of alcoholic cirrhosis s/p two
transplants in [**2136**], then in [**2137**] who presented with acute
altered mental status on [**2144-3-13**] and subsequently intubated due
to inability to protect airway. She had a prolonged hospital
course summarized below. Please see additional problem list
below for further details:
.
#) Hypoxic respiratory failure: She presented on [**3-13**] with
altered mental status and was intubated due to inability protect
her airway. she was extubated on [**3-15**] with improvement in her
respiratory status and mental status however she began to desat
down to upper 70's and her mental status became altered again
therefore was reintubated on the same day. Her second intubation
was most likley [**3-4**] to volume overload. At that point her LOS
was +11 liters in setting of volume resuscitation and renal
failure. There was an asymmetry noted on x-ray and she was
started on treatment for HCAP on cefepime and vancomycin. ECHO
did not showed any wall motion abnormalities with a preserved EF
of 55% in the setting elevated cardiac enzymes. She continued to
be volume overloaded despite being on a lasix drip and with her
renal failure was not putting out adequate urine. She was
subsequenlty started on CVVH which helped to slowly diurese
fluid off of her lungs. Once her respiratory status improved,
she was successfully extubated on [**2144-3-22**].
.
#) Hypotension: Unclear etiology. Cardiac event was thought
unlikely, but possible as initial insult given no ECG changes,
pain free and Trop T flat with normal echocardiogram. The most
likely cause was narcotic overdose given she had been altered,
found in the snow 3 days before, and fell down her stairs.
Furthermore, in the hospital we noted correlation with her
mental status and BP with narcotic and ambien administration.
Infection as the initial culpruit is unlikely given she was
afebrile, normal CT scan of the chest (initially), negative
blood cultures, CMV, [**Doctor First Name **], glucan, and no leukocytosis or
left-shift. However, it is possible than an NSTEMi could have
happened days prior to presentation and be the cause of her AMS
and hypotension. PE was not ruled out with PE-CT given the renal
failure and we thought that she could eventually recover her
kidney function.
.
#) VAP: Several days into hospitalization, patient developed
severe parenchymal opacities in the left lung and was
intermittently spiking fevers. Patient treated with
vancomycin/cefepime/flagyl for 8 day course for HCAP and
possible aspiration. Still visible on chest x-ray.
.
#) [**Last Name (un) **]: Severe, oliguric, most likely secondary to ATN given
muddy brown casts on urine from hypotension [**3-4**] AMS/dehydration
vs sepsis. Her CK was too low for myoglobinuria in the [**2133**]
range. There were small ammount of dysmorphic RBCs and
innumerable brown-moddy casts. However, [**Doctor First Name **], ANCA, AMA were
negative anc complement was normal. Patient eventually required
CVVH while in the ICU and was transitioned to HD. After multiple
days of holidays she continued to retain fluid (despite her
increasing urine output) and her creatinine trended up, so HD
was resumed again. A timed urine collection estimated a GFR <
20. Her Hep B negative without Hep B surface antibody, and Hep C
negative and PPD were negative. We believe she will be
permanently on HD, but would suggest re-assesing at some point
given UOP is ~300 cc/day.
.
#) Altered Mental Status: Unclear etiology for her altered
mental status, but thought to be secondarely to narcotics and
ambien. She required intubation due to altered mental status and
inability to protect airway given copious secretions. She was
treated for a pneumonia and her renal function improved with
CVVH. Her altered mental status resolved s/p extubation.
.
#) Elevated cardiac enzymes / NSTEMI - Initialy Trop T was 4
without any ECG changes suggesting ischemia (only peaked T waves
and QRS broadening with K of 8). ECHO did not show definitive
wall motion abnormalities with an EF of 55%. Cardiac enzymes
were stable initially and then peaked to Trop T of 7, which was
thought to be secondarely to the VAP and AFib with RVR. However,
on repeat CT scan of the chest 3 weeks later without contrast we
found califications of the LV, suggestive of a prior MI during
first week in the hospital. Repeat echocardiogram 3 weeks later
was unchanged with EF of 55% and no wall motion abnormalities.
.
#) Hyperkalemia: When she originally presented she was to be
hyperkalemic with QRS widening and peaked t-waves which resolved
within 2 days in the setting of renal failure. She received
kayexelate which she responed well to CVVH/HD.
.
#) s/p Liver transplant: Came with sirolimus level of 3
suggesting she was not taking her medications. She had not been
seen for more than 1 year in the transplant clinic. She came
with elevated LFTs to AST 70, ASLT 180, AP 209, TB 0.6, which
were thought to be to hypotension or lack of compliance with her
medications. LFTs imrpoved to normal on discharge with ALT 7,
AST 27, AP 125, TB 0.3. On the floor, prednisone was changed
back to rapamycin with no evidence of lung toxicity. She was
switched to sirolimus 1 mg daily (given her level was high in
the MICU with her home dose of 3 mg daily) and on Mycophenolate.
.
#) Atrial Fibrillation: The patient went into AFlutter on [**3-19**]
and spontaneously converted to NSR with Metoprolol. On the
floor, she remained in NSR. She had been receiving 5mg
metoprolol PRN in the MICU and oral metoprolol oraly in the
floor. She was on NSR on telemetry at all times. She was
eventually decreaed to 6.25 of metoprolol given she prefered
"pain medications" insted of cardiac protection with
beta-blockers. She understood the risks of this decision after
an extensive discussion with Dr. [**Last Name (STitle) 497**] (attending of record).
.
#) Hypoxic event / PE / Embolus: Patient had a temporal HD line
in the RIJ, which was changed over a wire as part of an
infectious work up (see below). Given she continued to spike
low-grade temperatures it was pulled to give her a line holiday.
30 seconds after pulling the line she developped hypoxia to 82%
on RA with SOB and respiratory distress that improved ith 100%
o2 with a NRB. CXR showed no change compared to prior and V/Q
scan was low probability for PE, but given the timing of the
event in relation to removal of the line, she was put on heparin
gtt and started on coumadin to complete 3 months of therapy. Our
differential diagnosis included air emboli, thrombo-embolic
event or septic ebloli to the lungs. CT scan did not show
caviation and showed evidence of a new PNA.
.
#) Hospital-Acquired PNA: Patient developed new shortness of
breath while in the floor as described above and had new PNA on
CT scan, so she was started on a 10-day course of
Vancomycin/Zosyn, which she should finish on [**2144-4-15**]. She has
been breathing comfortably on RA with good sats on ambulation
(though cannot walk more than few feet due to weakness and
deconditioning).
.
#) Fever: Extensive work up including [**Doctor First Name **], glucan, CMV,
mycolytics, blood cultures, C diff, CT scan of torso, RUQ US did
not show any source of infection. PICC was pulled in L arm and
culture did not grow anything. HD line was change over wire and
patient continued to spike. HD line was pulled and patient had a
5 day line holiday on Vanc/Zosyn for pneumonia and she has been
afebrile since line was pulled. Prior to discarge she had a
tunneled HD catheter was placed in the r IJ.
.
#. Hyperglycemia: The patient developed steroid induced
hyperglycemia in the MICU. She was kept on a humalog sliding
scale on the floor, which was discontinued after no longer
required with cessation of steroids.
Medications on Admission:
- Metoprolol 200mg PO BID
- Mycophenolate 250mg PO BID
- Nortriptyline 20mg PO HS
- Oxycontin 80mg PO BID
- Rapamune 4mg PO daily
- Zaleplon 10mg PO HS
- Calcium carbonate 600/400 unit tab PO BID
- MTV PO Daily
- Neurontin 300 mg qhs
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for SOB.
2. heparin (porcine) 1,000 unit/mL Solution Sig: Four (4)
Injection PRN (as needed) as needed for line flush.
3. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath.
4. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48H (every
48 hours).
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
7. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
9. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM: Please [**Name8 (MD) 138**] MD [**First Name (Titles) **] [**Last Name (Titles) 263**] is > 3.0 to adjust daily dosing.
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. sirolimus 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Please check Rapamycin levels weekly to determin goal ([**9-9**]).
Disp:*3 Tablet(s)* Refills:*0*
12. OxyContin 30 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO twice a day: Please do not
increase dose. If patient has continued pain, please [**Name8 (MD) 138**] MD.
13. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. piperacillin-tazobactam 2.25 gram Recon Soln Sig: One (1)
Recon Soln Intravenous Q8H (every 8 hours) for 4 days.
16. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: One (1) variable Intravenous ASDIR (AS DIRECTED)
for 3 days: Please see attached sliding scale. Goal PTT 60.
17. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
variable Intravenous HD PROTOCOL (HD Protochol) for 4 days:
Please have Nephrologist dose vancomycin after dialysis. Please
get random Vanc level prior to dialysis.
18. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Tunneled Access Line (e.g. Hickman), heparin dependent: Flush
with 10 mL Normal saline followed by Heparin as above daily and
PRN per lumen.
19. Insulin
Please follow attached sliding scale.
20. metoprolol tartrate 25 mg Tablet Sig: 0.25 Tablet PO twice a
day.
21. Labs
Please check weekly CBC w/diff, LFTs, BMP-7, [**Name8 (MD) 263**] and sirolimus
level and fax to Dr. [**Last Name (STitle) 497**] at ([**Telephone/Fax (1) 12173**].
22. Labs
Please check [**Telephone/Fax (1) 263**] on [**2144-4-12**]; target [**3-5**] for PE/DVT.
23. Appointment
When: WEDNESDAY [**2144-4-29**] at 1:40 PM
With: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**]/TRANSPLANT [**Hospital 1389**] CLINIC [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] [**Location (un) 701**]
Discharge Diagnosis:
Primary Diagnosis:
VAP/HAP
PE
NSTEMI
Anemia
ESRD on HD
Secondary Diagnosis:
Liver Transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mrs. [**Known lastname **]-
You were admitted to the hosptial for confusion and low blood
pressure. During your hospitalization you developed renal
failure requiring dialysis, an abnormal heart rhythm, a heart
attack, several penumonias (an infection of your lung), and a
clot in your lungs. You will be discharged to a rehab facility
where you can finish your treatment and continue to regain your
strength prior to returning home. While at rehab you require a
few more doses of antibiotics, in addition to blood thinners,
and dialysis. Listed below are the following medication
changes:
ADDED: warfarin, zosyn, vancomycin, albuterol, ipratropium,
gabapentin, atorvastatin, aspirin, B complex-vitamin C, folic
acid, iron, vitamin C, insulin, acetaminophen
STOPPED: zaleplon, calcium carbonate, multivitamin,
nortripyline,
CHANGED: Mycophenolate, rapamune, oxycontin, metoprolol
Followup Instructions:
Please have Rehab contact the following providers at [**Hospital1 18**] prior
to your discharge from the hospital:
1) Dr. [**Last Name (STitle) 497**] (Liver Specialist)
2) Dr. [**Last Name (STitle) **] (Cardiologist)
3) Dr. [**Last Name (STitle) 8682**], [**Name8 (MD) **] MD
It is important you go to all the appointments that are arranged
for you.
Department: TRANSPLANT
When: WEDNESDAY [**2144-4-29**] at 1:40 PM
With: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**]/TRANSPLANT [**Hospital 1389**] CLINIC [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2144-4-14**]
|
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51,245
| 121,019
|
53172
|
Discharge summary
|
report
|
Admission Date: [**2195-8-18**] Discharge Date: [**2195-9-7**]
Date of Birth: [**2126-11-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Iodine / Betadine
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Left hilar mass.
Major Surgical or Invasive Procedure:
bronch/med/ left thoracotomy bullectomy, talc pleuradesis [**2195-8-18**]
trach/peg [**2195-8-31**]
History of Present Illness:
The patient is a 68 year-old male with a history of severe COPD,
emphysema and bullous disease, who was recently diagnosed with a
left hilar mass, two
biopsies of which were negative. Two biopsies were done with
TBNA and were negative. The patient also has a past medical
history of multiple skin cancers as well as history of tobacco
use, parotid resection times 2 for adenocystic
carcinoma that required a right lower lobe wedge that showed
metastatic adenocystic carcinoma in the lower lobe. The patient
was admitted electively to undergo a bronchoscopy and
mediastinoscopy and, in case it was negative, he would undergo a
thoracotomy with possible resection of his left hilar mass. His
preoperative PFT's were borderline and it was obvious that he
would not tolerate a left pneumonectomy but he would do well
with a left upper lobectomy.
Past Medical History:
basal cell carcinoma s/p multiple skin resections
HTN
SVT
COPD
bx hilar mass with moderately differentiated adenocarcinoma
bilateral nephrolithiasis
carotid artery stenosis
history of syncope (echo negative)
parotid resection x 2 for adenocystic carcinoma
s/p mediastinoscopy and RLL wedge resection in [**2189**] for
metastatic mucoepidermoid carcinoma
Social History:
smoker, quitting earlier this year, 55-90 pack years
Worked as a beer shipper - heavy drinker (case) for 6 months
currently lives alone, working as consultant for engineering
company
Family History:
Basal cell carcinoma
HTN
lung cancer
Physical Exam:
Vitals during Postoperative check
97.7 97.4 100 91/62 15 94% 4L O2 NC
HEENT: Normocephalic, multiple scars to head from previous
surgeries, atraumatic, EOMi, MMM
Cardio: RRR distant heart sounds
Pulm: Coarse BS, [**Month (only) **] BS at bases
Abd: soft, NT, ND, act BS
LE: no edema
incision: CDI
Vitals during discharge:
98 97 94 138/92 20 96% on 10L via trach
NADS, AAOx4
RRR
CTAB
Abd: soft, nt, nd, act BS
wound: c/d/I
Ext: no c/c/e
Pertinent Results:
Path: negative LN; Hilar masses showing adenocarcinoma with
significant necrosis. It does not have the appearance of an
adenocystic carcinoma. It is positive for CK-7 and TTF-1 and
negative for CK20, supporting a pulmonary origin.
Sputum GS showing MSSA; BAL showing STAPH AUREUS COAG +.
10,000-100,000 ORGANISMS/ML. BETA STREPTOCOCCI, NOT GROUP A.
[**2195-8-18**] WBC-15.5*# RBC-5.51 Hgb-16.2 Hct-49.1 Plt Ct-234
[**2195-9-6**] WBC-10.3 RBC-4.59* Hgb-13.6* Hct-41.3 Plt Ct-527*
[**2195-8-18**] Glucose-135* UreaN-11 Creat-0.8 Na-138 K-4.4 Cl-107
HCO3-24
[**2195-9-5**] Glucose-92 UreaN-11 Creat-0.7 Na-137 K-4.2 Cl-101
HCO3-27
[**2195-8-31**] Type-ART pO2-94 pCO2-44 pH-7.44 calTCO2-31* Base XS-4
[**2195-8-25**] Type-ART pO2-75* pCO2-44 pH-7.43 calTCO2-30 Base XS-3
[**2195-8-22**] Type-ART pO2-100 pCO2-43 pH-7.42 calTCO2-29 Base XS-2
Intubated
CXR [**2195-9-5**]: IMPRESSION:
Small left pleural effusion has changed in distribution, but not
in overall size, including a small loculation projecting over
the region of atelectasis in the left midlung. Left basal
atelectasis has worsened slightly. Right lung is clear. Moderate
enlargement of the cardiac silhouette is stable. Tracheostomy
tube is now midline. Emphysema is best demonstrated in the right
upper lung zone.
Brief Hospital Course:
Patient was taken to the operating room by Dr. [**Last Name (STitle) **] on [**2195-8-18**]
for bronchoscopy, mediastinoscopy, left thoractomy, bullectomy,
shave biopsy of left hilar mass, and talc pleurodesis. Following
surgery, he was taken to the PACU for observation and
transferred to the general wards after clearance. He did require
some neoepinephrine for hypotension but was taken off it POD2.
Fluid boluses provided additional intravascular repletion and
his blood pressure maintained within normal limits. Epidural
was provided for pain control and oxygen provided via nasal
cannula for comfort. On POD2, patient found to have shortness of
breath, increased work of breathing, desaturation down to 80% on
face mask. CXR done showing pulmonary edema. Patient was NT
suctioned, lasix given with nebulizing treatment, stabilizing
his respiratory status. Without improvement in respiration
following treatment, patient was taken for flexible bronchoscopy
later that evening, intubated, and transferred to SICU for
further management. Bronchoscopy showed thick secretions and
mucus plugs, BAL done for culture and cytology analysis.
Cultures positive for Methicillin sensitive staph aureus and
nafcillin started for coverage. He was kept on CPAP with
pressure support. POD5, OGT provided to start tube-feeding. CT
with airleak and kept on water seal. Surgical team attempt to
wean ventilatory status. Patient was hypotensive and epidural
capped upon transfer to ICU. Neo was resumed for pressor
support. He was taken to OR again by Dr. [**Last Name (STitle) **] for trach/PEG
placement POD13 due to failure to successfully wean from vent.
Patient also placed on IV steroids to treat COPD and improve
respiratory status. Post tracheostomym patient able to
successfully wean from extubation. He was provided with
Passy-uir valve to help with speaking. Swallowing study on POD16
provided diet recommendations. Patient advanced to ground solids
and thin liquids, advanced to regular food as tolerated. On
POD18, patient went into atrial fibrillation. Lopressor provided
but did not convert immediately. He was hypotensive to sbp
70-80. No acute distress and asymptomatic. Responded to fluids
boluses later that evening. Cardiology also consulted to make
recommendations for at home regimen. His electrolytes were
monitored and repleted. Patient now will be dc home off
atenolol, lopressor 37.5mg every 6 hours and lisinopril added
for more bp control. On POD20, patient's tracheostomy tube was
replaced with unfenestrated 6Fr trach tube for better
ventilation in outpatient setting. He is stable, tolerating
regular foods, afebrile, ambulating, oxygenating with
tracheostomy and will be discharged to vent rehab for
conditioning support.
Medications on Admission:
Atenolol 50', Spiriva 1'. Stopped taking Soriatane (skin CA med)
and Flovent.
Discharge Medications:
1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
2. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for dry eyes.
3. Artificial Tear with Lanolin Ointment Sig: One (1) Appl
Ophthalmic QID (4 times a day) as needed.
4. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
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.
8. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
Three (3) mls Inhalation q4h prn ().
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
10. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO Q6H
(every 6 hours).
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) gms
Intravenous Q4H (every 4 hours) for 3 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
widespread skin cancer for which he has had multiple surgeries,
HTN, SVT, emphysema, tobacco abuse (quit earlier this year),
moderate
bilateral nephrolithiasis, carotid artery stenosis, and a
history of syncope with a full workup including an echo showing
preserved left ventricular function
PSH: multiple excisions of basal cell CA's and skin grafts,
removal of dura and flap (??), parotid resection x2 for
adenocystic CA [**2170**] & [**2182**], mediastinoscopy & RLL wedge rsxn
[**2189**] for metastatic mucoepidermoid CA
left hilar mass, talc pleuradesis, left bullectomy, trach/peg
[**2195-8-31**]
Discharge Condition:
deconditioned
Discharge Instructions:
call Dr.[**Name (NI) **] office [**Telephone/Fax (1) 4741**] if you develop fever,
chills, redness or drainage from your chest incision, chest
pain, shortness of breath or any breathing symptoms that concern
you.
Followup Instructions:
You have a follow up with Dr. [**Last Name (STitle) **] on the [**Hospital Ward Name **] [**Hospital Ward Name **]
clinical center [**Location (un) **] on [**2195-9-24**] at 3:30pm.
Please arrive 45 minutes prior to your appointment and report to
the [**Location (un) **] radiology for a CXR prior to yuor appointment.
Completed by:[**2195-9-10**]
|
[
"401.9",
"E878.8",
"162.2",
"V15.82",
"492.0",
"518.81",
"427.31",
"041.11",
"V10.02",
"458.29",
"V10.83",
"V09.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"40.11",
"32.29",
"34.22",
"38.91",
"96.6",
"96.72",
"33.24",
"34.92",
"43.11",
"31.1",
"34.06",
"03.90"
] |
icd9pcs
|
[
[
[]
]
] |
7684, 7763
|
3687, 6429
|
301, 403
|
8410, 8426
|
2382, 3664
|
8687, 9037
|
1872, 1910
|
6557, 7661
|
7784, 8389
|
6455, 6534
|
8450, 8664
|
1925, 2363
|
244, 263
|
431, 1277
|
1299, 1656
|
1672, 1856
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,328
| 192,998
|
17081+56833
|
Discharge summary
|
report+addendum
|
Admission Date: [**2139-6-24**] Discharge Date: [**2139-7-17**]
Date of Birth: [**2106-6-2**] Sex: M
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 33-year-old man
who had complaints of a headache on [**2139-6-20**]. He was seen at
an outside emergency room with increased blood pressure and
visual disturbances. He was sent home with prescriptions for
medication for his blood pressure and allergies and returned
with severe headache on [**2139-6-23**]. He had again hypertension
and visual changes and was transferred to [**Hospital1 346**] after a head CT showed subarachnoid
hemorrhage.
PAST MEDICAL HISTORY: 1. Asthma. 2. Spina bifida with
ventriculoperitoneal shunt as a child. 3. Hypertension. 4.
Renal failure.
PHYSICAL EXAMINATION: On admission the patient was awake,
alert, oriented x 3 with no pronator drift, moving all
extremities with good strength. His vital signs were stable.
His temperature was 101.1. He was on 0.3 mcg of Nipride to
keep his blood pressure less than 140-150.
LABORATORY DATA: His white count was 12.4, hematocrit 37.7,
platelet count 338. INR was 1.2, patient 13.6, PTT 22.6.
Sodium 139, K 4.0, chloride 104, CO2 23, BUN 22, creatinine
0.9, glucose 135.
HOSPITAL COURSE: The patient had a headache and on [**2139-6-25**]
was taken to angiography which showed a ruptured right A1-A2
junction aneurysm with severe radiographic vasospasm. The
patient had a coiling of this aneurysm and papaverine along
wiht intracranial angioplasty for severe vasospasm. Post
angiography the patient was sedated. His gaze was conjugate.
Pupils were 2.5 down to 2 bilaterally, minimally reactive. He
had no withdrawal to painful stimulation and no spontaneous
movements. His reflexes were decreased throughout. He had
positive pedal pulses. His groin site was clean, dry and intact
postoperatively. The patient had the Acom aneurysm
coiled and bilateral carotid MCA angioplasty for vasospasm.
On postprocedure day number one the patient did not respond
to voice, no response to pain. Pupils were 3.5 down to 3 and
brisk. He had forward gaze. The patient had a vent drain
placed and a head CT which showed no evidence of new
hemorrhage, but some evidence of questionable right frontal
infarct. The patient spiked to 103.1 on the 22nd and was
fully cultured.
On [**2139-6-26**] the patient was awakened to examination, withdrew
the right and left upper and lower extremities, withdrew the
right greater than left upper extremity, question of
localizing to pain in the uppers. Neurologically he was
improving. He was continued to be intubated, somewhat
lightly sedated and was kept on triple H therapy keeping his
central venous pressure greater than 10 and his blood
pressure 170-190 to help with vasospasm.
On [**2139-6-28**] the neurological examination was unchanged. The
patient had minimal lateral movement of the upper extremities
to pain and constant nonpurposeful movement of the lower
extremities. He withdrew to pain. His pupils were 2 mm and
reactive. He had intact cough, gag, and corneals. His ICP
drain remained at 5 cm above the tragus with a moderate
amount of serosanguinous drainage. The patient did not open
his eyes or follow commands. He continued to be hyperdynamic
and kept hypertensive for treatment of vasospasm.
On [**2139-7-1**] the patient began following commands, opening his
eyes spontaneously, tracking with his eyes, nodding his head
"yes" and "no" appropriately, would grasp with the right hand
but not with the left. He moved both legs freely and off the
bed but no to command. The patient was extubated on [**2139-7-2**]
and tolerated this well.
On [**2139-7-8**] the patient went for arteriogram which showed
good coiling of the aneurysm, though some persistent vasospasm.
On [**2139-7-10**] the patient's vent drain was removed. The
patient was kept in the intensive care unit over the weekend.
He was awake, alert, oriented x 3, following commands x 4.
He had a feeding tube place for inability to swallow and was
transferred to the floor on [**2139-7-13**]. He was awake, alert
and oriented x 3, moving all extremities with good strength
with still some residual left-sided weakness and left drift.
The patient failed swallow evaluation and therefore had a
feeding tube in place which he pulled out. Reevaluation was
performed on [**2139-7-15**] and those results are pending.
DISCHARGE MEDICATIONS:
1. Heparin 5,000 units subcutaneous q. 12 hours.
2. Pantoprazole 40 mg or b.p.o. q. 24 hours
3. Tylenol 650 p.o. q. 4 hours p.r.n.
4. Metoprolol 50 mg p.o. b.i.d.
5. Ceftriaxone 1 gram IV q. 24 hours.
CONDITION ON DISCHARGE: Stable.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2139-7-15**] 08:32
T: [**2139-7-15**] 08:55
JOB#: [**Job Number 48023**]
Name: [**Known lastname 8907**], [**Known firstname **] Unit No: [**Numeric Identifier 8908**]
Admission Date: [**2139-6-23**] Discharge Date: [**2139-7-23**]
Date of Birth: Sex: M
Service:
ADDENDUM: The patient's discharge was delayed until [**2139-7-23**] due to a lack of rehabilitation beds.
The patient's condition was stable at the time of discharge.
He remained neurologically intact for the remainder of his
time in the hospital and was transferred to rehabilitation
with followup with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 365**] in one month.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 5862**]
Dictated By:[**Last Name (NamePattern1) 366**]
MEDQUIST36
D: [**2140-1-13**] 11:06
T: [**2140-1-13**] 11:10
JOB#: [**Job Number 8909**]
|
[
"041.4",
"599.0",
"430",
"578.9",
"493.90",
"401.9",
"741.90",
"486",
"729.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.2",
"88.41",
"39.72",
"96.72",
"96.6",
"39.50",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
4446, 4648
|
1266, 4423
|
793, 1248
|
173, 637
|
660, 770
|
4673, 5814
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,504
| 172,657
|
37970
|
Discharge summary
|
report
|
Admission Date: [**2114-4-11**] Discharge Date: [**2114-4-17**]
Date of Birth: [**2076-4-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Pollen Extracts / Milk / Cat Hair Std Extract
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
pain between shoulder blades
Major Surgical or Invasive Procedure:
[**2114-4-11**] Valve-sparing aortic root replacement (32mm Gelweave
graft)
History of Present Illness:
This 37 year old white male has had pain between his shoulder
blades with exertion over the past several months, which is
occasionally severe in
nature. Stress test was negative, however CT scan revealed a
thoracic aortic aneurysm. He was seen by Dr. [**Last Name (STitle) **] and is
now referred to Dr.[**Last Name (STitle) 914**] for further evaluation of his dilated
aortic root. He is hypertensive and currently smokes [**2-3**] pack
per
day. He was seen most recently on [**2114-2-27**] with CT/echo. He was
started on
Losartan at that time. He was evaluated at [**Hospital3 1810**]
for
possible connective tissue disorder and Marfan's is not
likely.
Past Medical History:
Hypercholesterolemia
Thoracic Aortic Aneurysm
Hypertension
erectile dysfunction
Social History:
Occupation: Manager and bartender; laid off last week
Tobacco: 1ppd x 20 years. Has cut down to half a pack daily over
past couple weeks.
ETOH: [**5-7**] nights per week consuming 4-5 drinks.
Family History:
Grandfather died in 50s from ruptured aneurysm
Physical Exam:
Admission:
Pulse:82 reg Resp: O2 sat: 99% RA
B/P: Right: 158/98 Left: 145/93
Height:6'3" Weight:238 lbs
General: WDWN ,anxious, occ. cough
Skin: Dry, intact, warm.
HEENT: NCAT, PERRLA, EOMI, Sclera anicteric, OP benign, Teeth in
good repair. Palate has mild arching.
Neck: Supple [X] Full ROM [X] No JVD
Chest: Lungs clear bilaterally [X].
Heart: RRR, Nl S1-S2, No M/R/G
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]-no HSM/CVA tenderness
Extremities: Warm [X], well-perfused [X] Edema-none on right,
trace on left
Varicosities: None [X]
Neuro: Grossly intact, MAE, Strength 5/5;nonfocal exam
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: None Left: None
Pertinent Results:
Conclusions
Prebypass:
1. The left atrium and right atrium are normal in cavity size.
No mass/thrombus is seen in the left atrium or left atrial
appendage. No spontaneous echo contrast is seen in the left
atrial appendage.
2. No atrial septal defect is seen by 2D or color Doppler.
3. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). No masses or thrombi are seen in
the left ventricle.
4. The right ventricular cavity is dilated with normal free wall
contractility.
5. The aortic root is moderately dilated at the sinus level. The
ascending aorta is moderately dilated. There are simple atheroma
in the aortic arch. No thoracic aortic dissection is seen. The
dilation of the ascending aorta was dilated proximally and
tapered to less than 4cm in distal ascending aorta.
6. There are three aortic valve leaflets. There is no aortic
valve stenosis. No aortic regurgitation is seen.
7. The mitral valve leaflets are structurally normal. Trivial
mitral regurgitation is seen. No mitral stenosis.
8. There is no pericardial effusion.
Dr. [**Last Name (STitle) 914**] was notified in person of the results in person
[**2114-4-11**].
Postbypass:
Patient is in sinus rhythm on phyenylepherine infusion
1. A graft is seen in the ascending aorta and root with smooth
contours. There is no longer a visible st junction
2. The native aortic valve is insitu without regurgitation or
stenosis. The valve appears well seated without perivavluar
leaks or flow.
3. Initially, the LV septum appeared hypo/dyskinetic,but
normalized over time. Preserved biventricular function, LVEF
>55% by chest closure.
4. Mitral Reguritation remains trace to mild
5. Aortic arch and descending aortic contours intact without
evidence of dissection.
6. Remaining exam is unchanged.
7. All findings discussed with surgical team at the time of the
exam.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2114-4-11**] 15:11
[**2114-4-16**] 06:05AM BLOOD WBC-6.7 RBC-2.90* Hgb-9.4* Hct-26.5*
MCV-91 MCH-32.5* MCHC-35.6* RDW-12.7 Plt Ct-246
[**2114-4-15**] 06:55AM BLOOD WBC-6.6 RBC-2.86* Hgb-8.8* Hct-25.4*
MCV-89 MCH-30.7 MCHC-34.6 RDW-12.8 Plt Ct-186
[**2114-4-16**] 06:05AM BLOOD UreaN-17 Creat-0.9 K-3.2*
[**2114-4-14**] 07:25AM BLOOD Glucose-110* UreaN-19 Creat-0.8 Na-132*
K-4.3 Cl-93* HCO3-32 AnGap-11
[**2114-4-16**] 06:05AM BLOOD WBC-6.7 RBC-2.90* Hgb-9.4* Hct-26.5*
MCV-91 MCH-32.5* MCHC-35.6* RDW-12.7 Plt Ct-246
[**2114-4-17**] 05:40AM BLOOD Na-139 K-4.7 Cl-103 HCO3-26 AnGap-15
Brief Hospital Course:
He was admitted on [**4-11**] and underwent valve sparing aortic root
replacement with Dr. [**Last Name (STitle) 914**]. He was transferred to the CVICU in
stable condition on Phenylephrine and Propofol drips. Cefazolin
was used for surgical antibiotic prophylaxis.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable on no inotropic or vasopressor
support. Beta blocker was initiated and the patient was gently
diuresed toward the preoperative weight. The patient was
transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. He did
develop a fever. C-difficile toxin on two occassions was
negative and on questioning he has frequent diarrhea episodes
related to diet. This resolved with on Imodium tablet.
Urinalysis was negative. White blood cell count remained normal
and sternal incision did not show signs of infection. Fevers
resolved. 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 home in good
condition with appropriate follow up instructions.
Medications on Admission:
losartan 50 mg daily
toprol XL 50 mg daily
cialis prn
ambien 10 mg prn HS
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever, pain.
3. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) for 7 days.
Disp:*50 Tablet(s)* Refills:*0*
4. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain for 4 weeks.
Disp:*30 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
three times a day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Location (un) 5087**]
Discharge Diagnosis:
aortic root aneurysm
s/p valve-sparing root replacement
hypertension
hypercholesterolemia
erectile dysfunction
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating, gait steady
Sternal pain managed with Dilaudid prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) 914**] on [**5-15**] @ 1:00 pm ([**Telephone/Fax (1) 170**])
Primary Care Dr. [**Last Name (STitle) 41415**] in [**2-3**] weeks ([**Telephone/Fax (1) 61767**])
Cardiologist Dr. [**Last Name (STitle) 3321**] in [**2-3**] weeks
Completed by:[**2114-4-17**]
|
[
"441.2",
"518.0",
"710.9",
"780.62",
"305.00",
"518.5",
"305.1",
"401.9",
"607.84"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.2",
"39.61",
"38.45"
] |
icd9pcs
|
[
[
[]
]
] |
7550, 7627
|
5185, 6534
|
339, 417
|
7782, 7879
|
2357, 5162
|
8419, 8749
|
1434, 1483
|
6658, 7527
|
7648, 7761
|
6560, 6635
|
7903, 8396
|
1498, 2338
|
271, 301
|
445, 1104
|
1126, 1208
|
1224, 1418
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,880
| 124,940
|
4230
|
Discharge summary
|
report
|
Admission Date: [**2102-3-8**] Discharge Date: [**2102-3-14**]
Date of Birth: [**2041-3-26**] Sex: M
Service: NEUROSURGERY
Allergies:
Lactose
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Elective admission for coiling of right MCA aneursym
Major Surgical or Invasive Procedure:
Coiling of MCA anuersym
History of Present Illness:
Mr [**Known lastname 18391**] began having episodes of dizziness in [**12-22**], he was
referred to Dr [**Last Name (STitle) 6938**] who did an MRA and discovered a right MCA
aneurysm. He had an angiogram with Dr [**First Name (STitle) **] who then planned a
stent assisted coiling for [**2102-3-8**].
Past Medical History:
MCA Aneurysm
Hyperlipidemia
Hypertensive disorder
Decreased hearing in the right ear
Social History:
ETOH user consider heavy drinker in the past
Quit smoke for 15 years.
He lives by himself.
Family History:
Father died of cancer
Physical Exam:
Prior to admission:
His temperature was afebrile,
blood pressure lying down was 120/82, and pulse 72. Sitting was
140/78 with pulse 76, standing was 138/72. Generally, he is well
developed, well nourished with a supple neck and no carotid
bruit. Lymph: There is no cervical lymphadenopathy. Chest:
Clear to auscultation bilaterally. Heart: Regular rate and
rhythm. Abdomen is soft, nondistended, nontender. Extremities:
No clubbing, cyanosis, or edema. Neurological Exam: Mental
status, he is alert and oriented x3 with intact fluency and
comprehension. Cranial Nerves: No nystagmus on primary or end
gaze. His visual fields are full to confrontation, no
papilledema
in the fundi. Pupils equal, round, and reactive. Extraocular
movements intact. Intact light touch in V1 to V3 bilaterally.
Intact facial strength and symmetry. Hearing was intact
bilaterally. The Barany maneuver was negative. Intact tongue,
uvula, and palate, [**4-18**] sternocleidomastoid and trapezius. Motor:
Normal tone and bulk of all four extremities with no pronator
drift. He was 5/5 strength of all four extremities. Sensory
examination is intact to light touch and pinprick in all four
extremities. Vibration was intact in the toes bilaterally.
Reflexes were 3+ at the biceps bilaterally, 2+ at the triceps
and
brachioradialis, 3+ at the knees bilaterally, 3+ suprapatellars,
2+ at the ankles. Toes were downgoing bilaterally. Coordination
was intact for finger-nose-finger and heel-to-shin bilaterally.
Gait was normal stance and stride. Tandem gait was intact
On discharge:
Awake alert oriented x 3, speech slightly slurred, slight left
facial with left homonomous hemianopsia, motor full, sensory
full including facial sensation. No drift, ambulatory without
assistance.
Pertinent Results:
[**2102-3-13**] 04:35AM BLOOD WBC-6.1 RBC-4.18* Hgb-12.2* Hct-35.9*
MCV-86 MCH-29.3 MCHC-34.1 RDW-13.9 Plt Ct-273
[**2102-3-13**] 04:35AM BLOOD Plt Ct-273
[**2102-3-13**] 04:35AM BLOOD Glucose-96 UreaN-14 Creat-0.8 Na-145
K-3.9 Cl-109* HCO3-28 AnGap-12
[**2102-3-13**] 04:35AM BLOOD Calcium-9.3 Phos-4.3 Mg-2.2
[**2102-3-11**] 04:54AM BLOOD Osmolal-294
[**2102-3-11**] 03:10PM BLOOD %HbA1c-5.3
[**Known lastname **],[**Known firstname **] [**Medical Record Number 18392**] M 60 [**2041-3-26**]
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2102-3-8**]
7:36 PM
[**Last Name (LF) **],[**First Name3 (LF) **] J. NSURG SICU-B [**2102-3-8**] 7:36 PM
CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 18393**]
Reason: Please eval for ICH
[**Hospital 93**] MEDICAL CONDITION:
60 year old man s/p coiling R MCA
REASON FOR THIS EXAMINATION:
Please eval for ICH
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
INDICATION: 60-year-old status post right MCA coiling. Please
evaluate for
intracranial hemorrhage.
COMPARISON: CTA of the head, [**2101-11-4**].
NON-CONTRAST HEAD CT: There is no acute intracranial hemorrhage.
Streak
artifact from coils within the right M1 bifurcation aneurysm
obscure
evaluation of the immediate perianeurysmal area, however, there
is no sign of hemorrhage. No edema or mass effect. The
ventricles and sulci are normal in size and configuration. A
14-mm mucus retention cyst is noted within the right maxillary
sinus.
IMPRESSION: Status post right MCA aneurysmal coiling, with no
evidence of
hemorrhage.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 18394**] [**Name (STitle) 18395**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**]
Approved: [**Doctor First Name **] [**2102-3-9**] 12:12 PM
Imaging Lab
[**Known lastname **],[**Known firstname **] [**Medical Record Number 18392**] M 60 [**2041-3-26**]
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2102-3-10**]
2:56 PM
[**Last Name (LF) **],[**First Name3 (LF) **] J. NSURG SICU-B [**2102-3-10**] 2:56 PM
CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 18396**]
Reason: acute events
[**Hospital 93**] MEDICAL CONDITION:
60M with CN6 palsy on LEFT side
REASON FOR THIS EXAMINATION:
acute events
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Provisional Findings Impression: SPfc FRI [**2102-3-10**] 5:44 PM
New white matter hypodensities in the right frontal subcortical
areas as well
as at the caudate and internal capsule. These are concerning for
new areas of
infarction. These findings were discussed with Dr. [**Last Name (STitle) 18397**] at
4:05 p.m. on
[**2102-3-10**].
Final Report
HISTORY: Previous MCA aneurysm clipping and now possible left
cranial nerve palsy.
COMPARISON: Comparison is made to a CT of the head done on [**3-8**], [**2101**].
TECHNIQUE: Contiguous axial CT images were acquired through the
brain in the absence of intravenous contrast.
FINDINGS: There is a new area of parenchymal hypodensity on the
right, in the region of the internal capsule, caudate as well as
subcortical white matter at the right frontal lobes. These
findings are new since the previous scan of [**3-8**] and
concerning for possible areas of ischemia/infarction. There is
no intracranial hemorrhage or mass effect. Streak artifact from
coils within the right M1 bifurcation aneurysm obscures the
immediate peri-aneurysmal area. The ventricles and sulci are
normal in size and configuration. Also unchanged is a mucus
retention cyst in the right maxillary sinus. No fractures
identified.
IMPRESSION:
New right hypodensities as detailed above, concerning for
possible new areas of ischemia or infarction. There is no
evidence of intracranial hemorrhage. Recommend comparison with
clinical presentation and possible further evaluation with brain
MR, provided that the aneurysmal coils are appropriate for an MR
scanner. These findings and recommendations were discussed with
Dr.
[**Last Name (STitle) 18397**] at 4:05 p.m. on [**2102-3-10**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
DR. [**First Name8 (NamePattern2) 11136**] [**Last Name (NamePattern1) 11137**]
Approved: FRI [**2102-3-10**] 9:49 PM
[**Known lastname **],[**Known firstname **] [**Medical Record Number 18392**] M 60 [**2041-3-26**]
Radiology Report CAROTID SERIES COMPLETE Study Date of [**2102-3-13**]
10:42 AM
[**Last Name (LF) **],[**First Name3 (LF) **] J. NSURG FA11 [**2102-3-13**] 10:42 AM
CAROTID SERIES COMPLETE Clip # [**Clip Number (Radiology) 18398**]
Reason: MCA CVA
[**Hospital 93**] MEDICAL CONDITION:
60 year old man with mca stroke
REASON FOR THIS EXAMINATION:
stenosis?
Preliminary Report
Preliminary reports are not available for viewing.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Imaging Lab
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 18399**]TTE (Complete)
Done [**2102-3-13**] at 4:04:23 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] J.
[**Hospital1 18**] - Division of Neurosurger
[**Hospital Unit Name 18400**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2041-3-26**]
Age (years): 60 M Hgt (in): 66
BP (mm Hg): 142/88 Wgt (lb): 165
HR (bpm): 76 BSA (m2): 1.84 m2
Indication: Cerebrovascular event/TIA.
ICD-9 Codes: 435.9, 424.2
Test Information
Date/Time: [**2102-3-13**] at 16:04 Interpret MD: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) **], MD
Test Type: TTE (Complete) Son[**Name (NI) 930**]: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 18401**]
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: Saline Tech Quality: Adequate
Tape #: 2009W007-0:58 Machine: Vivid [**6-19**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.2 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 3.8 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.6 m/s
Left Atrium - Peak Pulm Vein D: 0.4 m/s
Left Atrium - Peak Pulm Vein A: 0.3 m/s < 0.4 m/s
Right Atrium - Four Chamber Length: 4.0 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.9 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.6 cm
Left Ventricle - Fractional Shortening: 0.33 >= 0.29
Left Ventricle - Ejection Fraction: >= 60% >= 55%
Left Ventricle - Lateral Peak E': *0.07 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': 0.09 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 8 < 15
Aorta - Sinus Level: 3.1 cm <= 3.6 cm
Aorta - Ascending: 2.9 cm <= 3.4 cm
Aorta - Arch: 2.4 cm <= 3.0 cm
Aortic Valve - Peak Velocity: 1.5 m/sec <= 2.0 m/sec
Mitral Valve - E Wave: 0.6 m/sec
Mitral Valve - A Wave: 0.9 m/sec
Mitral Valve - E/A ratio: 0.67
Mitral Valve - E Wave deceleration time: 223 ms 140-250 ms
Findings
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal
interatrial septum. No ASD or PFO by 2D, color Doppler or saline
contrast with maneuvers.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). No resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No masses or vegetations on aortic valve. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No
mass or vegetation on mitral valve. Mild mitral annular
calcification. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Indeterminate PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is normal in size. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). Right ventricular chamber size and free wall motion are
normal. The 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 masses or
vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. Trivial mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: No cardiac source of embolism identified. Preserved
global and regional biventricular systolic function. No
significant valvular abnormality seen.
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
Electronically signed by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2102-3-13**] 16:41
Brief Hospital Course:
Mr [**Known lastname 18391**] [**Last Name (Titles) 1834**] an elective coiling and stenting of a 7mm,
[**Hospital1 **]-lobed right MCA
aneurysm on [**3-8**], he was placed on Aspirin 325mg and Plavix75mg
after the angiogram (but not given heparin gtt) who later that
night was noted to have left facial droop, left arm and leg
weakness. Also had gaze deviation to the right and impaired
upward gaze. Duration of left sided weakness was about five
hours. A stroke neurology consult was obtained they did not feel
he needed a full stroke work up due to the finding of clot at
the stent. He [**Month/Year (2) 1834**] a second angiogram which showed a
thrombus adjacent to the stent in the right MCA. He was placed
on a heparin gtt. Repeat angiogram showed resolution of the
thrombus. CT brain showed acute infarct in the right putamen,
right frontal lobe near the caudate nucleus, and the right
supplementary area. Heparin gtt was eventually stopped.
He was seen by Urology due to hematuria and hx of elevated PSA.
They recommended following up with them in 4 weeks.
On day of discharge he is alert and oriented x3. Pertinent
findings on neuro exam, include Mild dysarthria, mild left
nasolabial fold flattening, no pronator drift. He is [**4-18**]
Strength in all four extremities. He was noted to have a
negative Romberg but on pivot and turn was off balance. A PT
consult was obtained and they cleared him for home. He did have
urinary retention with overflow voiding with 750 residual. He
was straight cathed and then was found to have 450 cc residual.
A foley catheter was inserted and maintained. He was discharged
to home with VNA for foley care. He will follow up with
urology.
He agrees with the plan for d/c home.
Medications on Admission:
Metropolol, Simvastatin
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. 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*
4. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 30 days.
Disp:*30 Tablet(s)* Refills:*0*
8. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 3
days: according to urology office instructions.
Disp:*6 Tablet(s)* Refills:*0*
9. 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:
[**Hospital 119**] Homecare
Discharge Diagnosis:
MCA Aneurysm s/p coiling
CVA right frontal subcortical areas as well as at the caudate
and internal capsule.
Hyperlipidemia
Post procedure urinary retention
Discharge Condition:
Neurologically stable
Discharge Instructions:
You were started on FLOMAX for your urinary retention
You were also precribed CIPRO / an antibiotic so that when you
follow up with urology for your foley manipulation, you are less
likely to get a urinary tract infection. Please ask them when
they would like you to take it....it will be in coordination
with your urology visit/appointment.
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Take Plavix (Clopidogrel) 75mg once daily for ONE Month only.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
Follow up in one month with Dr [**First Name (STitle) **] call for an appointment
[**Telephone/Fax (1) 1669**]
Provider: [**Name10 (NameIs) **] with Neurology [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD
Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2102-5-15**] 1:00
Follow up with Urology Dr [**Last Name (STitle) 770**]: Discussion for repeat
prostate biopsy had with patient. Please call [**Telephone/Fax (1) 5727**] to
arrange appointment for 1-2 weeks for urinary retention / foley
removal and 4-6 weeks for prostate follow up.
please also arrange for a formal eye exam. This can be arranged
through your primary care physician,.
Completed by:[**2102-3-14**]
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47,803
| 150,015
|
39449
|
Discharge summary
|
report
|
Admission Date: [**2154-10-16**] Discharge Date: [**2154-10-24**]
Date of Birth: [**2105-5-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
palpitations, increasing fatigue
Major Surgical or Invasive Procedure:
[**2154-10-17**]
1. Minimally invasive Maze procedure which consisted of
bilateral pulmonary vein isolation using the AtriCure
Synergy System with resection of left atrial appendage
as well as ganglionic mapping and ablation of positive
ganglia.
2. Full electrophysiology mapping and testing performed by
Dr. [**First Name8 (NamePattern2) 2259**] [**Last Name (NamePattern1) **] intraoperatively and dictated
separately.
History of Present Illness:
This is a 49 year old female with paroxsymal atrial fibrillation
for the last 9-10 years. Her symptoms include palpitations,
lightheadedness, diaphoresis and
fatigue. Last year she did have one episode of slurred speech
and
hemiparesis with quickly resolved. Since her TIA, she has been
on
Warfarin. Her episodes of A fib last 12-48 hours. She was
referred for surgical evaluation.
Past Medical History:
- Paroxsymal Atrial Fibrillation
- History of TIA
- Hypertension
- Dyslipidemia
- Morbid Obesity
- Anemia(unremarkable colonoscopy, Gastritis on EGD)
- Spinal Stenosis, s/p Nerve Block
- Uterine Leiomyoma, Endometrial Polyps
- syncope
Past Surgical History: 2 C-sections
Social History:
Race:Caucasian
Last Dental Exam:3 months ago
Lives with:husband, two teenage sons
Occupation:floral design instructor
Tobacco: Denies
ETOH: 4-5 drinks per week
Family History:
No premature coronary artery disease, dad with A Fib, both
parents have pacers
Physical Exam:
Pulse:56 Resp: 20 O2 sat: 99%
B/P Right:113/63 Left: 116/66
Height: 5'1" Weight: 220#
General:
Skin: Warm[x] Dry [x] intact [x]
HEENT: NCAT[x] PERRLA [x] EOMI [x]anicteric sclera;OP
unremarkable
Neck: Supple [x] Full ROM [x]no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur- 1/6 SEM
Abdomen: Soft [x] non-distended [x] non-tender [x]obese
bowel sounds + [x]; no HSM
Extremities: Warm [x], well-perfused [x] Edema -none
Varicosities: None [x]
Neuro: Grossly intact; MAE [**3-20**] strengths; nonfocal exam
Pulses:
Femoral Right: 2+ Left:2+
DP Right: NP Left:NP
PT [**Name (NI) 167**]:NP Left:NP
Radial Right: 2+ Left:2+
Carotid Bruit Right: none Left:none
Pertinent Results:
[**2154-10-24**] 04:55AM BLOOD WBC-7.5 RBC-4.13* Hgb-13.0 Hct-38.7
MCV-94 MCH-31.4 MCHC-33.5 RDW-14.0 Plt Ct-286
[**2154-10-24**] 04:55AM BLOOD Glucose-116* UreaN-20 Creat-0.7 Na-136
K-4.4 Cl-103 HCO3-25 AnGap-12
[**2154-10-24**] 04:55AM BLOOD PT-21.6* PTT-63.7* INR(PT)-2.0*
[**2154-10-23**] 04:40AM BLOOD PT-18.5* PTT-34.9 INR(PT)-1.7*
[**2154-10-22**] 04:18AM BLOOD PT-17.1* PTT-24.9 INR(PT)-1.5*
[**2154-10-21**] 02:37AM BLOOD PT-16.1* PTT-24.9 INR(PT)-1.4*
[**2154-10-22**] Echo:
LEFT ATRIUM: Moderate LA enlargement.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Overall normal LVEF (>55%). TDI E/e' < 8, suggesting normal PCWP
(<12mmHg). No resting LVOT gradient.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Mildly dilated aortic arch.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Physiologic MR (within normal limits).
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: Resting tachycardia (HR>100bpm)
Conclusions
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). The aortic arch is
mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. Physiologic mitral regurgitation is seen (within
normal limits). There is a trivial/physiologic pericardial
effusion
Brief Hospital Course:
This is a 49-year-old woman who was referred by Dr. [**First Name (STitle) **] for
paroxysmal atrial
fibrillation and a previous stroke. The patient wished to
proceed with surgical pulmonary vein isolation and resection of
left atrial appendage. She was admitted as same day admission
for a minimally invasive Maze procedure which consisted of
bilateral pulmonary vein isolation using the AtriCure Synergy
System with resection of left atrial appendage as well as
ganglionic mapping and ablation of positive
ganglia as well as a full electrophysiology mapping and testing
performed by Dr. [**First Name8 (NamePattern2) 2259**] [**Last Name (NamePattern1) **]. See operative note for full
details. POD 1 found the patient extubated, alert and oriented
and breathing comfortably. The patient was neurologically
intact and hemodynamically stable on no inotropic or vasopressor
support. Beta blocker was initiated and the patient was gently
diuresed toward the preoperative weight. She did develop atrial
flutter to the 130's and was given Flecainide and Lopressor was
titrated. She was having conversion pauses of up to 5 seconds,
therefore Lopressor was not titrated up any further. She was
changed to Maltaq on [**10-22**] per cardiology recommendation. At the
time of discharge, she was alternating between sinus rhythm in
the 70-80's and atrial fibrillation/ flutter in the 120-140's.
No further titration of medication was warranted at that time
per cardiology recommendations. The patient was transferred to
the telemetry floor for further recovery. Coumadin for started
for atrial fibrillation and she was bridged with Heparin drip
until her INR was therapeutic. Chest tubes and pacing wires
were discontinued without complication. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD 7 the
patient was ambulating freely, the wound was healing, pain was
controlled with oral analgesics and her INR was therapeutic.
The patient was discharged home with VNA services in good
condition with appropriate follow up instructions. Her Coumadin
was to be followed by the [**University/College **] [**Hospital 38299**] [**Hospital 197**] clinic and
they were contact[**Name (NI) **] with recent INR and doses. She was
instructed to take Coumadin 7.5 mg on [**10-24**] with plans for INR
draw [**10-25**] and further dosing instructions per the [**Hospital 197**]
clinic.
Medications on Admission:
Medications at home:
***Warfarin 7.5 mg Mon and Thurs;and 6.5 mg other days
Acebutolol 200 mg qAM, 400 mg qPM
Lyrica 75 mg [**Hospital1 **]
Flecainide 150 mg [**Hospital1 **]
Cal-Carb 600 plus D 200 units daily
ferrous sulfate 325 mg [**Hospital1 **]
MVI daily
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
4. pregabalin 75 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*0*
5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours): take around the clock for 5 days then change to as
needed . Tablet(s)
6. hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
7. indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) for 1 months.
Disp:*90 Capsule(s)* Refills:*0*
8. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
9. Outpatient Lab Work
INR drawn on [**2154-10-25**]
Goal INR 2.0-2.5
First draw [**10-25**]
Results to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 **] at [**Location 1268**]
phone ([**Telephone/Fax (1) 87166**]
10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. dronedarone 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for AFib.
12. Coumadin 5 mg Tablet Sig: 1-2 Tablets PO once a day: Take
7.5 mg on [**2154-10-24**] then as directed for INR goal 2.0-2.5.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Americare at Home Inc
Discharge Diagnosis:
Atrial Fibrillation s/p MAZE
Hypertension
Dyslipidemia
Spinal Stenosis
Syncope
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with tylenol ATC, Dilaudid prn
Incisions:
Bilateral mini thoracotomy - healing well, minimal erythema -
no drainage but ecchymosis present
Edema trace bilateral
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 2 weeks and while taking narcotics
No lifting more than 10 pounds for 4 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**] [**11-5**] tuesday at 1:30pm
Cardiologist: Dr [**First Name (STitle) **] - appt for [**10-22**] cancelled - his office
will call you with appt for later in [**Month (only) **]
Please call to schedule appointments with your
Primary Care Dr [**Last Name (STitle) **] in [**2-18**] weeks [**Telephone/Fax (1) 20035**]
**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 s/p
maze
Goal INR 2.0-2.5 Instructed to take Coumadin 7.5 mg on [**2154-10-24**]
First INR drawn on [**2154-10-25**]
Results to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 **] at [**Location 1268**]
phone ([**Telephone/Fax (1) 87166**]
Completed by:[**2154-10-24**]
|
[
"401.9",
"278.01",
"338.12",
"285.9",
"790.29",
"511.9",
"276.52",
"427.31",
"427.32",
"272.4",
"V58.61",
"V12.54",
"724.00",
"V85.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.33",
"37.27",
"37.22",
"88.55",
"37.26"
] |
icd9pcs
|
[
[
[]
]
] |
8798, 8850
|
4336, 6796
|
355, 802
|
8972, 9218
|
2564, 4313
|
9968, 10936
|
1703, 1784
|
7108, 8775
|
8871, 8951
|
6822, 6822
|
9242, 9945
|
6843, 7085
|
1494, 1509
|
1799, 2545
|
282, 317
|
830, 1214
|
1236, 1471
|
1525, 1687
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,122
| 149,616
|
41358
|
Discharge summary
|
report
|
Admission Date: [**2186-2-17**] Discharge Date: [**2186-2-25**]
Date of Birth: [**2120-8-9**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Penicillins / lisinopril / Shellfish / Atorvastatin /
Indocin / Calcium Magnesium + D / IV Dye, Iodine Containing
Attending:[**First Name3 (LF) 69390**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 65-year-old former smoker with a history of
dyslipidemia, HTN, poorly controlled DM2, CKD, hypothyroidism,
asthma, OSA, and morbid obese who presents with dyspnea and
chest pain and is admitted for management of ?ACS.
.
She was in her usual state of health until two weeks ago when
she began waking up with chest pain in the setting of blood
glucose >500 and also one or two days after her physician
advised her to stop her lasix. She described her CP as pressure,
tightness, sometimes radiating to her neck, and resolves with
improvement of her glucose. She also notes that she has had
worsening DOE since stopping her lasix, and that her CP was
associated with aggravation of this symptom. She is on insulin
and states that her usual a.m. glucose is 15-200; it does fall
after administration of insulin. ROS pos for orthopnea and PND.
She denies fevers, chills, n/v/d, dysuria, and other localizing
signs of infection. At baseline, she is very active, works two
jobs, and ambulates without CP or dyspnea.
.
In the ED, initial vital signs were 98.6 75 147/68 18 100%/RA.
EKG with ST-depressions in I, aVL slightly more pronounced than
prior EKGs. Trop was 0.64 and she was started on a heparin gtt
empirically for ACS; aspirin was not given b/c she has a hives
allergy to the medication. She was guaiac negative.
.
On the floor, she is CP free and speaking on the phone with her
son.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
dyslipidemia
HTN
DM2
hypothyroidism
asthma
OSA
morbid obesity
CKD
depression
hysterectomy
s/p roux-en-y gastric bypass
Social History:
She lives with her son and works as a case manager at a
methadone clinic in [**Location (un) 86**]. Has a 60 pack-year smoking history
and quit 20 years ago (3 ppd x 20 years). She does not drink
alcohol, denies drug use.
Family History:
Positive for colon cancer.
Physical Exam:
VS: 98 HR 91 BP 141/64 RR 18 Sat 99%/RA.
GENERAL: morbidly obese, NAD
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with no JVD
CARDIAC: RRR, no m/r/g. No thrills, lifts. No S3 or S4.
LUNGS: CTAB, no crackles, wheezes, rhonchi.
ABDOMEN: Soft, obese, NTND. No HSM or tenderness.
EXTREMITIES: trace LE edema, warm and well perfused
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
[**2186-2-20**] 08:20AM BLOOD WBC-5.3 RBC-3.55* Hgb-10.1* Hct-29.9*
MCV-84 MCH-28.3 MCHC-33.6 RDW-14.0 Plt Ct-230
[**2186-2-17**] 04:00PM BLOOD WBC-4.5 RBC-3.55* Hgb-9.9* Hct-29.6*
MCV-83 MCH-28.0 MCHC-33.5 RDW-14.0 Plt Ct-216
[**2186-2-20**] 08:20AM BLOOD Glucose-132* UreaN-50* Creat-1.9* Na-140
K-4.7 Cl-106 HCO3-25 AnGap-14
[**2186-2-19**] 07:25AM BLOOD Glucose-94 UreaN-46* Creat-1.7* Na-142
K-3.9 Cl-107 HCO3-26 AnGap-13
[**2186-2-18**] 08:35AM BLOOD Glucose-170* UreaN-43* Creat-1.8* Na-143
K-4.3 Cl-107 HCO3-26 AnGap-14
[**2186-2-18**] 08:35AM BLOOD CK-MB-4 cTropnT-0.56* proBNP-5424*
[**2186-2-17**] 10:30PM BLOOD CK-MB-6 cTropnT-0.44*
CXR: FINDINGS: Frontal and lateral views of the chest were
obtained. No focal consolidation, pleural effusion, or evidence
of pneumothorax is seen. The cardiac silhouette is top normal.
No overt pulmonary edema is seen. Degenerative changes are noted
along the spine. IMPRESSION: Top normal cardiac silhouette
without overt pulmonary edema.
Cardiac Catherization:
1. Coronary angiography in this right-dominant system
demonstrated three vessel disease. The LMCA had no
angiographically apparent disease. The LAD had a 90% mid
stenosis. The LCx had a 90% mid stenosis involving an OM branch.
The RCA was diffusely diseased and occluded in its mid portion.
2. Resting hemodynamics revealed elevated right and left-sided
filling presures with RVEDP 16mmHg and LVEDP 34mmHg. There was
moderate pulmonary arterial hypertension with PASP 48mmHg. The
cardiac index was preserved at 3.2 L/min/m2. The systemic and
pulmonary vascular resistances were normal at 1168 and 114
dynes-sec/cm5 respectively. There was mild systemic arterial
hypertension with SBP 144mmHg and DBP 78mmHg.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Moderate pulmonary hypertension.
3. Elevated left- and right-sided filling pressures.
Brief Hospital Course:
Ms. [**Known lastname **] is a 65-year-old former smoker with a history of
dyslipidemia, HTN, poorly controlled DM2, CKD, hypothyroidism,
asthma, OSA, and morbid obese who presents with dyspnea and
chest pain and is admitted for management of ?ACS.
.
# CORONARIES/?NSTEMI: patient with several risk factors for CAD
but no known diagnosis. Chest pain is atypical in quality with
hyperglycemia as aggravating factor but not clearly associated
with exertion. Major process driving symptoms seems to be
worsening dyspnea in the setting of likely volume overload. DDx
for chest pain also includes PE, pulm edema/heart failure, pna,
pleurisy, and GERD.
Patient ruled out for an MI, but an ECHO done in hosiptal
demonstrated regional systolic dysfunction suggestive of
multivessel CAD. For this reason patient was transferred to the
CCU for aspirin allergy desensitization prior to Cardiac
Catherization. Pt had ASA desensitization in CCU, which she
tolerated without event. She went for RHC and LHC, which
revealed elevated filling pressures with mean wedge 26.
Additionally, pt had 3VD, and no intervention was pursued, with
recommended CABG. She tolerated the procedure well without
complications. However, CK was checked in cath for unclear
reasons and was found to be elevated. CE's showed elevated MB
and trops when added on. However, on recheck they were
downtrending. She was without chest pain and ECG was unchanged.
The decision was made to manage this patient's coronary artery
disease medically and defer discussion of CABG till a later time
point. Patient was started on plavix and diltiazem.
.
INACTIVE ISSUES:
.
# DM2/hyperglycemia: has chronically poorly controlled BG and
worsened control for the past two weeks with values >400. No
localizing signs of infection. Diabetic diet, ISS, finger
sticks
.
# ?Acute heart failure/pulm edema: patient reports worsening
dyspnea on exertion since stopping lasix per her PCP; notes
lasix was stopped b/c of rising creatinine. CXR supports mild
volume overload. Patient's lasix was restarted with stable
cratinine of 1.8-1.9.
.
# HTN:
- continued home meds.
.
# ?Acute vs chronic kidney disease: patient states she has had
CKD for a few years but does not know baseline creatinine. On
[**Name (NI) **], unclear whether current creatinine represents acute kidney
injury. states that CKD may have worsened after a colonoscopy in
[**1-10**] for which she was given citrate of magnesia for a prep; not
clear this medication associated with renal impairment.
.
# Dyslipidemia: continued statin
.
# Hypothyroidism:
- continue levoxyl
.
# OSA:- cpap
. .
CODE: Full
.
COMM: sister, [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 90042**].
Transitional Issues: Three vessel disease - patient is to follow
up with Dr. [**Last Name (STitle) 6512**] regarding medical management of her CAD.
Medications on Admission:
crestor 20 mg daily
irbesartan 75 mg daily
Lantus 38u qhs, humalog ISS
Levothyroixine 150 mcg daily; 300 mcg one day per week
fexofenadine 60 mg daily prn
meclizine 25 mg tid prn
lasix 20 mg daily (stopped two weeks ago)
flovent inhaler 110 mcg, take 2 puffs [**Hospital1 **]
proair 90 mcg inhaler, take 2 puffs q4-6 hr
Discharge Medications:
1. levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a
day: take 300mg once a week as previously.
2. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Flovent HFA 110 mcg/Actuation Aerosol Sig: Two (2)
Inhalation twice a day.
4. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2)
Inhalation every 4-6 hours.
5. Lantus 100 unit/mL Solution Sig: Thirty Eight (38) units
Subcutaneous at bedtime.
6. Humalog 100 unit/mL Solution Sig: 1-10 units Subcutaneous
QACHS: please follow the sliding scale as previously.
7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. meclizine 25 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for nausea.
9. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
Disp:*30 Capsule, Extended Release(s)* Refills:*2*
10. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO once a day
as needed for allergy symptoms. Tablet(s)
13. irbesartan 75 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1)Coronary Artery Disease
2) Chronic Renal Failure
Discharge Condition:
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Ms.[**Known lastname **],
You were admitted to our hospital for a complaint of chest pain.
There was a concern that one of the arteries of your heart may
be blocked and a decision was made to have you undergo a stress
test to determine the amount of the blockage of your coronary
arteries. The test demonstrated that you have disease in all
three vessels supplying your heart. After a discussion with your
cardiologist, we have decided to treat this with medications.
The following changes were made to your medications
START Plavix (clopidogrel) 75mg Daily
START Aspirin 325mg Daily (do not stop taking Aspirin or Plavix
unless told to do so by a cardiologist).
START Diltiazem 120mg Extended Release Daily
Followup Instructions:
Name: [**Last Name (LF) **], [**Name8 (MD) **] MD
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2261**]
Appointment: Wednesday [**2186-3-1**] 2:00pm
Please go for your appointment with Dr. [**Last Name (STitle) 6512**] on [**3-15**] at
910AM
[**First Name8 (NamePattern2) 20**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 69391**]
Completed by:[**2186-2-26**]
|
[
"V45.86",
"403.90",
"585.9",
"285.21",
"493.90",
"327.23",
"428.21",
"250.00",
"411.1",
"244.9",
"414.01",
"428.0",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
9749, 9755
|
5296, 6898
|
395, 401
|
9869, 9959
|
3405, 5125
|
10759, 11251
|
2876, 2904
|
8505, 9726
|
9776, 9776
|
8161, 8482
|
5142, 5273
|
10020, 10736
|
2919, 3386
|
2412, 2470
|
8007, 8135
|
345, 357
|
429, 2308
|
6915, 7986
|
9795, 9848
|
9974, 9996
|
2501, 2621
|
2330, 2392
|
2637, 2860
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,579
| 173,470
|
21348
|
Discharge summary
|
report
|
Admission Date: [**2182-6-22**] Discharge Date: [**2182-7-10**]
Date of Birth: [**2107-5-27**] Sex: F
Service: [**Last Name (un) **]
ADMISSION DIAGNOSIS: Cholangitis/sepsis.
HISTORY OF PRESENT ILLNESS: This patient is a 78-year old
female who presents with a 3-day history of sharp epigastric
pain that radiates to the upper abdomen. She denies any
vomiting but has had nausea, decreased appetite, fevers, and
chills. She also reported liquid stools with her last bowel
movement on the morning of admission and dark urine.
She was first evaluated at an outside hospital where she was
found to be jaundiced and had a total bilirubin of 9.9 and an
amylase/lipase of 2500/3900. The patient was transferred to
[**Hospital1 69**] for further workup and
management.
PAST MEDICAL HISTORY: Arthritis with severe contractures and
difficulty with walking.
PAST SURGICAL HISTORY: Status post appendectomy.
MEDICATIONS ON ADMISSION: Advil.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed a
temperature of 96.2, her heart rate was 123, her blood
pressure was 204/104, her respiratory rate was 32 to 43, and
her oxygen saturation was 100 percent on oxygen. In general,
alert and oriented times three and in respiratory distress.
Icteric and jaundiced. Rales bilaterally on chest
examination. Cardiovascular examination revealed a rate and
rhythm, tachycardic. Gastrointestinal examination revealed
the abdomen was soft and nondistended. Tender in the right
upper quadrant and epigastrium. No [**Doctor Last Name **] sign. The
extremities were warm and with no edema bilaterally.
PERTINENT LABORATORY VALUES ON PRESENTATION: Complete blood
count revealed a white blood cell count of 13.1, her
hematocrit was 33.2, and her platelets were 200. Sodium was
143, potassium was 3.1, chloride was 108, bicarbonate was 22,
blood urea nitrogen was 12, creatinine was 0.5, and blood
glucose was 58. Her lactate was 2.6. Her alanine-
aminotransferase was 112, her aspartate aminotransferase was
57, her alkaline phosphatase was 595, her total bilirubin was
9.9, her amylase was 1700, and her lipase was 4200. Her INR
was 1.4. Her partial thromboplastin time was 28.6.
PERTINENT RADIOLOGY-IMAGING: An ultrasound demonstrated
multiple small stones with extrahepatic biliary dilatation,
common bile duct dilation to 20 mm with a stone measuring 17
mm in the common bile duct.
SUMMARY OF HOSPITAL COURSE BY ISSUES-SYSTEMS: The patient
was transferred from an outside hospital on [**2182-6-22**] for
further workup of the patient's epigastric pain, jaundice,
and developing respiratory distress.
She was intubated in the Emergency Department for fair
oxygenation. She underwent an emergent endoscopic retrograde
cholangiopancreatography for attempted stone removal on the
day of admission. During the endoscopic retrograde
cholangiopancreatography, they were able to place a stent in
the common bile duct but they were unable to extract the
stone in the common bile duct.
She was transferred to the Unit for further care where she
developed a septic physiology. She was started on Xigris for
her sepsis.
FLUIDS, ELECTROLYTES AND NUTRITION ISSUES: The patient
remained nothing by mouth throughout most of her hospital
course. She was started on total parenteral nutrition within
five days of her hospitalization and remained on total
parenteral nutrition throughout her hospital course.
GASTROENTEROLOGY ISSUES: The patient underwent her
endoscopic retrograde cholangiopancreatography as stated
above on [**2182-6-22**]. As above, the endoscopic retrograde
cholangiopancreatography procedure was unable to extract the
common bile duct stone. The Gastroenterology Service
recommended a second endoscopic retrograde
cholangiopancreatography attempt be made when the patient
recovered from her sepsis. It is now planned that the
patient will undergo a repeat endoscopic retrograde
cholangiopancreatography one week following discharge. Her
liver function tests have fluctuated throughout her hospital
course but have decreased dramatically since her admission.
RESPIRATORY ISSUES: The patient demonstrated a septic
physiology upon admission to [**Hospital1 188**]. She was intubated, and she was finally extubated in
the Intensive Care Unit within five days.
She was transferred to the floor on [**2182-6-30**] but soon
developed respiratory distress and was transferred back to
the Intensive Care Unit; again, for a septic physiology. She
was intubated and remained intubated throughout her Intensive
Care Unit course until [**7-6**] when she was extubated without
complications. Her respiratory status remained stable
throughout the rest of her hospitalization, and she was
weaned off her oxygen after she was transferred to the floor
on [**2182-7-7**].
INFECTIOUS DISEASE ISSUES: The patient was admitted for her
septic physiology on [**6-22**] and was intubated during that
time period. She was placed on vancomycin, levofloxacin, and
Flagyl for broad antibiotic coverage. Her sepsis remained of
unclear etiology, but she did grow out blood cultures
positive for Klebsiella.
When she was transferred to the floor on [**6-30**], she again
developed hypotension with systolic blood pressures in the
70s and was given fluids with a Neo-Synephrine drip. She was
re-intubated during that time and also started on Zosyn. She
remained on vancomycin throughout her hospital course. She
is to receive a total of 21 days of antibiotics. The
Gastroenterology Service did not feel that her cholangitis
was the source of her sepsis.
Since transfer out of the Unit on [**2182-7-7**] the patient
has remained stable, and her sepsis has seemed to have
resolved.
DISCHARGE STATUS: To rehabilitation.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES: Cholangitis/sepsis.
DISCHARGE INSTRUCTIONS-FOLLOWUP: The patient was instructed
to follow up with the Gastroenterology Service for a repeat
endoscopic retrograde cholangiopancreatography for attempt at
stone removal one week following discharge.
The patient was instructed to continue on total parenteral
nutrition until fully tolerating a regular diet and can be
weaned off appropriately.
MEDICATIONS ON DISCHARGE:
1. Vancomycin 1 gram intravenously q.24h. (until [**2182-7-12**]).
2. Zosyn 4.5 grams intravenously q.8h. (until [**2182-7-12**]).
3. Lopressor 7.5 mg intravenously q.6h.
4. Ipratropium inhaler 2 puffs q.4h.
5. Protonix 40 mg intravenously q.24h.
[**Name6 (MD) 5183**] [**Last Name (NamePattern4) 5184**], [**MD Number(1) 5185**]
Dictated By:[**Last Name (NamePattern1) 52598**]
MEDQUIST36
D: [**2182-7-9**] 08:08:39
T: [**2182-7-9**] 08:45:03
Job#: [**Job Number 56418**]
|
[
"576.1",
"038.9",
"995.94",
"577.1",
"038.49",
"574.51",
"518.82",
"995.93",
"276.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.04",
"38.93",
"96.07",
"00.11",
"99.15",
"93.90",
"38.91",
"51.87"
] |
icd9pcs
|
[
[
[]
]
] |
5804, 6198
|
6224, 6729
|
955, 5748
|
901, 928
|
176, 197
|
226, 789
|
812, 877
|
5773, 5782
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,378
| 121,159
|
50787
|
Discharge summary
|
report
|
Admission Date: [**2109-6-27**] Discharge Date: [**2109-7-12**]
Date of Birth: [**2047-12-7**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5547**]
Chief Complaint:
Dysphagia
Major Surgical or Invasive Procedure:
Exploratory laparotomy, radical resection of liposarcoma en bloc
including total gastrectomy and roux-en-y esophagojejunostomy,
reimplantation of right common hepatic artery onto the celiac
origin of the abdominal aorta, and partial resection of L
hemidiaphragm with primary repair, L chest tube thoracostomy
[**2109-6-27**]
Bronchoalveolar lavage, [**2109-6-30**]
PICC line placement, [**2109-7-7**]
L chest pigtail placement, [**2109-7-11**]
Exploratory laparotomy, attempted repair of aortoenteric fistula
with attempt at primary repair and attempt at endovascular stent
placement [**2109-7-12**]
History of Present Illness:
61-year-old female had previously undergone resection of a left
retroperitoneal liposarcoma with an en bloc distal
pancreatectomy, splenectomy, left adrenalectomy, and left
nephrectomy in [**2104-8-20**]. She received no adjuvant
treatment. The final pathology was a well-differentiated
retroperitoneal liposarcoma with sclerosis with tumor focally
present at the margins. She was followed expectantly without
recurrence of disease until [**Month (only) 216**] of last year when she
developed dysphagia. Initial workup, including an upper
endoscopy and barium swallow, was unremarkable. A CT
colonography, performed in [**Month (only) 404**] of this year as a routine
colorectal screening test, identified a 5 x 7 cm soft tissue
mass in the region of the GE junction. Further imaging
confirmed this mass to be inseparable from the aorta and celiac
axis and intimately associated with the distal esophagus and
proximal stomach. In addition, there was another recurrence in
the left nephrectomy bed. A CT scan of the chest ruled out
metastatic disease to the lungs. Patient received preoperative
radiation therapy, which she tolerated well with improvement in
her symptoms of dysphagia, although the mass appeared to
increase slightly in size on cross-sectional imaging. Given the
lack of other effective treatments for a well-differentiated
liposarcoma and the low likelihood of developing distant
metastatic disease in the near term, she was offered an attempt
at en bloc resection for local control, which she agreed to do.
Past Medical History:
Liposarcoma s/p en bloc retroperitoneal mass resection (distal
pancreatectomy, splenectomy, L nephrectomy, L adrenalectomy)
[**2103**]
s/p tonsillectomy, ~40yrs ago
L shoulder inflammation, tx'd with cortisone injection
Social History:
The patient is married with two stepchildren and one other
child. She is accompanied to the visit today by a friend. She
has a trivial tobacco history, having quit at the age of 29, and
occasionally drinks alcohol. She works out extensively in the
gym with the aide of a trainer. She is not
currently employed.
Family History:
Family history is remarkable for a maternal aunt with breast
cancer. There is no other family history of malignancy.
Physical Exam:
Afebrile, vital signs stable.
A&Ox3, NAD.
Sclerae are anicteric.
Neck and supraclavicular fossae are supple without adenopathy.
Lungs are clear to auscultation bilaterally.
Heart is regular rate and rhythm.
Abdomen shows a well-healed left paramedian incision without
hernia. It is soft. There is some mild tenderness in the
epigastrium. There is a poorly defined mass in the upper
abdomen. There is no hepatomegaly. There is no ascites.
Extremities show no edema.
Brief Hospital Course:
Patient was admitted postoperatively to the SICU, under the care
of the East Surgical service. Please see operative reports
(Surgery and Vascular) for details of the procedure. She
remained intubated with light pressor requirements that were
weaned off by the first post-operative day, when she was
successfully extubated. She remained with a CVL, NJ tube, Chest
tube, JP drain, and Foley catheter. Pain was managed
successfully with a PCA. On POD 3, the chest tube was placed to
water seal but a LLL collapse was noted on CXR, prompting a
bronchoalveolar lavage for successful clearance of a mucus plug,
which improved her respiratory status.
She was transferred to the floor on the following day, and the
chest tube removed on the day after that. Her pain control
remained the PCA, with fentanyl patch added. The NJ tube was
removed and, on POD 6, an UGI demonstrated no anastamotic leak,
permitting intiation of an oral diet with sips progressing to
clears. The output from the JP drain was newly noted to be
feculent with an amylase nearly 4000, although she displayed no
signs of abdominal sepsis. A CT abdomen/pelvis was performed on
POD 8, demonstrating oral contrast extravasation into the LUQ in
the region of the JP drain, with associated L pleural effusion
and atelectasis. An operative exploration for repair of the
enterotomy was offered to the patient, who declined, and local
control of the leak was managed with the existing JP drain.
Antibiotic coverage consisted of Vanco, Cipro, Flagyl,
coincident with a coag-negative staph UTI. A PICC line was
placed on POD 10 for administration of TPN as the patient's oral
intake remained insufficient. Pt had a brief run of
non-sustained VTach, asymptomatic, for which electrolytes were
checked and cardiac enzymes were cycled (and negative). She was
noted on POD 11 to have orthostatic hypotension, Hct was found
to be 22 and responded to 28 after transfusion of 2 units of
PRBCs. Repeat abdominal CT scan on POD 12 demonstrated minimal
interval change. Thoracic surgery was consulted for the
persistent pleural effusion, with concerns of possible feculent
spillage, so a pigtail catheter was placed by interventional
pulmonology on POD 14, finding clear serous fluid. The pigtail
was connected to a pleurevac on wall suction.
Overnight on POD 15, she was noted to be hypotensive with
hematochezia. She was transferred to the SICU with a Hct of 22,
and transfused 2 units of PRBCs. Her hemodynamics stabilized
with good urine output, although her follow-up hematocrit was
only 25. A few hours later, around noontime, another episode of
hematochezia occurred, this time more significant, and she was
intubated for profound hypotension. She required more
transfusions and crystalloid to maintain a sufficient blood
pressure; a femoral arterial line and internal jugular central
venous line were placed. Because of her hemodynamic
instability, it was decided to bring her to the operating room,
in conjunction with discussion and consent from the family, with
involvement of vascular surgery for question of arterioenteric
fistula. Please see operative notes for details, but in brief
it was discovered that she had a large-size aortoesophageal
fistula with poor tissue quality of the thoracic aorta,
presumably infected, preventing successful repair. Given the
dire situation, discussion was held with the family, and no
further measures were to be attempted. During closure of her
incisions, vital signs were lost and she expired on the
operating room table.
Medications on Admission:
Tylenol
Discharge Disposition:
Expired
Discharge Diagnosis:
death
massive gastrointestinal hemorrhage due to aortoesophageal
fistula
liposarcoma
enterotomy
malnutrition
urinary tract infection
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
[
"427.1",
"E879.9",
"198.0",
"511.9",
"263.9",
"197.8",
"998.11",
"512.1",
"V10.89",
"447.2",
"198.89",
"041.19",
"458.9",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"99.15",
"38.93",
"34.81",
"34.09",
"39.59",
"99.04",
"93.90",
"92.29",
"43.99",
"34.04",
"38.66",
"39.73"
] |
icd9pcs
|
[
[
[]
]
] |
7312, 7321
|
3710, 7254
|
324, 925
|
7497, 7506
|
7558, 7564
|
3080, 3200
|
7342, 7476
|
7280, 7289
|
7530, 7535
|
3215, 3687
|
275, 286
|
953, 2488
|
2510, 2731
|
2747, 3064
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,814
| 139,139
|
12269+56350
|
Discharge summary
|
report+addendum
|
Admission Date: [**2144-2-19**] Discharge Date: [**2144-3-20**]
Date of Birth: [**2083-4-26**] Sex: F
Service:
HISTORY OF THE PRESENT ILLNESS: The patient is a 60-year-old
white female, who presented to an outside hospital the
morning of [**2-19**], with the chief complaint of weakness
and sensory changes in the left arm and leg since
approximately 3 a.m. that morning. Head CT was obtained and
reportedly positive for a right basal ganglia
interparenchymal hemorrhage. The patient was noted to have
slurred speech, dysarthric, some swallowing difficulties.
The patient then rapidly deteriorated, becoming unresponsive
and right pupil become dilated and nonreactive. The patient
was emergently intubated, stabilized, and given [**Location (un) **] to
[**Hospital1 69**] for further management.
The patient's coagulation studies at the outside hospital
revealed the following: INR 4.4. The patient has been on
Coumadin for cerebrovascular accident in the past; she was
left with right sided weakness and the cerebrovascular
accident was 14 months prior to this most recent event. She
also has a history of hypertension and increased cholesterol.
ALLERGIES: The patient has an allergy to PENICILLIN.
PHYSICAL EXAMINATION: On examination, she was intubated
uneventfully upon arrival. Pupils were 7-mm and dilated,
nonreactive on the right, 3-mm and nonreactive on the left.
The lungs revealed scattered coarse breath sounds. She was
tachycardiac, sinus rhythm at 108. ABDOMEN: Abdomen was
obese, distended, positive bowel sounds. EXTREMITIES:
Extremities revealed no clubbing, cyanosis or edema.
NEUROLOGICAL: The patient had five to six beats of clonus in
the left lower extremity, positive mild withdrawal to deep
painful stimuli in the right upper extremity, nonresponsive
in the left upper extremity and no spontaneous movements
noted. The patient does not grimace to pain. Head: No gag
reflex.
LABORATORY DATA: Labs on admission revealed the following:
White count 13, hematocrit 40, platelet count 527,000, sodium
140, potassium 3.8, chloride 108, CO2 22, BUN 17, creatinine
.7, glucose 134, PTs 47, INR 4.4 at the outside hospital.
Labs upon arrival after two units of FFP: INR down to 2.1.
The ABG was 7.44, 240, 34, 24, and 99. The patient had
ventilation drain placed. Head CT at [**Hospital1 190**] showed a 4.9-cm x 3-cm right basal ganglion
interparenchymal hemorrhage with blood now filling the right
posterior [**Doctor Last Name 534**] of the lateral ventricle and filling the right
temporal [**Doctor Last Name 534**] as well with obstructive hydrocephalus. The
patient had ventilation drain place on [**2-20**]. The patient
also had temperature spike on admission to 102.2. On [**2-21**],
neurological examination was slightly improved. The patient
is to continue to have no eye opening, but moved the right
side spontaneously, extended to pain in the left upper
extremity. She did follow some commands. Pupils 2 -mm on
the left and 3.5 on the right; both sluggish to react. She
underwent an arteriogram to rule out any vascular
malformation to cause the bleeding, which was negative.
Chest x-ray showed left lower lobe pneumonia. The patient
was started on Vancomycin for aspiration pneumonia. The
patient continued to spike temperatures to 102.9. The
patient had blood, urine, and sputum cultures sent; all are
pending.
The patient was started on Bactrim for sinusitis on [**2-22**]. On
[**3-25**], the patient again spiked a temperature up to 103.2. The
patient was fully cultured to date. Sputum from the 19th
showed gram-positive rods. On the 18th, oral flora. Urine
is pending from the 19th. On the 17th it was negative.
Nasal swab was positive for gram-positive rods.
The patient continued on Vancomycin and Bactrim for
aspiration pneumonia and sinusitis. The patient had repeat
head CT on [**2-23**], which was essentially unchanged with still
significant mass effect. Neurologically, the patient was
opening her eyes to sternal rub. Pupils: Right was larger
than the left. Both sluggish and reactive, no corneals on
the right. The patient was not following commands and
extending to pain in the bilateral upper extremities with
slight withdrawal on the lower extremities. The CSF was sent
and it was negative for no growth.
On [**3-26**] the patient had right IJ line changed over a wire.
The patient had ventilation drain clamped on [**2-25**] and had
trial of CPAP with pressure support. The patient continued
to spike temperatures to 102.8 on [**2-26**]. All cultures were
sent and all pending are negative including sputum, urine,
blood, and CSF. Catheter tip also revealed no growth, on
[**2-26**]. The patient was having difficulty with respiratory
status on [**2-26**] with poor saturations. The patient's PEEP was
increased. The patient remained on SIMV at 60% with 500
times 6 and 10 of PEEP and 5 of pressor support.
On [**2-28**], the patient bit through her ET tube and a required
reintubation. On [**2-26**], the patient's ventilation drain was
discontinued. Sputum culture from [**2-26**] showed rare
gram-negative rods. The patient was started on Levofloxacin.
The patient was seen for a question of tongue laceration
after intubation. This required no surgical intervention.
The patient continues to spike temperatures to 102.2 on the
26th. Cultures, blood, from the 23rd were negative. Sputum
from the 23rd revealed sparse yeast and rare gram-negative
rods. Urine was negative. Catheter tip was negative. CSF
was negative. Neurologically, the patient was sedated, not
following command. Pupils equal and reactive but sluggish.
.................... in the upper extremities, slight
withdrawal in the lower extremities.
On [**3-1**], the patient had ventilation drain replaced secondary
to deterioration and neurological status. The patient had no
significant change after ventilation drain placed.
On [**3-2**], the patient was seen on rounds and found to have a
new left blown pupil. Head CT showed no significant change.
Ventilation drain was placed on [**3-2**].
On [**3-3**] pupils were three down 2.5 bilaterally, extensor
posturing in the bilateral lower extremities and withdrawal
again in the lower extremities. The patient was weaned to
CPAP and to continue to spike temperatures to 102.7, without
any clear-cut source of infection.
On [**3-3**], the patient had tracheostomy and PEG placed without
complication.
On [**3-9**], the patient showed .................... on the right
hand, opened eyes to noxious stimulation. Pupils on the left
continued to be larger than the right, but reactive and
minimal movement to painful stimulation with increased tone.
The patient continued on Vancomycin for ventilation drain
prophylaxis. The patient had VP shunt placed on [**3-13**], which
was done without complication. The patient remained
intubated, unable to be weaned off the ventilator. She had a
bronchoscopy done on [**3-12**], which showed mucus plugging with
nothing positive growing from her sputum from the
bronchoscopy.
Neurologically, the patient currently opens her eyes. She
shows ....................on the right hand. She has a left
hemiparesis. She withdraws her lower extremities to painful
stimulation. She does not track with her eyes. She does
follow simple commands. She is currently on CPAP with 12 of
pressure support and 40%. Most recent gas from [**3-19**] revealed
743, 30, 96 and 21. She is alert, following simple commands,
withdrawing both her legs and minimal withdrawal of the left
upper extremity. Labs on [**3-19**] revealed the following: White
count 12.7, hematocrit 30.6, platelet count 414,000, sodium
141, potassium 3.2, chloride 106, CO2 17, BUN 17, creatinine
.4, glucose 178.
Currently, she has gram-negative rods in her sputum from the
10th. She is currently on Levofloxacin. She has a PICC line
in place. She is neurologically stable. She is being
followed by the Department of Physical Therapy and
Occupational Therapy. She will require vented rehabilitation
bed.
MEDICATIONS ON DISCHARGE:
1. Heparin 5000 units subcutaneously b.i.d.
2. Albuterol 2 puffs q.4 to 6h.
3. Zantac 150 mg per G-tube b.i.d.
4. Tylenol 650 p.o.q.4h.p.r.n.
5. Atrovent 2 puffs q.4 to 6h.p.r.n.
6. Levofloxacin 500 mg per G tube q.d., which started on
[**2144-3-14**].
7. Lopressor 100 mg per NG t.i.d.
8. Tylenol 650 p.o.q.4h.p.r.n.
9. Dulcolax 10 mg p.o.q.d.p.r.n.
CONDITION ON DISCHARGE: Stable.
FOLLOW-UP CARE: The patient will followup with Dr. [**Last Name (STitle) **] in
four weeks.
[**Last Name (LF) **],[**First Name3 (LF) **] M. M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2144-3-19**] 12:19
T: [**2144-3-19**] 13:11
JOB#: [**Job Number 38318**]
Name: [**Known lastname 6933**], [**Known firstname 2219**] T Unit No: [**Numeric Identifier 6934**]
Admission Date: [**2144-2-19**] Discharge Date: [**2144-3-25**]
Date of Birth: [**2083-4-26**] Sex: F
Service:
This is an addendum to a previous discharge summary dated
[**2144-3-20**], and covers events occurring after that date only.
In brief, the patient is a 60 year old female who presented
on [**2144-2-19**], with weakness of the left arm and leg to an
outside hospital. Head CT showed a large right basal ganglia
bleed. She had been on Coumadin for a prior cerebrovascular
accident with a supratherapeutic INR of 4.4. She was
intubated and managed in the SICU by the neurosurgical
service until [**2144-3-24**], upon which date she was transferred
to the Medical Intensive Care Unit team for further vent
management and rehabilitation placement.
Her SICU course is summarized in the prior discharge summary
but is significant for ventricular drain placement on
[**2144-2-20**], and ventriculoperitoneal shunt placement on
[**2144-3-13**]. Throughout her SICU course, the patient had been
intermittently febrile with an elevated white blood cell
count. Chest x-ray showed a left sided infiltrate and
bronchoscopy with BAL cultures grew Methicillin sensitive
Staphylococcus aureus and Enterobacter sensitive to
Levofloxacin. The patient was treated with Levofloxacin
as well as a short course of Bactrim for synergy. She was
treated with Vancomycin for her Methicillin sensitive
Staphylococcus aureus given her Penicillin allergy.
The patient defervesced and improved from a respiratory
standpoint. She was able to have her ventilatory support
weaned and on transfer she was receiving 10 of pressure
support and 5 of PEEP. On transfer, her secretions were
still noted to be thick and somewhat purulent. Repeat gram
stain of her sputum sent on [**2144-3-25**], shows gram positive
cocci in pairs and clusters which likely represent persistent
Methicillin sensitive Staphylococcus aureus. Respiratory
culture is pending at the time of this dictation.
It is the feeling of the Medical Intensive Care Unit team
that she likely has a resolving pneumonia versus a
tracheobronchitis which is responsible for her continued
secretions. Her leukocytosis is not felt to represent active
infection, however, is more likely related to her large
intraparenchymal bleed and the ongoing inflammatory response
related to that. She has remained afebrile over the last
week of her hospitalization.
Her physical examination on [**2144-3-25**], revealed temperature
98, heart rate 68, blood pressure 140/70, respiratory rate
26, oxygen saturation 98% on vent settings of pressure
support 10, PEEP 5, FIO2 0.4. In general, the patient
appears comfortable breathing on the vent. She is alert.
She spontaneously opens her eyes. She obeys simple commands
and can nod her head yes and no in response to questions.
Her right pupil is 4.0 centimeters, irregular and
nonreactive. Her left pupil is 5.0 centimeters and
sluggishly reactive. She was unable to track with her eyes.
She is unable to open her mouth. There is no elevated
jugular venous pressure in her neck, however, examination is
difficult secondary to her obesity. Her heart examination is
regular with a normal S1 and S2, no murmurs or gallops
appreciated. Her lungs are clear to auscultation
bilaterally, auscultated anteriorly and laterally. Her
abdomen is obese, soft, nontender, nondistended, with good
bowel sounds. Her extremities are without pitting edema.
She has a PICC line in the right antecubital fossa without
surrounding erythema or discharge. She has no skin rashes.
Neurologically as previously stated, she is alert and
responds to verbal commands. She will blink her eyes. She
can squeeze her right hand. She can wiggle her right toes to
command. She has not exhibited any movement of the left arm
or leg and appears to have a flaccid paralysis on the left
side. Her toes are upgoing bilaterally. Her deep tendon
reflexes are 1+ in the left upper extremity, 3+ at the left
knee, 2+ at the right knee and 2+ in the right upper
extremity. Ankle reflexes are unable to be obtained.
Her most recent laboratory work on [**2144-3-25**], reveals a white
blood cell count of 17.9, hematocrit 29.8, platelet count
380,000. Sodium 137, potassium 3.7, chloride 98, bicarbonate
26, blood urea nitrogen 15, creatinine 0.3, glucose 137.
Calcium 9.4, albumin 3.4, magnesium 1.7, phosphorus 3.9, free
calcium 1.13, and venous pH 7.41.
Chest x-ray on [**2144-3-25**], revealed partial resolution of the
pneumonic consolidation in the left lower lobe. There are no
pleural effusions.
DISCHARGE DIAGNOSES:
1. Right basal ganglia intraparenchymal hemorrhage.
2. Status post tracheostomy.
3. Status post percutaneous endoscopic gastrostomy tube
placement.
4. Hypertension.
5. Penicillin allergy.
6. Full code.
MEDICATIONS ON DISCHARGE:
1. Vancomycin one gram intravenous b.i.d. to end [**2144-4-2**].
2. Levofloxacin 500 mg per percutaneous endoscopic
gastrostomy tube q.d. to end [**2144-4-2**].
3. Albuterol two puffs in the line q.i.d. p.r.n.
4. Lopressor 100 mg per gastrostomy tube b.i.d.
5. Tylenol 650 mg per gastrostomy tube q6hours p.r.n.
6. Dulcolax 10 mg PR b.i.d. p.r.n.
7. Promote with fiber tube feeds at goal of 60 cc/hour.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 5862**]
Dictated By:[**Name8 (MD) 6549**]
MEDQUIST36
D: [**2144-3-25**] 17:47
T: [**2144-3-25**] 19:43
JOB#: [**Job Number **]
|
[
"V58.61",
"996.59",
"342.02",
"482.41",
"331.4",
"790.92",
"461.3",
"431",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.22",
"02.42",
"38.93",
"93.90",
"31.1",
"02.39",
"96.04",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
13568, 13777
|
13803, 14452
|
1250, 8072
|
8484, 13547
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,621
| 173,717
|
27311
|
Discharge summary
|
report
|
Admission Date: [**2128-3-19**] Discharge Date: [**2128-4-2**]
Date of Birth: [**2071-6-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Cardiac arrest
Major Surgical or Invasive Procedure:
[**2128-3-24**] Aortic Valve Replacement(21mm St. [**Male First Name (un) 923**] Mechanical Valve)
and Single Vessel Coronary Artery Bypass Grafting utilizing the
left internal mammary artery to the left anterior descending.
[**2128-3-22**] Cardiac catherization
History of Present Illness:
Mr. [**Known lastname 66956**] is a 56 yo man who presents as a transfer after
sustaining a cardiac arrest during an exercise tolerance test.
He reports that at the start of the ETT, he began to get dizzy.
This was followed by chest pain and then LOC. Per report, the pt
was hypotensive and bradycardic, then had an asystolic arrest.
He fell onto the treadmill. CPR was initiated, and the pt had
rapid ROSC (3-5 minutes). By the time of EMS arrival, he was
awake and alert. Upon arrival to the OSH, he was in atrial
fibrillation with RVR. He received a total of 20 mg of IV
metoprolol and converted to sinus rhythm. He underwent pan-CT
scan, which did not demonstrate any significant injuries. He was
transiently on a heparin drip. An echocardiogram reportedly
demonstrated [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 0.8 cm2 with a peak gradient of 62 mm Hg
and a mean gradient of 41 mmHg. He reports worsening exercise
tolerance and progressive exertional angina over the past few
months. He had a nose bleed after his arrest today, but has
otherwise not had any bleeding events.
Past Medical History:
Bicuspid aortic valve with severe aortic stenosis
Coronary Artery Disease s/p DES to mid-LAD in [**2124**]
Dyslipidemia
Social History:
Active smoker, smokes 1 ppd, 20+ PY smoking history. Drinks EtOH
on weekends, not to excess. Denies drug abuse. Lives with
girlfriend.
Family History:
No family history of early MI, otherwise non-contributory.
Physical Exam:
VS: 37.2, 84, 109/80, 16, 96%
GENERAL: Obese man, NAD, pleasant, appropriate, cooperative
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 6 cm.
CARDIAC: III/VI systolic murmur heard best at the RUSB,
relatively late peaking, no loss of S2, radiates to clavicle. No
audible diastolic murmur.
CHEST: tender over anterior L lower rib cage
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Obese, soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: Mild chronic venous stasis changes
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
[**2128-3-19**] 10:50PM BLOOD WBC-9.0 RBC-3.95* Hgb-13.1* Hct-36.0*
MCV-91 MCH-33.2* MCHC-36.4* RDW-13.2 Plt Ct-131*
[**2128-3-19**] 10:50PM BLOOD PT-13.0 PTT-24.5 INR(PT)-1.1
[**2128-3-19**] 10:50PM BLOOD Glucose-113* UreaN-14 Creat-0.9 Na-136
K-3.9 Cl-103 HCO3-24 AnGap-13
[**2128-3-19**] 10:50PM BLOOD CK(CPK)-573*
[**2128-3-19**] 10:50PM BLOOD CK-MB-37* MB Indx-6.5* cTropnT-0.67*
[**2128-3-19**] 10:50PM BLOOD Calcium-8.6 Phos-3.3 Mg-1.9
[**2128-3-22**] 02:45PM BLOOD %HbA1c-5.9
[**2128-3-22**] Cardiac Cath:
1. Coronary angiography of this left dominant system revealed 1
vessel coronary disease. The LMCA was short and had no
angiographically apparent coronary disease. The LAD had a 90%
stenosis proximal to the prior Cypher stents. The remainder of
the LAD was without angiographically significant disease. The
LCX was patent but there was a 30-40% stenosis at the origin of
OM1. The RCA was small and without significant disease. 2.
Resting hemodynamics revealed mildly elevated right-sided
filling pressures and moderately elevated left-sided filling
pressures. The RA mean was 21 mm Hg, RVEDP 21 mm Hg, PASP 47 mm
Hg with a mean of 33 mm Hg, and a PCWP of 21 mm Hg. The cardiac
output was 5.0 and index 2.3 l/min/m2. 3. Left ventriculography
was deferred. 4. The aortic valve was not crossed as it was
known to be critically stenosed.
[**2128-3-22**] Carotid Ultrasound:
Less than 40% stenosis of the bilateral internal carotid
arteries.
[**2128-3-23**] Chest CT Scan:
1. Thoracic aorta normal in caliber throughout, without evidence
of aneurysm. Aortic diameter measurements are listed above. 2.
Multiple noncalcified sub 5 mm pulmonary nodules are seen
throughout the lungs. Recommend follow up in one year. 3. Subtle
bronchial irregularities, compatible with chronic airway
disease. 4. No evidence of acute cardiopulmonary process. Normal
cardiac size. Calcified aortic valves. Stent in proximal LAD.
Conclusions
A patent foramen ovale is present. There is moderate symmetric
left ventricular hypertrophy. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion. The
aortic valve leaflets are severely thickened/deformed. There is
severe aortic valve stenosis (area <0.8cm2). Mild to moderate
([**12-19**]+) aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. Mild (1+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. There is no
pericardial effusion.
PRELIMINARY REPORT Not reviewed/approved by the Attending
Anesthesia Physician.
POSTBYPASS
Patient is on a phenylephrine infusion. A well seated, well
functioning mechanical valve seen in the aortic position. No
perivalvular leaks. Max grad is 50 mmHg with a mean gradient of
36 mmHg. LV looks underfilled. LV EF is similar at 60%. Aortic
contour is smooth after decannulation.
Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2128-4-1**] 10:59
?????? [**2121**] CareGroup IS. All rights
[**2128-4-2**] 06:05AM BLOOD WBC-8.0 RBC-3.05* Hgb-9.1* Hct-27.7*
MCV-91 MCH-30.0 MCHC-33.0 RDW-13.9 Plt Ct-372
[**2128-4-2**] 06:05AM BLOOD Plt Ct-372
[**2128-4-2**] 06:05AM BLOOD PT-32.2* PTT-30.6 INR(PT)-3.3*
[**2128-4-2**] 06:05AM BLOOD Glucose-99 UreaN-17 Creat-1.2 Na-138
K-5.0 Cl-101 HCO3-30 AnGap-12
[**2128-3-22**] 02:45PM BLOOD ALT-35 AST-28 AlkPhos-60 TotBili-0.7
[**2128-4-2**] 06:05AM BLOOD Mg-2.1
[**2128-3-20**] 05:04AM BLOOD CK-MB-25* MB Indx-4.6 cTropnT-0.62*
Brief Hospital Course:
Mr. [**Known lastname 66956**] was admitted to the medical ICU. Cardiac
biomarkers were initially elevated but improved over several
days. He remained stable on medical therapy. On [**3-20**], he
underwent cardiac catheterization whgich revealed AS and LAD
disease.Referred to Dr. [**First Name (STitle) **] and underwent surgery on [**3-24**].
Transferred to the CVICU in stable condition on titrated
propofol and phenylephrine drips. Extubated the following
morning. Went back into A fib and was treated with amiodarone.
Chest tubes removed on POD #2.Transferred to floor on POD #4 to
begin increasing his activity level. Coumadin anticoagulation
started for intermittent A fib. EP consulted and amiodarone
discontinued with further titration of beta blockade. Cleared
for discharge to home on POD #9. Target INR 2.0-2.5. Coumadin to
be followed by Dr. [**Last Name (STitle) 29070**].
Medications on Admission:
Aspirin 81 daily
Clopidogrel 75 daily
Atorvastatin 40 daily
Atenolol 50 daily
Omeprazole 20 daily
Fish Oil 1000 daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Outpatient [**Name (NI) **] Work
PT/INR for coumadin dosing with goal INR 2.5-3.0 for mechanical
aortic valve with first draw [**4-4**] sunday with results to cardiac
surgery [**Telephone/Fax (1) 170**] after that to be followed by Dr [**Last Name (STitle) 66588**] -
office # [**Telephone/Fax (1) 37284**] fax [**Telephone/Fax (1) 66957**] with draw tuesday [**4-6**]
with results to Dr [**Last Name (STitle) 66588**]
4. Warfarin 2 mg Tablet Sig: goal INR 2.5-3.0 Tablets PO once a
day: please adjust dose as instructed .
Disp:*60 Tablet(s)* Refills:*0*
5. Warfarin 5 mg Tablet Sig: goal INR 2.5-3.0 Tablets PO once a
day: please adjust dose as instructed .
Disp:*60 Tablet(s)* Refills:*0*
6. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
9. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day): to bilateral feet .
Disp:*qs qs* Refills:*0*
10. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*0*
11. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
12. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
13. Outpatient [**Hospital1 **] Work
coumadin please take 5 mg on saturday [**4-3**], VNA will come sunday
and check [**Month/Year (2) **] - calling the cardiac surgery office for dosing
because Dr [**Last Name (STitle) 66588**] office will be closed
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Coronary artery disease s/p Coronary Artery Bypass Grafting
Bicuspid Aortic Valve s/p Aortic valve replacement
Atrial Flutter post op
Atrial fibrillation preoperative
Cardiac Arrest at outside hospital
Acute diasystolic heart failure
Dyslipidemia
Lung Nodules
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**]
Heart monitor for evaluation of rhythm - please press button if
feel fast heart rate or at least once a day and call in as
instructed
PT/INR for coumadin dosing with goal INR 2.5-3.0 for mechanical
aortic valve with first draw [**4-4**] sunday with results to cardiac
surgery [**Telephone/Fax (1) 170**] after that to be followed by Dr [**Last Name (STitle) 66588**] -
office # [**Telephone/Fax (1) 37284**] fax [**Telephone/Fax (1) 66957**]
Followup Instructions:
Please call to schedule appointments
Dr. [**Last Name (STitle) 29070**] in 1 week [**Telephone/Fax (1) 37284**]
Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
[**Doctor Last Name **] of hearts monitor being followed by EP service Dr [**Last Name (STitle) **]
call holter [**Last Name (STitle) **] with questions [**Telephone/Fax (1) 3104**], to call in daily
with [**Location (un) 1131**] as instructed
PT/INR for coumadin dosing with goal INR 2.5-3.0 for mechanical
aortic valve with first draw [**4-4**] sunday with results to cardiac
surgery [**Telephone/Fax (1) 170**] after that to be followed by Dr [**Last Name (STitle) 66588**] -
office # [**Telephone/Fax (1) 37284**] fax [**Telephone/Fax (1) 66957**] with draw tuesday [**4-6**]
with results to Dr [**Last Name (STitle) 66588**]
Completed by:[**2128-4-13**]
|
[
"746.4",
"414.01",
"427.32",
"427.5",
"427.31",
"997.1",
"272.4",
"428.31",
"530.81",
"428.0",
"518.89",
"V45.82",
"424.1",
"E878.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"35.22",
"36.15",
"37.23",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
9828, 9903
|
6612, 7500
|
287, 552
|
10207, 10214
|
2930, 6589
|
11167, 12009
|
1993, 2054
|
7669, 9805
|
9924, 10186
|
7526, 7646
|
10238, 11144
|
2069, 2911
|
233, 249
|
580, 1681
|
1703, 1824
|
1840, 1977
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,425
| 103,346
|
3951
|
Discharge summary
|
report
|
Admission Date: [**2160-7-20**] Discharge Date: [**2160-7-21**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
Cordis placement, intubation, codeblue
History of Present Illness:
Mrs. [**Known lastname **] is an 86 year old lady that first presented to [**Hospital1 18**]
[**Location (un) 620**] on [**7-13**] with melena, left sided abdominal hematocrit
found to be 19. She underwent Endoscopy (#1) with blood clots,
no source of bleeding and superifical erosions. She was
transfused 2 units pRBCs, started on protonix, ibuprofen stopped
and d/c'd home after 2 days of not bleeding. On [**7-18**] she
contact[**Name (NI) **] Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to return to the hospital with
continued melena and was rescoped (#2) found to have clot and
erosive gastritis. She was rescoped on [**7-19**] and found to have a
vessel in the Cardia with a dieulafoy lesion, injected epi and
clipped. [**7-20**] early AM the patient vomiting bright red blood
with continued melena and was scoped a final time (#4) with too
much blood in the stomach to identify.
.
Ms. [**Known lastname **] is an 86 year old lady transferred from [**Location (un) 620**] after a
series of recent upper GI bleeds from a dieulafoy lesion s/p
epinepherine injection and 2 endoscopies. She was discharged
from [**Location (un) 620**] and then readmitted on [**7-18**] with recurrent
hematemesis and melena.
.
Gastroscopy was performed on [**7-18**] emergently but no cause of
bleeding could be seen. The Dieulafoy lesion with visible
vessel was seen, with no active bleeding but with large clot in
the fundus which was clipped with a hemoclip and injected with
epinepherine. Transfused 2 units
.
On arrival to the MICU, the patient is uncomfortable complaining
of the need to go to the bathroom, lightheadedness/weakness and
abdominal pain. She denies difficulty breathing, chest pain.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
s/p Appendectomy
Pancreatic Resection for benign tumor
Abdominal Lymphoma
Rheumatoid Arthritis
Hysterectomy
Lysis of adhesions
Multiple c-sections
R Hip pain
Social History:
Lives at home, ex smoker quit in the [**2119**], occasional EtOH
Family History:
N/C
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T: 96.4 BP: 126/43 P: 110 R: 19 O2: 100% 2LNC
General: Alert, oriented, uncomfortable appearing
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally
CV: Rapid rate, no murmur appreciated
Abdomen: soft, tender, worst in the LLQ, bowel sounds present,
no rebound tenderness or guarding
Rectal: Melena on rectal exam
GU: foley in place
Ext: cool, edematous, 1+ pulses
Pertinent Results:
ADMISSION LABS
[**2160-7-20**] 08:00AM BLOOD WBC-7.5 RBC-3.75* Hgb-11.7* Hct-33.7*
MCV-90 MCH-31.2 MCHC-34.7 RDW-16.1* Plt Ct-157
[**2160-7-20**] 08:00AM BLOOD Neuts-82.4* Lymphs-12.1* Monos-4.9
Eos-0.4 Baso-0.2
[**2160-7-20**] 08:00AM BLOOD PT-14.0* PTT-28.9 INR(PT)-1.2*
[**2160-7-20**] 08:00AM BLOOD Plt Ct-157
[**2160-7-20**] 08:00AM BLOOD Fibrino-320
[**2160-7-20**] 08:00AM BLOOD Glucose-139* UreaN-11 Creat-0.6 Na-142
K-4.1 Cl-118* HCO3-18* AnGap-10
[**2160-7-20**] 08:00AM BLOOD CK(CPK)-530* Amylase-35
[**2160-7-20**] 08:00AM BLOOD Calcium-5.9* Phos-2.4* Mg-1.5*
[**2160-7-20**] 01:21PM BLOOD Type-MIX pH-7.33*
[**2160-7-20**] 10:01AM BLOOD Lactate-1.1
[**2160-7-20**] 01:21PM BLOOD freeCa-1.07*
CTA - [**2160-7-20**]
1. No definite etiology to gastrointestinal bleeding identified.
Recommend
further evaluation with tagged red blood cell scan or an
angiography as
clinically appropriate.
2. Trace free fluid seen dependently in the pelvis.
3. Atherosclerotic disease.
4. Small bilateral pleural effusions.
5. Patent arterial system, with small amount of atherosclerotic
disease.
Incidental note is made of an independent origin of the common
hepatic artery
directly from the aorta.
6. Drainage of the spleen is via the SMV.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
Upper GI Bleed: The patient's history is significant for a
worsening GI bleed with unknown anatomy secondary to pancreatic
cyst resection. Repeated endoscopy suggests a source in the
cardia (likely dieulafoy lesion). The patient is currently
tachycardic with stable blood pressures and continued melena
output. Unclear contribution from NSAIDs. Concerned for
perforation. We maintained vascular access and checked Q4H Hct,
Coags, Fibrinogen, Platelets, Lactate, Venous Sat, iCal. She
was consented for blood. Our goal for transfusion Hct >30, INR
<2.0, Plt >50. Surgery, GI were made aware. A CTA was done
early on [**2160-7-20**], which showed no obvious bleed, and IR
deferred intervention. She was maintained on protonix IV gtt
and octreotide. Cardiac enzymes were cycled. The pt was HD
stable with stable Hcts throughout the day. Unfortunately, the
night of HD 2, the pt developed acute hypotension with nausea.
Her Hct was 28 from 30, and her coags were INR 1.2 and PTT 32.4
(improved from previous). She became unresponsive, and a code
blue was called. The pt had gone into PEA arrest, a dose of epi
was given and chest compressions started at 12:30 am. She
regained a pulse and began spontaneously breathing. No shock
was delivered. Then, again she lost her pulse after 5 minutes,
and went into PEA arrest. She was coded for a total of 45
minutes, received epi, atropine, vasopressin, bicarb, calcium,
magnesium, and rapidly infused with 5 units of pRBCs, 1 of FFP,
1 of platelets. A gas that was obtained during the code was
7.13/53/38. Unfortunately, she did not regain a pulse and
remained in PEA. Time of death was 1:15 am on [**2160-7-21**].
Medications on Admission:
- Amlodipine 10 mg daily
- Acetaminophen 325-650 mg PO Q6H prn pain
- Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
- Clopidogrel 75 mg Tablet PO DAILY
- Fluticasone-Salmeterol 250-50 mcg/Dose Disk Inhalation [**Hospital1 **]
- Furosemide 40 mg PO once a day
- Hydralazine 25 mg PO TID
- Isosorbide Mononitrate 30 mg Tablet PO daily
- Simvastatin 20 mg PO once a day
- ISS (lantus 46U, Sliding scale)
- Docusate Sodium 100 mg PO BID
- Senna 8.6 mg [**12-15**] PO HS
- Ipratropium-Albuterol 18 mcg-103 mcg 1-2 Puffs IH Q6H PRN SOB
- Cholecalciferol (Vitamin D3) 1,000 unit PO once a day.
- Nitroglycerin 0.4 mg/dose Spray Q5min X 3 PRN Chest pain
- Multivitamin PO DAILY
- Lidocaine 5 %(700 mg/patch) appl DAILY
- Ascorbic acid 500mg DAILY
- Aspirin 81 mg PO DAILY
- Calcium Carbonate 500 mg 2 Tablet PO QID with meals.
- Cholecalciferol (Vitamin D3) 1,000 unit Tablet PO once a day
- Cyanocobalamin 1,000 mcg PO once a day.
- Trazodone 25 mg PO HS PRN for insomnia.
- Ranitidine HCl 150 mg PO once a day.
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2160-7-21**]
|
[
"714.0",
"V10.79",
"537.84",
"458.9",
"427.5",
"787.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"99.60",
"31.42"
] |
icd9pcs
|
[
[
[]
]
] |
7331, 7340
|
4556, 6233
|
278, 318
|
7392, 7402
|
3223, 4533
|
7454, 7624
|
2712, 2717
|
7302, 7308
|
7361, 7371
|
6259, 7279
|
7426, 7431
|
2732, 3204
|
2091, 2433
|
230, 240
|
346, 2072
|
2455, 2614
|
2630, 2696
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,009
| 155,618
|
22256
|
Discharge summary
|
report
|
Admission Date: [**2167-8-5**] Discharge Date: [**2167-8-13**]
Date of Birth: [**2119-6-10**] Sex: F
Service: SURGERY
Allergies:
Meperidine / Heparin Agents
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
ETOH Cirrhosis, HCC
Major Surgical or Invasive Procedure:
liver [**First Name3 (LF) **] [**2167-8-6**]
History of Present Illness:
Ms. [**Known lastname 58028**] is a 48 year old female with a history of
alcoholic cirrhosis, HCC, portal hypertension, and variceal
hemorrhage. S/P radiofrequency ablation of 1.4 cm lesion in
liver [**2166-9-5**]. S/P TIPS placement. The patient is here today to
receive a liver [**Year (4 digits) **].
Past Medical History:
Osteoarthritis
H/o alcohol abuse
Benzodiazapine abuse
Alcohol-induced cirrhosis ([**2157**]) s/p TIPS
Alcohol-induced pancreatitis
Gastroesophageal reflux disease
Ovarian cysts
Caesarian-section x2
Appendectomy
Tubal ligation
Thrombocytopenia
Social History:
Lives with husband and 16 y/o daughter in [**Name (NI) **] ME. Limited
employment secondary to health. 12 pack-year smoking history,
currently [**12-7**] ppd. ETOH abuse. benzodiazapine abuse.
Family History:
mother 64 died of emphysema
father 67 died of ETOH related dz
Physical Exam:
Vitals: 96.9 73 113/63 22 98% RA BG=92
General: sitting comfortable in bed, communicating and answering
questions appropriately.
HEENT: NC/AT, anicteric sclerae, MMM, no cervical or
supraclavicular lymphadenothy
CV: RRR, normal s1s2, no mgr
Lungs: CTAB, no rhonchi rales or wheezes.
Abdomen: soft, nt/nd, no guarding, scars present from previous
surgeries.
Extremities: warm, well perfused, pulses palpable bilaterally,
no
edema.
Labs:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2167-8-5**] 12:57 4.7 4.35 13.5 36.2 83 31.1 37.4* 14.1 66
PT = 14.5, PTT = 31.3, INR = 1.3
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2167-8-5**] 12:57 90 6 1.3* 140 3.5 104 26 14
ALT AST Alk Phos TotBili
18 33 106* 1.8*
Albumin Calcium Phos Mg
4.3 9.6 2.6 1.9
HCG = 7
Imaging:
Liver Ultrasound: IMPRESSION: No significant change since prior
ultrasound. See official report for specific findings.
CT abd w/ w/out contrast: PND
CT chest w/wout contrast PND
Pertinent Results:
[**2167-8-11**] 06:00AM BLOOD WBC-7.9 RBC-4.86 Hgb-14.8 Hct-39.8 MCV-82
MCH-30.3 MCHC-37.1* RDW-14.0 Plt Ct-48*
[**2167-8-11**] 06:00AM BLOOD PT-11.8 PTT-21.2* INR(PT)-1.0
[**2167-8-11**] 06:00AM BLOOD Glucose-79 UreaN-43* Creat-1.3* Na-138
K-3.3 Cl-96 HCO3-28 AnGap-17
[**2167-8-11**] 06:00AM BLOOD ALT-170* AST-86* AlkPhos-204* TotBili-1.3
[**2167-8-11**] 06:00AM BLOOD Albumin-4.1 Calcium-9.1 Phos-1.7* Mg-1.6
[**2167-8-11**] 06:00AM BLOOD tacroFK-6.4
Brief Hospital Course:
On [**2167-8-6**], she underwent deceased donor liver [**Date Range **] from
donor with past h/o of renal [**Date Range **] and HIT. Two JP drains
were placed. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please refer to
operative note for details. Postop, she was sent to the SICU for
management. She received blood per pathway protocol. She
remained hemodynamically stable. LFTs initially increased then
trended down. JP drainage was non-bilious. Liver duplex
demonstrated normal vasculature. She was extubated. On [**8-7**], HIT
was negative.
She was transferred out of the SICU. Diet was advanced and
tolerated. IV meds were switched to oral meds. IV dilaudid was
switched to oxycodone. Cellcept was well tolerated and steroids
were tapered. Prograf was started on postop day 1. Doses were
adjusted per trough levels. She required minimal sliding scale
insulin. She became independent with ambulation.
LFTs trended down except for abrupt increase in alk phos on [**8-9**]
when alk phos increased from 94 to 251. Repeat liver duplex
demonstrated patent vasculature and non dilated biliary tree. A
small perihepatic collection was noted. Platelets decreased to
48 from 78 on [**8-11**]. Repeat HIT on [**8-9**] was negative.
The 2nd JP was removed [**8-13**]. She did well with medication
teaching. She was instructed to check her blood sugars because
she had glucose in 360 range the morning of discharge after
drinking ensure. Scripts were provided for Free style lite meter
supplies.
Medications on Admission:
lactulose 10 gram/15 mL Solution 30ML Solution(s) by mouth at HS
lansoprazole [Prevacid] 30 mg Capsule, Delayed Release(E.C.) 1
[**Hospital1 **]
lidocaine 5 % (700 mg/patch) Adhesive Patch, TP to knee qd
propranolol 40 mg Tablet 1 Tablet(s) by mouth twice a day
rifaximin [Xifaxan] 550 mg Tablet 1 Tablet(s) by mouth two times
a day
spironolactone 50 mg Tablet 3 Tablet(s) by mouth once a day
100mg qAm and 50mg QPM
tramadol 50 mg Tablet 1 Tablet(s) by mouth three to four times
per day
trazodone 50 mg Tablet 2 Tablet(s) by mouth at bedtime
Allergies:
Meperidine
Discharge Medications:
1. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
2. prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily):
follow printed taper schedule.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
6. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
7. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for knee pain.
9. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H (every
12 hours).
10. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
11. trazodone 50 mg Tablet Sig: 0.5 Tablet PO prn: HS as needed
for insomnia.
12. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
13. FreeStyle Lite Strips Strip Sig: One (1) Miscellaneous
twice a day.
Disp:*1 box* Refills:*2*
14. FreeStyle Lancets Misc Sig: One (1) Miscellaneous twice
a day.
Disp:*1 box* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 **] of southern me
Discharge Diagnosis:
ETOH/HCC cirrhosis
hyperglycemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Please call the [**Hospital6 1326**] Office [**Telephone/Fax (1) 673**] if you develop
any of the following:
fever (temperature of 101 or greater), shaking chills, nausea,
vomiting, inability to take any of your medications, jaundice,
increased abdominal pain, incision redness/bleeding/drainage or
leg edema.
You will need to have blood drawn every Monday and Thursday for
lab monitoring
You may shower
No driving while taking pain medication
No heavy lifting/straining
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2167-8-21**] 1:40
Provider: [**Name10 (NameIs) **] SOCIAL WORKER Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2167-8-21**] 2:40
Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2167-8-28**] 2:40
Completed by:[**2167-8-13**]
|
[
"715.90",
"303.93",
"571.2",
"305.1",
"287.5",
"V10.07",
"456.1",
"530.81",
"572.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.59",
"00.93"
] |
icd9pcs
|
[
[
[]
]
] |
6309, 6371
|
2798, 4330
|
306, 353
|
6448, 6448
|
2319, 2775
|
7127, 7576
|
1182, 1245
|
4953, 6286
|
6392, 6427
|
4356, 4930
|
6631, 7104
|
1260, 2300
|
247, 268
|
381, 688
|
6463, 6607
|
710, 955
|
971, 1166
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,959
| 162,707
|
42379
|
Discharge summary
|
report
|
Admission Date: [**2115-1-3**] Discharge Date: [**2115-1-22**]
Date of Birth: [**2058-4-11**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1363**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Lumbar puncture
Bone marrow biopsy
Thyroid biopsy
History of Present Illness:
56 year old male with past medical history of coronary artery
disease, depression who presented from OSH with altered mental
status, was admitted to the [**Hospital Unit Name 153**] where he was found to have
malignancy based on bone marrow aspirate with unknown primary
now stable and transferred to the floor.
.
At baseline, the patient works as an advocate for mentally
impaired adults and do jogging every day. Back in [**Month (only) 205**] he
developed DOE and persistent angina. He eventually had a cardiac
catheterization in [**Month (only) **] with stent placement times 2. As
per
PCP, [**Name10 (NameIs) **] patient was not the same after this events. He was
taking aspirin, crestor, lisinopril, metoprolol and zoloft after
discharge. As per his wife (who meets him every 1-2 weeks) he
continued working until 3 weeks ago when he started having some
problems at work and concentrating. His mood was down and had
constant ideas about sadness. Approximately on [**12-23**] he
stopped taking all his meds, and he developed insomnia,
forgetfulness, his PO intake decreased and his concentration
problems worsened. Three days later, he contact[**Name (NI) **] his PCP, [**Name10 (NameIs) 1023**]
gave him a prescription of ambien and cymbalta 30mg PO daily
thinking on serotonin withdrawal. His symptoms continued
worsening, and he then developed progressive nausea, loose
stools
and stomach cramping. He also started getting more confused, so
he was brought to [**Hospital3 **] ER on [**12-28**] and was admitted the
next day early morning.
.
Per OSH records, the etiology of the patient's delirium remained
unclear although there was suspicion for TTP given anemia and
thrombocytopenia. Neurology consult had planned LP but it was
never performed in the setting of low platelets. Heme/Onc
consulted there also. Urine tox screen reportedly negative and
head CT unremarkable. MRI there was read as multiple foci of
signal abnormality consistent with atypical MS [**First Name (Titles) **] [**Last Name (Titles) **] diseases
or sarcoidosis. His blood work was mainly notable for ESR 76 and
CRP 65 as well as platelets which trended down to 19. At [**Location (un) 21541**], the patient remained confused and slightly tachycardic but
no focal neurological deficits. He also had pain all over his
body. As per the wife, she was told her husband had
bacteria in the bowel, then tick borne infection, anemia, brain
abnormalities at MRI, and finally to consider colonoscopy. She
got frustrated according to her because they were only repleting
his potassium, so she signed him out AMA on Tuesday [**1-1**].
.
At home, the patient was even more confused and complaining of
whole body pain. Patient was moaning all night, so she contact[**Name (NI) **]
his PCP again who recommended to call an ambulance. EMS found
the
patient at home with an empty bottle of Ambien at his side, but
as per wife there was only one pill remaining there. At [**Hospital3 **]
ED, the patient remained confused and slightly tachycardic but
no
focal neurological deficits. His wife requested a transfer to
[**Name (NI) 86**] for further evaluation. He was not started on any
antibiotics.
.
In the [**Hospital1 18**] ED, initial vital signs were: T99.7, HR88,
BP172/74, RR18, 97% on RA. He did spike a fever of 101.8. The
patient appeared ill and pale, alert and oriented X 0. He was
treated with Morphine for pain. Heme/Onc was consulted and felt
this was consistent with hemolytic process. ADAMS13 was ordered
for low likihood of TTP but a possibility. The patient was
empirically treated with acyclovir, vancomycin and ceftriaxone
for meningitis. Labs were notable for DDimer 13,570; CK [**2033**];
AST 1510/ALT 100; LDH 6890; Lipase 89; TBili 1.0; DBili 0.4;
Albumin 3.4. Fibrinogen, lactate and uric acid were normal. He
had a condom cath placed but had not put out urine.
.
Past Medical History:
- Coronary artery disease; s/p stenting x2 [**2114-8-30**], x2
[**2102-3-30**], h/o MI in [**2092**] s/p stent
- Cardiomyopathy with EF 49% and inferoseptal hypokinesis.
- Abdominal aortic aneurysm
- Depression
- Dyslipidemia
- HTN
- GERD
Social History:
Prior to this was actively working as an advocate for mentally
impaired adults, for the State of [**State 350**]. He would go
jogging everyday. No known [**Doctor Last Name 6641**] or toxin exposures per wife.
Wife denies tobacco and illicits in the patient.
Family History:
Unknown
Physical Exam:
Physical Exam on Admission:
Vitals: T: 98.9 BP: 154/72 P: 101 R: 14 O2: 97% on RA
General: Alert, not oriented, no acute distress, comfortable,
smiling
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Soft, supple, JVP not elevated, no nuchal rigidity
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops, no spider angioma
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: Condom cath in place
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema; mildly erythematous macules on bilateral knees, no
asterixis
.
Physical Exam on Discharge:
Vitals - Tc 97.6 Tm 98 BP 130/90 HR 95-115 RR 20 O2 99% RA
GENERAL: NAD
SKIN: warm and well perfused, salmon colored rash on anterior
distal lower extremities, folliculitis on back as well as
scattered on chest
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD; thyroid does not feel enlarged, no palpable nodule
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly, bruit on right renal
artery region
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: alert to self, hospital, not oriented to date, knows his
wife is [**Name (NI) **].
Pertinent Results:
Labs on Admission:
[**2115-1-2**] 11:30PM WBC-4.4 RBC-3.60* HGB-10.6* HCT-28.4* MCV-79*
MCH-29.4 MCHC-37.2* RDW-16.3*
[**2115-1-2**] 11:30PM NEUTS-51.5 LYMPHS-38.9 MONOS-6.0 EOS-2.8
BASOS-0.8
[**2115-1-2**] 11:30PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-OCCASIONAL MICROCYT-1+ POLYCHROM-OCCASIONAL
OVALOCYT-OCCASIONAL SCHISTOCY-1+ TEARDROP-OCCASIONAL
[**2115-1-2**] 11:30PM PT-13.1* PTT-32.0 INR(PT)-1.2*
[**2115-1-2**] 11:30PM FIBRINOGE-572*
[**2115-1-2**] 11:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2115-1-2**] 11:30PM HAPTOGLOB-41
[**2115-1-2**] 11:30PM ALBUMIN-3.4* CALCIUM-10.8* PHOSPHATE-5.3*
MAGNESIUM-1.8 URIC ACID-6.4
[**2115-1-2**] 11:30PM CK-MB-2
[**2115-1-2**] 11:30PM cTropnT-<0.01
[**2115-1-2**] 11:30PM LIPASE-89*
[**2115-1-2**] 11:30PM ALT(SGPT)-100* AST(SGOT)-1510* LD(LDH)-6890*
CK(CPK)-[**2033**]* ALK PHOS-185* TOT BILI-1.9* DIR BILI-0.4* INDIR
BIL-1.5
[**2115-1-2**] 11:30PM GLUCOSE-109* UREA N-24* CREAT-1.1 SODIUM-138
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-23 ANION GAP-17
[**2115-1-3**] 12:58AM D-DIMER-[**Numeric Identifier **]*
[**2115-1-3**] 04:17AM RET AUT-1.2
.
Relevant Labs:
[**2115-1-3**] 06:47AM CORTISOL-15.5
[**2115-1-3**] 06:47AM TSH-4.5*
[**2115-1-3**] 06:47AM calTIBC-190* VIT B12-1179* HAPTOGLOB-40
TRF-146*
[**2115-1-3**] 01:10PM SED RATE-100*
[**2115-1-3**] 01:10PM CRP-239.1*
[**2115-1-3**] 01:10PM AMMONIA-91*
[**2115-1-3**] 01:10PM FERRITIN-[**Numeric Identifier 15010**]*
[**2115-1-3**] 11:15PM ANTITPO-16
[**2115-1-3**] 11:15PM GGT-44
[**2115-1-3**] 06:13PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-0 POLYS-0
LYMPHS-0 MONOS-0
[**2115-1-3**] 06:13PM CEREBROSPINAL FLUID (CSF) PROTEIN-42
GLUCOSE-52
[**2115-1-6**] 04:11AM BLOOD CD3%-72.5 CD3Abs-1416 16/56%-13.8
16/56Ab-269
[**2115-1-3**] 11:15PM BLOOD GGT-44
[**2115-1-3**] 06:47AM BLOOD Albumin-3.0* Calcium-9.9 Phos-4.9* Mg-2.2
UricAcd-5.9 Iron-149
[**2115-1-4**] 05:17AM BLOOD Triglyc-246*
[**2115-1-5**] 04:13PM BLOOD HCG-LESS THAN
[**2115-1-5**] 04:13PM BLOOD CEA-3037* PSA-0.6 AFP-<1.0
[**2115-1-3**] 11:15PM BLOOD antiTPO-16
[**2115-1-17**] 03:05PM BLOOD Metanephrines (Plasma)-1 H (normal = 0.9)
[**2115-1-13**] 05:00PM BLOOD NEURONAL NUCLEAR ([**Doctor Last Name **]) ANTIBODIES-Test:
neg
[**2115-1-11**] 04:40AM BLOOD CALCITONIN-Test [**Numeric Identifier 63238**]
[**2115-1-8**] 05:15AM BLOOD CA [**21**]-9 -572
[**2115-1-4**] 12:55PM BLOOD MYCOPLASMA PNEUMONIAE ANTIBODY, IGG- 1.68
H
[**2115-1-4**] 12:55PM BLOOD MYCOPLASMA PNEUMONIAE ANTIBODY IGM-Test -
236 N
[**2115-1-3**] 11:15PM BLOOD LEPTOSPIRA ANTIBODY-Neg
[**2115-1-3**] 11:15PM BLOOD ANGIOTENSIN 1 - CONVERTING [**Last Name (un) **]-14 N
[**2115-1-3**] 01:10PM BLOOD BABESIA ANTIBODIES, IGG AND IGM- neg
[**2115-1-3**] 06:47AM BLOOD ANAPLASMA PHAGOCYTOPHILUM (HUMAN
GRANULOCYTIC EHRLICHIA [**Doctor Last Name **]) IGG/IGM neg
RPR neg
HIV ab neg
Serum [**Doctor Last Name **], EBV, CMV, Cryptococcal ag neg
Urine legionella neg
.
Blood Smear:
few moderate sized platelets;
poikiolocytosis and anisocytosis with some spherocytes,
occassional retic, occassional helmets, with no schisto and rare
bite cells
.
Micro:
Blood cultures neg X6
Urine cultures neg
CSF cultures neg
Bone marrow fungal cultures pending
.
CSF: Neg for HSV, EBV, CMV, AFG, GMS, cryptococcal ag as well as
ACE and CJD.
.
Images:
CT HEAD W/O CONTRAST Study Date of [**2115-1-2**]
No CT evidence for acute intracranial process
.
CHEST (SINGLE VIEW) Study Date of [**2115-1-3**]
Interstitial abnormality, chronicity indeterminate
.
Brain MRI [**2114-12-29**] at [**Hospital3 **] Hospital
Numerous foci of signal abnormality on subcortical white matter
with abnormal enhancement. Possible atypical MS, [**Hospital3 **] disease or
sarcoid.
.
Abdominal US [**1-3**]:
1. Mild extra-hepatic biliary ductal dilatation. The common bile
duct
measures 1 cm. No intrahepatic biliary dilation.
2. Multiple echogenic foci in the liver, the largest measuring
3.1 cm. These lesions are probably hepatic hemangiomas absence
of known intrinsic liver disease. If there is suspicion for
underlying malignancy or risk factors for primary liver lesions,
these lesions can be further evaluated with multiphasic CT or
hepatic MR.
3. Patent hepatic vasculature with antegrade flow.
.
CT Torso [**1-4**]:
1. Multiple sites of osseous metastatic disease as described
with no definite primary lesion identified. In particular, there
is a pathologic T12 fracture with small amount of associated
epidural soft tissue for which MRI is recommended for further
evaluation.
2. Small bilateral non-hemorrhagic pleural effusions with
adjacent
compressive atelectasis.
3. Small pericardial effusion.
4. Extensive coronary artery calcifications.
5. Hepatic lesions, as detailed above, one of which represents a
hemangioma and are stable dating back to [**2108**] exam.
6. Colonic diverticula without associated inflammatory changes.
7. Nonspecific presacral fluid.
.
Chest x-ray [**1-5**]:
There is progression of left lower lobe consolidation concerning
for
progression of left lower lobe pneumonia. Heart size and
mediastinum are unremarkable. Linear scarring in the right upper
lung is unchanged.
.
Renal US [**1-7**]:
1. No evidence of renal artery stenosis.
2. Echogenic hepatic lesion noted on prior ultrasound of [**2115-1-3**]
is consistent with hepatic hemangioma.
3. Mild ectasia of the distal aorta.
.
TTE [**1-7**]:
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-5 mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). Right ventricular chamber size and free wall motion are
normal. The aortic root is mildly dilated at the sinus level.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is a trivial/physiologic pericardial effusion.
.
IMPRESSION: Normal biventricular systolic function. Mildly
dilated aortc sinus and ascending aorta. No significant valvular
disease.
.
MRI head [**1-10**]:
1. Two linear enhancing foci, likely developmental venous
anomaly (DVA).
2. Diffusely abnormal bone marrow signal in cervical spine and
skull base, in keeping with known bone marrow infiltration of
malignancy.
3. Encephalomalacia in the bilateral inferior frontal lobes
could be from prior trauma, correlate clinically.
.
MRI spine [**1-10**]:
1. Diffuse bone marrow infiltration with malignancy.
2. T11 mild compression fracture and small epidural soft tissue
component in the anterior epidural space at this level. No
significant canal narrowing (< 25 % canal narrowing).
3. Signal in the cord preserved.
4. Four lumbar vertebral bodies. Sacralization of L5 with
rudimentary disk at L5-S1.
.
EKG: Sinus tachycardia, HR 112, normal axis, mildly prolonged PR
at 142, QTc 402, no ST elevations/ TW inversions. Normal R wave
progression.
.
Tissue Analysis:
Bone marrow biopsy: marrow packed with carcinoma, The core is
extensively necrotic. Viable tumor cells are positive for
cytokeratin cocktail, cytokeratin 7, synaptophysin,
chromogranin, TTF-1, and calcitonin. Negative stains include
cytokeratin 20, LCA, C-kit, S-100, PSA, PSAP, HepPar1, CDX2, and
thyroglobulin. Controls are adequate. These results, in
combination with the finding of a thyroid nodule noted on
imaging studies, strongly suggest metastatic medullary carcinoma
of the thyroid, although, metastatic neuroendocrine carcinoma
from other primary sites are less likely possibilities.
.
Thyroid biopsy:
POSITIVE FOR MALIGNANT CELLS.
Poorly differentiated neoplasm compatible with
medullary thyroid carcinoma, see note.
Note:
Tumor cells are dispersed (single cell pattern) and show
nuclear enlargement and irregularity with variably prominent
nucleoli and moderate amounts of cytoplasm.
In the context of a prior bone metastasis (S12-857P; [**2115-1-4**])
in wich tumor cells were positive for calcitonin, the
morphology is consistent with medullary thyroid carcinoma.
.
Labs on Discharge:
[**2115-1-22**] 05:55AM BLOOD WBC-7.1# RBC-3.62* Hgb-10.2* Hct-29.3*
MCV-81* MCH-28.2 MCHC-34.7 RDW-16.9* Plt Ct-88*
[**2115-1-22**] 05:55AM BLOOD Neuts-61 Bands-1 Lymphs-29 Monos-7 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-2* NRBC-1*
[**2115-1-22**] 05:55AM BLOOD PT-13.2* PTT-28.6 INR(PT)-1.2*
[**2115-1-22**] 05:55AM BLOOD Glucose-113* UreaN-11 Creat-0.8 Na-144
K-4.1 Cl-109* HCO3-24 AnGap-15
[**2115-1-22**] 05:55AM BLOOD ALT-13 AST-23 AlkPhos-286* TotBili-0.6
[**2115-1-22**] 05:55AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.0
Brief Hospital Course:
56 year old male with past medical history of coronary artery
disease, depression who presented with altered mental status,
anemia, thrombocytopenia and was diagnosed with metastatic
medullary thyroid cancer.
.
# Altered mental status: Initially, differential was quite broad
including bacterial vs. viral vs. tick borne infection, TTP,
organic brain disease, toxins. Patient was initially started on
acyclovir, ceftriaxone, and vancomycin for meningitis, though
suspicion for bacterial meningitis was low. Once LP done on [**1-4**] ruled out bacterial and HSV infection, antibiotics were
discontinued. Patient's serum tox tests were negative. TSH and
B12 were normal. Blood cryptococcal Ag, RPR, [**Month (only) **] all negative.
CSF Cryptococcal Ag negative. Gm stain negative. [**1-3**] parasite
smear negative x 1, anaplasma, Babesia, Leptospira aso negative
and serum HSV, RPR, HIV also neg. Patient then had a bone
marrow biopsy, which preliminarily showed a "packed" marrow with
carcinoma of unclear origin and was later confirmed to be
medullary thyroid cancer. Most likely, neurological symptoms are
likely a paraneoplastic encephalitic syndrome vs. miliary
metastases of thyroid cancer.
MRI at OSH showed some white matter changes which were non
specific. Repeat MRI brain [**1-10**] with no process to account of
AMS. During the admission, neuro-onc evaluated the patient and
reviewed the imaging. Neuro onc suggested that the 2 small
lesions on MRI could actually represent foci of metastatic
disease and may also account for the altered mental status.
Neuro surgery was consulted for biopsy. If biopsy + for
medullary thyroid ca, would do whole brain XRT with hope that
mental status would improve. However, biopsy was deferred given
risk of the procedure and XRT was deferred as well. Patient was
intermittently agitated during the admission, but was stabilized
on haldol 2 mg tid (psychiatry team was involved). In setting
of standing Haldol, had repeat ECGs, last one on [**1-18**] with QTc
of 440.
.
# Medullary Thyroid Cancer: Bone marrow biopsy initially with
carcinoma, further tests confirmed medullary thyroid cancer. CT
torso with pathologic fracture at T12, but no clear primary. MRI
spine showed diffuse bone marrow metastases but ruled out spinal
cord compression. Spine surgery evalauted the patient given
pathologic fracture. Felt that no intervention was needed at
this time. Patient will follow up with Dr. [**Last Name (STitle) **] from spine
surgery as an outpatient. MRI brain with no mass at OSH. Repeat
MRI at [**Hospital1 18**] showed nonspecific changes as well as 2 nondescript
lesions. In regards to tumor markers, PSA/AFP/Hcg not elevated,
CEA 3000, Ca [**21**]-9 547, calcitonin [**Numeric Identifier 63238**], consistent with
medullary thyroid cancer. Thyroid US did show a nodule, largest
1.9x1.7 cm. Had biopsy [**1-15**] which confirmed medullary thyroid
cancer. Given association of MEN syndromes with medullary
thyroid, will consulted endocrine who recommended testing for
plasma metanephrines to rule out pheochromocytoma, but no
further testing as patient does not have any children. On
discharge, patient with follow up with Dr. [**Last Name (STitle) **] for
treatment of cancer with chemotherapy, likely Vandetanib. He
will also follow up in brain tumor with Dr. [**Last Name (STitle) 724**] to further
assess for possible whole brain xrt as above.
.
# Hypernatremia: Patient with hypernatremia during
hospitalization, peak Na 155. He was on D5W at 175cc/hr and on
discharge Na was 144. Encouraged PO intake of free water and
were able to d/c IV fluids.
.
# Thrombocytopenia/Anemia: Secondary to bone marrow
infilatration from carcinoma. Checked daily CBCs and tranfused
platelets if <10 or actively bleeding and pRBCs if hct <25. Was
transfused 6 units of pRBCs throughout admission, last unit on
[**1-16**] and 2 units of platelets, last unit on [**1-4**].
.
# Renal artery bruit: On exam, auscultated bruit in region of R
renal artery. Differential included renal artery stenosis, or
radiation from AAA. Not due to mass abutting on artery as no
mass visualized on CT torso. Renal US with no renal artery
stenosis. Likely radiation from AAA.
.
# LFT abnormalities/elevated CK: Initially, significant
elevation in AST but only mild elevation in ALT, suggesting most
likely a musculoskeletal process. Tbili no longer elevated. LDH
concerning for myelodysplastic process though uric acid normal.
Abdominal imaging with several hypodense lesions in the liver
consistent with hemangiomas. LFTs trended down to normal on d/c
except still some elevation in alk phos.
.
# CAD: Had multiple stents placed in the past,unclear which
type, though patient apparently only on aspirin, not [**Last Name (LF) 4532**], [**First Name3 (LF) **]
probably bare metal stent. Continued metoprol, lisinopril, but
held aspirin.
.
TRANSITIONS OF CARE:
-full code
-will need frequent CBC, Chem 7 checks to assess for
anemia/thrombocytopenia and Na
-will f/u with Dr. [**Last Name (STitle) 724**] in brain tumor clinic and with Dr.
[**Last Name (STitle) **] for thyroid cancer treatement.
-will f/u with Dr. [**Last Name (STitle) **] from spine surgery
-weekly ECGs to assess QTc given patient is on standing haldol
-Communication: Patient, wife [**Name (NI) **] ([**Telephone/Fax (1) 91771**]). Wife is
allegedly the health care proxy but her competence for this role
has been questioned.
Medications on Admission:
ambien
cymbalta
aspirin 81mg
crestor
metoprolol
lisinopril
Discharge Medications:
1. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
3. haloperidol 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
5. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
6. haloperidol lactate 5 mg/mL Solution Sig: Two (2) mg
Injection Q6H (every 6 hours) as needed for agitation.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed for constipation.
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 38380**] [**Hospital **] Nursing and Rehab
Discharge Diagnosis:
Primary
1. Metastatic medullary thyroid cancer
2. Altered mental status
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 49676**],
.
You were admitted to the hospital for confusion. You were
initially in the ICU, where you underwent extensive testing. You
underwent bone marrow biopsy as well, which showed that you have
cancer. On further testing, it was determined that you have
medullary thyroid cancer. You had multiple imaging studies,
including that of the brain and the spine. An MRI of the spine
showed that you have a fracture from the cancer but it is not
compressing the spinal cord. The orthopedic surgeons saw you in
the hospital and did not feel that the fracture needed
intervention. You will follow up with orthopedics as an
outpatient. MRI of the brain showed that you have cancer
involvement of the brain as well.
.
We have made several changes to your medications. The updated
list is included.
.
On discharge, you will need to follow up with Dr. [**Last Name (STitle) 724**] in brain
tumor clinic, with Dr. [**Last Name (STitle) **] to discuss treatment of the
thyroid cancer, and Dr. [**Last Name (STitle) **], the spine doctor.
.
It was a pleasure taking care of you, we wish you all the best.
Followup Instructions:
Department: NEUROLOGY/NEURO-ONCOLOGY
When: MONDAY [**2115-1-28**] at 9:30 AM
With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD [**Telephone/Fax (1) 1844**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2115-1-30**] at 3:00 PM
With: [**Last Name (LF) 3150**],[**Name8 (MD) **] MD [**Telephone/Fax (1) 11133**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Name: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 91772**], MD
Specialty: Internal Medicine
Location: [**Hospital3 **] INTERNAL MEDICINE
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 58635**]
Phone: [**Telephone/Fax (1) 31938**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Department: SPINE CENTER
When: TUESDAY [**2115-2-5**] at 4:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 54448**], MD [**Telephone/Fax (1) 3736**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1368**]
Completed by:[**2115-1-23**]
|
[
"198.5",
"193",
"573.9",
"272.4",
"733.13",
"276.0",
"348.39",
"530.81",
"198.3",
"425.4",
"284.19",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"06.11",
"03.31",
"41.31"
] |
icd9pcs
|
[
[
[]
]
] |
21323, 21404
|
15019, 15240
|
325, 377
|
21520, 21520
|
6364, 6369
|
22856, 24316
|
4817, 4826
|
20560, 21300
|
21425, 21499
|
20477, 20537
|
21702, 22833
|
4841, 4855
|
5556, 6345
|
264, 287
|
14478, 14996
|
405, 4262
|
6383, 14458
|
21535, 21678
|
19914, 20451
|
4284, 4524
|
4540, 4801
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,872
| 187,216
|
35013
|
Discharge summary
|
report
|
Admission Date: [**2141-11-9**] Discharge Date: [**2141-11-17**]
Date of Birth: [**2059-12-26**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
stridor, ? airway issues with tracheostomy here for bronchoscopy
Major Surgical or Invasive Procedure:
[**11-9**]: flexible bronchoscopy
[**11-10**]: re cannulation of tracheostomy and capping
[**2141-11-16**]: Excessive mucus plugs and secretions in the T-tube
with subglottic proximal mucosalswelling and edema.
Bronchoscopy (flexible). Exchange tracheostomy
History of Present Illness:
81-year-old woman with history of Parkinson's disease S/P a
mechanical fall few months ago with C2-C4 fracture S/P spinal
fusion/hardware placement. She
underwent a tracheostomy tube secondary to concern for unstable
cervical spine. In [**Hospital 100**] Rehab she did very well with
the Passy-Muir valve. However, when her trach is capped, she
develops stridor and desaturates. Patient underwent flex bronch
today in the OR under deep sedation (No rigid bronch was
performed due to concern about spinal instablility) showed
small/ moderate granulation tissue/ridge in proximal trachea
ant
wall with severe cervical malacia proximal to the trach tube
with
complete dynamic collapse. Patient is being admitted for pre-op
eval by neurosurgical service for spinal stability for neck
hyperextension during rigid bronchoscopy.
Past Medical History:
Laryngeal swelling, respiratory failure
Parkinson's Disease
Mechanical Fall: C2-C4 Fracture s/p fusion Cervical Spine [**5-7**]
Tracheostomy prophylaxis [**5-7**]
History of Pneumonia
Social History:
Permanent resident at [**Hospital **] rehab
Family History:
Noncontributory.
Physical Exam:
T 99.3 BP 152/84 HR 65 RR 23 O2 Sat 99% on 3 L.
GENERAL: The patient is an elderly female, in no significant
respiratory distress. She has a Passy-Muir valve in place. She
has a tracheostomy tube, which is just lateral to the midline.
She has fairly significant kyphoscoliosis.
NECK: Supple. She had expiratory but not inspiratory stridor
with the Passy-Muir valve.
CHEST: She has coarse breath sounds bilaterally.
HEART: Regular rate.no murmurs.
ABDOMEN: Soft. noorganomegaly
NEUROLOGIC: She was alert and oriented x3. Gait was not
tested.
Pertinent Results:
[**2141-11-16**] WBC-5.6 RBC-3.46* Hgb-10.6* Hct-31.9* Plt Ct-259
[**2141-11-15**] WBC-6.9 RBC-3.24* Hgb-10.2* Hct-29.8* Plt Ct-273
[**2141-11-14**] WBC-7.3 RBC-3.22* Hgb-10.2* Hct-30.2* Plt Ct-253
[**2141-11-10**] WBC-11.5* RBC-3.46* Hgb-10.6* Hct-31.6* Plt Ct-246
[**2141-11-16**] Glucose-89 UreaN-13 Creat-0.5 Na-144 K-4.1 Cl-102
HCO3-34*
[**2141-11-15**] Glucose-89 UreaN-14 Creat-0.6 Na-142 K-3.8 Cl-100
HCO3-34*
[**2141-11-16**] Calcium-8.9 Phos-3.3 Mg-2.0
[**2141-11-10**] Glucose-93 UreaN-14 Creat-0.5 Na-141 K-3.9 Cl-104
HCO3-33*
[**2141-11-10**] Calcium-9.3 Phos-3.3 Mg-2.0
[**2141-11-15**] 5:42 am MRSA SCREEN Source: Nasal swab.
FINAL REPORT [**2141-11-17**] MRSA SCREEN (Final [**2141-11-17**]): No MRSA
isolated.
[**2141-11-15**] 5:21 am SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
GRAM STAIN (Final [**2141-11-15**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Preliminary):
SPARSE GROWTH OROPHARYNGEAL FLORA.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
[**2141-11-11**] 4:44 pm URINE Source: Catheter.
FINAL REPORT [**2141-11-13**]**
URINE CULTURE (Final [**2141-11-13**]):
GRAM NEGATIVE ROD(S). ~3000/ML.
CXR:
A tracheostomy is in place.
Hiatal hernia is large. Blunting of right costophrenic angle is
likely
chronic. Lungs are otherwise clear with no focal area of
significant
atelectasis. Cardiomegaly is mild. Hilar contours are otherwise
normal.
Clips are in the right axilla. Kyphosis is increased, and bones
seem
osteopenic.
[**11-10**] CXR: There is a very large hiatal hernia which occupies
the mid section of the chest. There is large left lower lobe
consolidation with air bronchograms and a moderate left pleural
effusion. These findings have increased since prior study. There
is also focal right lower lobe consolidation. Heart is enlarged.
Aorta is tortuous. Tracheostomy remains in the midline.
AP CHEST [**11-14**]
Severe bibasilar consolidation which developed between [**11-2**] and [**11-10**] has worsened on the right since [**11-12**],
stable on the left since [**11-10**] though associated moderate
left pleural effusion is slightly smaller today than on [**11-14**]. Moderate-to-severe cardiomegaly is stable. Esophagus is
distended above a large gastric hiatus hernia. No pneumothorax.
Brief Hospital Course:
The patient was admitted to the hospital and underwent a
flexible bronchoscopy which showed small/ moderate granulation
tissue/ridge in proximal trachea anterior wall with severe
cervical malacia proximal to the trach tube with complete
dynamic collapse. She underwent exchange trach cannulation and
was capped with no significant result in the immediate period.
She was saturating well and had no major issues and was without
stridor.
.
On telemetry on [**2141-11-10**] at around 6pm, she was noted to become
bradycardic for about 45 seconds down to the 30s. [**Name8 (MD) **] MD was
immediately aware and entered the room to notice her cyanotic
and minimally responsive. At this time, her pulses were weak and
she was notably hypoxic and without spontaneous respirations.
She was minimally arousable to sternal rub. A code blue was
initiated. Her trach was immediately uncapped and her airway was
suctioned vigorously with good response. Her ABG was notable for
mild respiratory acidosis consistent with respiratory failure.
She responded well to positive pressure ventilation and was
brought to the MICU for further intensive monitoring. She
regained mental status.
.
MICU course:
This is an 81 y/o woman with PMH notable for Parkinson's disease
and C2-4 fracture s/p fusion with tracheostomy due to recurrent
pneumonia admitted to MICU after PEA arrest on the floor.
.
# Respiratory distress: Patient was noted to be apneic on the
floor prior to PEA arrest. Likely related to mucous plugging but
patient reportedly had dinner so could be related to aspiration.
Per notes from [**Hospital 100**] Rehab was eating a soft diet there with
thin liquids. Do not feel that there is evidence of new
pneumonia at this time (no WBC elevation, no fever); will
continue to monitor for signs/symptoms of infection. CXR with
LLL opacity consistant with resolving mucous plugging
- npo for now, consider soft diet after stable on trach mask
- weaned off ventilation, now on TM at 40%
- continue to monitor closely and suction prn
- IP team to see today to decide dispo ?????? d/w IP team pt to go to
floor
- continue albuterol/atrovent nebs with mucomyst nebs
- further trach interventions (i.e., rigid bronch) per IP team
-CXR tomorrow to eval change in LLL opacity ?????? persistent LLL
opacity, c/w atelectasis, PA and lateral may be better to assess
-blood gas this AM [**11-11**] to better assess pulmonary status in
presence of increased CO2
.
# s/p PEA arrest: Likely related to hypoxia secondary to the
above. Telemetry monitoring during time of event appears to have
artifact (versus VT but out of sync on 2 leads so this is
unlikely) followed by bradycardia. Artifact could represent
chest compressions and no other telemetry strips printed from
time of event. Cardiac enzymes sent peri-code negative and ekg
is unchanged from prior.
- repeat EKG without any new changes
- cardiac enzymes neg x2 [**44**] hrs apart, no need for 3rd set.
- monitor respiratory status closely as above
.
# Osteoporosis: Continue calcium and vitamin D.
.
# Parkinson's disease: Continue sinemet, mirtazapine, modafinil
and entacapone (the last two ordered non-formulary)
.
# FEN: npo for now while on positive pressure ventilation, soft
diet with thick nectar liquids when back on trach collar/cap,
replete lytes prn
.
# PPx: hep sc tid, ppi, bowel meds, chlorhexidine mouth care
.
______________________________________________________________
After her MICU course, the patient was stable and received a
T-Tube on [**11-13**] which she tolerated well. There were some
proximal narrowing points found on her bronchoscopy, so the
patient was left uncapped with a PM valve intermittently. She
tolerated this well. She then subsequently was admitted to the
SICU on [**11-14**] for increased secretions and was discharged to the
floor on [**11-15**] after aggressive suctioning. Throughout the rest
of her stay, she continued uncapped with intermittent PM valve
utilization for speaking, and was noted to have some minor
breath stacking when her PM was placed for long periods.
Therefore, it was deemed that she was not a strong candidate for
capping completely. She is, however, a good candidate for
intermittent usage of PM for vocalization. She underwent
diagnostic/therapeutic bronchoscopy on [**11-16**] and mucus was
cleared from her airways. She tolerated the procedure well and
was brought to the floor, again uncapped, because of upper
airway edema. Therefore, we are sending her out on steriods for
a few more days. She is able to suction herself and maintain her
airway with the t-tube uncapped.
Medications on Admission:
Meds at rehab:
acetylcysteine neb [**Hospital1 **]
albuterol neb q6h
calcium carbonate 650 mg [**Hospital1 **] (via peg)
carbidopa/levodopa 37.5/150 tid (give at 0630, 1100, and 1600)
carbodopa/levodopa 12.5/50 at 0830
carbidopa/levodopa 37.5/150 at 1400
vit d 1000 U daily
cyanocobalamin 1000 mcg daily
bisacodyl 10 mg daily prn
mag hydroxide 30 ml once daily prn
ambien 5 mg prn
miconazole powder prn
mupirocin to anterior neck [**Hospital1 **]
senna 17.2 mg at bedtime
omeprazole 20 mg [**Hospital1 **]
modafinil 50 mg [**Hospital1 **] (0800, 1400)
mirtazapine 30 mg at bedtime
atrovent neb q6h
ferrous sulfate 325 mg at bedtime (g tube)
entacapone 200 mg at 0630, 11, 1400, 1600 (with sinemet)
.
MEDS on transfer:
acetylcysteine 20% neb [**Hospital1 **]
calcium carbonate 500 [**Hospital1 **] (given via PEG)
vit d 800 U daily
cyanocobalamin 1000 mcg daily
ambien 5 mg qhs
colace 100 mg [**Hospital1 **]
omeprazole 20 mg [**Hospital1 **]
hep sc tid
sinemet 25/100, 1.5 tab tid
albuterol inhalers prn
.
ALLERGIES: nkda
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day) as needed
for GERD.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day) as needed for DVT prophylaxis.
3. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for constipation.
4. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscellaneous [**Hospital1 **] (2 times a day) as needed for secretions.
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for bronchospasm.
6. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
10. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days.
11. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
12. Modafinil 100 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
13. Carbidopa-Levodopa 25-100 mg Tablet Sig: 1.5 Tablets PO QID
(4 times a day) as needed for Parkinson: 0630, 1100, 1400 &
1600.
14. Carbidopa-Levodopa 25-100 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily): 0830.
15. Entacapone 200 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours.
16. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO BID (2 times
a day).
17. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Laryngeal swelling, respiratory failure
Parkinson's Disease
Mechanical Fall: 1months C2-C4 Fracture s/p fusion Cervical
Spine [**5-7**]
Tracheostomy prophylaxis [**5-7**]
Discharge Condition:
Stable
Discharge Instructions:
You should call Dr. [**Last Name (STitle) 80052**] or Dr.[**Name (NI) 14680**] office if you are
having trouble with your tracheostomy tube or if you develop
chest pain, shortness of breath, fever, chills, productive
cough, blood in sputum or any other symptoms that concern you.
DO NOT CAP TRACH
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 17398**]. as directed
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
Completed by:[**2141-11-20**]
|
[
"E879.8",
"553.3",
"518.84",
"519.02",
"733.00",
"519.19",
"V15.51",
"332.0",
"933.1",
"427.5",
"E912"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.23",
"96.05",
"33.22",
"33.23",
"96.71",
"31.74"
] |
icd9pcs
|
[
[
[]
]
] |
12174, 12240
|
4867, 9453
|
387, 650
|
12455, 12464
|
2399, 3441
|
12810, 13043
|
1790, 1809
|
10526, 12151
|
12261, 12434
|
9479, 10179
|
12488, 12787
|
1824, 2380
|
3482, 4844
|
283, 349
|
678, 1506
|
1528, 1713
|
1729, 1774
|
10197, 10503
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,209
| 119,081
|
33419
|
Discharge summary
|
report
|
Admission Date: [**2134-3-7**] Discharge Date: [**2134-3-10**]
Date of Birth: [**2071-4-1**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Abdominal pain, fever
Major Surgical or Invasive Procedure:
Line placement
History of Present Illness:
62 male w/ PMH of HIV presented to CC ED this AM with 12 hour
history of worsening LLQ pain. Pt states he felt constipated on
the day PTA, successfully self treated with enema after which he
began having cramping abd pain worsening throughout the night.
Associated with mild nausea. He was concerned he might have food
poisoning so induced emesis ~6x that night. Pt unable to sleep
due to pain, presented to ED in am. Found to have obstructing
stone at UVJ on CT and + UA, was tx to [**Hospital1 18**] for further care.
[**Hospital1 18**] ED course:
Febrile to 104, hypotensive to 70/40s, hypoxic to 78%.
Central and arterial lines placed. Pt bolused. Started on broad
spectrum abx, amp and gent. Seen by urology in ED. Tx to unit
for septic mgmt.
Pt stated that one month prior to admission he had experienced a
UTI presenting as gross hematuria and dysuria. He was initially
started on cipro then switched to bactrim for ~2.5 week course.
He states he never felt like he fully recovered and described a
"twinge" and sensation of straining with urination. Per his ID
doctor he was known to have cipro resistant organisms in his
urine. According to the pt he has a history of UTIs, but prior
to one month ago hadn't had one for over 4 years.
He denies personal or family history of nephrolithiasis. On ROS,
endorses slight HA with fevers, + fevers and chills. No CP or
SOB. + mild abdominal pain, located in LLQ, currently [**3-7**], was
[**9-5**] in am. No back or flank pain. No dysuria or hematuria. No
joint pain. + Constipation, + flatus.
Past Medical History:
HIV (last CD4 in 300s, VL undetectable)
Recurrent UTIs
Hyperlipidemia
ARV related neuropathy and lipodystrophy
Social History:
Retired lawyer and teacher/camp counselor. Living in [**State 108**] and
[**Hospital3 **] with partner. Former [**Name2 (NI) 1818**], quit 13 years ago ~25 pack
year history. 2 ETOH beverages/week. No drug use or hx of IVDU.
Family History:
Brother with prostate CA
Sister s/p valve repair and PPM placement, breast CA
Physical Exam:
VS: Tc: 99.4 Tm: 100.7 BP:119/70 (103-120/60-70) HR: 77-97 RR:27
O2sat96 RA
GEN: pleasant, comfortable, NAD, mildly tachypneic
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions.
NECK: no supraclavicular or cervical lymphadenopathy, no jvd
RESP: CTA b/l with good air movement throughout, slight crackles
b/l at bases
CV: RR, S1 and S2 wnl, no m/r/g
ABD: minimal distention, nontender, no masses or
hepatosplenomegaly. No flank tenderness. + BS.
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.
Pertinent Results:
CT Abdomen/Pelvis:
No evidence of hydronephrosis or hydroureter or distal left
ureteric stone. The left ureter cannot be visualized throughout
its length but no good evidence for renal calculi isidentified.
There is a tiny punctate submillimeter eccentric focus of
intravesical high attenuation, which conceivably may represent a
stone fragment but it appears remote from the distal left
ureter/UVJ.
Renal US: : Left percutaneous nephrostomy was not performed as
no evident hydronephrosis was identified, most likely related to
passage of stone.
CXR: Lung volumes are mildly diminished. The lungs are clear
without consolidation or edema. There is mild tortuosity of
thoracic aorta. The cardiac silhouette is within normal limits
for size. No effusion or pneumothorax is noted. The visualized
osseous structures are unremarkable.
[**2134-3-7**] 01:50PM URINE COLOR-Yellow APPEAR-Clear SP
[**Last Name (un) 155**]-GREATER THAN 1.030
[**2134-3-7**] 01:50PM URINE BLOOD-SM NITRITE-POS PROTEIN-TR
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
[**2134-3-7**] 01:50PM URINE RBC-0 WBC->50 BACTERIA-MOD YEAST-NONE
EPI-0-2
Brief Hospital Course:
62 year old male with HIV, hx of UTI 1 month ago, otherwise
healthy presenting with 1 day LLQ pain, obstructing stone at VUJ
and sepsis originally admitted to the intensive care unit and
then called out to the floor once stable.
.
#Sepsis/Gram negative bacteremia: On arrival to [**Hospital1 18**], the
patient was hypotensive, febrile and hypoxic, requiring fluids
and pressors. He was also found to have significant bandemia and
a markedly positive UA. He was found to have a
vesico-ureteteral junction obstructing renal stone which was the
most likely etiology of his sepsis. He was resuscitated with IV
fluids while in the intensive care unit. He was placed on broad
spectrum antibiotics while awaiting urine/blood culture results.
Once the urine and blood cultures were available, the patient
was switched to ceftriaxone until his discharge. He was sent
home to complete a two week course of cefpodoxime.
.
#Vesico-ureteteral junction obstructing renal stone which was
seen on CT at OSH. No prior personal history of stones. The
patient was seen by Urology who felt he may need a nephrostomy
tube. However, on repeat CT here, the stone appeared to have
passed and required no further intervention.
.
#ARF: Unknown baseline creatinine, 1.8 on admission, CrCl ~40.
Likely post-renal in setting of obstruction. His creatinine was
trending down at discharge. The patient was advised to follow
up with his primary care physician and to have his creatinine
checked soon after discharge.
.
#HIV. The patient was continued on his home ARV regimen, renally
dosed.
.
# Hyperlipidemia: His Tricor was held while he was in the
hospital. The patient was advised to restart his medication
upon discharge home.
.
# Code Status: Full, d/w pt
.
# Communication: both daughters, HCP is daughter [**Name (NI) 402**] [**Name (NI) **]
[**Telephone/Fax (1) 77543**]
Medications on Admission:
Epizicom
Tenofovir 300mg daily
Sustiva 600mg QHS
Tricor
Flomax
Viagra
Discharge Medications:
1. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Medications
Please resume your Tricor, Flomax and Viagra as prescribed by
your outpatient physician.
6. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
# Urosepsis secondary to vesico-ureteral junction obstructing
renal stone
Secondary:
# HIV
# Recurrent UTIs
# Hyperlipidemia
# ARV related lipodystrophy and neuropathy
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital with an infection in your
blood from a stone blocking your ureter. While you were in the
hospital we treated you with intravenous antibiotics. We are
discharging you on a two week course of antibiotics. Please
complete this course of antibiotics.
We did not change any of your other medications. Please take
all your other medications as prescribed by your outpatient
physicians.
Please make a follow up appointment with your outpatient
physician within two weeks of discharge. At that appointment,
please have your physician check your creatinine level to ensure
it has returned to baseline.
Please return to the hospital immediately with a fever greater
than 101 or any other symptoms you find concerning, including
back pain or abdominal.
Followup Instructions:
Please follow up with your primary care doctor within one to two
weeks of discharge. Please call [**Telephone/Fax (1) 3616**] to schedule an
appointment with Dr. [**Last Name (STitle) 77544**]. Please have your kidney
function (BUN/Cr) checked at that time.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
|
[
"785.52",
"V08",
"038.9",
"272.4",
"592.1",
"995.92",
"584.9",
"355.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6681, 6687
|
4168, 6030
|
288, 304
|
6908, 6917
|
3003, 4145
|
7749, 8103
|
2273, 2352
|
6151, 6658
|
6708, 6887
|
6056, 6128
|
6941, 7726
|
2367, 2984
|
227, 250
|
332, 1880
|
1902, 2015
|
2031, 2257
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,728
| 179,225
|
12083
|
Discharge summary
|
report
|
Admission Date: [**2173-9-16**] Discharge Date: [**2173-9-21**]
Date of Birth: [**2098-1-26**] Sex: M
Service: MEDICINE
Allergies:
A.C.E Inhibitors / Lidocaine / Hydrocodone/Acetaminophen /
Codeine
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Acute on chronic systolic heart failure
Shortness of breath
[**First Name3 (LF) **] bleed
Major Surgical or Invasive Procedure:
Nasal packing by ENT
History of Present Illness:
75M with CAD s/p CABGx2 and multiple caths, EF 35%, moderate AS,
PPM DM2, who presents with a history of shortness of breath due
to acute on chronic systolic heart failure. Cath [**2173-3-12**] at
[**Hospital1 1774**] showed LMCA had a distal 40% stenosis. The LAD, ramus, and
RCA were proximally occluded. LCX had a patent stent. The
LIMA-LAD and SVG-ramus were patent, and the SVG- RCA had a
proximal 30%-40%. He presented to the ED yesterday with [**Hospital1 **]
bleeding. He denies any chest pain or SOB.
.
In ED, nasopharynx was [**Hospital1 37883**]. Pt was hemodynamically stable.
Past Medical History:
-CAD S/P CABG and stent placements in LMCA and LCX
-CABG [**2146**], [**2159**]
-Type 2 Diabetes mellitus
-bilateral ten toe amputation following cholesterol emboli after
CABG
-Hypertension
-Hypercholesterolemia
-Paroxysmal atrial fibrillation/flutter
-Aortic stenosis (valve area 0.8)
-History of multiple strokes s/p bilateral carotid stents
-Peripheral arterial disease
-Gout
-Chronic kidney disease (baseline Cr 1.4-1.9)
-Mild dementia
-Status post pacer implantation in [**2172-5-30**] for AV conduction
delay (2:1 conduction with ventricular rate of approximately 30)
-Chronic myositis with elevated CK
-Remote syncope with no inducible arrhythmias at EP Study
Social History:
Social history is significant for the absence of current tobacco
use, but smoked a pipe in past, quit 50 yrs ago. There is no
history of alcohol abuse. There is no family history of
premature coronary artery disease or sudden death. Married. Wife
has [**Name2 (NI) 11964**]. Patient is primary caregiver. Lives in [**Location **]
in [**Hospital3 **] center. Retired pilot and thermodynamics
specialist. Father died in 90's of unknown causes. Mother died
in 80's of liver cancer.
Family History:
Father died in 90's of unknown causes.
Mother died in 80's of liver cancer.
Physical Exam:
VS: T 98.5, 108/54, 85, 19, 92-98% 30% face tent
Gen: WDWN middle aged male in NAD, resp or otherwise. mildly
sleepy but awake, alert, conversational and appropriate
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with no JVD to angle of jaw
CV: RR, normal S1, S2. systolic murmur LUSB radiating to
carotids.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. crackles at bases
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: trace LE edema.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
MEDICAL DECISION MAKING
Pertinent Results:
[**2173-9-16**] 10:44PM CK(CPK)-119
[**2173-9-16**] 10:44PM CK-MB-10 MB INDX-8.4* cTropnT-0.03*
[**2173-9-16**] 10:44PM HCT-33.4*
[**2173-9-16**] 03:05PM GLUCOSE-190* UREA N-30* CREAT-2.0* SODIUM-138
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-25 ANION GAP-17
[**2173-9-16**] 03:05PM estGFR-Using this
[**2173-9-16**] 03:05PM CK(CPK)-86
[**2173-9-16**] 03:05PM CK-MB-5 cTropnT-0.03*
[**2173-9-16**] 03:05PM WBC-10.1 RBC-3.54* HGB-10.8* HCT-32.8* MCV-92
MCH-30.5 MCHC-32.9 RDW-14.2
[**2173-9-16**] 03:05PM NEUTS-74.5* LYMPHS-16.4* MONOS-5.3 EOS-2.9
BASOS-0.8
[**2173-9-16**] 03:05PM PLT COUNT-542*#
[**2173-9-16**] 03:05PM PT-25.0* PTT-32.8 INR(PT)-2.5*
.
.
.
[**2173-9-20**] 08:40AM BLOOD WBC-8.9 RBC-3.28* Hgb-10.1* Hct-30.1*
MCV-92 MCH-30.7 MCHC-33.5 RDW-14.1 Plt Ct-488*
[**2173-9-16**] 03:05PM BLOOD Neuts-74.5* Lymphs-16.4* Monos-5.3
Eos-2.9 Baso-0.8
[**2173-9-20**] 08:40AM BLOOD Plt Ct-488*
[**2173-9-20**] 08:40AM BLOOD PT-14.3* PTT-26.2 INR(PT)-1.3*
[**2173-9-20**] 08:40AM BLOOD Glucose-109* UreaN-15 Creat-1.6* Na-140
K-4.1 Cl-106 HCO3-25 AnGap-13
[**2173-9-18**] 07:40AM BLOOD CK(CPK)-158
[**2173-9-17**] 02:10PM BLOOD CK(CPK)-172
[**2173-9-17**] 04:11AM BLOOD ALT-23 AST-29 CK(CPK)-173 AlkPhos-80
TotBili-0.5
[**2173-9-18**] 07:40AM BLOOD CK-MB-8 cTropnT-0.25*
[**2173-9-17**] 02:10PM BLOOD CK-MB-19* MB Indx-11.0* cTropnT-0.34*
proBNP-5805*
[**2173-9-17**] 04:11AM BLOOD CK-MB-18* MB Indx-10.4* cTropnT-0.15*
[**2173-9-16**] 10:44PM BLOOD CK-MB-10 MB Indx-8.4* cTropnT-0.03*
[**2173-9-16**] 03:05PM BLOOD CK-MB-5 cTropnT-0.03*
[**2173-9-20**] 08:40AM BLOOD Mg-2.3
[**2173-9-17**] 04:11AM BLOOD Calcium-8.2* Phos-3.1 Mg-2.0
.
.
pCXR [**2173-9-17**]:
IMPRESSION: Small left pleural effusion.
Brief Hospital Course:
75M with CAD s/p CABGx2 and multiple caths, EF 35%, moderate AS,
PPM DM2, who now presents with shortness of breath and
tachycardia. Diagnosed with acute on chronic systolic heart
failure exacerbation with troponin leak.
.
1. Cardiac:
a. Coronaries:
The patient had no chest pain symptoms, though was found to have
elevated troponins in the setting of CHF. The peak troponin was
up to 0.35, peak CK 173, MB 18. These were noted to be trending
dow. The mild enzyme elevation was likely attributable to CHF vs
demand ischemia. There is a history of CAD s/p cabg x2. Cath
[**3-6**] at [**Hospital1 1774**] revealed patent grafts. The patient was continued
on aspirin, plavix, lipitor 80, Beta blocker.
.
b. Pump:
The patient presented intially with CHF and he was diuresed to
euvolemic. There is a history of CHF with EF 35%. He was
continued on beta blocker and ACE.
.
c. Rhythm:
There is a history of paroxysmal afib on coumadin. Pacemaker was
for for 2:1 AV block [**6-4**]. In the ED, the patient was noted to
have a complex rhythm which showed pacer spikes. This was
consistent with an SVT with pacer tracking. There was initially
concern in the ED for possible ventricular tachycardia though
review of the ECG strip by cardiology confirmed that this was
not the case. The ECG showed a sinus tachycardia with
ventricular pacing.
.
d. Valves:
There is a history of aortic stenosis, [**Location (un) 109**] 1.1 mean gradient 32
by cath at [**Hospital1 1774**] [**2173-3-12**]. The plan is for non-operative
management per Dr. [**Last Name (STitle) **] since pt is a poor surgical candidate and
has complex aortic atheroma
.
2. Epistaxis:
There was heavy bleeding on presentation, enough to fill a cup
or two per the patient. This was controlled with the nasal
packing by ENT. The packing was left in place until the day
prior to discharge. Coumadin was held initially. The plan for
anticoagulation and antiplatelet therapy was discussed with the
patient's outpatient cardiologist, Dr. [**Last Name (STitle) **]. Dr. [**Last Name (STitle) **] recommended
continuing dual anti-platelet therapy given the concern for
stent thrombosis, which the patient was assessed as high risk
for this given his coronary anatomy. He had taxus stent in [**12-6**].
The plan was to pursue a lower INR target for anticoagulation
from 1.8 - 2.5, though this would be recalibrated to 2.0 - 3.0
as an outpatient if there was no further bleeding.
.
DM2:
The patient was continued on insulin and sliding scale.
.
Access: PIV
Proph: anticoagulated, PPI
Medications on Admission:
Protonix 40 daily
ASA 325 daily
Lasix 20 daily
Humulog 25U QAC
Isordil 60 daily
Lantus 60U Qhs
Lidex [**Hospital1 **]
Plavix 75 daily
Nitroglycerin 0.3 prn
Valsartan 80 daily
Lipitor 80 daily
Metoprolol 25 daily
Coumadin 10 daily
Senna
Colace
Prednisone
Clobetasol
Mupirocin 2% Cream
Hydrocortisone 1% Ointment
Calcipotriene 0.005% Cream
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Clobetasol 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
6. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical DAILY
(Daily).
7. Hydrocortisone 1 % Ointment Sig: One (1) Appl Topical DAILY
(Daily).
8. Calcipotriene 0.005 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
9. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
11. Insulin Glargine 100 unit/mL Solution Sig: Seventy (70)
Units [**Hospital1 37882**] qHS.
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Coumadin 2.5 mg Tablet Sig: Four (4) Tablet PO once a day:
please take a directed by coumadin clinic. New target INR per
patient's cardiologist is 1.8 - 2.5.
14. Outpatient Lab Work
INR check Thursday [**9-23**] or Friday [**9-24**]
Discharge Disposition:
Home With Service
Facility:
Care Tenders
Discharge Diagnosis:
Primary Diagnosis:
epistaxis
Acute on chronic systolic CHF exacerbation
Secondary Diagnosis:
Coronary artery disease
Paroxysmal atrial fibrillation
Discharge Condition:
stable
Discharge Instructions:
You came to the hospital because you had a significant
nosebleed. Otolaryngology doctors [**Name5 (PTitle) 37883**] the [**Name5 (PTitle) **] to stop the
bleedingl. We stopped your coumadin medicine while you were in
the hospital, although we are restarting this medicine now that
you are being discharged.
You should hold the valsartan for now because your blood
pressure was running lower. This should be restarted by Dr.
[**First Name (STitle) **] when he sees you in clinic on [**9-24**] if your blood
pressure is improved. We recommend increasing the lantus dose
from 60 units daily to 70 units daily. You should resume all of
your other medications as previously including the coumadin.
If you have further episodes of bleeding, if you have chest
pain, shortness of breath, or any other concerning symptoms,
please call your doctor or go to the emergency room.
Followup Instructions:
You have an appointment scheduled to see you primary care
physician. [**Name10 (NameIs) 2169**] [**First Name11 (Name Pattern1) 569**] [**Last Name (NamePattern4) 12637**], M.D. Date/Time:[**2173-9-24**]
10:00
Please have an INR check on Thursday or Friday that should be
followed up by the [**Hospital3 **]
You have an appointment scheduled to see your cardiologist.
Provider [**Name9 (PRE) **] [**Name8 (MD) 20141**], M.D. Phone:[**Telephone/Fax (1) 4022**]
Date/Time:[**2173-10-28**] 10:20
Provider [**First Name11 (Name Pattern1) 2747**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1971**]
Date/Time:[**2173-12-1**] 11:15
|
[
"696.1",
"427.89",
"424.1",
"784.7",
"788.30",
"250.00",
"427.31",
"428.43",
"V45.01",
"414.01",
"V58.61",
"274.9",
"E934.2",
"272.4",
"585.9",
"443.9",
"426.3",
"413.9",
"403.90",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"21.02"
] |
icd9pcs
|
[
[
[]
]
] |
9165, 9208
|
4933, 7462
|
417, 440
|
9401, 9410
|
3188, 4910
|
10328, 11024
|
2262, 2339
|
7851, 9142
|
9229, 9229
|
7488, 7828
|
9434, 10305
|
2354, 3169
|
288, 379
|
468, 1058
|
9323, 9380
|
9248, 9302
|
1080, 1750
|
1766, 2246
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,754
| 148,044
|
48590
|
Discharge summary
|
report
|
Admission Date: [**2160-6-20**] Discharge Date: [**2160-6-24**]
Date of Birth: [**2110-4-27**] Sex: F
Service: MED
CHIEF COMPLAINT: Respiratory distress.
HISTORY OF PRESENT ILLNESS: A 50-year-old female, with a
history of COPD, pulmonary hypertension on home O2, with
reported baseline SATs of 93-95 percent on 2 liters, a
history of prior intubation in [**7-26**] for hypocapnic
respiratory failure complicated by a MRSA pneumonia. Prior
ABG's from OMR suggest that a baseline gas is pH 7.33, PCO2
59, PO2 68. The patient had last been previously admitted in
[**2160-2-24**] with a presumed COPD flare with negative CTA
for PE, and was treated with a short course of BIPAP,
steroids and doxycycline. Over the last 2 or 3 days, the
patient reports increased dyspnea with exertion. Usually
wears home O2 just in the evening, but over the last couple
of days has begun to use it constantly. Has increased her
MDI use, begun using nebs 2 days ago. She reports fever the
last 24 hours, and also admits to positive sick contacts,
notably her husband with a URI. She has a chronic,
nonproductive cough which is unchanged over the last several
days. Denies chest pain. Positive consistently a smoker [**1-25**]
to 1 pack per day since [**2160-1-24**].
Arrived in the ED and found to be hypoxic to 86 percent on 3
liters. Tachycardic to 120's. Ruled out for PE by CTA which
showed a question of atypical pneumonia. She had a white
cell count which was elevated to 15,000 with a left shift,
and was febrile to 100.5. She got Levaquin 500 mg x 1, Solu-
Medrol 125, and nebulizers. She had a gas which showed a pH
of 7.34, PCO2 64, PO2 46. Subsequently started on BIPAP.
After a temporary desaturation to 70 percent with ambulation,
we switched to 8 and 8 with subsequent gas 7.35, 66, 54.
Subsequently taken off BIPAP with ABG of 7.31, 70, 54 on 28
percent face mask. Currently, the patient complaining of
mild shortness of breath slightly worse than her baseline,
but improved since arrival in the ED.
PAST MEDICAL HISTORY: COPD. No PFT's in system, but history
of prior intubations as per HPI.
COPD on home O2. Again, no documentation, but patient
reports receiving 2 liters usually in the evening time.
Mild pulmonary hypertension.
Polycythemia.
MRSA cellulitis from peripheral IV.
MEDICATIONS AS OUTPATIENT:
1. Albuterol MDI prn.
2. Flovent 2 puffs [**Hospital1 **].
3. DuoNeb q 4 prn.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: She has a 60-pack year history. Still
smoking 1 pack per day. Lives with husband and 3 kids, and
retired.
EXAM: Temperature 99.6, blood pressure 134/65, pulse 101,
mildly tachypneic at 16-20's, 88 percent on 40 percent face
mask. She was in mild respiratory distress but able to speak
in complete sentences.
HEENT: Unremarkable. JVP is within normal limits.
CARDIOVASCULAR: She is tachycardic but regular.
LUNGS: Significant for marked decreased air movement with
expiratory wheezing and bibasilar crackles.
ABDOMINAL EXAM: Benign.
EXTREMITIES: Show 1 plus pitting edema.
NEUROLOGICAL: Grossly intact.
LABORATORIES: White count 15.5. Of note, it was 14,000 in
[**2-27**]. Hematocrit 52. Also of note, that has been
consistent with previous lab values starting in [**Month (only) 956**] of
this year. Platelet count 182. Chemistries: 139, 4.2,
chloride 97, bicarb 32, BUN 12, creatinine 0.5, glucose 104.
She had a chest x-ray which showed a question of old
bibasilar patchy infiltrates, essentially unchanged from
[**2160**]. She had a CAT scan which was negative for PE, but did
diffuse bilateral opacities consistent with an atypical
pneumonia, and also reactive lymphadenopathy. She had an EKG
which showed a sinus tach to 120 beats per minute with right
and left atrial abnormalities. No ST or T wave changes.
HOSPITAL COURSE BY REVIEW OF SYSTEMS:
1. PULMONARY: The patient admitted for mildly increased
respiratory distress and then found to be with moderate to
severe hypoxia. The exact etiology of her hypoxia is
unclear. It is presumed that she does have reasonably
moderate to severe COPD. Furthermore, it is likely that
the patient is chronically hypoxic, but has become quite
adaptive to this, as evidenced by her polycythemia.
Furthermore, it is unclear if the patient was far off her
baseline in terms of her oxygen requirement. During her
hospital admission, the patient was treated empirically
with a 7-day course of Levaquin. Of note, her chest x-ray
and CT did not clearly indicate an active infection. She
was started on Solu-Medrol and later switched to
prednisone which will be tapered, which is due to be
completed on [**7-4**]. She received aggressive treatment
with nebulizers, both Atrovent and albuterol, q 4 h. In
addition, she was started on BIPAP which she will be going
home with. Her current settings at this point are 14 and
8. She will require a formal sleep evaluation to finalize
her BIPAP plans. Meanwhile, her oxygen requirements will
need to be titrated to her activity levels. At the time
of dictation, the patient was satting well on 2 liters
nasal cannula with rest, but studies with ambulation
suggest that the patient may require up to 3-4 liters to
supply goal oxygen level between 88 to 91/92 percent.
She was started on nicotine transdermal patches, and has been
encouraged and advised on several occasions that she must
quit tobacco use. It also has been recommended that the
patient will need follow-up with the pulmonologist, and also
could benefit from some outpatient pulmonary rehab to
reinforce the importance of compliance with medications, and
avoidance of tobacco. As mentioned above, it is unclear as
to the complete etiology of her hypoxia. It is felt that her
COPD does play a strong role. A PE was ruled out by CTA.
Furthermore, a preliminary echo with bubble studies indicate
that the patient does not have an atrial septal defect, or
PFO which could cause a profound shunt and hypoxia.
1. CARDIOVASCULAR: The patient remained hemodynamically
stable during her hospital course. She was not felt to be
in CHF as the cause of her hypoxia. As mentioned above,
she had had preliminary echocardiogram with bubble studies
which did not indicate a true interatrial shunt or PFO.
At the time of this dictation, it is planned that the
patient may undergo additional testing to rule this
phenomenon out.
1. HEMATOLOGY: As mentioned above, the patient has a new
polycythemia since [**Month (only) 956**] of this year. It is felt, at
this time, that the most likely etiology is her severe
hypoxia, which is being worked up, as above, via sleep
studies and echocardiograms ruling out shunts.
1. INFECTIOUS DISEASE: The patient came in with low-grade
fevers and mildly elevated white blood cell count, and has
been treated with Levaquin for a 7-day course for empiric
purposes.
1. GI ISSUES: None.
1. RENAL/FEN/ENDO: The patient's fingerstick's were well-
controlled with sliding scale. She has been started on
Vitamin D and calcium for prophylaxis, given her history
of steroids, and also just her history of tobacco and
obesity. Her renal function has remained stable.
1. CODE: At this point, the patient wishes to remain on full
code. She would be amenable to being intubated.
DISCHARGE DIAGNOSES: Chronic obstructive pulmonary
disease/question of exacerbation, improving.
Polycythemia.
DISCHARGE CONDITION: Fair.
DISCHARGE MEDICATIONS:
1. Levaquin 500 mg qd for a 7-day course to be completed on
[**6-25**].
2. Senokot prn.
3. Serevent 1 puff [**Hospital1 **].
4. Nicotine patch 14 mg qd for 6 weeks.
5. Pepcid 20 [**Hospital1 **] x 10 days
6. Albuterol and Atrovent nebs prn.
7. Prednisone 40 mg qd until [**6-25**]. Prednisone 30 mg qd from
[**6-26**] to [**6-28**]. Prednisone 20 mg qd from [**6-29**] to [**7-1**].
Prednisone 10 mg qd from [**7-2**] to [**7-4**].
8. Vitamin D 400 mg qd.
9. Calcium 500 mg tid.
As mentioned above, the patient will also be going home on
BIPAP which is being arranged at the time of dictation. In
addition, it is unclear as to her final O2 requirements. She
will need follow-up with her PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. She
has been advised to follow-up with the pulmonologist, Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 217**], and has also been advised that she
will need a follow-up for official sleep study review.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], [**MD Number(1) 4546**]
Dictated By:[**Last Name (NamePattern1) 11267**]
MEDQUIST36
D: [**2160-6-23**] 11:21:12
T: [**2160-6-23**] 12:16:22
Job#: [**Job Number 34177**]
|
[
"305.1",
"491.21",
"799.0",
"278.00",
"780.6",
"416.8",
"682.3",
"289.0",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7539, 7546
|
7426, 7517
|
7569, 8894
|
3863, 7404
|
154, 177
|
206, 2035
|
2058, 2470
|
2487, 3844
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,426
| 114,097
|
22601
|
Discharge summary
|
report
|
Admission Date: [**2152-10-2**] Discharge Date: [**2152-10-27**]
Date of Birth: [**2152-9-30**] Sex: M
Service: NB
HISTORY: Full-term infant admitted to the Neonatal Intensive
Care Unit at 1.5 days of life with E coli meningitis.
Infant born at 40 weeks to a 32-year-old gravida 1, para 0
now 1 mother. Prenatal screens: B positive, antibody
negative, hepatitis B surface antigen negative, rubella
immune, GBS positive. Antepartum reportedly benign.
Admitted in labor. No maternal fever. Rupture of membranes
1.5 hours prior to delivery. Received antepartum ampicillin
in one hour prior to delivery. Spontaneous vaginal delivery
with Apgars of 9 at 1 minute and 9 at 5 minutes.
Infant was sent to the Neonatal Intensive Care Unit for
routine sepsis evaluation for incompletely prophylaxed
maternal GBS colonization. Well appearing at that time. CBC
showed a white blood cell count of 22.4 with 61 neutrophils,
8 bands, hematocrit 49.6 percent, platelets 351,000. Blood
culture noted to be growing gram-negative rods early on the
morning of [**10-2**]. Infant concurrently with fever to
102. Infant was transferred to the Neonatal Intensive Care
Unit at that time for repeat blood culture, CBC, white blood
cell count 10.7 with 70 neutrophils, 10 bands, hematocrit
44.7 percent, platelets 310,000. LP (spinal fluid) white
blood cell count 19,975, red blood cells [**Pager number **], protein 415,
glucose less than 2, and initiation of parenteral ampicillin
and gentamicin. Cerebrospinal fluid Gram stain showed 2 plus
gram-negative rods and 4 plus polys. The patient is admitted
for gram-negative meningitis.
PHYSICAL EXAMINATION ON ADMISSION: Birth weight 3205 grams.
Length 20.5 cm. Head circumference 33.5 cm. Exam is
remarkable for mildly tachypneic and irritable term infant
was pink, color, mildly facially icteric. Flat anterior
fontanel, normal facies, intact palate, no grunting, flaring,
or retracting, peculiar breath sounds, no murmur, present
femoral pulses, flat, soft, and nontender abdomen, and normal
phallus. Testes in scrotum, stable hips, normal tone and
activity for gestational age.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Infant has remained
in room air throughout this hospitalization with oxygen
saturations greater than 95 percent, respiratory rate 30s-
60s. Infant has not had any apnea or bradycardia this
hospitalization. Infant has remained hemodynamically stable
this hospitalization. He has had a soft intermittent murmur
noted, mean blood pressures have been 55-67. An
echocardiogram on [**10-16**] revealed patent foramen ovale,
left-to-right flow, no vegetation, good biventricular
function.
Fluid, electrolytes, and nutrition: Throughout this
hospitalization, infant has been eating adlib on demand
breast milk 20 calories/ounce or Similac 20 calories/ounce.
Infant has been taking in over 200 cc/kg/day p.o. The most
recent weight is 4475 grams. The most recent head
circumference was 37.75 at the time of discharge. Infant has
been receiving daily head
circumferences throughout this hospitalization. The most
recent electrolytes on day of life 17 showed a sodium of 139,
chloride 103, hemolyzed potassium of 6.6, PCO2 of 22. Infant
has been tolerating feedings without difficulty. Infant
received a renal ultrasound on [**10-10**], which was within
normal limits.
GI: Infant has not received phototherapy this
hospitalization. Maximum bilirubin level on day of life
three was 10.8 with a direct of 0.5. Repeat bilirubin level
on day of life four was 8.7 with direct 0.4.
Hematology: CBC on day of 0 and day of life two as above.
The most recent CBC drawn on day of life 13 showed a white
blood cell count of 25, hematocrit 37.8 percent, platelets
1,147,000, 47 neutrophils, and 0 bands. Infant has not
received any blood transfusions this hospitalization.
ID: Infant was started on ampicillin and gentamicin and
cefotaxime was also added until the organism was identified.
On day of life three, the organism was identified as
ampicillin-resistant E. coli. Repeat blood culture was drawn
on [**10-3**] and it remains negative to date. The infant
received a total of seven days of gentamicin and continued on
Cefotaxime through [**10-31**]. A repeat CSF exam on [**10-31**]
showed 26 WBCs (7 polys, 42 lymphs). Protein was 69 with a
glucose of 38.
Infectious Disease has been involved and the current
recommendation is disonitnue therapy and discharge to home
with close follow-up.
A lumbar
puncture was obtained on day of life nine, which showed a
white blood cell count of 1,025, red blood cells [**Pager number **], protein
393, and glucose 16. The most recent lumbar puncture on day
of life 23 showed a white blood cell count of 68, RBC, 383,
protein 78, and glucose 38. Infant has had issues with
temperature instability requiring Tylenol. Recently rectal
temperatures have been stable over the past week.
Neurology: Neurology and Neurosurgery from [**Hospital3 18242**] has been involved and MRI on [**10-15**] revealed
retrocerebellar subdural empyema of the posterior fossa.
Major vascular structures skull base are normal. Midline
structures are normal. No parenchymal signal abnormalities,
mass lesions, or hydrocephalus.
Infant has been receiving daily head circumferences. A
repeat brain MRI on [**10-24**] showed that there has been
interval resolution in previously seen subdural collections
in the posterior fossa that were consistent with empyema. A
small amount of enhancement is still evident in the effected
regions. Ventricles are normal in size and are symmetric
bilaterally. No mass lesions or midline shift. Infant is to
receive followup in the Neonatal [**Hospital 878**] Clinic with Dr.
[**Last Name (STitle) 58606**] and an appointment has already been made for
[**11-15**] at 8 a.m. Hearing screening was performed on
[**10-1**] with automated auditory brain stem responses.
Infant passed both ears. Infant needs a repeat hearing
examination prior to discharge home.
[**Hospital1 69**] Social Work is involved
with family. The contact social worker is [**Name (NI) 553**] [**Name (NI) **] and she
can be reached at ([**Telephone/Fax (1) 24237**]. Parent's primary language
is Mandarin. Father does speak some English. Mother does
not speak English.
CONDITION ON DISCHARGE: Infant s/p treatment of E. coli
meningitis, stable on room air.
DISCHARGE DISPOSITION: Home with parents
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**Hospital1 **], phone number is ([**Telephone/Fax (1) 58607**]. Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] who
is caring for the infant in the newborn nursery has spoken
with Dr [**Last Name (STitle) **] on the day of discharge.
CARE AND RECOMMENDATIONS: Feedings at discharge: Breast
milk 20 calories/ounce or Similac 20 calories/ounce p.o.
adlib.
Medications: NONE
State newborn screens were sent on [**10-3**] and [**10-6**]. Both specimens were out of range for hemoglobinopathy,
also thalassemia.
Infant received hepatitis B vaccine on [**10-5**].
CONSULTS DURING THIS HOSPITALIZATION: Infectious Disease,
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 50148**], phone number ([**Telephone/Fax (1) 58608**]. ID fellow Dr
[**First Name8 (NamePattern2) 636**] [**Last Name (NamePattern1) **] Beeper ([**Telephone/Fax (1) 50151**] beeper [**Pager number **]
Neurology, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 58609**], phone number is ([**Telephone/Fax (1) 58610**].
Cardiology, Dr. [**First Name4 (NamePattern1) 1439**] [**Last Name (NamePattern1) 4027**], phone number is ([**Telephone/Fax (1) 58611**].
Neurosurgery, Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **], phone number is ([**Telephone/Fax (1) 58612**].
FOLLOW-UP APPOINTMENTS: Primary pediatrician to be arranged
for day after discharge.
Follow up with Neonatal [**Hospital 878**] Clinic on [**11-15**] at
8 a.m. Phone number is ([**Telephone/Fax (1) 56746**].
DISCHARGE DIAGNOSES: E. coli meningitis, subdural fluid
collection and bacteremia.
The [**Hospital3 1810**] medical record for Baby [**Known lastname **] is
[**Numeric Identifier 58613**].
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2152-10-27**] 02:44:29
T: [**2152-10-27**] 05:11:23
Job#: [**Job Number 58614**]
|
[
"320.82",
"V30.00",
"V05.3",
"324.0",
"790.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.55",
"03.31",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6421, 6806
|
8113, 8552
|
6833, 6842
|
2191, 6306
|
7904, 8091
|
6857, 7879
|
1685, 2162
|
6331, 6397
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,644
| 118,003
|
4398
|
Discharge summary
|
report
|
Admission Date: [**2200-4-7**] Discharge Date: [**2200-4-10**]
Date of Birth: [**2146-9-21**] Sex: F
Service: CARDIAC INTENSIVE CARE MEDICINE
CHIEF COMPLAINT: The patient was admitted to the Cardiac
Intensive Care Unit Medicine Service on [**2200-4-7**], with the
chief complaint of acute myocardial infarction and fever.
HISTORY OF PRESENT ILLNESS: The patient is a 53 year old
white female with a history of coronary artery disease,
hypertension, hypercholesterolemia and two pack per day
tobacco use with previous coronary artery bypass graft
surgery presenting to an outside hospital on [**2200-4-6**], with a
two day history of fevers and confusion. The patient had a
CT scan of the chest at that time which revealed pneumonia by
report in the left lower lobe.
While in the outside hospital Emergency Department, the
patient complained of chest pain. The patient states that
she has had this pain for approximately two weeks with no
relief. She was given Levofloxacin for apparent community
acquired pneumonia and cardiac enzymes were cycled. The
patient was found to have a troponin of 3.98 which rose to
6.10 as well as CK MBs of 17.3 and 15.2 but no CPKs were
recorded. The patient's white blood cell count at that time
was 20.6. The patient received Lovenox and Aspirin and was
transferred to the Cardiac Intensive Care Unit at [**Hospital1 346**] for further management.
Of note, the patient's husband reports that she possibly took
approximately 17 tablets of 300 mg of Neurontin in the five
days prior to admission.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post coronary artery
bypass graft.
2. Hypertension.
3. Elevated cholesterol.
4. Chronic low back pain.
5. Bronchitis.
6. Question of liver disease.
7. Gastroesophageal reflux disease.
8. Depression.
ALLERGIES: Nitroglycerin produces significant decrease in
blood pressure. Tape and bee stings.
MEDICATIONS ON ADMISSION:
1. Robaxin 750 mg two tablets q4hours p.r.n.
2. Alprazolam 1.5 mg q.i.d.
3. Lipitor 80 mg p.o. q.d.
4. Gemfibrozil 600 mg b.i.d.
5. Zoloft 150 mg q.d.
6. Prilosec 20 mg q.d.
7. Trazodone 150 mg q.h.s.
8. Duragesic patch 100 mcg q72hours.
9. Enteric Coated Aspirin 81 mg q.d.
10. Vancenase inhaler p.r.n.
11. Oxycodone 10 mg q4hours p.r.n.
12. Neurontin 300 mg p.o. b.i.d. to t.i.d.
SOCIAL HISTORY: The patient smokes two packs per day of
tobacco and drinks alcohol socially. She is married and
lives with her husband.
FAMILY HISTORY: Notable for positive coronary artery disease
although no further or more specific history could be
obtained.
PHYSICAL EXAMINATION: On admission, the patient's vital
signs were as follows: Temperature 98.2, pulse 83,
respiratory rate 17, blood pressure 89/50 with a mean of 67,
oxygen saturation 98% on nonrebreather. Of note, the patient
states that her blood pressure usually runs between 80 and 90
systolic. In general, the patient was alert although had
difficulty remembering and formulating thoughts. Head, eyes,
ears, nose and throat examination - The pupils are equal,
round, and reactive to light and accommodation. Extraocular
movements are intact. Sclera anicteric. Conjunctivae pink.
Slight jaundice and pallor. The neck was supple with no
lymphadenopathy. The lungs demonstrate coarse rhonchi,
question of upper airway sounds transmitted to the anterior
and midaxillary line. Cardiovascular regular rate and
rhythm, S1 and S2, no murmurs, rubs or gallops. The abdomen
was soft, nontender, nondistended, with normoactive bowel
sounds. The extremities were warm, 2+ dorsalis pedis pulses
bilaterally. No edema. Femoral pulses 2+, no bruits.
Rectal examination was guaiac negative per Emergency
Department report at the outside hospital.
LABORATORY DATA: From the outside hospital, white count 20.6
with 89 neutrophils, 1 band, 5 lymphocytes, 4 monocytes,
hematocrit 38.2, platelets 222, MCV 94.9. Sodium 138,
potassium 4.1, chloride 98, bicarbonate 37, blood urea
nitrogen 16, creatinine 0.7, glucose 111. Prothrombin time
12.3, partial thromboplastin time 28.9, INR 1.05. As
previously mentioned, troponin was 3.98 and 6.10 as well as
CK MBs of 17.3 and 15.2 although no CPKs obtainable. Albumin
3.4, total protein 6.5, alkaline phosphatase 148, AST 109,
ALT 25, total bilirubin 0.3, calcium 8.9. Urinalysis was
notable for urine protein of 30.
Electrocardiogram showed normal sinus rhythm with a rate of
88 beats per minute. Q-Tc 443, normal axis. ST elevations
in leads III, aVF, ST depressions in leads I, aVL and V1
through V3 with a Q wave in lead III.
Chest x-ray showed no infiltrate and no pulmonary edema
although CT scan did show some question of a left lower lobe
infiltrate not seen on chest x-ray.
HOSPITAL COURSE: The patient was admitted for management of
confusion, fever, elevated white count, chest pain, and
question of myocardial infarction in the setting of coronary
artery disease, status post coronary artery bypass graft four
years prior. CKs were cycled. The patient was held NPO and
family members were [**Name (NI) 653**]. The patient was continued on
Levofloxacin as started at the outside hospital and given
inhalers p.r.n.
A psychiatry consultation was obtained on the morning of
[**2200-4-7**], given the patient's significant degree of
disorientation and confusion and labile emotions. The
psychiatrist's impression was that the patient was suffering
from delirium with waxing and [**Doctor Last Name 688**] mental status
examination with poor memory. At the time of the interview,
the patient was agreeing to consider catheterization although
it was noted that if she changed her mind given the
importance of this procedure that her husband and children
should be [**Doctor Last Name 653**] regarding consent for the procedure and
that her capacity to consent at that time should be held in
question. Recommendations were made for Haldol p.r.n. as
well as Xanax. B12, folate, RPR and TSH were all ordered
which returned as normal. The patient also had a head CT at
the outside hospital which was unremarkable.
CKs were sent at our hospital with initial level of CPK 464,
MB 12 and a troponin of 49 obtained. The patient had been
placed on Heparin prior to the anticipation of cardiac
catheterization. The patient was initially consented to have
cardiac catheterization on [**2200-4-7**], although had an acute
decompensation in mental status and anxiety attack and it was
determined that she would be at high risk for the procedure
at that time. Thus, the procedure was deferred to the
morning of [**2200-4-8**], and findings were as follows:
Left ventricular ejection fraction 62%. Inferior
hypokinesis. Normal valves. Discrete proximal right
coronary artery lesion of 100% stenosis. Left main 100%
discrete stenosis. Mid left anterior descending discrete
100% stenosis, 50% discrete midcircumflex stenosis. Bypass
graft saphenous vein graft to the right coronary artery was
100% discrete stenosis. Left internal mammary artery to the
left anterior descending patent and RIMA to the right
coronary artery with a 40% stenosis. No intervention was
performed.
It was determined that the patient should be maximized on
medical therapy only. The patient was prescribed with
Aspirin and Plavix at that time and given diuresis for
increasing oxygen requirement. The patient returned to the
floor in stable condition and was to the Step-Down Cardiac
Unit on [**2200-4-8**]. The patient returned to baseline mental
status throughout the remainder of her hospital stay and was
determined to be in stable condition by [**2200-4-10**], to be
discharged. The patient was in agreement with this plan.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post coronary artery
bypass graft in [**2195**], now with occluded saphenous vein
graft to be medically managed.
2. Hypertension.
3. Elevated cholesterol.
4. Chronic low back pain.
5. Bronchitis with possible acute pneumonia.
6. Gastroesophageal reflux disease.
7. Depression.
DISCHARGE MEDICATIONS:
1. Levofloxacin 500 mg p.o. q.d. times nine days to complete
a fourteen day course.
2. Plavix 75 mg one p.o. q.d.
3. Colace 100 mg p.o. b.i.d. p.r.n. for constipation.
4. Neutra-Phos one packet p.o. b.i.d. times thirty days.
5. Prilosec 20 mg p.o. q.d.
6. Enteric Coated Aspirin 325 mg p.o. q.d.
7. Zoloft 150 mg p.o. q.d.
8. Lipitor 80 mg p.o. q.d.
9. Trazodone 150 mg p.o. q.h.s.
10. Fentanyl patch 100 mcg transdermal every three days.
11. Atrovent inhaler two puffs b.i.d.
12. Tylenol #3 p.r.n.
13. Alprazolam 1.5 mg p.o. q.i.d. p.r.n.
14. Gemfibrozil 600 mg p.o. q.d.
15. Neurontin 300 mg p.o. t.i.d.
The patient was to follow-up with her regular cardiologist,
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], in one to two weeks after discharge.
Consideration is to be made in the future as to whether or
not the patient's blood pressure can tolerate addition of
either an ace inhibitor or a beta blocker to her medical
regimen for mortality benefit.
[**First Name8 (NamePattern2) 2206**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 18924**]
Dictated By:[**Last Name (NamePattern1) 7118**]
MEDQUIST36
D: [**2200-4-10**] 12:15
T: [**2200-4-12**] 08:50
JOB#: [**Job Number 18925**]
|
[
"293.0",
"305.1",
"414.01",
"530.81",
"486",
"410.71",
"V45.81",
"414.02",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"88.42",
"88.56",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
2498, 2608
|
7707, 8035
|
8058, 9362
|
1950, 2342
|
4766, 7686
|
2631, 4748
|
177, 341
|
370, 1557
|
1579, 1924
|
2359, 2481
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,370
| 173,336
|
39573
|
Discharge summary
|
report
|
Admission Date: [**2134-9-21**] Discharge Date: [**2134-10-5**]
Date of Birth: [**2072-8-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting x3 (LIMA-LAD,SVG-OM,SVG-RCA)
[**2134-9-23**]
History of Present Illness:
This 62 year old white male presented to [**Hospital 5871**] hospital with
[**10-24**] angina which developed on lifting a 35lb bag and resolved
with rest. He ruled in for a NSTEMI and was transferred to MWMC
for further evaluation with cardiac catheterization and coronary
angiography. cardiac catheterization revealed triple vessel
disease. He was transferred for surgical evaluation. He did
receive loading dose of Plavix and 75mg daily with the last dose
[**2134-9-21**].
Past Medical History:
s/p non ST el;evation myocardial infarction
hypertension
hypercholesterolemia
asthma
angina
coronary artery disease
Social History:
Lives with: significant other, [**Name (NI) 16901**] (uses wheelchair, health is
not stellar)
Occupation: laid off last year- worked as truck driver
Tobacco: quit 12yrs ago, 66pack year history
ETOH: none
Family History:
mother died at 78yo with h/o CVA
father died at 64 ?MI
Physical Exam:
Admission:
Pulse: 77 Resp: 18 O2 sat: 94%RA
B/P Right: 113/70 Left:
Height: 5'4" Weight: 87.7kg
General: WGWN, NAD, appears stated age
Skin: Dry [x] intact [x] no rash
HEENT: PERRLA [x] EOMI [x] arcus senilis
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x] diminished throughout
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema- none
Varicosities: None [x]
Neuro: Grossly intact x
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: cath site, 2+ Left: 2+
Carotid Bruit Right: Left:
no bruits
Pertinent Results:
[**2134-9-25**]
The left atrium is moderately dilated. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded in addition to
akinetic basal to mid inferior and anteroseptal walls. Overall
left ventricular systolic function is moderately depressed
(LVEF= 35 %). The right ventricular cavity is moderately dilated
with moderate global free wall hypokinesis. There is abnormal
septal motion/position. 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. Moderate [2+]
tricuspid regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
[**2134-9-27**] 12:49PM BLOOD Hct-28.2*
[**2134-9-27**] 02:35AM BLOOD WBC-7.2 RBC-3.04* Hgb-8.7* Hct-26.7*
MCV-88 MCH-28.8 MCHC-32.7 RDW-15.1 Plt Ct-165
[**2134-9-27**] 12:49PM BLOOD Na-139 K-4.3 Cl-97
[**2134-9-27**] 02:35AM BLOOD Glucose-116* UreaN-17 Creat-0.9 Na-140
K-4.2 Cl-99 HCO3-34* AnGap-11
[**2134-10-5**] 04:20AM BLOOD WBC-9.7 RBC-3.29* Hgb-9.6* Hct-29.4*
MCV-89 MCH-29.3 MCHC-32.8 RDW-15.8* Plt Ct-518*
[**2134-10-5**] 04:20AM BLOOD PT-15.1* INR(PT)-1.3*
[**2134-10-4**] 04:20AM BLOOD PT-15.0* PTT-95.7* INR(PT)-1.3*
[**2134-10-3**] 03:15PM BLOOD PT-14.2* PTT-77.5* INR(PT)-1.2*
[**2134-10-5**] 04:20AM BLOOD UreaN-25* Creat-1.1 Na-139 K-4.6 Cl-102
[**2134-10-4**] 04:20AM BLOOD Glucose-118* UreaN-27* Creat-1.2 Na-140
K-4.7 Cl-101 HCO3-31 AnGap-13
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
Operating Room on [**2134-9-23**] where he underwent coronary artery
bypass grafting x3. See operative note for full details. Overall
the patient tolerated the procedure well and post-operatively
was transferred to the CVICU in stable condition for recovery
and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable on no inotropic or vasopressor
support. Beta blocker was initiated and the patient was gently
diuresed toward the preoperative weight. The patient was
transferred to the telemetry floor for further recovery.
On POD1 night the patient went into atrial fibrillation briefly
then sustained ventricular tachycardia. He did not lose
consciousness throughout the episode. He was bolused with
Amiodarone and transferred to the CVICU, hemodynamically stable
in sinus rhythm. Electrophysiology was consulted. He remained
in sinus rhythm until the following night when he developed
ventricular tacycardia requiring defibrillation x 4, Amiodarone
and Lidocaine boluses and drips, IV Lopressor and overdrive
ventricular pacing with return to sinus rhythm. The following
day he went into a rapid atrial fibrillation and IV Lopressor
was increased. He went into a sustained ventricular tachycardia
on the following morning and Amiodarone was bolused and
additional IV Lopressor was given.
Heparin was started for anticoagulation for atrial fibrillation.
A right chest tube was placed on post operative day 3 for a
pneumothorax. The lung was rexpanded on the following chest
xray and the chest tubes and pacing wires were discontinued
without complication. The patient was evaluated by the Physical
Therapy service for assistance with strength and mobility.
An electrophysiology study was conducted on [**10-4**] and VT was
easily induced. The EP attending felt that a defibrillator was
not yet indicated as this might represent reperfusion or scar.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts was arranged, with results to be forwarded to
Dr. [**Last Name (STitle) 81807**]. Amiodarone was tapered over the three weeks
after discharge. By the time of discharge on POD 12 the patient
was ambulating independently, the wounds were healing well and
pain was controlled with oral analgesics. The patient was
discharged to [**Location (un) 931**] House in [**Location (un) 932**] in good condition with
appropriate follow up instructions. Coumadin will be managed by
the rehabilitation facility with a goal INR of [**2-16**].5.
Medications on Admission:
Medications on transfer:
aspirin 325mg daily
simvastatin 80mg daily
Coreg 3.125 [**Hospital1 **]
lisinopril 5mg daily
SL NTG prn
morphine prn
Plavix 75mg daily, 600mg on [**2134-9-19**]
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. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
Disp:*30 Tablet(s)* Refills:*0*
3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 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:*30 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO three
times a day.
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. Coumadin 2.5 mg Tablet Sig: as directed Tablet PO once a day:
INR goal 2-2.5.
8. Amiodarone 200 mg Tablet Sig: as directed Tablet PO TID (3
times a day): two tablets(400mg) TID for 7days, then one tablet
(200mg) TID for two weeks, then on etablet a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 931**] House Nursing & Rehabilitation Center - [**Location (un) 932**]
Discharge Diagnosis:
coronary Artery Disease
s/p coronary artery bypass bypass grafts x 3
s/p nonST elevation myocardial infarction
hypertension
hypercholesterolemia
asthma
angina
postoperative ventricular tachycardia
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage. 1+ Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr.[**Last Name (STitle) **] for Dr. [**Last Name (STitle) **] at [**Hospital1 **] on [**2134-10-21**] at 9am
Cardiologist: Dr.[**Last Name (STitle) 6254**] on [**2134-11-1**] at 3:00pm
Please call to schedule appointments with your
Primary Care Dr. [**First Name (STitle) **] in [**4-19**] weeks [**Telephone/Fax (1) 87351**]
**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
Completed by:[**2134-10-5**]
|
[
"512.1",
"427.31",
"493.90",
"997.1",
"272.0",
"410.71",
"414.01",
"401.9",
"E878.2",
"427.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"37.27",
"34.09",
"37.26",
"36.15",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
7690, 7804
|
3803, 6449
|
332, 411
|
8045, 8261
|
2125, 3780
|
9101, 9773
|
1299, 1356
|
6686, 7667
|
7825, 8024
|
6475, 6475
|
8285, 9078
|
1371, 2106
|
281, 294
|
439, 920
|
6500, 6663
|
942, 1060
|
1076, 1283
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,116
| 186,183
|
97
|
Discharge summary
|
report
|
Admission Date: [**2179-1-29**] Discharge Date: [**2179-2-2**]
Date of Birth: [**2093-2-16**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
none
History of Present Illness:
85-year-old female atrial fibrillation, schizophrenia, dementia
presents from nursing home with respiratory distress.
.
The patient was in her usual state of health until this AM. At
that time she was found by nursing home staff in respiratory
distress with O2 sats of 70% on RA. EMS was contact[**Name (NI) **] and she
was started on supplemental oxygen with NRB and O2 sats
responded to 98%. She was also noted to be hot (no document of
temperature) with cough and green sputum. She was transported to
[**Hospital1 18**] ED.
.
In the ED, initial vitals were: T 99.8, HR 90, BP 171/85, RR 28,
SaO2 98% NRB15L. EKG with Afib RVR to 130s and LVH. SBP 180s.
WBC 16. BNP 12,600. CXR interpreted as concerning for CHF. She
was given nitroglycerin gtt, diltiazem 10mg IV x2, aspirin,
levofloxacin and furosemide 20mg IV x1. Per documents she
received 2L IVF. She was temporarily started on BIPAP however
did not tolerate well with hypotension and tachycardia. This was
discontinued and patient has been stable with vitals at transfer
of HR 105, BP 129/66, RR 26, SaO2 100% NRB.
.
Currently, no distress although neglects left side. No movement
of left side. No respiratory distress.
.
ROS: Unable to obtain.
Past Medical History:
- Atrial fibrillation/flutter
- Schizophrenia
- Anemia
- h/o syncope
- Dementia
- Cardiomyopathy
- Paroxysmal ventricular tachycardia
- h/o C. Diff colitis
- h/o peptic ulcer disease
- PPD positive
- h/o cellulitis
Social History:
Reportedly non-verbal although can communicate when in pain.
Lives at [**First Name8 (NamePattern2) 1116**] [**Last Name (NamePattern1) **] Nursing Home. Normally can say name and
walks with shuffling gait. No known history of smoking.
Family History:
Unable to obtain.
Physical Exam:
ADMISSION EXAM:
VS: T: 96.2 Ax BP: 171/81 HR: 123 RR: 24 O2sat: 99% NRB 15L
GEN: non-verbal, no apparent distress, some wasting
HEENT: PERRL, eyes deviated to right, dry MM, op without lesions
although limited view
Neck: no supraclavicular or cervical lymphadenopathy
apprecaited, ?low JVD, difficult to assess given patient
position, left SCM muscle tense, right SCM not tense, head
deviated to right, resists movement to left
RESP: no accessory muscle use, not cooperative, bilateral
crackles diffuse but more prominent at bases, decreased air
movement although decrease respiratory effort
CV: irregular, tachycardic, S1 and S2 wnl, II/VI systolic murmur
at RUSB
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: warm, no edema
SKIN: hematoma with edema on low back from recent fall
NEURO: Non-verbal, non cooperative with exam, moves hands and
toes on right upon command. Moves toes on command on left. No
movement or response of left hand. Appears to have left neglect
although difficult to assess. Flaccid on left side. Normal tone
on right side.
DISCHARGE EXAM: 99.2 141/97 104 24 92% RA
GENERAL: difficult to arouse, mildly labored breathing, NAD
HEENT: sclera anicteric, dry mucous membranes
CV: irregularly irregular rhythm, tachycardic
RESP: bibasilar crackles with transmitted upper airway sounds
ABD: bowel sounds present, soft, non-tender
EXT: DPs 2+ bilateraly, no edema
NEURO: left facial droop, patient not moving left side, not
following commands, posturing of right upper ext
SKIN: papular rash with erythematous background on neck and
abdomen, non-tender to palpation on exam, no pustules or
vesicles noted
Pertinent Results:
ADMISSION LABS:
[**2179-1-29**] 06:35AM BLOOD WBC-16.7* RBC-4.07* Hgb-12.6 Hct-38.2
MCV-94 MCH-31.1 MCHC-33.1 RDW-15.5 Plt Ct-366
[**2179-1-29**] 06:35AM BLOOD Glucose-131* UreaN-25* Creat-0.9 Na-141
K-5.4* Cl-106 HCO3-23 AnGap-17
[**2179-1-29**] 06:35AM BLOOD proBNP-[**Numeric Identifier 1117**]*
[**2179-1-29**] 06:35AM BLOOD cTropnT-<0.01
[**2179-1-29**] 11:40AM BLOOD Calcium-8.2* Phos-3.2 Mg-1.8
[**2179-1-29**] 06:42AM BLOOD Lactate-3.0*
[**2179-1-29**] 11:40AM BLOOD CK(CPK)-28*
[**2179-1-29**] 11:40AM BLOOD CK-MB-3 cTropnT-<0.01
MICRO:
[**2179-1-29**] Blood culture: pending
.
IMAGING:
[**2179-1-29**] EKG #1: Atrial fibrillation with rapid ventricular
response. Non-specific intraventricular conduction delay. Left
ventricular hypertrophy. Poor R wave progression could be due to
left ventricular hypertrophy. Non-specific ST-T wave changes
could be due to left ventricular hypertrophy, although cannot
exclude ischemia. Clinical correlation is suggested. No previous
tracing available for comparison.
[**2179-1-29**] EKG #2: Atrial fibrillation with a controlled ventricular
response. Non-specific intraventricular conduction delay. Left
ventricular hypertrophy. Poor R wave progression could be due to
left ventricular hypertrophy. Non-specific ST-T wave changes
could be due to left ventricular hypertrophy, although cannot
exclude ischemia. Compared to tracing #1 ventricular rate is
slower.
[**2179-1-29**] CXR:
1. Mild pulmonary edema.
2. Mild cardiomegaly.
3. Hyperexpanded lungs, could be due to emphysema.
[**2179-1-29**] CTA Head/Neck:
1. Acute right MCA distribution infarction with acute occlusion
demonstrated within the right middle cerebral artery. No
collateral flow.
2. No evidence of vascular dissection. Mild atherosclerotic
plaque as
detailed above.
Brief Hospital Course:
85 year old female with a history of schizophrenia and dementia
who presented in repiratory distress and was found to have a new
MCA stroke. After goals of care discussion with patient's
guardian, she was made comfort measures only, and expired on
[**2179-2-2**].
#. Respiratory Distress: Patient's O2 sats were in high 90s on
NRB on arrival to ED. She was noted to be in afib with RVR, and
CXR was concerning for pulmonary edema. Patient was treated
with nitro gtt, diltiazem, aspirin, levofloxacin and furosemide.
BiPAP attempted, but patient did not tolerate well; developed
hypotension and increased tachycardia. She was admitted to the
ICU for further evaluation and management of respiratory
distress. After Code Stroke called on arrival to ICU in setting
of left hemiparesis (see below), and imaging revealed large R
MCA infarct, decision was made to focus on comfort care only.
Patient transferred to floor, where she received morphine as
needed for pain and SOB.
.
#. CVA: On arrival to ICU, patient was noted to have left
hemiparesis. Code Stroke called, and CT Head/Neck revealed
right MCA infarct. Given the history of recent falls and her
limited pre-stroke functionality, the decision was made not to
give heparin or tPA. After discussion with the patient's
guardian, it was felt that she would not want to pursue
aggressive treatment given poor prognosis, and patient was made
CMO.
.
#. Atrial fibrillation: Patient noted to be in afib with RVR on
presentation. She was initially on diltiazem gtt, but this was
discontinued once patient made CMO.
.
#. Rash: Patient noted to have papular rash on erythematous
background on neck and abdomen. Was felt to be most likely
secondary to a drug rash. Of note, patient received lasix,
which may have caused reaction as patient has history of sulfa
allergy. Patient received sarna lotion as needed, as well as
hydrocortisone cream.
.
#. Goals of care: Per discussion with patient's guardian,
patient's code status changed to comfort measures only. Plan
was for discharge back to skilled nursing facility with hospice,
however patient expired on [**2179-2-2**] prior to discharge. Her
guardian was notified, and declined an autopsy.
Medications on Admission:
- metoprolol succinate 50mg PO daily
- Diltiazem XR 120mg PO daily
- Colace 100mg PO daily
- MVI PO daily
- Calcium
- Lorazepam 0.5mg PO BID
- guaifenesin 10 mL p.o. q.6h. p.r.n.
- acetaminophen prn
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnosis: Cerebrovascular accident (stroke), rash
Secondary Diagnoses: atrial fibrillation, schizophrenia,
dementia
Discharge Condition:
Patient expired.
Discharge Instructions:
None; patient expired.
Followup Instructions:
None; patient expired.
|
[
"782.1",
"799.02",
"342.00",
"295.90",
"425.4",
"434.91",
"V49.86",
"518.4",
"427.31",
"294.8",
"V66.7",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8040, 8049
|
5560, 7761
|
312, 318
|
8219, 8237
|
3751, 3751
|
8308, 8333
|
2058, 2077
|
8011, 8017
|
8070, 8070
|
7787, 7988
|
8261, 8285
|
2092, 3157
|
8151, 8198
|
3173, 3732
|
252, 274
|
346, 1550
|
3767, 5537
|
8089, 8130
|
1572, 1789
|
1805, 2042
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,327
| 116,562
|
367
|
Discharge summary
|
report
|
Admission Date: [**2119-9-10**] Discharge Date: [**2119-9-15**]
Date of Birth: [**2065-7-31**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
Right internal jugular line ([**9-10**])
History of Present Illness:
53 yo M w/ h/o Down's syndrome, non-verbal at baseline,
hypothyroidism, cataracts, dysphagia s/p G-tube, h/o aspiration
pna's, hypoNa on 4Lnc QHS who presents w/ cough and hypoxia from
group home.
Per report, patient with acute on chronic cough found to desat
to 88% on RA this AM. Looked as if he were in respiratory
distress. Per OMR had been empirically treated for pna back in
[**6-/2118**] w/ multiple notes documenting cough.
In the ED, initial VS were: 98.2 74 92/50 28 100% nrb. Tmax
100.2. On exam +crackles L>R. Labs notable for Na 129, Cl 93,
HCO3 28, BUN 11, Cr 0.8, Glu 114, Lactate 1.4, UA neg
leuk/nitr/3wbc/neg bact/epis O, wbc 7.2, HCT 41.3, plt 313. CXR:
gastric distention, bibasilar atelectasis. He received
ceftriaxone and levo, vanc, and Flagyl, 1LNS.
A right IJ was placed and followup chest x-ray showed small
right upper lobe pneumothorax.
On the floor, Abx were narrowed to Zosyn. He became hypotensive
to 76/doppler, thick secretions on nasotracheal suctioning and
increased work of breathing. Mentation was unchanged during
event and held his sats at 100% on 3LNC. CXR showed new
pneumothorax and bilateral infiltrates. He received
albuterol/impratropium and 500cc NS, pressures improved to
83/doppler. He was transferred to the MICU for hypotension.
On arrival to the MICU, the patient is lethargic, awakens to
sternal rub, does not interact. Not in acute distress.
Past Medical History:
Down's syndrome, non-verbal at baseline
-Alzheimer's
-B12 deficiency
-hypothyroidism
-cataracts, legally blind
-dysphagia s/p G-tube
-h/o aspiration pna's
-h/o DVT
-h/o cdiff
Social History:
Lives in a group home, brothers very involved with care.
Family History:
No memory disorders
Physical Exam:
General: Lethargic, arouses to sternal rub, no acute distress
HEENT: Pupils equal, round and reactive
Neck: No LAD
CV: Regular rate and rhythm, no murmurs
Lungs: No accessory muscle use, no retractios. Good air
movement. Diffuse ronchi throughout.
Abd: Soft, Gtube site c/d/i, normoactive BS, nontender
nondistended
GU: Foley in place
Ext: warm, well perfused, 2+ pulses pedal pulses, no clubbing,
cyanosis or edema
Pertinent Results:
Admission Labs:
[**2119-9-10**] 11:02PM URINE HOURS-RANDOM UREA N-59 CREAT-7
SODIUM-127 POTASSIUM-11 CHLORIDE-126
[**2119-9-10**] 11:02PM URINE OSMOLAL-291
[**2119-9-10**] 11:02PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2119-9-10**] 10:32PM GLUCOSE-96 UREA N-6 CREAT-0.5 SODIUM-135
POTASSIUM-3.4 CHLORIDE-99 TOTAL CO2-31 ANION GAP-8
[**2119-9-10**] 10:32PM CALCIUM-7.9* PHOSPHATE-2.6* MAGNESIUM-1.8
[**2119-9-10**] 10:32PM TSH-3.0
[**2119-9-10**] 10:32PM WBC-5.9 RBC-3.55* HGB-12.5* HCT-36.9*
MCV-104* MCH-35.3* MCHC-33.9 RDW-13.3
[**2119-9-10**] 10:32PM PLT COUNT-262
[**2119-9-10**] 09:07AM LACTATE-1.4
[**2119-9-10**] 08:55AM GLUCOSE-114* UREA N-11 CREAT-0.8 SODIUM-129*
POTASSIUM-4.4 CHLORIDE-93* TOTAL CO2-28 ANION GAP-12
[**2119-9-10**] 08:55AM WBC-7.2# RBC-3.99* HGB-14.0 HCT-41.3 MCV-104*
MCH-35.2* MCHC-34.0 RDW-12.9
[**2119-9-10**] 08:55AM NEUTS-79.7* LYMPHS-13.4* MONOS-4.5 EOS-1.5
BASOS-0.9
[**2119-9-10**] 08:55AM PLT COUNT-313
[**Hospital3 **]:
[**2119-9-12**] 06:36AM BLOOD Albumin-2.9* Calcium-7.9*
[**2119-9-10**] 10:32PM BLOOD TSH-3.0
[**2119-9-11**] 03:28AM BLOOD Cortsol-11.9
[**2119-9-13**] 05:13AM BLOOD Vanco-24.9*
[**2119-9-13**] 09:58PM BLOOD Vanco-19.8
Discharge Labs:
[**2119-9-15**] 05:50AM BLOOD WBC-5.4 RBC-3.71* Hgb-13.1* Hct-39.9*
MCV-108* MCH-35.2* MCHC-32.8 RDW-12.9 Plt Ct-264
[**2119-9-15**] 05:50AM BLOOD Glucose-94 UreaN-7 Creat-0.9 Na-138 K-4.2
Cl-97 HCO3-31 AnGap-14
Microbiology:
[**2119-9-14**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL;
FUNGAL CULTURE-PRELIMINARY
[**2119-9-10**] URINE Legionella Urinary Antigen - FINAL
[**2119-9-10**] URINE CULTURE - FINAL
[**2119-9-10**] MRSA SCREEN - POSITIVE FOR METHICILLIN RESISTANT
STAPH AUREUS
[**2119-9-10**] BLOOD CULTURE - PENDING
Imaging:
CXR [**2119-9-10**]: Two frontal radiographs were obtained. Lung volumes
are low. There is no
focal consolidation, large effusion, or pneumothorax. There are
no abnormal cardiac or mediastinal contours. Basilar
atelectasis is noted.
CXR [**2119-9-11**]: As compared to the previous radiograph, there is
increasing radiodensity in the right lung, predominating in the
right upper lobe. Developing pneumonia cannot be excluded.
CXR [**2119-9-14**]: As compared to the previous radiograph, the
current image is taken in a highly rotated patient position. As
a result, hyperlucency of the left lung apex without definite
signs of pneumothorax is seen. The pre-existing opacity at the
right lung apex is unchanged. Lung volumes have minimally
decreased, but the pre-existing signs suggesting fluid overload
have decreased. No evidence of pleural effusions, interposition
of colon between the liver and the abdominal wall. Unchanged
position of the right internal jugular vein catheter. Unchanged
appearance of the cardiac silhouette.
CXR [**2119-9-15**]: The lungs are now clear. Right upper lobe opacity
has completely resolved. There is only minimal bibasilar
atelectasis. Right jugular line ends in upper SVC. Mediastinal
and cardiac contours are normal. No significant pleural
effusions or pneumothorax.
CT Head without contrast [**2119-9-15**]: pending at time of discharge
Brief Hospital Course:
SUMMARY: 54 yo M w/ h/o Down's syndrome, non-verbal at baseline,
hypothyroidism, dysphagia s/p G-tube, h/o aspiration pna's,
hypoNa on 4Lnc QHS who presents w/ cough and hypoxia from group
home.
# Hypotension: Blood pressure on the floor dropped to 92/50 and
he was transferred to the MICU where his blood pressure
responded to fluid boluses (total 3L). The etiology of his
hypotension is likely secondary to acute infection. On CXR he
has a possible right lobe infiltrate that could represent
infection, pneumonitis or pulmonary edema. He was started on IV
Vanc and Zosyn for coverage of healthcare associated pneumonia
since he lives in a group home. At the time of discharge, his
blood pressure was at baseline (100s/80s) and did not require
pressors.
# Respiratory Distress: Initially hypoxic to 88% at group home.
No evidence of CHF by exam or CXR. No history of CHF in past.
Could be secondary to infiltrate in right lobe that could
represent pneumona, pneumonitis or pulmonary edema. EKG did not
have any ischemic changes. On [**9-10**] patient had RIJ placed and
follow up CXR showed small pneumothorax but there was no change
in the patient's respiratory status. He was put on supplemental
oxygen, and on [**9-11**] CXR showed resolution of the pneumothorax.
He was discharged on a total 14 day course of antibiotics for
his presumed HCAP, due to complete [**9-24**]. At the time of
discharge, his oxygen saturation was high 90s on 2L nasal
cannula.
# pulmonary edema: No cardiac history, but patient developed
findings c/w pulmonary edema on CXR after minimal fluids. EKG
was unconcerning.
# Seizure Disorder: Etiology unclear. Myoclonic jerks observed
after transfer from MICU to the floor, and EEG showed seizure
activity. His home Keppra was increased to 1.5g [**Hospital1 **].
# HypoNa: Chronic per facility records, though hypovolemic this
admission. Resolved with fluid resuscitation.
# Down's syndrome, non-verbal at baseline: Per NH at baseline.
Given his lack of responsiveness, head imaging was performed to
ensure lack of new pathology.
# Hypothyroidism: Continued on home synthroid. TSH was normal.
# Social: Over the last few months that patient's health has
been declining and he was made DNR/DNI by HCP (brother).
Currently in discussion with PCP about making [**Name9 (PRE) 3225**] and moving to
hospice care. During this admission a meeting with the
patient's group home, DMH case worker, [**Hospital1 18**] social work and
case management, [**Hospital 18**] medical staff, and the patient's two
brothers was held to discuss his prognosis and goals of care.
The medical team stated that the patient's overall life
expectancy is in the range of months, but that this could be
much shorter if he has an acute respiratory event. He will
continue to aspirate and may continue to have infections.
However, treating these infections may require him to remain in
a hospital, which his family agrees is not the best setting for
his comfort. His brothers recognized that moving to hospice/DNH
and taking him back to the group home would improve his quality
of life, but they were concerned that this might shorten his
overall lifespan. After discussion of the options, they decided
to complete this course of antibiotics (2 weeks) and then plan
to return him to the group home. They recognized that this
course of treatment may not provide him any long-term benefit,
and that he could die while undergoing the treatment. They
stated that they would consider a DNH order after this current
course of antibiotics.
FOLLOW-UP ISSUES
1. Please follow up on his blood cultures and sputum cultures.
They were pending at the time of discharge.
2. Please evaluate for evidence of seizure-like activity. At the
time of discharge, he was having occasional myoclonic jerks that
did not correspond to epileptiform discharges on EEG. He may
need an EEG at a future time.
3. Please check his sodium and fluid balance, as he presented
initially with hyponatremia, likely secondary to dehydration.
4. Patient tested positive for MRSA, and should be on contact
precautions.
5. Head CT read pending on discharge, may show signs of subacute
pathology that changes his overall prognosis.
6. IV Zosyn and vancomycin planned 14 day course through [**9-24**],
however this may be adjusted by the patient's response and
clinical situation.
Medications on Admission:
- Acetaminophen 650 mg PO Q4H:PRN Pain/Fever
- Atropine Sulfate 1% 2 DROP SL Q4H:PRN Secretions
- Bacitracin Ointment 1 Appl TP [**Hospital1 **]:PRN open wounds
- Bisacodyl 10 mg PO/PR DAILY:PRN constipation
- Denta 5000 Plus *NF* (sodium fluoride) 1.1 % Dental [**Hospital1 **]
- Fleet Enema 1 Enema PR DAILY:PRN constipation
- Haloperidol 0.5-1 mg NG Q4H:PRN agitation
- Kaopectate (bismuth subsalicy) *NF* (bismuth subsalicylate)
- LeVETiracetam 500 mg PO QAM
- LeVETiracetam 1000 mg PO QPM
- Levothyroxine Sodium 88 mcg PO/NG QAM
- Lorazepam 0.5 mg PO/NG Q4H:PRN Anxiety
- Milk of Magnesia 30 mL NG PRN constipation
- Multivitamins 5 mL PO/NG DAILY
- Neutra-Phos 1 PKT PO BID
- OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain/Shortness
of Breath
- Simethicone 40 mg PO Q4H
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN Pain/Fever
2. Bacitracin Ointment 1 Appl TP [**Hospital1 **]:PRN open wounds
Apply to open wounds on coccyx and buttocks
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. Fleet Enema 1 Enema PR DAILY:PRN constipation
If dulcolax not effective
5. Haloperidol 0.5-1 mg NG Q4H:PRN agitation
Via G tube
6. LeVETiracetam 1500 mg PO BID
7. Levothyroxine Sodium 88 mcg PO QAM
Via G tube
8. Lorazepam 0.5 mg PO Q4H:PRN Anxiety
Via G tube
9. Milk of Magnesia 30 mL PO PRN constipation
If no BM for 3 days. Give via G tube
10. Multivitamins 5 mL PO DAILY
Via G tube
11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN
Pain/Shortness of Breath
12. Simethicone 40 mg PO Q4H
13. Denta 5000 Plus *NF* (sodium fluoride) 1.1 % Dental [**Hospital1 **]
14. Kaopectate (bismuth subsalicy) *NF* (bismuth subsalicylate)
262 mg/15 mL Oral QD:PRN diarrhea
Per G tube
15. Neutra-Phos 1 PKT PO BID
16. Atropine Sulfate 1% 2 DROP SL Q4H:PRN Secretions
17. Vancomycin 1000 mg IV Q 12H
RX *vancomycin 500 mg 1000mg IV twice a day Disp #*44 Each
Refills:*0
18. Piperacillin-Tazobactam 4.5 g IV Q8H
RX *piperacillin-tazobactam 4.5 gram 4.5mg IV every 8 hours Disp
#*33 Each Refills:*0
19. Ipratropium Bromide Neb 1 NEB IH Q6H wheezing, dyspnea
RX *ipratropium bromide 0.2 mg/mL (0.02 %) 1 NEB Every six
hours Disp #*15 Each Refills:*1
20. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea, wheezing
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 NEB Every six
hours Disp #*15 Each Refills:*1
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
- Aspiration pneumonia
Secondary:
- hypvolemia
- Hypotension
- Hyponatremia
- Seizure disorder
- Down's syndrome
- Alzheimer's dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic and not arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 3291**],
It was a pleasure taking care of you in the hospital. You were
admitted for shortness of breath, and were found to have an
infection of your lungs from chronic aspiration. You were
treated with IV antibiotics and regular suctioning of oral
secretions, and your breathing improved. Your blood pressure was
also occasionally low, and received IV fluids. You were found to
have seizure activity during this hospitalization, and your home
doses of keppra was increased.
Please start taking the following medications:
1. IV vancomycin 1gm twice a day
2. Piperacillin-Tazobactam 4.5 g IV every 8 hours
3. Albuterol 0.083% Neb Soln every 6 hours as needed for
shortness of breath
4. Ipratropium Bromide Neb every 6 hours as needed for shortness
of breath
Please change the dosing on the following medications:
1. Levetiracetam 1500 mg twice a day
Please continue to take your other medications.
Followup Instructions:
Department: PODIATRY
When: MONDAY [**2119-9-18**] at 2:20 PM
With: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2120-5-2**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2119-9-15**]
|
[
"458.9",
"V12.51",
"707.03",
"707.22",
"787.20",
"300.00",
"518.81",
"276.1",
"V49.86",
"564.00",
"512.1",
"294.10",
"758.0",
"345.90",
"366.9",
"244.9",
"344.00",
"331.0",
"V46.3",
"507.0",
"369.4",
"275.41",
"V44.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
12526, 12597
|
5815, 10171
|
324, 366
|
12786, 12786
|
2560, 2560
|
13919, 14721
|
2087, 2108
|
11002, 12503
|
12618, 12765
|
10197, 10979
|
12967, 13896
|
3850, 5792
|
2123, 2541
|
264, 286
|
394, 1796
|
2576, 3834
|
12801, 12943
|
1818, 1995
|
2011, 2071
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,177
| 157,717
|
39142
|
Discharge summary
|
report
|
Admission Date: [**2126-10-6**] Discharge Date: [**2126-10-9**]
Date of Birth: [**2069-3-12**] Sex: M
Service: SURGERY
Allergies:
Tetracycline / Doxycycline
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
57M with h/o type A aortic dissection and aneurysm of
thoracic and abdominal aorta as well as bilateral iliac
arteries,
status post thoracoabdominal aneurysm repair with multibranched
Dacron graft on [**2126-9-10**], complicated by anastamotic leak,
abdominal compartment syndrome, bilateral LE paraplegia, LLE
compartment syndrome, pneumonia, and prolonged intubation
requiring tracheostomy. He was discharged to a high care level
rehabilitation facility yesterday and returns today after
experiencing five minutes of substernal chest pain at
approximately 5:00am the morning of admission. The pain did not
radiate and
was self-limited. He noted that the afternoon prior to
admission he experienced some left arm pain at the elbow which
he attributed to
physical therapy. At the time of presentation to the ED, he was
asymptomatic and felt well.
Past Medical History:
Past Medical History:
- Thoracoabdominal Aneurysm with Chronic Type B Dissection
- Hypertension
- Recent History of Subdural Hematoma s/p Fall(improved on past
CT scan)
- History of Elevated PSA(normal now per patient)
- Left Eye Sclera Scar from trauma
Past Surgical History:
s/p Aortic Dissection Repair [**2117**] at [**Hospital1 112**](median sternotomy)
s/p Arch Replacement [**2119**] at [**Hospital1 112**] [**2119**](left thoractomy)
Social History:
Last Dental Exam: No recent exam
Lives with: Wife(in [**State 5887**])
Occupation: Pastor
Tobacco: Denies
ETOH: Denies
Family History:
No premature coronary artery disease
Physical Exam:
EXAM:
100.0 86 135/65 18 100% TM 0.35
Gen awake, alert, NAD
CV RRR
Chest CTAB
Abd soft, nontender, nondistended; wound granulating, dressing
clean, retention sutures in place
Ext LLE fasciotomy sites clean, dry, intact; 2+ edema to knees
b/l; palpable DP/PT pulses b/l
Pertinent Results:
Admission Labs:
12.1 > 24.5 < 343
135 103 44
------------< 109
5.8 24 1.8
Ca 8.3 Mg 2.2 Phos 3.7
Trop 0.42
PTT 29.2 INR 1.1
MICRO:
[**9-15**] - sputum cx: enterobacter cloacae, sensitive to cipro
[**10-3**] - sputum cx: MRSA
IMAGING:
[**2126-10-6**] - CXR: no acute cardiopulmonary process; bibasilar
atelectasis
[**2126-10-6**] - EKG: mild ST elevation in V3, unchanged from previous
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the CVICU. EKG was unchanged from
prior and cardiology felt that the entire clinical picture was
of low suspicion for acute plaque rupture given his renal
failure and previously elevated cardiac markers, instead much
more likely a demand ischemia in the setting of his medical
illnesses and exertion at rehab. He was transfused with 2 units
of blood for his Hct of 24 and responded appropriately with Hct
increasing to 29.8 and staying constant throughout his
hospitalization. His troponins leveled off and trended
downwards starting at 0.42-->.45-->.54-->.52-->.47. He had no
further episodes of chest pain.
His white count was initially 12.1 on admission and sputum
cultures from prior admission revealed MRSA+. He was started on
vanco and continued on the cipro which he was continued on as
outpatient. After no new growth from the cultures and mini-BAL
negative for bacteria and being afebrile since admission, the
antibiotics were stopped.
On discharge, Mr. [**Known lastname **] was afebrile, vitals within normal
limits and reported feeling "much better".
His labs on discharge:
10.1
8.4>------<278
30.3
131 / 100 / 43
----------------<101
5.6 / 24 / 1.7
Trop 0.47 CKMB 17
Discharge Medications:
1. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
QOD ().
4. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
12. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
14. Collagenase Clostridium hist. 250 unit/g Ointment Sig: One
(1) Appl Topical DAILY (Daily).
15. Hydralazine 20 mg/mL Solution Sig: Ten (10) mg Injection Q6H
(every 6 hours) as needed for SBP > 180.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
- Myocardial demand ischemia
- Renal Insufficiency
- Paraplegia
- Thoracoabdominal Aneurysm with Chronic Type B Dissection
- Hypertension
- Recent History of Subdural Hematoma s/p Fall(improved on past
CT scan)
- History of Elevated PSA(normal now per patient)
- Left Eye Sclera Scar from trauma
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:
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 and while taking
narcotics
5. Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Please call to confirm follow-up appointments in 10 days-2 weeks
from discharge.
Vascular Surgeon: Dr. [**Last Name (STitle) **]
Date: 9:15 AM, Monday, [**2126-10-21**]
Phone: ([**Telephone/Fax (1) 22785**]
Cardiac Surgeon: Dr. [**Last Name (STitle) 914**]
Date: 1:45 PM, Tuesday, [**2126-10-22**]
Phone: ([**Telephone/Fax (1) 1504**]
General Surgeon: Dr. [**Last Name (STitle) **]
Date: 2:30 PM, Tuesday, [**2126-10-22**]
Phone: ([**Telephone/Fax (1) 36338**]
Cardiologist: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Phone: ([**Telephone/Fax (1) 32215**]
Please call Dr.[**Name (NI) 5452**] office to set up an appointment at your
convenience within the next 2 weeks.
Completed by:[**2126-10-9**]
|
[
"V44.0",
"411.89",
"707.03",
"403.90",
"V45.89",
"441.03",
"V44.1",
"344.1",
"707.22",
"482.42",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
5097, 5167
|
2581, 3698
|
298, 304
|
5507, 5507
|
2149, 2149
|
6381, 7109
|
1802, 1840
|
3852, 5074
|
5188, 5486
|
5683, 6358
|
1483, 1649
|
1855, 2130
|
247, 260
|
3722, 3829
|
332, 1184
|
2167, 2558
|
5522, 5659
|
1228, 1460
|
1665, 1786
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,941
| 164,300
|
34100
|
Discharge summary
|
report
|
Admission Date: [**2144-9-19**] Discharge Date: [**2144-12-3**]
Date of Birth: [**2085-7-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
A fib with RVR
Major Surgical or Invasive Procedure:
Right side thoracoscentesis on [**2144-10-28**]
History of Present Illness:
59yF with h/o mental retardation, Nodular sclerosing Hodgkins
Lymphoma s/p chemo, refractory paroxysmal a.fib w/RVR, ileus,
pericardial effusion requiring window and pleural effusions, who
p/w Afib w/ RVR after being discharged on [**2144-9-18**] to rehab
following hospitalization for tachypnea and increased O2
requirement.
This past hospitalization was complicated by refractory afib
with RVR requiring amiodarone ggt for conversion, GNR bacteremia
with ecoli, enterobacter, and two species of klebsiella,
recurring ileus necessitating rectal tube decompression, herpes
simplex ulceration of the mouth and hypercarbia and somnolence
requiring intubation.
At Rehab, she was noted to be in afib RVR 140s with HR 120-150,
SBP 100-115/40-50, 20, 97 room air. On readmission, she was
given a bolus of 150mg IV amiodarone given with minimal response
(rate in 120s, SBP 90). Cardiac U/S showed pericardial fluid.
Cardology was consulted, and recommended IVF (given 1300cc) and
beta blockade once pressure had stablized. She was given Cipro
and fluconazole in the ED, and then transferred to the [**Hospital Unit Name 153**] for
monitoring and further management of low BP and Afib/RVR.
Past Medical History:
Oncologic history:
She was admitted to [**Hospital6 2561**] on [**2144-6-12**] with SOB. An
echo showed pericardial effusion with no evidence of tamponade.
She was found to have an elevated CRP and negative [**Doctor First Name **] and RF.
She was discharged with recommendations for a short interval
follow up and recomendation for pericardiocentesis.
.
She was admitted to [**Hospital1 18**] on [**2144-6-22**] for evaluation of
abdomenal distention in the setting of recent dx of pericardial
effusion and iron def anemia. CT on admission showed pericardial
effusion with evidence of tamponade. Pericardiocentesis on
[**2144-6-24**] produced 510mL of serosanguinous fluid with
predominantly lymphocytes, a few mesothelial cells and blood but
no malignant cells. Given these findings a full malignancy
work-up was done. CT torso ([**2144-7-6**]) showed diffuse
lymphadenopathy, diffuse colonic thickening and incresing
abdominal distention which was thought to be functional by both
radiology and GI, and was relieved by rectal tube. FNA biopsy of
a left axillary lymph node on [**2144-6-30**] was non diagnostic. She
was discharged on [**2144-7-7**] with instructions to see her PCP
within [**Name Initial (PRE) **] week for excisional LN biopsy.
.
on [**2144-7-16**] she represented to [**Location (un) 745**] [**Hospital 3678**] Hospital and was
transferred to [**Hospital1 18**] with hypoxia, pleural effusion and
pericardial effusion. Excisional LN biopsy of a L
supraclavicular LN showed classical Hodgkin's lymphoma.
Thoracentesis was attempted, but unsuccessful. Her labs at that
time showed WBC 12.6 with 98% PMN and 2% Ly, Hb 8.3, HCT 28.1,
PLT 472K, ESR 107 and Albumin 3.0. Of note, EF is >55%. CTA
chest was negative for PE but did reveal a mass compressing SVC.
Patient continued to be hypoxic to the 80's on 100% face mask
and had persistent Afib w/RVR to 140s. She was transferred to
the [**Hospital Unit Name 153**] because of increased bedside nursing care needs.
.
In the [**Hospital Unit Name 153**] she was started on a modified EACoPP protocol on
[**2144-7-21**] with cytoxan, doxorubicin on day 1 and etoposide days
[**2-13**]. Her ICU course was complicated by paroxysmal Afib with RVR.
On [**2144-7-23**] she was started on amiodarone and metoprolol and was
eventually rate and rhythm controlled. On [**2144-7-24**] she became
more somnolent with ABG showing PCO2 of 81. A thoracocentesis
drained 1.6L of fluid which showed "many small lymphocytes and
scattered reactive mesothelial cells." The fluid culture and
Gram stain were sterile. She was intubated for 3 days and
extubated one day prior to transfer to BMT.
- Xfer to [**Hospital Unit Name 153**] on [**7-25**] for AFib with RVR and hypotension
with pulse 160s and SBP to 80s. She was restarted on amio IV and
spontaneously converted to NSR. Her BP stabilized while in
sinus. Her pulsus was recorded as 4 but she did have pulmonary
congestion and distended neck veins. An echo was obtained which
showed RV and RA collapse w tamponade physiology.
- On [**2144-8-24**], cardiac surgery was urgently consulted
following the echo that revealed significant pericardial
effusion and right ventricular collapse. Given those findings,
she was brought to the operating room where Dr. [**Last Name (STitle) **] performed
urgent pericardial window. She tolerated the procedure well and
there were no complications. Approximately 150 cc of clear fluid
was removed and sent for cytology. Following the operation she
was brought to the CVICU for monitoring. Within 24 hours, she
was extubated without incident. She was maintained on Amiodarone
and beta blockade for intermittent atrial fibrillation. TPN was
continued for her chronic ileus. Her CVICU course was otherwise
uneventful and she transferred to the SDU on postoperative day
one. She continued to experience atrial fibrillation. Her
mediastinal chest tube was eventually removed on [**2144-8-31**]. She
eventually transferred back to the BMT service on
[**2144-9-2**].
.
OTHER PAST MEDICAL HISTORY
- Nodular sclerosing hodgkin's disease s/p ICE
- h/o pericardial effusion s/p drainage; path/cytology
inconclusive
- h/o paroxysmal a-fib w/ RVR s/p pericardiocentesis; no
anticoagulation 2/2 blood pericardial effusion
- Mental retardation of unknown etiology.
- h/o ileus requiring occasional rectal tube
- Status post volvulus and sigmoid resection.
- DJD
- Bilateral knock knees (talus valgus, pes planus).
- Neurodermatitis.
- Psoriasis.
- History of obesity.
- Status post left oophorectomy.
- microcytic, iron deficiency anemia, recently started on iron
- GERD
- S/p left nephrectomy
Social History:
nonsmoker, nondrinker, lives at long term care facility- [**Last Name (un) 18355**]
Center for mentally disabled. Her HCP is her brother [**Name (NI) **].
Family History:
Father died of prostate cancer but also had CAD w/CABG and colon
cancer. A maternal aunt had ovarian and breast cancer. MI and
CAD throughout family on both sides. Mother is still living.
Physical Exam:
Gen: conversational mimicking voice, follows commands, NAD,
Oriented x 1.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pale, MMM mildly dry, poor dentition.
Neck: difficult to assess JVP
CV: irregularly irregular, No m/r/g
Chest: Decreased BS at bases but otherwise clear, breathing
comfortably
Abd: midline scar noted, distended, tympanic to percussion, no
tenderness to palpation, soft
Ext: 1+ edema
Skin: macular areas of hypopigmentation on chest and arms BL,
small psoriatic appearing area on right forearm.
Pulses:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Neuro: CN II-XII grossly intact, moving all 4 ext spontaneously,
follows commands.
Pertinent Results:
CBC
[**2144-9-19**]: WBC-3.6*# RBC-2.62* HGB-8.4* HCT-24.5* MCV-93 MCH-32.2*
MCHC-34.4 RDW-18.9*
[**2144-9-18**] WBC-19.2* RBC-2.30* HGB-7.2* HCT-21.6* MCV-94 MCH-31.5
MCHC-33.4 RDW-19.5*
Chem7
[**2144-9-19**]: GLUCOSE-105 UREA N-12 CREAT-0.2* SODIUM-138
POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-25 ANION GAP-9 CALCIUM-7.7*
PHOSPHATE-2.0* MAGNESIUM-2.0
[**2144-9-18**]: GLUCOSE-130* UREA N-11 CREAT-0.3* SODIUM-135
POTASSIUM-2.9* CHLORIDE-102 TOTAL CO2-28 ANION GAP-8
Micro
[**2144-9-19**] 03:13AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-TR
COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.022
RBC-[**4-15**]* WBC-[**7-21**]* BACTERIA-FEW YEAST-FEW EPI-0 URIC ACID-FEW
MUCOUS-RARE
Cardiac enzymes:
[**2144-9-19**] 03:00AM CK(CPK)-31 CK-MB-3 cTropnT-<0.01
Coags
[**2144-9-19**] 03:00AM PT-12.9 PTT-24.5 INR(PT)-1.1
Brief Hospital Course:
59F with mental retardation w/ recent dx of Nodular sclerosing
Hodgkins Lymphoma s/p chemotherapy, admitted with Afib and RVR
of unclear precipitant.
.
# Atrial fibrillation with RVR: The patient initially presented
with A fib with RVR and hypotension and thus was admitted to the
[**Hospital Unit Name 153**] (please see [**Hospital Unit Name 153**] #1, below). She received an Amiodarone
drip and was brought under control before returning to the
floor, having returned to sinus rhythm and on amiodarone and
metoprolol. Unfortunately, she returned to atrial fibrillation
with RVR. She was not hemodynamically unstable, but her atrial
fibrillation was quite difficult to control and her rate didn't
decrease despite multiple doses of IV metoprolol. At that time
the treating team was unwilling to give IV calcium channel
blockers as the patient had experienced profound hypotension
when treated with them in the past. Thus, she was transferred
back to the [**Hospital Unit Name 153**] again briefly to receive another IV amiodarone
load, after which she once again returned to the floor on
increased metoprolol dosing and an oral amiodarone load
schedule. After her return to the floor she continued to have
long periods of atrial fibrillation of up to 7 hours at a time
that was not responsive to IV beta blockers by push. Each time
she spontaneously converted back to sinus. Finally, after
maximizing her dose of beta blocker the patient was started on
oral calcium channel blockers and remained in sinus rhythm
thereafter. Patient was transferred back to the [**Hospital Unit Name 153**] for
respiratory distress that required intubation (please see [**Hospital Unit Name 153**]
#2, below). Patient had low blood pressures at that time. She
continued PO amiodarone, however metoprolol and calcium channel
blocker were held. After extubation for improved respiratory
status, patient was restarted on her low dose metoprolol with
hold parameters for heart rate and blood pressure. Thereafter,
on PO metoprolol, diltiazem, and amiodarone she remained in NSR
with stable hemodynamic parameters.
.
Late in her hospital stay, while stable, an EKG demonstrated a
long QT interval >500. There was no evidence of ventricular
arrhythmia on telemetry. The cardiology consulting service
evaluated the patient and felt that the QT was likely due to her
relatively high dose of amiodarone. Given her stability,
however, the decision was made to continue with [**Hospital1 **] dosing of
amiodarone during her hospital stay. Upon discharge, she has
follow-up arranged with a cardiologist who will consider
tapering this medication.
.
#Neutropenic fever: The patient had a fever during her
neutropenic period from her first cycle of ICE (axillary temp of
99.5 = oral temp of 100.4). She also had a new left upper lobe
infiltrate at this time and thus was initially started on
cefepime, vanco for empiric treatment of neutropenic fever. The
cefepime was changed to Pipercillin/Tazobactam on the day after
this over concern of sacral skin breakdown in the context of
fecal incontinence over concern for fecal soiling and to gain
greater anerobic coverage. She was seen by pulmonary who raised
concern for fungal infection over the appearance of the lung
infiltrate but as patient remained afebrile her coverage was not
broadened. Her B-glucan and galactomannan assays were negative.
Coverage was discontinued after 10 days of no longer being
neutropenic. Patient was not febrile again. On transfer to the
[**Hospital Unit Name 153**] patient was febrile and hypotensive. With concerns for
possible septic picture patient was started on broad spectrum
antibiotic coverage. Her fevers resolved, and her antibiotics
were discontinued when she was no longer neutropenic.
.
#Hypoxia: Patient had onset of hypoxia needing 2-4L of O2 by
nasal cannula in order to maintain sats >92% during her second
ICU stay. CT chest was obtained and showed new left upper lobe
infiltrate as well as large pleural effusions bilaterally. Her
pneumonia was treated (as above) but thoracentesis deferred as
she was thrombocytopenic at that time. As her hypoxia resolved
with treatment of her probable pneumonia and was resolved by the
time her thrombocytopenia resolved we did not pursue
thoracentesis further. Patient had repeated episode of hypoxia
which resulted in repeat transfer to the [**Hospital Unit Name 153**], felt to be due
likely due to aspiration & mucus plugging in the setting of
depressed mental status, coughing and emesis. Maintained vent
setting of [**6-15**] 40% FIO2 for over 24 hs then successfully
extubated. Initial extubation failed, placed again on vent.
Secondary extubation successful with pretreatment with IV
steroids. A component of pulmonary edema thought to contribute
to respiratory compromise, so she was diuresed for several days.
Thereafter, diuresis was stopped and volume status remained
stable.
.
In the weeks prior to discharge, Ms. [**Known lastname 78644**] oxygen
saturation remained 92-95% on room air, and she was apparently
comfortable. Repeat chest xray showed persistent bilateral
pleural effusions that were stable. The interventional
pulmonology team advised that no intervention be performed given
the stability of the finding. She will follow up with them as
an outpatient.
.
# Hemopericardium: Given the patient's history of
hemopericardium there was initially concern this could be
contributing to her difficult to control A fib despite the fact
she had a pericardial window in place. Repeat echocardiograms
in this hospitalization continued to show a small,
hemodynamically insignificant pericardial effusion. No
intervention was performed.
.
# Lymphoma: NSHL as per pathology from supraclavicular LN
biopsy. During this hospitalization the patient nadired from
her first cycle of ICE and completed her second cycle. Pt is
s/p EACoPP protocol on [**2144-7-21**] with cytoxan, doxorubacin on day
1 and etoposide on days [**2-13**]. Pt has also had pericardial
tamponade s/p pericardiocentesis on [**2144-6-24**] and pericardial
window on [**2143-7-25**] as above. Pt initiated ICE chemo reg on
[**2144-10-9**]. She was given transfusions as needed. Twenty
sessions of XRT to mediastinal mass was administered without
complications.
.
# Ileus/abdominal distention: The patient has a long history of
an ileus/abdominal distension (?s/p ileal and sigmoid resection)
and this was a constant concern throughout her hospitalization,
has large dilated loops on portable film. Suspicion is for
hirschprung-like syndrome but no official diagnosis is known.
With frequent repositioning this remained stable on exam,
without apparent pain. PO vancomycin was continued. The
infectious disease consulting service advised that this
medication be tapered and eventually as an outpatient after her
course of Bactrim had been completed in order to avoid the
development of resistant organisms.
.
# Urinary tract infection: The patient had an indwelling
catheter throughout her stay. Late in the course of her time in
the hospital, while she was hemodynamically stable, her urine
was noted to be cloudy. Cultures grew ESBL-producing E Coli.
She was initially treated with meropenem. The catheter was
changed, and the urine became sterile. A 5-day course of
Bactrim was recommended by the consulting infectious disease
course, to be completed at her rehab facility.
# Speech and swallow: Because aspiration was thought to have
contributed to her respiratory distress, she was initially given
tube feeds after extubation. Later, she was able to tolerate
advancing POs with supervision. The speech and swallow
consultants recommended that she continue indefinitely on a diet
of soft solids.
# Access: The patient had multiple PICCs and peripheral IVs
placed for access, which she repeatedly pulled out. A PICC was
placed prior to discharge.
[**Hospital Unit Name 153**] course #1:
On arrival to the ICU, pt was in acute respiratory distress with
sats in 70s. Sats came up to low 90s on the NRB but pt
continued to have increased work of breathing, not moving air
well bilaterally. Decision was made to intubate for resp
distress. ETT was placed successfully, no issues with
hypotension. Her hypoxia was thought to be due to aspiration
and mucus plugging in the setting of depressed mental status.
The patient was maintained on mechanical ventilation and
assessed daily for ability to extubate and her sedation was
weaned as tolerated. Exacerbating her pulmonary pathology was
fluid overload, and a goal of 1-2L negative/day was set to
relieve the pulmonary edema complicating her clinical status. On
[**10-15**], the patient was thought fit for extubation. She did well
for several hours on CPAP but began to tire out and needed to be
reintubated. The patient tolerated this well however within a
short time after being reintubated her blood pressure dropped
and she spiked a fever. Concern for sepsis arose and she was
given IV fluids and levophed for BP control. She was
pan-cultured and broad spectrum antibiotics were continued. Less
than 12 hours later she was taken off pressors and remained
hemodynamically stable.
The patient was pan-cultured; her blood cultures remained
negative, her sputum grew out yeast as did her urine. She was
maintained on her prophylactic antibiotics and broad coverage
while her cultures were pending. She became neutropenic during
this admission, which fell in line with her chemotherapy nadir.
She was continued on antibiotics during this time while her
counts rose.
The patient repeatedly went in and out of atrial fibrillation
during this admission. Her heart rate was also found to be quite
labile, ranging from 40-140s within one day's time, while
maintaining stable blood pressures and remaining asymptomatic.
She was continued on amiodarone throughout her stay and kept on
telemetry. She was retarted on metoprolol PO once her blood
pressure could tolerate.
[**Hospital Unit Name 153**] course #2 ([**Date range (1) 41899**]):
Patient was admitted to the [**Hospital Unit Name 153**] in acute respiratory distress
again. Patient did not require intubation. Patient with large
pleural effusion which was tapped via thoracenetesis. Patient
was also continued to be aggressively diuresed with IV lasix.
Patient was initially on shovel mask and face mask and with
thoracentesis, agressive chest PT was able to be transitioned
back to 2L NC which was her baseline on previous [**Hospital Unit Name 153**] discharge.
In addition, cardiology consult was obtained for persistent
atrial fibrillation. Question as to whether or not to start
digoxin. Cardiology reccomended maximizing current medications
which include amiodarone and diltiazem prior to initiating
another [**Doctor Last Name 360**]. Diltiazem was uptitrated to 60 QID which patient
tolerated well without incident. In addition, WBC trended
upward and as of [**10-30**] patient was no longer neutropenic. As
patient has completed more than necessary course of antibiotics
and no longer neutropenic, d/c Vanco, Cefepime, caspofungin.
Continued regimen for c. diff (with previous history of c. diff)
with plan to keep c. diff treatment on for 14 days after last
dose of other antibiotics. Patient got additional dose of
neulasta in order to ensure that pt not neutropenic. She was
transferred back to the BMT service for continued treatment of
lymphoma.
Medications on Admission:
Acetaminophen 650 mg PO prn
Linezolid 600 mg PO Q12H for 3 days for uti
Ceftriaxone-Dextrose 1 gram/50 mL 1 IV Q24H for 1 days for UTI
Furosemide 20 mg Injection [**Hospital1 **]
Amiodarone 200 mg PO BID
Filgrastim 300 mcg/mL One (1) Injection Q24H
Heparin, Porcine (PF) 10 unit/mL Syringe 2 ML Iv PRN for
flush
Insulin Lispro 100 unit/mL Solution 1 Subcutaneous ASDIR
Metoclopramide 5 mg Injection Q6H prn
Simethicone 80 mg Tablet PO TID
Camphor-Menthol 0.5-0.5 % Lotion Topical QID prn itching
Metoprolol Tartrate 25 mg PO BID
Vancomycin 250 mg PO Q6H
Heparin 5000 units Injection TID
Nystatin 100,000 unit/mL 5 ML PO QID
Acyclovir Sodium 400mg Recon Solns Intravenous Q8H
Pantoprazole 40 mg Recon Soln
Ondansetron HCl (PF) 4 mg/2 mL Solution prn; 75ml/hr [**2-12**] normal
saline
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
four times a day: Please hold for SBP <100, HR <50.
5. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO every six
(6) hours.
6. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day): Please hold for SBP <100, HR <50.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily):
Please hold for SBP <100.
9. Pantoprazole 40 mg Susp,Delayed Release for Recon Sig: One
(1) PO once a day.
10. Prochlorperazine Maleate 5 mg Tablet Sig: One (1) Tablet PO
Q8H (every 8 hours) as needed for nausea.
11. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 5 days: day 1 [**2144-12-2**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary Diagnosis:
--------------------
Pericardial effusion s/p pericardial window
Atrial fibrillation with rapid ventricular response
Nodular sclerosing hodgkins disease D+8 of ICE
Secondary Diagnoses:
- mental retardation of unknown etiology
- h/o ileus requiring occasional rectal tube
- Status post volvulus and sigmoid resection.
- DJD
- Bilateral knock knees (talus valgus, pes planus).
- Neurodermatitis.
- Psoriasis.
- History of obesity.
- Status post left oophorectomy.
- microcytic, iron deficiency anemia, recently started on iron
- GERD
- S/p left nephrectomy
Discharge Condition:
afebrile, vital signs stable
Discharge Instructions:
You were admitted to the hospital because of a fast heart rate
and low blood pressure. You were in the intensive care unit
several times to help manage this. New medications were started,
and your heart, blood pressure, and breathing all improved. You
then stayed in the hospital for several weeks to receive
radiation therapy for your lymphoma.
Your medications have been changed.
Please stop the following medications:
linezolid
ceftriaxone
furosemine
filgrastim
insulin
metoclopramide
simethicone
nystatin
The following medications have been added:
lisinopril
docusate
diltiazem
prochlorperazine as needed for nausea
bactrim for 5 days
Please keep all follow-up appointments as these are important to
help maintain your health.
Please call your doctor or come to the emergency room if you
have shortness of breath, chest pain, temperature >100 F, or any
concerning changes in your health.
Followup Instructions:
[**2144-12-24**]:
Cardiology Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2144-12-14**] 3:20
[**2144-12-29**]:
Pulmonary Provider: [**Name10 (NameIs) 17853**] CLINIC INTERVENTIONAL PULMONARY
(SB) Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2144-12-29**] 1:00
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 5072**] Date/Time:[**2144-12-29**]
2:00
[**2145-1-1**]
Oncology Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4380**], MD Phone:[**Telephone/Fax (1) 3237**]
Date/Time:[**2145-1-1**] 4:00
Provider: [**Name10 (NameIs) 11021**] [**Name11 (NameIs) 11022**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2145-1-1**] 4:00
Completed by:[**2144-12-8**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[
[
[]
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21531, 21610
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337, 386
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19668, 20475
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22284, 23183
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6635, 7294
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21836, 22208
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8081, 8204
|
283, 299
|
414, 1600
|
21650, 21815
|
1622, 6240
|
6256, 6413
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,172
| 132,145
|
8910
|
Discharge summary
|
report
|
Admission Date: [**2117-6-6**] Discharge Date: [**2117-6-15**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1436**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This [**Age over 90 **] year old male presents with shortness of breath.
He has a history of congestive heart failure with EF of 35%,
coronary artery disease with most recent PCI in [**3-/2116**] w/ DES in
proximal
LAD and stent in RCA, atrial fibrillation, and a history of
abdominal aortic aneurysm (dimensions unknown).
He presents with several weeks of shortness of breath that is
more significant than his baseline dyspnea, characterized by
long pauses between sentences. He has been instructed to use
oxygen at night but does not do so. On morning prior to
admission, his visiting nurse noted an O2 sat of 78% with atrial
fibrillation to rates in the 150s. He presented to the ED. In
the ED he was initially placed on a non-rebreather which was
quickly weaned to 2 L NC. Saturations were near 100%. Chest
x-ray revealed no pulmonary edema; lower extremities were not
edematous. A hematocrit was obtained at 24% which is 10 points
below his normal - 5 days ago his HCT was 32%. Over the past
several months, his MCV has decreased and his platelet count has
trended up. He has been constipated for the past week until
this morning when he had a milk of magnesia enema; he moved lots
of stool but unclear if blood was noted.
Also of note - he has been having difficulty swallowing water -
such that he feels it gets stuck halfway down his esophagus, at
times causing him to choke or regurgitate. He no longer
swallows solids. These symptoms have been present for > 1 week
but probably less than 1 month. For this reason, he has been
eating canned soups with high salt load - his shortness of
breath has worsened over this period with intermittent orthopnea
and lower extremity edema.
Recently he was in the CCU for IV diuresis - he was discharged
on an increased dose of lasix and his lisinopril was held in the
setting of hypotension; a beta blocker was also considered given
his PACs which were potentially contributing to his hypotension
however this was held because of his recent hypotension as well.
Currently upon transfer to the MICU he is feeling well, with no
dyspnea that he reports, although between sentences he must
pause. Denies orthopnea, PND, lower extremity swelling,
syncope, dizziness, chest pressure or palpitations. No cough,
hemoptysis, hematemesis, melena, abdominal pain. Review of
systems only positive as above (dysphagia, resolved
constipation, intermittent shortness of breath).
His vitals at time of transfer are BP of 78/40, HR 120, RR 16,
O2 sat 95% on 2 L, and temp 98.
Past Medical History:
Diabetes mellitus
CAD s/p stenting RCA and LAD, last cath 4 yrs ago
Hypercholesterolemia
Hypertension
Senile purpura
Colon cancer s/p colon resection and s/p splenectomy [**2083**]
Macular degeneration, left eye
Osteoarthritis
Mild Aortic stenosis (valve area 1.2-1.9)
Squamous Cell Carcinoma
Osteoarthritis
BPH
Abdominal Aortic Aneurysm
Social History:
Lives at home alone in [**Location (un) **]; he has a visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 30969**]r that comes once a week. He has been married for 63
years. He is a retired
newspaper printer. Remote history of smoking 20pack years. No
alcohol. Has a daughter and has a son who is an ophtamologist
in CT.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM
BP of 78/40, HR 120, RR 16, O2 sat 95% on 2 L, and temp 98.
Gen: Caucasian male, sitting up in bed, pleasant, alert and
oriented X 3, appropriate to conversation
HEENT: Conjunctival pallor, skin looks somewhat pale as well to
family members, oropharynx clear
Cardiac: [**Name (NI) 22116**] to level of jaw, no murmurs appreciable,
tachycardic, irregular rate
Pulm: dry crackles at bases bilaterally
Abd: soft and nontender with no distension, normal bowel sounds
Ext: no edema appreciable
Discharge PHYSICAL EXAMINATION
Vitals: T: 98.2, BP: 99/66, HR 96 (88-114), RR 16-20, O2: 97%
RA.
Admit wt 66.7 kg
Gen: Pleasant, calm, NAD, charming,
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Supple, No LAD. [**Name (NI) 22116**] 10 cm. Normal carotid upstroke.
CV: RRR. normal S1,S2. III/VI harsh mid peaking
crescendo/decrescendo murmur with preserved S2 at the RUSB with
radiation to the neck. II/VI blowing HSM at the LLSB and apex.
LUNGS: Breath sounds bilaterally, no rhonchi, fine inspiratory
crackles.
ABD: NABS. Soft, NT, ND.
EXT: WWP, 1+ LE edema.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Non-focal
Pertinent Results:
I) ADMISSION LABS
[**2117-6-6**] 12:27PM BLOOD WBC-11.2* RBC-2.99* Hgb-6.9* Hct-24.5*
MCV-82 MCH-23.2* MCHC-28.3* RDW-22.4* Plt Ct-426
[**2117-6-6**] 12:27PM BLOOD Neuts-83.1* Lymphs-10.5* Monos-6.0
Eos-0.1 Baso-0.3
[**2117-6-6**] 12:27PM BLOOD PT-13.8* PTT-23.8* INR(PT)-1.3*
[**2117-6-6**] 12:27PM BLOOD Glucose-319* UreaN-84* Creat-1.5* Na-140
K-5.0 Cl-100 HCO3-26 AnGap-19
[**2117-6-8**] 04:23AM BLOOD CK(CPK)-41*
[**2117-6-6**] 12:27PM BLOOD proBNP-[**Numeric Identifier 30970**]*
[**2117-6-6**] 12:27PM BLOOD cTropnT-0.03*
[**2117-6-6**] 12:27PM BLOOD Iron-13*
[**2117-6-6**] 03:45PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.014
[**2117-6-6**] 03:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-TR Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2117-6-6**] 03:45PM URINE
II) Imaging:
RESTING DATA
EKG: SINUS FREQ. ISOLATED ABPS AND VPBS.
HEART RATE: 73 BLOOD PRESSURE: 110/60
PROTOCOL
STAGE TIME SPEED ELEVATION [**Doctor Last Name 10502**] HEART BLOOD RPP
(MIN) (MPH) (%) RATE PRESSURE
1 0-4.5 5MCG/ KG/MIN 114 96/56 [**Numeric Identifier 30971**]
TOTAL EXERCISE TIME: 4.5 % MAX HRT RATE ACHIEVED: 89
SYMPTOMS: NONE
ST DEPRESSION: NONE
INTERPRETATION: This [**Age over 90 **] year old man with a PMH of old MI, PCI,
AS,
CHF, DM2 and AF was referred to the lab for evaluation of aortic
valve
function. The patient was infused with 5 mcg/kg/min of
dobutamine over
4.5 minutes as was stopped for achieving target workload. No
arm, neck,
back or chest discomfort was reported by the patient throughout
the
study. There were no significant ST segment changes during the
infusion
or in recovery. The rhythm was sinus with frequent isolated
apbs, vpbs
and several ventricular couplets. Appropriate hemodynamic
response to
low dose dobutamine infusion.
IMPRESSION: No symptoms, ischemic EKG changes or sustained
ectopy.
Echo report will be sent separately.
DSE:
The left ventricular cavity is moderately dilated. Overall left
ventricular systolic function is severely depressed (LVEF=
20-25%). Right ventricular chamber size and free wall motion are
normal. There is critical aortic valve stenosis (valve area
<0.8cm2). Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.]
IMPRESSION: Severely depressed left ventricular systolic
function - only the basal segments have appreciable systolic
function. The aortic valve is likely severely stenotic. Prior to
dobutamine gradient across the valve was as high as 60mm Hg peak
and 33mm Hg mean after an atrial premature contraction with
consequent prolonged ventricular filling. This suggested that
the valve was intrinsically stenotic. This was confirmed with
low-dose dobutamine when average LVOT velocities increased from
0.5 m/s to 0.7m/s and average AV velocities from 2.7m/s to
3.5m/sec. Again, after a VPC, peak gradient was as high as 73 mm
Hg and mean 41mm Hg.
US Doppler:
HISTORY:
82-year-old man with right upper extremity DVT, PICC line
removed, assess
progression of DVT.
COMPARISON: Right arm ultrasound [**2117-6-12**].
FINDINGS:
Grayscale, color and Doppler images were obtained of the right
IJ, subclavian,
axillary, brachial and basilic veins. Note is made that the
right cephalic
vein could not be identified.
Occlusive thrombus is seen again within the right axillary vein
and in one of
the two right brachial veins. Additionally, on today's exam the
right basilic
vein demonstrates occlusive thrombus. These veins do not
compress and do not
demonstrate vascular flow on color Doppler imaging.
No thrombus is seen within the right subclavian vein or within
the right IJ.
IMPRESSION:
Continued appearance of deep vein thrombosis within the right
axillary vein
and within one of the two right brachial veins. Additionally
DVT is seen
today within the right basilic vein.
Discharge:
[**2117-6-15**] 07:27AM BLOOD WBC-10.6 RBC-2.92* Hgb-8.2* Hct-27.4*
MCV-94 MCH-28.2 MCHC-30.1* RDW-24.1* Plt Ct-260
[**2117-6-15**] 01:15PM BLOOD Hct-27.3*
[**2117-6-8**] 03:09PM BLOOD Ret Man-3.4*
[**2117-6-15**] 07:27AM BLOOD Glucose-130* UreaN-31* Creat-1.0 Na-139
K-4.1 Cl-110* HCO3-21* AnGap-12
[**2117-6-15**] 07:27AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.0
[**2117-6-9**] 03:55AM BLOOD Hapto-108
[**2117-6-8**] 03:09PM BLOOD Folate-18.6
[**2117-6-6**] 12:27PM BLOOD calTIBC-347 VitB12-489 Ferritn-25*
TRF-267
Pending: None
Brief Hospital Course:
[**Age over 90 **]M with CAD, ischemic cardiomyopathy, aortic stenosis, atrial
fibrillation, chronic occult bleed, who presented to [**Hospital1 18**] with
hypoxia and shortness of breath in the setting of afib with RVR
and anemia who has an ongoing bleed of probable GI pathology.
[**Age over 90 **] year old male with a past medical history signficant for
colon cancer resection and splenectomy ([**2083**]), AAA, CAD,
ischemic cardiomyopathy, atrial fibrillation, and severe aortic
stenosis who presented to [**Hospital1 18**] with hypoxia and shortness of
breath in the setting of atrial fibrillation with RVR and
anemia. Initially the patient was admitted to the MICU secondary
for concern for hypotension. In the MICU, a PICC was placed for
central access and he was started on pressors. He was
asymptomatic with blood pressures in the 70s-80s. He was noted
to be anemic. He was transfused 2 units. Following a small
amount of diuretics the patient was no longer in atrial
fibrillation. He was subsequently sent to the cardiology service
for workup of his aortic stenosis. Dobutamine stress echo showed
a valve area of .8 and an EF of 25%. The patient patient
continued to have an on-going bleed. His stools were guiac
positive but negative for melena or bright red blood. For this
reason, GI believed that it was highly unlikely that his
bleeding was GI in nature as he was receiving approximately one
unit per day. Losing more than 100cc of blood in a day results
in frank melena or blood in the stool. However, this was moot
point as the patient did not want invasive procedures (i.e.
colonoscopy). The patient was noted to have an upper extremity
dvt secondary to his PICC line. The picc line was pulled and he
was started on anticoagulation which resulted in more rapid
bleeding. Of note, there was no hemodynamic instability.
Anticoagulation was held and plavix was reduced to 81mg. A goals
of care meeting was held with the family (please see OMR notes
for full detail). The patient and his family decided that he did
not want further workup for his anemia, cardiac disease, or UE
DVT. He wanted to enjoy the rest of his productive life at home
with his family. After stopping the various blood thinning
medications, his hct remained stable and he was discharged home
with the instructions to follow up with his pcp for possible
transfusions in the future to manage his symptoms.
Anemia:
Patient with HCT of 24 without anticoagulation. One week ago his
HCT was 33. Patient is guaic positive. Patient with guiac
positive stool on DRE and stool sample x 2. No signs of frank
melena or hematochezia. Patient has required 5 units and
continues to drop hct. GI bleed is certainly a culprit, however,
anemia likely multifactorial. Suboptimal reticulocyte count
indicating an insufficient marrow response. Patient is currently
transfusion dependent. Given his cardiovascular status, it is
diffult to ascertain if patient could even safely undergo bowel
prep and colonoscopy with severe heart disease. Discussion with
the patient is that he would not want a GI procedure and as long
as his bleed were to slow down enough to to the point where he
could safely receive transfusions as an outpatient, he would
greatly prefer that.
-Symptomatic transfusions
-Iron supplementation
RUE Swelling: Patient with PICC in the RUE. New onset right
sided swelling compared to left. Ultrasound confirmed RUE DVT.
Patient has not had any increased swelling. Positive radial
pulses, no distal parathesias. Given the patients ongoing bleed
and greatly elevated PTT will hold heparin for this morning
until repeat crit. Discussion with patient is that he does not
want ongoing anticoagulation secondary to the frequent blood
tests.
Chronic CHF:
Patient appears well compensated from a volume standpoint. He is
euvolemic. Given his ischemic cardiomyopathy with depressed EF
the patient could benefit from a beta blocker for his
tachycardia and decreased EF. However, we are currently limited
by his hypotension.
Currently holding beta blocker/ace inhibitor in order to avoid
symptomatic hypotension.
[ ] Holding heart failure medications in the setting of
hypotension.
Note Date: [**2117-6-14**]
Signed by [**Name6 (MD) 488**] [**Name8 (MD) **], MD on [**2117-6-14**] at 5:38 pm
Affiliation: [**Hospital1 18**]
Today, I met with Mr. [**Known lastname 30968**] and discussed treatment options
and goals of care and I also met with the patient and his 3
children (health care proxy present) to discuss goals of care
going forward.
Mr. [**Known lastname 30968**] has coronary artery disease, severe aortic
stenosis,
with an LVEF of 25%. He has worked with physical therapy
extensively and he is able to ambulate on room air 25 to 50 feet
(which has been his baseline). He is currently very comfortable
on room air and prior to this hospitalization, reports having a
very good quality of life and enjoys the company of his family
and is very high functioning in his ADL's with given the
severity
of his AS. During this hospitalization, the patient has had
transfusion dependent anemia. He likely is bleeding from a GI
source but this is unclear. Unfortunately, during this
hospitalization, he has developed a RUE DVT associated with PICC
line.
The risks vs. benefits of anticoagulation for this patient (who
has a chronic slow bleed) were discussed. The family was
informed
that there was a definite risk of life threatening pulmonary
embolus without anticoagulation. They were also informed that
anticoagulation has risks of major bleeding. With regards to the
DVT the patient and his family wanted to treat this very
conservatively. It was mutually decided upon that the risks of
anticoagulation are high. Therefore, an ultra-sound would be
preformed to monitor for the evolution of the clot. If this clot
was progressing or symptomatic (causing swelling, numbness, ect)
then anticoagulation would be re-considered. However, if the
clot
appeared stable the patient and family would like to not
anticoagulate and take the risk that the patient might develop
complications from the DVT (such as PE or swelling, numbness
ect).
The patient's anemia was also adressed. He has an ongoing bleed
of unclear etiology (probably GI related). The patient and his
family did not want colonoscopy. The patient and his family want
for the patient to be able to go home and carry-on with his
life.
The patient and family and health care provider would like to be
sure that the rate of bleeding was slow enough that he could
safely go home and would have his hct followed up in 48 hours by
his PCP. [**Name10 (NameIs) 3754**] was also the understanding that the patient may
require transfusions down the road.
All the patient's questions were answered. THe patients family's
questiosn were answered. Senior resident Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] confirmed
these wishes.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD
pgy1 [**Numeric Identifier 30972**]
Note Date: [**2117-6-15**]
Signed by [**Name6 (MD) **] [**Name8 (MD) **], MD on [**2117-6-15**] at 7:25 pm Affiliation:
[**Hospital1 18**]
Dr. [**Last Name (STitle) **]
I hope all is well.
Following up on our last conversation. Mr. [**Known lastname 30968**] looks
spectacular. His HCT is 27. We gave him 1 u of RBC for a HCT of
24 yesterday and then it was 27 this AM and this afternoon. We
talked it over with Mr. [**Known lastname 30968**] and his daughter/HCP and I
wanted to relay to you the upshot. Obviously, though, a full DC
summary shall be available for your review shortly.
1. He wanted to go home and avoid a colonoscopy. As you know, we
believe that he was bleeding from an unknown source exacerbated
by aspirin and plavix and later heparin (for his upper DVT). We
believe and explained to him that he will continue to bleed but
we are hopeful that this will be slow enough such that iron
supplementation and transfusions prn can help. I confronted him
with the possibility that he might bleed quickly and not make it
to a transfusion, that this might "result in his death" - he
understood that and was at peace with the possibility. He
understood that this condition limits his life expectancy. We
discharged him on asprin 81
- For your upcoming appt, please consider checking a HCT,
adjusting his iron regimen (IV?) and arranging transfusions.
Perhaps you could also consider bridging him to a hospice VNA
2. The DVT. He had a PICC associated DVT and was heparinized. We
discussed it with him and laid out the risks and benefits.
Giving
the bleeding experience, we supported his choice to forego
anticoagulation. We took serial ultrasounds and discussed the
matter with a vascular specialist who recommended following the
UE DVT for extension. I explained to Mr. [**Known lastname 30968**] that extension
meant that a clot could go to his lungs and "kill you". Again, I
supported his choice to forego anticoag on account of the
bleeding risk.
He has been a true pleasure to care for and has been very
appreciative and satisfied with his hospitalization. He will see
you on thursday.
Thanks again
ET
[**First Name11 (Name Pattern1) 5279**] [**Last Name (NamePattern1) 30973**] MD
Senior Resident, Internal Medicine
[**Hospital1 69**]
Medication Changes
1. Please start IRON 325mg once a day
2. Please start colace 200mg once a day
3. Please start senna 1 tab twice a day
4. Please take miralax on an as needed basis but it is important
that you have at least one to two bowel movements per day.
4. Start a multivitamin once a day
5. STOP Furosemide 40mg.
6. STOP Plavix
7. Decrease Aspirin to 81mg per day.
8. Restart Metformin 850 mg twice a day
9. Restart Glipizide 2.5mg once a day
Transitional Issues:
1. Consider initiating discussion of hospice care with the
patient.
2. Check HCT for blood transfusions PRN
Medications on Admission:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: do not take more than 4g in 24 hours.
8. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
9. metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day.
10. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual prn as needed for chest pain.
11. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
Disp:*120 Capsule(s)* Refills:*2*
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
4. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Miralax 17 gram Powder in Packet Sig: One (1) PO once a day
as needed for constipation.
Disp:*30 packets* Refills:*1*
7. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
8. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
9. metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day.
10. Outpatient Lab Work
Please check CBC on [**6-17**] and fax results to [**Telephone/Fax (1) 6443**]
[**Last Name (LF) **], [**Name8 (MD) **] MD.
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
Mauel [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 12448**] Home Care Agency, Inc
Discharge Diagnosis:
1. Critical Aortic Stenosis
2. Chronic Systolic Heart Failure with LVEF of 25%
3. Anemia
4. Lower GI bleed
5. Right upper extremity DVT
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 30968**],
You were found on this admission to have on going GI bleeding
which is causing you anemia (low blood count). Per your wishes
we did not pursue the GI bleeding with a colonoscopy. Over the
past 24 hours your bleeding has slowed down to the point where
your blood levels are stable. It is VERY important that you
follow up with Dr. [**Last Name (STitle) 7790**] for rechecking your blood levels in
48 hours. You may continue to have ongoing bleeding and require
transfusions in the future. It is very important that you talk
with your primary care doctor about your anemia going forward
and the most appropriate ways in which to manage it.
In addition, you have severe aortic stenosis and your heart
dose not pump very well. We have been holding your cardiac
medications in the setting of your low blood pressure. Please
discuss this with your PCP when you follow up with him. Since
we are starting you on oral iron, a medication which causes
constipation, it is EXTREMELY important that you take your bowel
medications everyday so that you do not become constipated.
You also have a blood clot in your arm. We are not going to
start you on anticoagulation according to your wishes.
Anticoagulation can cause signficant bleeding. If you wish to
start anticoagulation for this blood clot please discuss this
with your PCP.
We have made the following changes to your medications:
1. Please start IRON 325mg once a day
2. Please start colace 200mg once a day
3. Please start senna 1 tab twice a day
4. Please take miralax on an as needed basis but it is important
that you have at least one to two bowel movements per day.
4. Start a multivitamin once a day
5. STOP Furosemide 40mg.
6. STOP Plavix
7. Decrease Aspirin to 81mg per day.
8. Restart Metformin 850 mg twice a day
9. Restart Glipizide 2.5mg once a day
-You need to talk with your cardiologist and primary care
physician about resuming cardiac medications
8. Please check your laboratory values to see if your blood
count is low before you see your primary care doctor.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs. If you experience any of the danger signs listed
below please go to the nearest emergency department.
Followup Instructions:
Department: [**Hospital1 18**] [**Location (un) 2352**]
When: THURSDAY [**2117-6-17**] at 2:10 PM
With: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: CARDIAC SERVICES
When: THURSDAY [**2117-7-8**] at 3:20 PM
With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: WEDNESDAY [**2117-8-25**] at 11:25 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: WEDNESDAY [**2117-8-25**] at 11:45 AM
With: [**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
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"424.1",
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icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
21473, 21599
|
9410, 19102
|
270, 276
|
21779, 21779
|
4875, 9387
|
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|
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|
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|
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|
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|
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|
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|
19123, 19233
|
23381, 24224
|
211, 232
|
304, 2834
|
21794, 21938
|
2856, 3196
|
3212, 3549
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,684
| 160,334
|
9573
|
Discharge summary
|
report
|
Admission Date: [**2111-9-11**] Discharge Date: [**2111-9-20**]
Date of Birth: [**2042-4-24**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3127**]
Chief Complaint:
Left Flank Pain
Major Surgical or Invasive Procedure:
Left radical nephrectomy
History of Present Illness:
Mr. [**Known lastname 32481**] is a 69-year-old gentleman who is
status post kidney transplant. He presented on [**9-11**] complaining
of
sudden onset left flank pain. CT scan and MR confirmed a
large perinephric hematoma with no evidence of mass. His
chest CT was normal. He was scheduled for elective left
radical nephrectomy. However, due to instability and increase
in pain during his stay, he was brought emergently to the
operating
room for Left Radical nephrectomy.
Past Medical History:
ESRD secondary to IGA nephropathy
CAD
Angina
Atrial fibrillation
Hypercholesterolemia
GERD
Social History:
No history of alcohol, tobacco or drugs
Family History:
Non contributory
Physical Exam:
GEN: Pleasant male in mild distress.
HEENT the oropharynx is clear with moist mucous
membranes and anicteric sclera. The neck is supple,
nontender without lymphadenopathy. The heart is regular rate
and rhythm. Lungs are clear to auscultation bilaterally.
The abdomen is soft and nondistended with tenderness to
palpation over the right lower quadrant and associated
guarding. There is no rebound tenderness and no bruit. The
extremities are warm without clubbing, cyanosis or edema.
Pertinent Results:
[**2111-9-11**] 08:20PM WBC-13.0*# RBC-4.14* HGB-12.5* HCT-34.9*
MCV-84 MCH-30.2 MCHC-35.7* RDW-13.9
[**2111-9-11**] 08:46PM HGB-13.0* calcHCT-39
[**2111-9-11**] 08:20PM PT-12.8 PTT-24.8 INR(PT)-1.1
Brief Hospital Course:
Patient admitted on [**9-11**] complaining of Left flank pain. CT/MRI
showed large perinephric hematoma with retroperitoneal bleeding.
Patient was given 1 unit of PRBCs and serial Hct were checked,
patient's hematocrit remained stable overnight.
[**9-12**]: Patient remained hemodynamically stable. Patient was
transfused a second unit of Packed RBCs for a low but stable
hematocrit.
[**9-13**]: Hematocrit remained stable, pre-op work-up and planning
was initiated for L nephrectomy. Chest CT was obtained to rule
out other sources of bleeding.
[**9-14**]: Cardiology consulted for pre-op work-up. Patient had
sudden new-onset L flank pain upon returning from Pre-op CXR and
a sudden temperature spike. Decision was made to take patient to
OR emergently for Left Nephrectomy of native kidney
[**9-15**]: Patient remained in PACU until mid-morning for post-op
care, monitoring. Transferred to floor in stable condition
[**9-16**]: Patient remained stable post-operatively with normal labs
and stable Hct.
[**9-17**]: Patient had a cardiac echo (TTE) to evaluate murmur, study
was unremarkable. Patient had an episode of sudden tachycardiak,
shortness while moving from bed to chair. EKG was obtained which
was evaluated by cardiology and showed possible AV nodal
re-entrant tachycardia. Patient was given IV lopressor and soon
returned to [**Location 213**] sinus rhythm.
[**9-18**]: Patient remained hemodynamically stable, continued his
post-op recovery with increasing ambulation. No other acute
events.
[**9-19**]:
Medications on Admission:
CellCept 1000mg [**Hospital1 **]
ASA 325 QD
bactrim ss 1 qd
Prograf 5mg [**Hospital1 **]
Isordil 30mg po BID
metoprolol 50 [**Hospital1 **]
Pravachol 20 qd
prednisone 7.5mg qd
Discharge Medications:
1. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
3. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Isosorbide Dinitrate 5 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day) for 2 doses.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Perinephric hematoma of Left native kidney
Discharge Condition:
Good
Discharge Instructions:
Please call if you develop fever >101.5, shortness of breath,
chest pain, palpatations, nausea, vomiting, chills, sweats or if
you have any other questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 3626**] within 1 week.
Please follow-up with your outpatient cardiologist for further
work up of your occasional chest pain and shortness of breath,
and for a stress test.
Completed by:[**2111-9-22**]
|
[
"997.1",
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"427.31",
"V42.0",
"427.1",
"585.6",
"593.81",
"414.01",
"E878.6",
"251.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.51",
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] |
icd9pcs
|
[
[
[]
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] |
4439, 4488
|
1814, 3342
|
330, 357
|
4575, 4582
|
1585, 1791
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|
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4509, 4554
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|
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|
275, 292
|
385, 860
|
882, 975
|
991, 1032
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,377
| 125,336
|
39102
|
Discharge summary
|
report
|
Admission Date: [**2124-1-4**] Discharge Date: [**2124-1-18**]
Date of Birth: [**2071-5-15**] Sex: M
Service: MEDICINE
Allergies:
Prochlorperazine
Attending:[**First Name3 (LF) 2024**]
Chief Complaint:
low Hct
Major Surgical or Invasive Procedure:
left gastric artery embolization
triple lumen placement
port-a-cath placement
History of Present Illness:
History of Present Illness: This is a 52 year old male with
metastatic esophageal cancer with recurrent GI bleeding who
presented to the ED yesterday with low Hct of 20.6. Pt was seen
by his outpt onc provider in clinic yesterday clinic yesterday
for possible chemotherapy, however, it was delayed because of
the low Hct. Of note, pt recently received 2 units of blood on
[**12-31**] with a hematocrit of 24 and 2 units on [**12-28**]. Pt reported
several episodes of hematemesis likely due to a migrated
esophageal stent vs. erosion through the gasric wall. Of note
the patient was admitted last month for a similar presentation
and no EGD was performed at that time.
.
In the [**Name (NI) **], pt triggered for a SBP of 88 but stated that his
blood pressure runs in the high-80s to low-90s. The patient
received 2 units of pRBCs with a post-transfusion hematocrit of
22.9. He was also started on a Protonix drip. GI was consulted
and they felt the stent appears adherent to the gastric wall and
will be difficult to remove. Endoscopy is also unlikely to be
pursued but there may be potential for embolization. Pt was then
sent to ICU for close monitoring.
.
In the ICU, pt received a total of 3 more units of pRBCs. This
am, Hct was 24.2, with another post-transfusion Hct pending. Pt
remained hemodynamically stable. GI is following, decided not
to pursue endoscopy. Role for IR procedure to identify the
source of bleed is also not likely to be high yield. Pt's outpt
oncologist is planning for further chemotherapy once pt is
stablized after blood transfusions.
.
On the floor, pt has no complaints. He reports continuing black
bowl movements, has not had hematemesis since admission. Has
some abdominal discomfort, but feels this is more from hunger
than anything else, is not complaining of pain. Denies cough,
fevers, chills or any other complaints. Has unit of blood
running currently.
.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations. Denies
cough, shortness of breath, or wheezes. Denies nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denies arthralgias or
myalgias. Denies rashes or skin breakdown. No numbness/tingling
in extremities. No feelings of depression or anxiety. All other
review of systems negative
Past Medical History:
Past Oncologic History:
Metastatic esophogeal cancer to the liver, tissue diagnosis
on [**6-4**] poorly-differentiated carcinoma with neuroendocrine
differentiation, s/p esophagogastroduodenoscopy with esophageal
stent placement [**2123-6-3**], chemotherapy, s/p cycle 7 of EOX
(epirubicin, oxaliplatin and xeloda)
.
Other Past Medical History:
History of torn R ACL (not repaired)
Left leg > right leg varicose veins which is chronic since
remote skiing accident
History of RUE DVT in the setting of PICC line ([**6-/2123**])
Osteoarthritis
Social History:
- technology officer to guide engineers, now on long term
disability
- Tobacco: None
- Alcohol: None (socially, none since [**5-/2123**])
- Illicits: None
Family History:
- denies cancer, heart disease, diabetes, clotting or bleeding
diseases
Physical Exam:
exam at discharge:
96.5 104/56 75 18 94%
Pertinent Results:
[**2124-1-4**] 09:27AM BLOOD WBC-8.1 RBC-2.18* Hgb-6.6* Hct-20.6*
MCV-95 MCH-30.4 MCHC-32.2 RDW-18.0* Plt Ct-227
[**2124-1-6**] 03:20PM BLOOD Hct-26.0*
[**2124-1-8**] 06:10AM BLOOD WBC-12.8*# RBC-2.92* Hgb-8.5* Hct-26.1*
MCV-89 MCH-29.1 MCHC-32.6 RDW-17.8* Plt Ct-345
[**2124-1-10**] 07:56AM BLOOD WBC-10.2 RBC-2.89* Hgb-8.9* Hct-25.5*
MCV-88 MCH-30.9 MCHC-35.1* RDW-16.1* Plt Ct-155
[**2124-1-12**] 12:00PM BLOOD WBC-8.6 RBC-2.17* Hgb-6.7* Hct-18.7*
MCV-86 MCH-31.0 MCHC-36.0* RDW-15.2 Plt Ct-134*
[**2124-1-13**] 05:52PM BLOOD WBC-7.1 RBC-3.41* Hgb-10.3* Hct-28.7*
MCV-84 MCH-30.2 MCHC-35.9* RDW-15.6* Plt Ct-117*
[**2124-1-16**] 07:30AM BLOOD WBC-4.9 RBC-2.76* Hgb-8.4* Hct-24.4*
MCV-88 MCH-30.4 MCHC-34.4 RDW-15.4 Plt Ct-103*
[**2124-1-18**] 04:38AM BLOOD WBC-1.6*# RBC-2.81* Hgb-8.8* Hct-24.1*
MCV-86 MCH-31.3 MCHC-36.5* RDW-15.0 Plt Ct-106*
[**2124-1-17**] 06:30AM BLOOD PT-11.8 PTT-25.5 INR(PT)-1.0
[**2124-1-13**] 06:16AM BLOOD PT-17.3* PTT-55.8* INR(PT)-1.5*
[**2124-1-10**] 07:56AM BLOOD PT-14.7* PTT-28.1 INR(PT)-1.3*
[**2124-1-4**] 11:00AM BLOOD PT-13.2 PTT-26.4 INR(PT)-1.1
[**2124-1-13**] 05:52PM BLOOD Fibrino-660*
[**2124-1-18**] 04:38AM BLOOD Glucose-89 UreaN-9 Creat-0.5 Na-127*
K-3.7 Cl-95* HCO3-29 AnGap-7*
[**2124-1-16**] 06:00AM BLOOD Glucose-94 UreaN-12 Creat-0.5 Na-127*
K-3.7 Cl-97 HCO3-28 AnGap-6*
[**2124-1-14**] 06:32AM BLOOD Glucose-108* UreaN-12 Creat-0.4* Na-126*
K-3.8 Cl-96 HCO3-26 AnGap-8
[**2124-1-12**] 12:00PM BLOOD Glucose-84 UreaN-12 Creat-0.4* Na-132*
K-3.5 Cl-100 HCO3-24 AnGap-12
[**2124-1-10**] 07:56AM BLOOD Glucose-94 UreaN-23* Creat-0.4* Na-133
K-3.5 Cl-104 HCO3-23 AnGap-10
[**2124-1-6**] 07:15AM BLOOD Glucose-84 UreaN-16 Creat-0.6 Na-133
K-4.4 Cl-100 HCO3-28 AnGap-9
[**2124-1-4**] 09:27AM BLOOD UreaN-10 Creat-0.5 Na-133 K-4.1 Cl-99
HCO3-31 AnGap-7*
[**2124-1-14**] 06:32AM BLOOD ALT-10 AST-36 LD(LDH)-787* AlkPhos-149*
TotBili-0.6
[**2124-1-4**] 09:27AM BLOOD ALT-16 AST-36 LD(LDH)-248 AlkPhos-223*
TotBili-0.4
[**2124-1-18**] 04:38AM BLOOD Albumin-1.8* Calcium-7.3* Phos-3.5 Mg-1.7
[**2124-1-10**] 07:56AM BLOOD Albumin-1.5* Calcium-7.0* Phos-2.8 Mg-1.7
[**2124-1-4**] 09:27AM BLOOD Albumin-2.1* Calcium-7.9* Mg-2.0
.
MICRO:
[**2124-1-5**] BLOOD CULTURE Blood Culture,
Routine-negative
[**2124-1-5**] URINE URINE CULTURE-negative
.
[**2124-1-10**] Transcatheter embolization: IMPRESSION: Successful coil
and particle embolization of the left gastric artery with
satisfactory angiographic results. Successful deployment of
right common femoral artery closure device with good hemostasis.
.
[**2124-1-11**] LENIs: IMPRESSION:
Non-occlusive thrombus within the right cephalic vein at the
site of a
catheter.
.
[**2124-1-12**]: Catheter placement: IMPRESSION: Placement of a
double-lumen Port-A-Cath was deferred due to the patient's
development of a supraventricular tachycardia . The medical team
requested a 16 cm x 7 French triple-lumen central venous line to
be placed for administration of IV fluids, access, and
medications. The line was placed without complication, secured,
and a sterile dressing was applied.
.
[**2124-1-17**]: Port-A-Cath placement: IMPRESSION: Uncomplicated
placement of 20 cm double-lumen chest Port-A-Cath via right
internal jugular vein with ultrasound guidance with hard copy
images on file. The tip of the catheter terminates at the
cavoatrial junction and is ready to use.
Brief Hospital Course:
This is a 52 yo male with metastatic esophageal cancer with
recurrent GI bleeding who presented to the ED [**1-4**] with low
Hct.
.
# Anemia/Hemetemesis: This is likely [**3-9**] to active GIB from
known esophageal + gastric masses. Pt was initially admitted to
the ICU. Pt received 2 units of pRBCs in ED and started on a
Protonix drip. GI was consulted and they felt the stent appears
adherent to the gastric wall and will be difficult to remove.
Endoscopy was not pursued. Pt received 3 more units of pRBCs in
the ICU and pt's Hct was stable, pt remained hemodynamically
stable, this he was transferred to the floor. On the OMED
service, transfusions were continued, Hct was checked q8-12h.
Pt was then taken for IR embolization on [**1-10**], during the left
gastric artery was successfully embolized. Pt however had
recurrent bleeding and downtrending of Hct post procedure down
to 18.9, requiring more transfusions. Also had thrombocytopenia,
likely due to dilution, consumption and possibly BM supression
from chemo which improved after 1 platelet transfusion. INR and
PTT trended up likely d/t nutritional deficiency and dilution,
now improved with single dose of Vit K yesterday. Fibrinogen was
not low. Pt was continued on IV PPI [**Hospital1 **], then transitioned to
PO. Pt's Hct stabilized somewhat by day of discharge and pt was
discharged with a close f/u with outpt oncologist for further
blood check.
.
# Esophageal ca: Pt has metastatic esophogeal cancer to the
liver, tissue diagnosis on [**6-4**] showed poorly-differentiated
carcinoma with neuroendocrine differentiation. Pt is s/p
esophagogastroduodenoscopy with esophageal stent placement on
[**2123-6-3**], chemotherapy, s/p cycle 7 of EOX (epirubicin,
oxaliplatin and xeloda). Pt's outpt oncologist, Dr. [**Last Name (STitle) 3274**],
intiated chemotherapy during this admission. Pt received
Cisplatin/CPT11 on [**1-5**] and again on [**1-13**]. Pain control with
Acetaminophen, Oxycontin and Dialudid PRN. Nausea was managed
with Zofran and Ativan PRN. Oral Maalox PRN was used for
heartburn.
.
# SVT: Pt had a single episode of SVT during IR placement of
central line on [**2124-1-12**]. This is was likely a complication of
guide-wire insertion during the vascular access procedure. The
episode resolved with 6mg IV Adenosine. Pt remained in NSR
since. Pt was monitored on tele.
.
# Hyponatremia: Pt's Na was slowly down trending to 126. Was
perhaps due to a lot of fluids he received with chemo. Na
improved with increased salt intake and fluid restriction to
1000ml/day.
.
# Asymetrical extremity edema: DVT ruled RUE and LLE ruled out
per US.
.
# Access: Pt had poor IV access, so pt went down to IR for a
Port-A-Cath. Pt however had SVT, this only a triple lumen IJ
was placed. Pt returned to IR suite on [**1-17**] and the line was
successfully converted to a port.
.
# Depression: Pt was continued on home Citalopram.
.
Pt had a regular diet as tolerated, Nutrition was following who
recommended Ensure suppl. Pt was also on oncology repletion
scales. Pain control was with Oxycontin, Acetaminophen and
Dialudid PRN. Pt was on a bowel regimen. DVT PPx was with
pneumoboots given GI bleed. Pt was full code.
Medications on Admission:
1. Citalopram 10 mg PO daily
2. Lorazepam 1 mg PO Q8H anxiety or insomnia
3. Ondansetron ODT 8 mg Q6-8H nausea
4. Oxycodone 5 mg tablets, 1-2 tablets Q4-6H pain
5. OxyContin 10 mg [**Hospital1 **]
6. Pantoprazole 40 mg daily
7. Zolpidem 10 mg HS insomnia
8. Mylanta Oral
9. Dilaudid Oral
10. Capecitabine Oral
Discharge Medications:
1. lorazepam 1 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea/anxiety.
2. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every 6-8 hours as needed for nausea.
4. oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Three (3)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*0*
5. 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*
6. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
7. hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
8. capecitabine Oral
9. Mylanta Oral
10. metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times
a day).
Disp:*45 Tablet(s)* Refills:*0*
11. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for bloating.
Disp:*30 Tablet, Chewable(s)* Refills:*0*
12. 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*
13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
14. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
esophageal carcinoma
upper GI bleeding
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 86651**],
You were admitted because of anemia caused by bleeding from your
upper intestinal tract. You recieved blood transfusions to
compensate for your blood loss. You underwent an embolization
procedure by interventional radiology in attempt to stop the
bleeding from the arteries near your esophagus and stomach. You
also recieved chemotherapy during your hospital stay. A
Port-a-cath was placed to help in future chemotherapy infusions.
.
The following change was made to your medications:
INCREASE pantoprazole 40mg tablet to twice daily
INCREASE oxycontin to 30mg twice daily for control of your pain
(this is a long acting medication which is taken regularly and
should be distinguished from oxycodone which is short acting and
taken as needed for pain)
START metoclopramide 5 mg 3 times a day
START simethicone 80 mg 4 times a day as needed for bloating
START docusate sodium 100 mg 2 times a day as needed for
constipation
START senna 8.6 mg 2 times a day as needed for constipation
.
Please continue to take the rest of your home medications
without change.
Followup Instructions:
Please come in for a hematocrit and electrolyte check on
Thursday at Dr.[**Name (NI) 3279**] office.
Completed by:[**2124-1-26**]
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77,013
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35511
|
Discharge summary
|
report
|
Admission Date: [**2191-3-18**] Discharge Date: [**2191-4-16**]
Date of Birth: [**2151-5-7**] Sex: M
Service: MEDICINE
Allergies:
Keppra
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Weakness, altered mental status
Major Surgical or Invasive Procedure:
Endotracheal intubation
Lumbar puncture
Central venous line insertion
Atrial line insertion
Thoracentesis x2
Tracheostomy
Dobhoff feeding tube
Percutaneous endoscopic gastrostomy tube
History of Present Illness:
39 yo m w/ hx EtOH abuse, no other significant PMH, presents
with extreme weakness of his legs and arms. Pt reports being in
usoh until [**1-10**] when he began to notice right leg swelling and
weakness. This has slowly progressed to involve bilateral leg
weakness and mild discomfort, as well as arm weakness, that he
cannot describe further. He was seen at [**Hospital1 778**] where he was
told
that his liver enzymes were elevated, and was started on
"vitamin supplementation" although he is unsure exactly what
kind. He does report N/V 2 days ago, brought up iced tea that
he had recently drank. No dark or bloody BMs; one BM per day.
No abd pain, fevers. Does admit to "swelling" multiple
extremities. Pt with long hx of EtOH use; drank 8-9 beers/day
for many years.
Over last 2 years 4 vodkas per night. Last drink 4 days ago per
his report. Denies hx of withdrawal. No recent tylenol use,
herbal meds, or other medications. He adamantly denies other
ingestions.
In [**Name (NI) **], pt noted to be jaundiced. Head CT negative. Abd CT with
thickened esophagus, fatty, enlarged liver, and large appendix,
but othewise negative. Labs extremely abn with Na 119, HCO3 8,
glucose 31, AG 32, Cr 0.7, AST 169, ALT 31, ALK 105, TB 6.3, CK
NL, Lactate 12, NH3 13, Serum Osms 280, urine/serum tox screen
negative except for EtOH level of 110. ABG 7.45/14/141. Urine
urobililogen 8, + ketones. UNa < 10. Hct 24 to 20 with IVFs.
Guaiac negative per report. Vitals with BPs 90's systolic, HR
120's. Pt started empirically on vanc/zosyn, given a banana
bag, and 6 L NS.
Past Medical History:
Alcohol abuse
Ankle Fracture
Social History:
On disability, previously worked in finance. MSM lives with
partner, Denies tobacco/IVDU. Drinks 5 vodka drinks/day. Tattoo
from [**2178**].
Family History:
Noncontributory
Physical Exam:
ICU Admission Exam:
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Head CT [**2191-3-17**]: No acute intracranial process.
.
CXR [**2191-3-17**]: No acute intrathoracic process.
.
CT abdomen [**2191-3-17**]: Diffuse esophageal wall thickening
consistent with esophagitis. Appendix measures up to 8mm and
appears indistinct- any evidence for acute appendicitis?
Hypoattenuating liver may represent fatty infiltration A few
small hypoattenuating hepatic lesions are of unclear etiology.
Trace free fluid.
.
TTE [**2191-3-18**]: Mildly dilated left ventricular cavity with
vigorous global systolic function and high cardiac output. No
significant valvular disease or pulmonary hypertension.
.
CXR [**2191-3-20**]: The NG tube is coiled in the stomach with the tip
in the mid
stomach. There are new bilateral infiltrates in the left lower
lobe and in
the right lower lobe with the left lower lobe infiltrate being
more densely opacified on the right.
.
MRI Spine [**3-21**]: 3. At L4/5, there is a left lateral disc
protrusion which contacts the left [**Name (NI) 5774**] nerve root in the
moderately narrowed left neural foramen
.
MRI Brain [**3-21**]: Minimal T2 hyperintensity in the periventricular
white matter abutting the lateral ventricles, which is a non
specific finding. While sometimes seen in asymptomatic patients,
it also may seen in demyelinating disease, Lyme disease,
sarcoidosis or other infectious/postinfectious states.
.
EMG [**3-22**]: Limited, abnormal study. There is electrophysiologic
evidence for a moderate- to-severe generalized sensorimotor
polyneuropathy with axonal features. Based on the limited data
available, there is no electrophysiologic evidence for a
demyelinating polyneuropathy, as in Guillain-[**Location (un) **] syndrome
.
CXR [**3-24**]: Left lower lobe opacity may represent pneumonia with
parapneumonic effusion given history.
.
CT chest [**3-24**]: 1. Mild pulmonary edema and moderate bilateral
pleural effusions. 2. Solitary focus of infection or small
infarction right upper lobe. Followup with routine chest
radiographs recommended.
3. Bibasilar consolidation is more likely atelectasis than
pneumonia.
.
Bilateral LENIs [**3-25**]: No evidence of DVT in either lower
extremity.
.
EEG [**3-25**]: Largely normal EEG for wakefulness and drowsiness.
There
was plentiful movement artifact, obscuring large portions of the
background. There were no areas of persistent focal slowing, and
there were no epileptiform features.
.
CTA chest [**3-25**]: 1. No PE to the segmental level.
2. Moderate bilateral effusions with associated compression
atelectasis are unchanged since yesterday.
3. Right apical lung lesion may represent infection or infarct
but should be followed after therapy to ensure resolution or
stability.
.
CT head [**3-25**]: While the study is very limited by motion, a new
small isodense left frontoparietal subdural collection could
represent subacute hemorrhage.
.
CXR [**3-26**]: The ET tube is 5.9 cm above the carina. The NG tube is
in the stomach. There is a moderate left effusion and left
retrocardiac
opacification consistent with volume loss/infiltrate. Compared
to the prior study, the left effusion is increased in size.
.
RUQ US [**3-26**]:
1. Mild splenomegaly. Slightly increased liver echogenicity.
2. Ascites.
3. Right pleural effusion.
4. Mildly distended gallbladder, containing thick bile/sludge,
which can be seen in the prolonged fasting state.
.
CXR [**3-27**]: Moderate bilateral pleural effusion, stable on the
left, increased on the right since [**3-26**]. Upper lungs
clear. Heart size normal. ET tube and nasogastric tube in
standard placements. No radiopaque central venous catheter is
noted. Right apical lung lesion seen on recent chest CT and CTA
scans is not clearly visible on conventional bedside radiographs
suggesting it is not enlarging rapidly, but followup is
indicated.
.
Left UE US [**3-28**]: No evidence of left upper extremity deep venous
thrombosis.
.
CXR [**3-29**]: In comparison with the study of [**3-27**], the nasogastric
tube has
been removed and replaced with a Dobbhoff tube that extends to
the mid body of the stomach. Endotracheal tube has been removed.
The bilateral hazy opacification consistent with pleural fluid
is seen at both bases. It appears to be less prominent, though
some of this could reflect the upright rather than supine
position.
.
CXR [**3-30**]: Left lower lobe consolidation has been present since
it developed between [**3-18**] and [**3-20**] could be
persistent pneumonia, or alternatively atelectasis. Moderate
right and small left pleural effusion have increased since
[**3-29**], though heart size is normal and unchanged. No
pneumothorax. Feeding tube ends in the stomach.
.
Echo [**4-4**]:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF>55%). The
estimated cardiac index is high (>4.0L/min/m2). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. There
is no valvular aortic stenosis. The increased transaortic
velocity is likely related to high cardiac output. The mitral
valve appears structurally normal with trivial mitral
regurgitation. The pulmonary artery systolic pressure could not
be determined. There is a trivial/physiologic pericardial
effusion.
IMPRESSION: Normal biventricular systolic function, with high
cardiac output c/w a high output state (hyperthyroidism, shunt,
anemia, etc).
Compared with the prior study (images reviewed) of [**2191-3-18**],
trivial pericardial effusion is new. Other findings are similar.
.
CTA Chest, CT abdomen and pelvis with contrast [**2191-4-4**]:
1. No evidence of pulmonary embolus. Slightly limited study,
particularly in the upper lobes.
2. Large bilateral nonhemorrhagic pleural effusions are
increased. There is no CT evidence to suggest empyema (no thick
or enhancing pleura).
3. Worsened consolidation in the left upper lobe, suggestive of
worsening
pneumonia. A nodular opacity in the right upper lobe is
decreased in size,
but follow up to complete resolution is recommended. Followup
may be obtained when treatment concludes and the patient's
clinical condition improves.
4. Possible tracheomalacia, though this is not a dedicated study
to evaluate for this.
5. Collection of fluid posterior to the pancreatic body as
described, new
from the prior study of [**3-17**], most likely a locule of
ascites fluid
rather than a discrete collection. There is a clear fat plane
between this
fluid and the pancreas. The pancreas is unremarkable in
appearance with
homogeneous enhancement.
5. Splenomegaly, with the spleen increased in size comparing to
[**3-17**] (15 cm today versus 11.5 cm previously).
Prominent/enlarged liver.
6. New small amount of ascites fluid.
7. Increased gallbladder distention. There is concern for
gallbladder
pathology, consider dedicated son[**Name (NI) 867**].
.
CT Head [**2191-4-4**]
IMPRESSION: Normal CT of the sinuses. No evidence of sinusitis.
.
MRI brain [**2191-4-5**]
1. Small subdural collection along the left convexity has
decreased in size, but increased in complexity and viscosity.
Evaluation for associated contrast enhancement is technically
limited.
2. New nonspecific signal abnormality in the central pons, which
may
represent a subacute infarction or central pontine myelinolysis.
Infectious and inflammatory causes should also be considered.
The location of this lesion does not correspond to typical or
atypical manifestations of Wernicke encephalopathy.
.
MRA brain [**2191-4-6**]
Apparent short-segment stenosis in the distal right vertebral
artery, immediately proximal to the basilar artery origin, which
may be
artifactual. The basilar artery and other major intracranial
arteries appear patent.
.
CT chest [**4-7**]
Worsening bilateral symmetrical mostly perihilar consolidation
in both
upper lobes and right middle lobe, likely due to pulmonary
edema. Extensive consolidation within both lower lobes could
potentially reflect developing ARDS. Multifocal rapidly
progressing multifocal pneumonia and pulmonary hemorrhage are
also in the differential. Improvement of bilateral
nonhemorrhagic pleural effusions, now moderate. Possible anemia.
Ascites.
.
CXR [**4-12**]
In comparison with the study of [**4-11**], there is little overall
change
in the bilateral ground-glass densities compatible with
congestive failure. Bilateral pleural effusions persist. The
left subclavian catheter has been removed. Tracheostomy tube and
Dobbhoff tube remain in place.
.
MRI head [**4-12**]:
1. Unchanged small left subdural collection. Evaluation for
contrast
enhancement is again technically limited by patient motion
artifact.
2. Slightly increased prominence of the geographic focal
T2-signal
abnormality in the central pons, which may relate to further
evolution and/or technical factors; the appearance remains in
keeping with central pontine myelinolysis, as suggested
previously, which could be correlated with volume/serum
osmolality shifts at time of its development. There is no
evidence of extra-pontine myelinolysis.
3. No new intracranial process.
.
CXR [**4-14**]:
Tracheostomy tube tip terminates 2.5 cm above carina and feeding
tube remains within the proximal stomach. Cardiac silhouette is
enlarged but unchanged in size, and there is persistent vascular
engorgement accompanied by bilateral confluent perihilar
opacities likely representing widespread, but slightly improving
pulmonary edema. Layering bilateral moderate pleural effusions
are present, right greater than left.
LABS:
[**2191-4-1**] 07:15AM BLOOD WBC-7.3 RBC-2.50* Hgb-8.5* Hct-25.0*
MCV-100* MCH-33.9* MCHC-34.0 RDW-17.7* Plt Ct-259
[**2191-3-17**] 08:05PM BLOOD WBC-12.4* RBC-2.38* Hgb-8.7* Hct-24.3*
MCV-102* MCH-36.4* MCHC-35.7* RDW-13.7 Plt Ct-246
[**2191-3-24**] 06:00AM BLOOD Neuts-91* Bands-0 Lymphs-1* Monos-7 Eos-0
Baso-1 Atyps-0 Metas-0 Myelos-0
[**2191-3-25**] 06:05AM BLOOD Hypochr-OCCASIONAL Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-1+ Target-OCCASIONAL
Schisto-OCCASIONAL Burr-1+ Stipple-OCCASIONAL
[**2191-3-30**] 12:50PM BLOOD PT-19.1* PTT-63.9* INR(PT)-1.8*
[**2191-3-26**] 04:01AM BLOOD Fibrino-194 D-Dimer-As of [**1-4**]
[**2191-3-18**] 03:12AM BLOOD FDP-10-40*
[**2191-4-1**] 07:15AM BLOOD Glucose-118* UreaN-10 Creat-0.5 Na-139
K-3.5 Cl-109* HCO3-24 AnGap-10
[**2191-3-17**] 08:05PM BLOOD Glucose-31* UreaN-14 Creat-0.7 Na-119*
K-4.9 Cl-82* HCO3-10* AnGap-32*
[**2191-3-30**] 12:50PM BLOOD ALT-67* AST-139* AlkPhos-115 TotBili-2.6*
[**2191-3-17**] 08:05PM BLOOD ALT-31 AST-169* LD(LDH)-245 CK(CPK)-125
AlkPhos-105 TotBili-6.3*
[**2191-3-17**] 10:50PM BLOOD TotBili-6.5* DirBili-3.8* IndBili-2.7
[**2191-3-21**] 03:26AM BLOOD Lipase-808*
[**2191-3-30**] 12:50PM BLOOD Lipase-216*
[**2191-3-17**] 08:05PM BLOOD cTropnT-0.01
[**2191-3-17**] 08:05PM BLOOD CK-MB-6
[**2191-3-31**] 07:20AM BLOOD Calcium-8.2* Phos-3.5 Mg-1.7
[**2191-3-17**] 10:50PM BLOOD Albumin-2.2*
[**2191-3-30**] 12:50PM BLOOD VitB12-1711* Folate-13.5
[**2191-3-26**] 04:01AM BLOOD D-Dimer-5623*
[**2191-3-18**] 12:22PM BLOOD Hapto-29*
[**2191-3-18**] 12:22PM BLOOD Triglyc-78 HDL-12 CHOL/HD-5.9 LDLcalc-43
LDLmeas-<50
[**2191-3-17**] 10:50PM BLOOD Osmolal-280
[**2191-3-17**] 08:05PM BLOOD Ammonia-39
[**2191-3-22**] 04:45AM BLOOD TSH-6.7*
[**2191-3-25**] 06:05AM BLOOD Free T4-1.0
[**2191-3-17**] 08:05PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE
[**2191-3-18**] 03:12AM BLOOD Smooth-NEGATIVE
[**2191-3-18**] 03:12AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2191-3-18**] 02:20AM BLOOD [**Doctor First Name **]-NEGATIVE dsDNA-NEGATIVE
[**2191-3-19**] 01:12PM BLOOD HIV Ab-NEGATIVE
[**2191-3-17**] 08:05PM BLOOD ASA-NEG Ethanol-110* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2191-3-17**] 08:05PM BLOOD HCV Ab-NEGATIVE
[**2191-3-17**] 08:28PM BLOOD Lactate-13.4*
[**2191-3-26**] 01:56AM BLOOD Lactate-0.7 K-3.9
[**2191-3-18**] 03:12AM BLOOD HERPES SIMPLEX VIRUS 1 AND 2 ANTIBODY
IGM-Test Name
[**2191-3-18**] 03:12AM BLOOD BETA-HYDROXYBUTYRATE-Test
[**2191-3-18**] 02:20AM BLOOD HERPES SIMPLEX (HSV) 2, IGG-Test Name
[**2191-3-18**] 02:20AM BLOOD HERPES SIMPLEX (HSV) 1, IGG-Test
[**2191-3-18**] 02:20AM BLOOD CERULOPLASMIN-Test
[**2191-3-24**] 04:03PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-366*
Polys-91 Lymphs-9 Monos-0
[**2191-3-24**] 04:03PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-153*
Polys-78 Lymphs-22 Monos-0
[**2191-3-24**] 04:03PM CEREBROSPINAL FLUID (CSF) TotProt-28 Glucose-63
LD(LDH)-40
[**2191-3-24**] 04:03PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-Test Name
[**2191-3-30**] 11:51AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.037*
[**2191-3-30**] 11:51AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2191-3-30**] 11:51AM URINE RBC-5* WBC-6* Bacteri-NONE Yeast-NONE
Epi-0
.
[**2191-4-13**] 03:01AM BLOOD WBC-9.7 RBC-2.55* Hgb-8.4* Hct-24.9*
MCV-98 MCH-33.1* MCHC-33.7 RDW-17.6* Plt Ct-198
[**2191-4-11**] 02:51AM BLOOD Neuts-74.6* Lymphs-14.2* Monos-7.1
Eos-3.6 Baso-0.5
[**2191-4-13**] 03:01AM BLOOD Plt Ct-198
[**2191-4-13**] 03:01AM BLOOD PT-18.6* PTT-51.3* INR(PT)-1.7*
[**2191-4-13**] 03:01AM BLOOD Glucose-105 UreaN-17 Creat-0.4* Na-143
K-3.9 Cl-114* HCO3-23 AnGap-10
[**2191-4-12**] 03:37AM BLOOD ALT-69* AST-114* LD(LDH)-214 AlkPhos-167*
TotBili-1.1
[**2191-4-13**] 03:01AM BLOOD Calcium-8.4 Phos-4.0 Mg-1.8
[**2191-4-13**] 03:01AM BLOOD ANCA-NEGATIVE B
[**2191-3-19**] 01:12PM BLOOD HIV Ab-NEGATIVE
[**2191-3-18**] 03:12AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2191-3-18**] 02:20AM BLOOD [**Doctor First Name **]-NEGATIVE dsDNA-NEGATIVE
[**2191-3-18**] 03:12AM BLOOD Smooth-NEGATIVE
[**2191-3-17**] 08:05PM BLOOD HCV Ab-NEGATIVE
[**2191-4-12**] 01:03PM BLOOD Type-ART Temp-39.0 Rates-/24 FiO2-50
pO2-166* pCO2-34* pH-7.50* calTCO2-27 Base XS-4 \NOT INTUBATED
[**2191-4-12**] 04:13AM BLOOD Lactate-0.8
.
[**2191-4-7**] 05:44PM PLEURAL FLUID WBC-450* RBC-4050* Polys-74*
Lymphs-18* Monos-5* Macro-3*
[**2191-4-5**] 12:41PM PLEURAL TotProt-1.9 Glucose-128 LD(LDH)-89
Amylase-25 Albumin-<1.0
[**2191-4-5**] 05:54PM PLEURAL TotProt-1.3 Glucose-120 LD(LDH)-66
Amylase-20 Albumin-<1.0
[**2191-4-5**] 12:41PM PLEURAL WBC-433* RBC-1889* Polys-1* Lymphs-8*
Monos-2* Meso-10* Macro-79*
[**2191-4-5**] 05:54PM PLEURAL WBC-783* RBC-1783* Polys-1* Lymphs-3*
Monos-2* Meso-68* Macro-26*
.
Blood cultures: neg on [**2195-3-17**], 17, 19, 20, 25, 27, 28, [**4-3**], 2, 3, 4, 5
Urine cultures: neg on [**2195-3-17**], 25, 27, [**4-3**], 2, 3. Minimal
Staphylococcus on [**3-24**], pos for yeast [**4-11**]
Spinal fluid culture: neg
CMV, EBV, HCV neg
BAL: neg, no PCP, [**Name10 (NameIs) **] fungus, no Legionella
C Diff neg x 7
Sputum cx pos for yeast
Brief Hospital Course:
Hospital course summary:
Mr. [**Known lastname **] is a 39 year old male with ETOH abuse who presented on
[**3-18**] with lactic acidosis, profound weakness and found to be
severely thiamine deficient consistent with a diagnosis of Beri
Beri. He had components of both wet and dry: high output heart
failure, edema and severe weakness. The patient was repleted
aggressively with Thiamine, a multivitamin, and had an NG placed
for nutrition. He developed refeeding syndrome requiring
agressive electrolyte repletion. He developed ETOH withdrawal
and mental status changes approximately 24-48hr after admission.
He was treated with small doses of benzos and mental status
improved somewhat before he was called out to the general
medicine team on [**3-21**]. Initially, the patient was working with
PT/OT and was evaluated by speech & swallow. On [**3-23**], he was
advanced a dysphagia diet and the following day, he spiked a
fever to 101.8. Initial infectious work up revealed negative UA,
neg Blood Cx, negative Cdiff and possible infiltrate on CXR.
Chest CT revealed bilateral pleural effusions and atelectasis.
Lumbar puncture showed 2 WBCs, RBC 366, glucose 62 and protein
28. The patient was started on Vanc, Zosyn, and Cipro for
possible HAP/Asp PNA. He triggered on [**2191-3-24**] for tachypnea,
tachycardia, and hypoxia. His hypoxia resolved, and CTA was
subsequently negative for PE. Mental status further deteriorated
after fevers began and there was concern for intermittent
seizures due to bilateral upper extremity tremors and periodic
eye deviation. 2mg Ativan was given without significant
improvement. The patient was loaded with Keppra 1gram, started
on empiric Acyclovir 700mg IV TID and Keppra 1500mg [**Hospital1 **]. The
neurology attending recommended transfer to MICU where he had
continuous EEG monitoring.
After Keppra loading the patient became more somnolent and
acidotic and required intubation for airway protection. CT
revealed a small 4mm subdural hematoma but follow up MRI showed
resolution. ABGs improved quickly on the vent and the patient
was easily awakened and extubated on [**3-27**]. He continued to be
dysarthric, have low grade fevers and tachycardia to 90s-110s.
He was continued on Vanc/Zosyn for presumed aspiration pneumonia
but no positive cultures. The 24hr EEG monitoring was been
discontinued, NGT was removed and the patient was taking some
meds crushed in apple sauce and was advanced to dysphagia diet.
Upon return to the medicine floor, the patient continued to have
fluctuating mental status, occasional tachycardia and
temperatures, presumed to be related to repeated aspiration
pneumonitis. All cultures continued to be negative. The patient
had a dobhoff tube placed for primary nutrition with tube feeds
and eventually was restarted on pureed oral feeding only when
alert and awake. The patient was again transferred to the ICU
for tachycardia and tachypnea that did not resolve with
non-rebreather treatment, and with fevers to 102F.
## Weakness: On initial presentation the patient was
quadraplegic. With thiamine repletion he improved to extremity
strength of [**4-6**]/5 and plateaued at this strength. He was seen by
PT and OT while in house and discharged to [**Hospital 98**] rehab for
aggressive rehabilitation.
## AMS: When initially hospitalized, pt had been completely
alert and oriented. His mental status then deteriorated and
fluctuated, consistent with delirium. Possibile etiologies are
broad and ultimately much of his mental status changes were
attributed to infection and central pontine myelinolysis. The
considered possibilities included:
1) Aspiration PNA - despite CT chest showing no consolidation
(does show bilateral pleural effusions), the patient completed a
course of Vancomycin and Zosyn. There was concern for repeated
aspiration pneumonitis to explain occasional fevers, tachycardia
and fluctuating mental status.
2) Seizures: The patient was noted to have involuntary upper
extremity shaking and eye deviation to the left. He had multiple
risk factors for seizures (ie cerebellar atrophy) but has had
repeated EEGs without findings consistent with seizure. He was
loaded and maintained on Keppra for several weeks. However,
ultimately keppra was found to be a cause of drug rash and
fevers, and neurology was not highly suspicious of seizure
activity in this patient. Thus keppra was discontinued.
3) Meningitis/encephalitis: In the setting of fever and AMS but
no meningeal signs, the patient had a lumbar puncture which was
inconsistent with bacterial infection or HSV. Empiric treatment
with broad antibiotics and acyclovir were stopped after
confirmed LP findings.
4) Intracranial bleed or infarct: CT head with 4mm frontal SDH,
but follow up MRI had no sign of bleed. This was thought to be
either artifact or transient SDH secondary to LP in setting of
elevated INR. A repeat MRI did show ongoing small subdural
collection, but per neurology, this was unlikely to be
contributing to the patient's poor mental status. A neurosurgery
consult was obtained, and they did not recommend drainage of
this collection.
5) Withdrawal: The patient was initially treated for withdrawal
but mental status deteriorated after he stopped [**Doctor Last Name **] on the
CIWA scale. Once about 7 days after his last etoh ingestion,
benzos were stopped out of concern for delirium.
6) Wernickes: Deemed unlikely given his initial presention with
normal MS. Also no findings on MRI of mammilary body
abnormality.
7) Hepatic encephalopathy: Given pt's alcohol hepatitis, he was
treated with lactulose and rifaximin for possible contribution
of encephalopathy to altered mental status. Once LFTs returned
to near normal, these meds were stopped, but waxing and [**Doctor Last Name 688**]
mental status persisted.
8) Pellagra: Per case reports, Niacin deficiency in setting of
thiamine repletion has been known to cause altered mental status
and shaking. Pt received niacin repletion via his tube feeds,
which contained 220% of daily niacin requirement.
9) Central Pontine Myelinolysis: Lesion was found on MRI [**2191-4-5**]
in the setting of ongoing altered mental status. An MRA was
obtained to definitively rule out stroke as cause of this
lesion, and MRA was normal. Per neurology, he likely has CPM due
to rapid correction of hyponatremia earler in his hospital
course. CPM is an irreversible process, and neurology consult
attributed his mental status to CPM; however the patient was
quite alert and oriented on the days immediately prior to
discharge, which indicates that he has not suffered an
irreversible insult.
## Respiratory Failure: Upon second transfer to the ICU, the
patient was tachycardic and tachypneic. LENIs were negative for
DVT and suspicion for pulmonary embolus was low. An ECHO was
obtained which showed hyperdynamic systolic function with a
small pericardial effusion and large bilateral pleural
effusions, likely related to his wet Beri-Beri. He was started
on vancomycin/zosyn/ciprofloxacin for presumed aspiration
pneumonia. He was diuresed with IV lasix boluses and he
underwent needle thoracentesis bilaterally on [**2191-4-5**]. Pleural
fluid was transudative and cultures were negative. The patient
was intubated for tachypnea and fatigue on [**2191-4-7**], likely in the
setting of extreme weakness due to BeriBeri and underwent
bronchoscopy that same day. His airways showed normal anatomy
and mucosa. He had RML and RUL bronchoalveolar lavage, which
returned mildly bloody fluid. This BAL fluid was negative for
infection and hemosiderin-laden macrophages. Ultimately the
patient's antibiotics were discontinued on [**2188-4-5**] because
infectious workup for pneumonia was negative, and these
medications were thought to be contributing to his fevers. He
had a repeat mini-bronchoalveolar lavage on [**4-11**], and again BAL
fluid was negative for infection. The patient underwent
tracheostomy on [**2191-4-11**] and was able to be weaned to trach mask
ventilation on [**2191-4-13**]. He had a Passy-Muir valve placed on [**4-13**]
to enable better speech.
## Fevers: Upon second transfer to ICU, the patient was febrile
and his fevers persisted despite antibiotic therapy and an
extensive infectious work-up. Ultimately, per ID consult, fever
was attributed to medications, and the patient deffervesced when
all antibiotics and keppra were discontinued. He subsequently
developed low grade fevers several days later which have
continued. A repeat infectious work-up was negative and his
mental status slowly cleared. His recurrent fevers are likely
related to his underlying CNS injury and may still have a
medication component. If the patient develops a fever at rehab,
this is likely due to the above, rather than a new infection,
and should not automatically precipitate transfer back to the
hospital.
## Drug Rash: The patient developed a wide-spread, erythematous,
confluent macular rash on [**4-12**]. A dermatology consult was
obtained, and the rash was attributed to a drug reaction. Keppra
and captopril were thought to be most the likely causes of the
rash, and both were discontinued. The rash had largely resolved
by the time of discharge, and the patient should be considered
allergic to keppra.
## Coagulopathy: The patient had an elevated PTT and INR thought
to be due to liver dysfunction and severe nutritional
deficiency. He had no evidence of DIC or active bleeding. He
received Vit K and FFP while in the ICU for possibility of
subdural hematoma and prior to invasive procedures. He also
received a total of 6 units of pRBCs for Hct <21.
## Volume status: The patient was consistently extravascularly
fluid overloaded, due to hypoalbuminemia from malnutrition,
beriberi related capillary leak, and initial aggressive fluid
resuscitation for tachycardia of unknown source. He was diuresed
with occasional IV lasix until he appeared euvolemic.
## Anemia: The patient was found to have a macrocytic anemia due
to malnutrition and alcohol effects. He was treated with B12 and
folate repletion. His hct has remained stable around 25. He was
also found to have guaiac positive stools. He was maintained on
a PPI and was transfused keep hct >21%.
## Tachycardia: Patient was tachycardic in 110s-120s for much of
his hospital course, likely due to his high-output cardiac
failure from wet BeriBeri and persistent fevers. Ultimately he
was placed on metoprolol with great improvement in his heart
rate to the 90s. Metoprolol 25mg TID should be continued as long
as he remains tachycardic, unless he becomes hypotensive to
SBP<100.
## Hyponatremia: The patient was hyponatremic throughout much of
his hospital stay. Hypothyroidism and adrenal insufficiency were
ruled out as possible etiologies. This was likely due to SIADH
in the setting of multiple pulmonary processes, and his sodium
had corrected by [**2191-4-7**] and has since remained stable.
## LFT abnormalities: On presentation the patient had LFT
abnormalities consistent with alcoholic hepatitis and
pancreatitis. Both improved throughout the admission.
## Nutrition: The patient was given tube feeds via gastric
dobhoff. On the day prior to discharge he had a PEG placed at
the bedside. This PEG can be used for tube feeds starting in the
afternoon of [**4-16**]. This PEG should not be removed until after
[**2191-5-16**].
Medications on Admission:
none
Discharge Medications:
1. Folic Acid 1 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily).
2. Therapeutic Multivitamin Liquid [**Month/Day/Year **]: One (1) Tablet PO
DAILY (Daily).
3. B-Complex with Vitamin C Tablet [**Month/Day/Year **]: One (1) Tablet PO
TID (3 times a day).
4. Thiamine HCl 100 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO DAILY
(Daily).
5. Acetaminophen 325 mg Tablet [**Month/Day/Year **]: 1-2 Tablets PO Q6H (every 6
hours) as needed.
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
8. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
9. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever.
10. Olanzapine 2.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times
a day) as needed for agitation.
11. Pyridoxine 50 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily).
12. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection TID (3 times a day).
13. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup [**Last Name (STitle) **]: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
14. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization [**Last Name (STitle) **]:
One (1) Inhalation Q4H (every 4 hours) as needed for wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
Beri Beri (thiamine deficiency with profound weakness)
Pyridoxine deficiency
Cardiomyopathy
Alcohol Withdrawal
Aspiration Pneumonia
Mental status changes
Secondary:
Alcohol Dependence
Malnutrition
Discharge Condition:
HR 80s-110, SBP 110-150s, daily fevers, tolerating trach mask
ventilation well, general physical weakness.
Discharge Instructions:
You were admitted with profound weakness and found to have
severe thiamine and pyridoxine deficiency. You were treated for
alcohol withdrawal and mental status changes likely due to
aspiration pneumonia. You have been followed closely by
neurology and will need ongoing follow up with them. You will
need to continue with aggressive physical therapy.
We have started you on nutritional supplements and anti-seizure
medications as shown below.
If you develop any chest pain, shortness of breath, mental
status changes, fevers or any other general worsening of
condition, please call your PCP or come directly to the ED.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in Neurology on the eighth
floor of the [**Hospital Ward Name 23**] Building, [**4-26**] at 9am.
Please call the Gastroenterology Department at [**Telephone/Fax (1) 463**] to
schedule a colonoscopy.
Please call the [**Hospital 778**] clinic to schedule a follow up
appointment prior to discharge from rehab.
|
[
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"253.6",
"265.0",
"425.7",
"432.1",
"286.9",
"518.81",
"276.2",
"577.0",
"693.0",
"E942.9",
"507.0",
"571.1",
"341.8",
"E936.3",
"357.4",
"344.00",
"265.2",
"348.30",
"578.9",
"780.39",
"291.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"33.24",
"96.71",
"96.72",
"43.11",
"96.04",
"31.1",
"45.13",
"34.91",
"38.93",
"03.31",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
30818, 30897
|
17823, 29167
|
298, 483
|
31148, 31257
|
2875, 17800
|
31929, 32294
|
2322, 2339
|
29222, 30795
|
30918, 31127
|
29193, 29199
|
31281, 31906
|
2354, 2856
|
227, 260
|
511, 2096
|
2118, 2148
|
2164, 2306
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,326
| 107,112
|
4926
|
Discharge summary
|
report
|
Admission Date: [**2119-9-8**] Discharge Date: [**2119-9-11**]
Date of Birth: [**2058-5-23**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
Chief Complaint: CP
.
Reason for MICU transfer: hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
60 year old male with pmh of seizure disorder, ESRD on HD (MWF),
nonischemic cardiomyopathy (EF~20-30%), h/o CAD and CVA,
hepatitis B who presented with hypotension and chest pain from
HD. Pt was receiving dialysis this am and started to c/o chest
pain. On arrival to [**Name (NI) **] pt denied chest pain, but stated that he
has a headache for 3 days. Per patient, he fell flat on his
face on Wednesday after receiving dialysis. He did not loose
conciousness. Not long after arriving to ED, he was triggered
for hypotension, down to 60's systolic. He reported that he had
on/off chest pain over past 2 days. PT also c/o non-bloody
diarrhea 4x per day, loss of appetite for 4 days, and has not
been eating, + chills. PT denies vomiting, sweats, changes in
vision. Pt feels he is not thinking well as he usually does,
and feels he has had decreased mental status for 2 days.
.
In ED, he was noted to have initial vitals of 96.9 100 138/105
16 100% 4L. He was noted to have a repeated BP down to as low
as 60s, now in 90s after IVF. EKG showed sinus @ 90, LAD, LBBB,
no scarbosa. Exam was notable for multiple small ~1cm sq skin
ulcerations on buttocks near anus. CT head showed no acute
pathology. CXR was unchanged from prior. Guaiac was noted
positive. Nephrology was consulted and Dr. [**Last Name (STitle) 17159**] will follow.
He was given 1 gram vancomycin, 1 gram ceftriaxone due to the
small pressure ulcer on back and hypotension. He recieved total
of 2.25 L in 500cc boluses, good BP response to SBP of 96. He
was admitted to MICU for potential sepsis workup. Access: left
femoral CVL triple lumen and Dilaysis Port Left Chest wall.
Precautions: MRSA and VRE.
.
On the floor, he appears to be in good spirit.
Past Medical History:
- Seizure disorder since mid [**2097**]'s after starting dialysis
- MSSA HD line infection with septic lung emboli [**9-1**] with left
pleural effusion
- H/o Hepatitis B, treated
- Non-ischemic cardiomyopathy, last EF 20-30%
- MI [**2086**] per pt
- CVA [**2086**] per pt (?residual LE weakness)
- ESRD on hemodialysis [**1-25**] HTN. EDW 80 kg as of [**2118-1-3**].
- Multiple thrombectomies in LUE and R thigh AV fistula
- Graft excision for infected thigh graft [**2117-5-26**]
- Hungry bone syndrome status post parathyroidectomy
- Pituitary mass
- Anemia of chronic disease
- s/p PEG tube placement [**2117-10-29**]
- Admission to MICU in [**10-2**] for seizure and hypotension
- Swab positive for MRSA and VRE at left groin site in [**10-2**] and
MRSA positive from same site [**11-2**]
.
Social History:
Retired piano and organ teacher. Has 2 PhDs (history and music)
and prefers to be called "Dr. [**Known lastname 2026**]." Walks with a walker at
baseline. Never smoker, no other drug use. Drinks 1 drink/week.
Has 2 sisters that live out of state, son died 3 years ago ("was
shot to death").
Family History:
Father with DM, mother died at age 41 of renal failure
Physical Exam:
Admission PE:
Vitals: T: 97.2 BP:121/74 P: 81 R: 18 O2: 100
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, DMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, hyperactive bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge PE:
VS: 96.9 111/52 66 18 100 on RA
General: pleasant gentleman, NAD, laying comfortably in bed
HEENT: Sclera anicteric, moist mucous membranes
Neck: supple, JVP not elevated, no LAD
Chest: L HD site no erythema, no tenderness to palpation
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, hyperactive bowel
sounds present
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2119-9-8**] 08:37PM GLUCOSE-92 UREA N-53* CREAT-10.1* SODIUM-141
POTASSIUM-4.5 CHLORIDE-99 TOTAL CO2-17* ANION GAP-30*
[**2119-9-8**] 08:37PM ALT(SGPT)-9 AST(SGOT)-15 LD(LDH)-147
CK(CPK)-185 ALK PHOS-116
[**2119-9-8**] 08:37PM CK-MB-4 cTropnT-0.13*
[**2119-9-8**] 08:37PM CALCIUM-8.7 PHOSPHATE-8.2*# MAGNESIUM-1.9
[**2119-9-8**] 08:37PM WBC-11.5* RBC-5.17 HGB-14.8 HCT-46.2 MCV-89
MCH-28.5 MCHC-32.0 RDW-14.1
[**2119-9-8**] 08:37PM NEUTS-84.7* LYMPHS-8.6* MONOS-4.1 EOS-2.3
BASOS-0.3
[**2119-9-8**] 08:37PM PLT COUNT-275
[**2119-9-8**] 08:37PM PT-13.9* PTT-28.3 INR(PT)-1.2*
[**2119-9-8**] 12:39PM LACTATE-2.9*
[**2119-9-8**] 12:15PM GLUCOSE-102* UREA N-45* CREAT-9.5*#
SODIUM-139 POTASSIUM-3.9 CHLORIDE-91* TOTAL CO2-17* ANION
GAP-35*
[**2119-9-8**] 12:15PM estGFR-Using this
[**2119-9-8**] 12:15PM ALT(SGPT)-11 AST(SGOT)-18 ALK PHOS-143* TOT
BILI-0.4
[**2119-9-8**] 12:15PM cTropnT-0.16*
[**2119-9-8**] 12:15PM ALBUMIN-4.6 CALCIUM-10.2 PHOSPHATE-6.3*#
MAGNESIUM-2.0
[**2119-9-8**] 12:15PM DIGOXIN-0.2*
[**2119-9-8**] 12:15PM WBC-13.5*# RBC-5.88 HGB-16.5 HCT-52.4* MCV-89
MCH-28.1 MCHC-31.5 RDW-14.1
[**2119-9-8**] 12:15PM NEUTS-89.5* LYMPHS-6.1* MONOS-2.7 EOS-1.5
BASOS-0.2
[**2119-9-8**] 12:15PM PLT COUNT-300#
[**2119-9-8**] 12:15PM PT-14.2* PTT-53.6* INR(PT)-1.2*
Brief Hospital Course:
60 year old male with pmh of seizure disorder, ESRD on HD (MWF),
nonischemic cardiomyopathy (EF~40-45%), h/o CAD and CVA,
hepatitis B admitted with chest pain and hypotension. Chest
pain resolved after arrival to the ED and did not recurr.
#Hypotension:
The patient was hypotensive in the setting of taking off excess
fluid in HD. His pressures responded to volume repletion with
3L IVF. This extra net negative fluid balance was also
exacerbated by the patient's diarrhea and poor PO intake in the
4-5 days preceding presentation. He continued to have loose
bowel movements while he was in the MICU. Stool cultures and
OVA/Parasites were sent. Blood cultures were drawn in the ED,
given the fact that the patient has a HD line and systemic
infection needed to be ruled out in the setting of his
hypotension. He was started on empiric Vanc and Ceftriaxone in
the unit and was continued on antibiotics until his blood
cultures were negative for 48 hours. While on the floor the
patient's blood pressures were in the low 100s. He was
triggered for pressures in the 60s, but it is unclear whether
these readings were accurate. He was completely asymptomatic
during this episode and was mentating normally. He was bolused
500 cc x2, and his repeat pressures using an automated BP
machine were in the low 100s. The patient remained in the low
100s during the rest of his admission after his antibiotics were
discontinued. He also remained afebrile. He will follow up with
Nephrology at which time midodrine may be added if hypotension
continues to be a problem.
.
# chest pain: The patient's chest pain resolved while in the ED
and he was ruled out for MI while in MICU with negative
troponins. The patient did not endorse chest pain during the
hospitalization. As per the MICU admission, the patient did
have transient changes in the ED on EKG, but his chest pain has
since resolved. Cardiology saw the patient and was not
concerned given the lack of symptoms. The patient's troponin
peaked at 0.16 and trended down to 0.14. Of note, his recent
baseline troponin within last year was 0.12-.014.
.
# diarrhea: While in the unit, the patient was still having
diarrhea. Stool cultures and ova and parasite, as well as Cdiff
were all sent. The patient was started on empiric Flagyl. Upon
transfer to the floor, the patient was no longer having diarrhea
and his empiric Flagyl was stopped. He was also found to be
Cdiff toxin negative.
.
# ESRD on HD: The patient was continued on his M, W, F dialysis
schedule while in patient. Renal was following and his volume
status was closely followed. All medictions were renally dosed
and neprhotoxic agents were avoided. The patient was also
started on nephrocaps during this admission.
.
# CAD/CHF: The patient's last ECHO was in [**12/2118**] with an EF
25-30%. He was ruled out for MI with negative troponins. The
patient is not on Lisinopril secondary to his low blood
pressures.
.
Chronic Issues:
.
# gout: The patient was continued on his home gout medications.
.
# seizure d/o: The patient was continued on his home
anti-seizure medications.
.
Transitional Issues:
.
# hypotension: The patient's blood pressures tend to run on the
lower side. Consider midodrine as outpatient in order to
prevent recurrence of hypotensive episodes.
.
# CAD:: The patient's CAD is not medically optimized, as he is
not on an ACE. If his pressures can tolerate it, consider
adding low dose Lisinopril. He is also not on a beta blocker.
Medications on Admission:
bisacodyl 5 mg Two Tablet PO DAILY
senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day PRN
calcium acetate 667 mg Capsule Sig: Four (4) Capsule PO TID
W/MEALS
folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY
ferrous sulfate 300 mg PO DAILY
sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS
gabapentin 100 mg Capsule Sig: Two (2) Capsule PO Q24H
levetiracetam 500 mg Tablet Sig: One (1) Tablet PO TID
levetiracetam 500 mg Tablet Sig: One (1) Tablet PO MWF
oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO TID
aspirin 81 mg PO DAILY
oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO MWF
simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
omeprazole 20 mg PO DAILY (Daily).
digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H PRN
gabapentin 100 mg Capsule 2 Capsule(s) by mouth Daily
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation.
Disp:*14 Tablet(s)* Refills:*0*
2. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*28 Tablet(s)* Refills:*2*
3. calcium acetate 667 mg Capsule Sig: Four (4) Capsule PO three
times a day: TID with meals.
Disp:*360 Capsule(s)* Refills:*0*
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO three
times a day.
Disp:*360 Tablet(s)* Refills:*0*
6. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO once a day.
7. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO three
times a day.
Disp:*60 Tablet(s)* Refills:*0*
8. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO as
directed: one tablet M,W, F with dialysis.
9. oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO three
times a day.
Disp:*120 Tablet(s)* Refills:*0*
10. oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO as
directed: 2 tablets PO MWF with dialysis.
11. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*14 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
12. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*28 Tablet(s)* Refills:*2*
13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*14 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
14. digoxin 125 mcg Tablet Sig: One (1) Tablet PO every other
day.
Disp:*10 Tablet(s)* Refills:*0*
15. allopurinol 100 mg Tablet Sig: One (1) Tablet PO every other
day.
Disp:*10 Tablet(s)* Refills:*0*
16. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO q6h PRN
as needed for fever or pain.
Disp:*20 Tablet(s)* Refills:*0*
17. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*14 capsules* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis:
hypotension
end stage renal disease on hemodialysis
secondary diagnosis:
seizure disorder
nonischemic cardiomyopathy
Discharge Condition:
Activity Status: ambulates with walker, uses wheelchair
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Dr. [**Known lastname 2026**],
It was a pleasure taking care of you while you were hospitalized
at [**Hospital1 18**]. You were initially admitted to the intensive care
unit because you blood pressures in the emergency department
were very low. It was unclear whether your low blood pressures
were due to not having enough fluid in your body (you were
reporting diarrhea and not drinking as much fluid) or if you had
a severe infection. While in the intensive care unit, we gave
you fluids and also started you on strong antibiotics. We drew
blood samples as well to check for any bacteria in your blood.
Once your blood pressures were stabilized, you were transferred
to the general medicine floor. On the floor you pressures have
been good, except for one episode when they dropped low.
However, your blood pressure responded well to fluids that we
gave you through you veins.
While you were in the hospital, the kidney doctors were also
following you and we continued your M, W, F dialysis schedule.
The following changes were made to your medications:
-START Nephrocaps 1 capsule daily by mouth
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please keep all follow-up appointments as below:
.
Department: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
When: THURSDAY [**2119-9-21**] at 10:30 AM
With: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] South [**Hospital **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
NOTE: This appointment is with a hospital-based doctor as part
of your transition from the hospital back to your primary care
provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary
care doctor in follow up
.
You will be followed by your nephrologist, Dr [**First Name (STitle) 805**] during
your upcoming dialysis appointment:
HD on M/W/F at [**Last Name (un) **] Dialysis Center in [**Location (un) **]
Completed by:[**2119-9-19**]
|
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icd9cm
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59,085
| 173,476
|
39498
|
Discharge summary
|
report
|
Admission Date: [**2183-2-1**] Discharge Date: [**2183-2-1**]
Date of Birth: [**2122-3-3**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Actos / Percocet / Cephalosporins
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
s/p Cardiac arrest
Major Surgical or Invasive Procedure:
None
History of Present Illness:
60 yo M with CAD, CHF EF 20% s/p ICD, IDDM, recent admission for
VT storm, who is transferred from OSH s/p cardiac arrest.
The history is passed down via multiple transitions of care, so
it is somewhat limited. Reportedly, the patient was found down
at rehab. It is thought that he was down for 15-20 minutes. He
was found pulseless, in asystole. He got 20-30 minutes of CPR en
route to [**Hospital6 5016**]. Intubation was attempted but was
unsuccessful pre-hospital, so put the patient on CPAP and
transferred to [**Hospital3 **]. At [**Hospital3 **], pulse was thready.
GCS was 3. Left tib I/O placed. Intubated.
On interrogation of the patient's ICD, it appears that the
patient had 3 episodes Vtach and 4 episodes of NSVT between 9:23
p.m. and 9:28 p.m. today. The sequence of events after that is
unclear, but after discussion with the EP fellow, it appears
that the patient received ATP and one shock before going into
PEA and then asystole.
The patient was med flighted to [**Hospital1 18**], where initial vital signs
were HR 80 BP 132/76 RR 23 Sat 100% on pressure support with
FiO2 100%. ABG was 7.38/45/270. CXR showed ET tube 2.7 cm above
the carina, Severe cardiomegaly, pulmonary vascular congestion,
and pulmonary edema, large right pleural effusion. CT head and
neck showed no acute process (wet read).
Of note, the patient was recently admitted to the CCU from [**1-24**]
to [**1-30**] for VT storm. He was treated with amiodarone and
mexilitine and discharged to rehab.
Review of systems is unobtainable.
Past Medical History:
Systolic heart failure with EF 20%
s/p DES to RCA
s/p ICD implanted on [**2180-4-26**]
OTHER PAST MEDICAL HISTORY:
Diabetes type II on insulin
Hypercholesterolemia
Peripheral neuropathy
Hypertriglyceridemia
Chronic systolic CHF
Afib on coumadin
Dilated non-ischemic cardiomyopathy
Multinodule goitor likely due to amiodarone
Social History:
-Tobacco history: Former smoker
-ETOH: no etoh
Is not married.
Family History:
Father died with rectal cancer
Mother has [**Name2 (NI) **] of colon ca, rheumatic valvular dz
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
VS: BP=99/74 HR=79 RR=17 O2 sat=96%
GENERAL: Intubated. Sedated. Rhythmically elevates shoulders.
HEENT: Sclera anicteric. Pupils 2-3 mm and fixed.
NECK: In cervical collar. Difficult to assess JVP secondary to
cervical collar.
CARDIAC: Very difficult to auscultate secondary to loud, coarse
breath sounds. RRR. No murmur, gallops, or rubs appreciated.
LUNGS: Diffusely course breath sounds.
ABDOMEN: Soft, NT/ND.
EXTREMITIES: There is edema in all 4 extremities. Radial and DP
pulses are 1+.
NEURO: Intubated. Sedated. Pupils fixed at 2-3 mm. Not
responsive to pain in any extremity.
Pertinent Results:
Admission labs:
[**2183-2-1**] 02:10AM BLOOD WBC-16.0* RBC-3.70* Hgb-11.1* Hct-32.6*
MCV-88 MCH-29.9 MCHC-34.0 RDW-16.1* Plt Ct-161
[**2183-2-1**] 02:10AM BLOOD WBC-16.0* RBC-3.70* Hgb-11.1* Hct-32.6*
MCV-88 MCH-29.9 MCHC-34.0 RDW-16.1* Plt Ct-161
[**2183-2-1**] 02:10AM BLOOD Neuts-89* Bands-1 Lymphs-2* Monos-7 Eos-0
Baso-0 Atyps-0 Metas-1* Myelos-0
[**2183-2-1**] 02:10AM BLOOD PT-23.9* PTT-34.3 INR(PT)-2.3*
[**2183-2-1**] 02:10AM BLOOD Glucose-212* UreaN-92* Creat-2.2* Na-121*
K-4.0 Cl-82*
[**2183-2-1**] 02:10AM BLOOD ALT-648* AST-558* AlkPhos-189*
TotBili-1.4
[**2183-2-1**] 02:10AM BLOOD Lipase-69*
[**2183-2-1**] 02:10AM BLOOD cTropnT-0.09*
[**2183-2-1**] 02:10AM BLOOD Calcium-8.2* Phos-4.9* Mg-2.6
[**2183-2-1**] 02:10AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2183-2-1**] 02:17AM BLOOD Type-ART Rates-/20 Tidal V-512 PEEP-5
FiO2-100 pO2-270* pCO2-45 pH-7.38 calTCO2-28 Base XS-1 AADO2-418
REQ O2-71 Intubat-INTUBATED Vent-SPONTANEOU
[**2183-2-1**] 02:17AM BLOOD Glucose-202* Lactate-2.1* Na-121* K-4.1
Cl-82*
Studies:
CT HEAD W/O CONTRAST Study Date of [**2183-2-1**] 1:23 AM
IMPRESSION:
1. No acute intracranial hemorrhage or mass effect. In
particular, there is no intracranial hemorrhage. If there is
continued clinical concern for
parenchymal changes/acute infarction, MR can be considered if
not CI; however, pt. has a pacemaker and hence, if there is
continued clinical concern,a follwo up CT Head can be considered
to assess for short term stability. See details above.
2. Minimal maxillary sinus disease.
CT C-SPINE W/O CONTRAST Study Date of [**2183-2-1**] 1:24 AM
IMPRESSION:
1. No acute fracture or traumatic malalignment of the cervical
spine.
2. Multilevel severe degenerative changes throughout the
cervical spine,
resulting in mild-to-moderate spinal canal stenosis.
NOTE ON ATTENDING REVIEW:
A few linear lucencies are noted in proximity to the anterior
osteophyte at the antero-inferior aspect of C5 and C6. While
these may relate to orientation, subtle fractures associated
with the osteophytes cannot be excluded. ( Se 701b, im 37, 40)
Assessment of prevertebral soft tissue swelling is limited at
C5/6 and C6/7 levels due to intubation. As the aptient cannot
have MRI due to apcemaker in-situ, consider follow up with PXR
after spine consult to clear the spine and exclude fractures.
CHEST (PORTABLE AP) Study Date of [**2183-2-1**] 1:29 AM
IMPRESSION:
1. Endotracheal tube terminating 2.7 cm above the carina.
2. Severe cardiomegaly with severe pulmonary vascular congestion
and
pulmonary edema.
3. Large right pleural effusion.
4. Orogastric tube within the stomach.
Brief Hospital Course:
60yo M w/ CAD, CHF with an EF of 20%, s/p BiV ICD, DM, AF on
coumadin, recent admission for VT storm, now readmitted to CCU
s/p cardiac arrest.
.
# Neuroprotection s/p cardiac arrest: Arrived with GCS of 3 and
Arctic Sun protocol initiated. Poor prognosis was discussed
with aunt, [**Name (NI) **]. She was understanding of patient's clinical
status and did not want escalation of care. Code status was
changed to DNR/DNI. Patient was rewarmed to better assess
neurologic function. Neurologic status continued to be poor and
the patient was terminally extubated.
.
# RHYTHM: Precipitant for event was VT -> PEA -> asystole. A-V
paced rhythm on admission. For anti-arrythmics, he was started
on amiodarone drip + mexiletine.
Warfarin was continued for atrial fibrillation.
.
# Blood pressures: Metoprolol, lisinopril, spironolactone, and
lasix all held in setting of hypotension/cardiogenic shock.
Medications on Admission:
bisacodyl 10 mg daily PRN constipation
senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID PRN Constipation
docusate sodium 100 mg [**Hospital1 **]
gemfibrozil 600 mg [**Hospital1 **]
atorvastatin 40 mg QHS
metoprolol succinate 25 mg daily
clopidogrel 75 mg daily
cholecalciferol (vitamin D3) [**2172**] units daily
multivitamin 1 Tablet PO DAILY
spironolactone 25 mg daily
mexiletine 150 mg PO Q12H
amiodarone 200 mg PO BID
Lantus 15 units at bedtime.
Humalog sliding scale
furosemide 80 mg PO BID
famotidine 20 mg PO Q12H
Niaspan Extended-Release 500 mg PO at bedtime
aspirin 81 mg daily
Discharge Medications:
Not applicable
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiac arrest
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
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[
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|
2256, 2321
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,777
| 100,059
|
22670
|
Discharge summary
|
report
|
Admission Date: [**2198-2-1**] Discharge Date: [**2198-2-19**]
Date of Birth: [**2129-10-28**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This 68 year old white male had
an abnormal stress test in 02/[**2194**]. He underwent cardiac
cath which revealed 100 percent RCA lesion. He had angina
again in [**2196**] and had an abnormal stress test and was re-
cathed, and that showed 100 percent RCA lesion, a 50 percent
left main stenosis, and a left circumflex stenosis. He had
no symptoms and surgery was deferred. He now has had a month
of angina again and had an abnormal treadmill with an EF down
to 27 percent. An angio on [**2198-1-31**] revealed a 95 percent
ostia left main, a 70 percent diagonal 2 lesion, 80 percent
OM and 100 percent RCA lesion with a normal LV. So he was
transferred to [**Hospital1 18**] for further treatment.
PAST MEDICAL HISTORY: His past medical history is
significant for a history of non-insulin dependent diabetes,
hypercholesterolemia, hypertension, prostate CA, and status
post removal of a basal cell carcinoma from his back two
weeks prior to admission. He is also status post cataract
surgery.
MEDICATIONS: His medications on admission were nitroglycerin
drip, Metformin, Lipitor, aspirin, multivitamin, Metamucil,
Atenolol.
ALLERGIES: He has no known allergies.
FAMILY HISTORY: Family history is significant for coronary
artery disease.
SOCIAL HISTORY: He does not smoke cigarettes and drinks
alcohol occasionally.
REVIEW OF SYSTEMS: His review of systems is as above.
PHYSICAL EXAMINATION: He is a well developed, well nourished
white male in no apparent distress. Vital signs stable.
Afebrile. HEENT exam normocephalic and atraumatic.
Extraocular movements are intact. Oropharynx benign. Neck
was supple. Full range of motion. No lymphadenopathy or
thyromegaly. Carotids 2 plus and equal bilaterally without
bruits. Lungs were clear to auscultation and percussion.
Cardiovascular exam regular rate and rhythm. Normal S1 and
S2 with no rubs, murmurs or gallops. Abdomen was soft and
nontender with positive bowel sounds. No masses or
hepatosplenomegaly. Extremities without cyanosis, clubbing
or edema. Pulses were 2 plus and equal bilaterally
throughout. Neuro exam was nonfocal.
HOSPITAL COURSE: Dr. [**Last Name (STitle) **] was consulted and on [**2198-2-2**]
the patient underwent a CABG times five with a free LIMA to
the LAD and reverse saphenous vein graft to the diagonal,
OM1, OM2 and PVA. Cross clamp time was 89 minutes. Total
bypass time was 125 minutes. He was transferred to the CSRU
on Neo in stable condition. He had a stable postop night.
He was extubated. On postoperative day one he was started on
a beta blocker and his nitro was weaned. Postop day two he
was transferred to the floor in stable condition and his
chest tubes were discontinued. Postop day three his
epicardial pacing wires were discontinued. Postop day number
four he began having sternal drainage. He was started on
Kefzol and had his wounds painted with Betadine tid. He did
have some more drainage and his lower two sternal wires
seemed to have pulled through on his x-ray, so on postop day
number five he underwent sternal re-wiring. He tolerated the
procedure well and was transferred back to the floor. He
continued to improve and had his chest tubes discontinued on
postop day number one from re-wiring. He was also changed to
Levofloxacin and Vanco. He continued to improve but
continued to have intermittent sternal drainage. He had
cultures which were negative. He had a PICC line placed and
was continued on Vanco. Eventually his drainage stopped
completely and he had two days of no drainage and his Vanco
was discontinued and he was discharged to home on a week of
Levofloxacin. So on postop day number 17 he was discharged
to home in stable condition.
LABORATORY DATA: His labs on discharge were white count
10,000, hematocrit 28.1, platelets 767,000, sodium 139,
potassium 5.2, chloride 104, CO2 28, BUN 17, creatinine 0.9,
blood sugar 116.
DISCHARGE MEDICATIONS:
1. Glucophage, 500 mg po bid.
2. Colace, 100 mg po bid.
3. Aspirin, 81 mg po q day.
4. Percocet, 1 to 2 po q4-6h prn pain.
5. Lipitor, 10 mg po q day.
6. Plavix, 75 mg po q day.
7. Lopressor, 100 mg po tid.
8. Lisinopril, 10 mg po q day.
9. Levofloxacin, 500 mg po q day for 7 days.
He will be seen by Dr. [**Last Name (STitle) **] in four weeks and by Dr. [**Last Name (STitle) 37063**]
in one to two weeks.
DISCHARGE DIAGNOSES: His discharge diagnoses include:
1. Coronary artery disease.
2. Hypertension.
3. Hyperlipidemia.
4. Non-insulin dependent diabetes.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2198-2-19**] 15:54:20
T: [**2198-2-19**] 16:33:56
Job#: [**Job Number 58744**]
|
[
"V10.46",
"E878.8",
"998.32",
"401.9",
"V10.83",
"411.1",
"250.00",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.79",
"36.15",
"39.61",
"36.14",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
1360, 1420
|
4526, 4896
|
4093, 4504
|
2304, 4070
|
1579, 2286
|
1520, 1556
|
165, 872
|
895, 1343
|
1437, 1500
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,847
| 190,479
|
24272
|
Discharge summary
|
report
|
Admission Date: [**2103-7-4**] Discharge Date: [**2103-7-21**]
Date of Birth: [**2056-7-2**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
s/p trauma (ATV pinned patient with LOC x 10 min)
Major Surgical or Invasive Procedure:
bronchoscopy [**7-10**]
History of Present Illness:
47M who fell backward off truck bed while at work and then was
pinned by ATV when it fell upon him. Reportedly, he was
unconscious at the scene for about 10 minutes & was intubated by
med flight en route for combativeness on transfer to [**Hospital1 18**]. No
reported seizures or hemodynaminc instability prior to arrival
at [**Hospital1 18**].
Past Medical History:
none
Social History:
+etOH (4 per day)
+cigs
Family History:
noncontributory
Physical Exam:
Afeb 96 114/70 12 100% (on AC)
Intubated sedated
RRR
CTA bilat
Soft nontender abdomen
Neuro: Had purposely moved all extremities prior to sedation for
intubation
Pertinent Results:
[**7-4**] CT head: L frontal SAH, R occipital SDH, nondisplaced
occipital skull fracture
C spine: neg
CT C/A/P: right 3rd-8th rib fractures with assoc RUL contusion
Brief Hospital Course:
Was loaded with dilantin in ED and then admitted to TSICU for
vent management after initial trauma evaluation. Neurosurgery
was consulted, and followed patient with serial CT scans. Due
to bleeding, SQ heparin was held until HD #4 (when CT head was
stable) & pneumoboots were used to prophylax vs DVTs. The
patient remained intubated until HD #14 ([**7-17**]), since he
developed copious pulmonary secretions (requiring therapeutic
bronch on [**7-10**]). His ICU course was also significant for
agitation, leukocytosis & high fevers (despite tx with levaquin
for h flu pneumonia). After extubation, he did very well & was
eventually transferred to the floor in good condition on HD #16.
His floor course was relatively unremarkable (passed bedside
swallow evaluation, cleared for home by PT) until the afternoon
of [**7-21**], when suddenly became unresponsive and hypoxic while
working with PT. Initial ABG & clinical story was consistent
with a massive pulmonary embolus. Despite initiation of CPR
immediately, the patient could not be revived & was pronounced
at 1407 after 30 minutes of CPR. The family & the medical
examiner were both notified.
Medications on Admission:
unknown
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
subdural hematoma
subarachnoid hematoma
occipital/basilar skull fracture
multiple rib fractures
pulmonary contusion
respiratory failure
pleural effusion
haemophilus pneumonia
ileus
DVT/PE
Discharge Condition:
deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2103-10-8**]
|
[
"E884.9",
"518.5",
"913.0",
"008.45",
"801.22",
"807.06",
"861.21",
"922.31",
"560.9",
"303.90",
"415.19",
"E916",
"427.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.07",
"99.60",
"94.62",
"96.72",
"33.22",
"38.91",
"96.04",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
2457, 2466
|
1211, 2371
|
319, 344
|
2697, 2707
|
1022, 1032
|
2759, 2793
|
806, 823
|
2429, 2434
|
2487, 2676
|
2397, 2406
|
2731, 2736
|
838, 1003
|
230, 281
|
372, 721
|
1041, 1188
|
743, 749
|
765, 790
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,514
| 108,455
|
20956
|
Discharge summary
|
report
|
Admission Date: [**2191-3-3**] Discharge Date: [**2191-3-28**]
Date of Birth: [**2124-4-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
1. endotracheal intubation
2. bronchoalveolar lavage
3. placement of OG tube
4. placement of R internal jugular venous catheter
5. placement of R subclavian venous catheter
6. thoracentesis
7. lumbar puncture
History of Present Illness:
66 yo M with h/o CLL and follicular lymphoma currently receiving
chemotherapy, myasthenia [**Last Name (un) 2902**] (Dx [**2185**]; last flare [**2187**]), and
h/o recent pneumonia, who presented on [**2191-3-3**] with 1 week of
URI sxs, fevers, and worsening SOB. Patient had "pneumonia" in
early [**Month (only) 956**] and was treated with Ceftriaxone and
Levofloxacin. He finished a 10 day course of Azithro yesterday
for URI sx. Yesterday the patient had worsening SOB and cough
productive of clear sputum associated with low grade fevers to
99. Pt reported no chest pain other than pressure with cough, +
chronic back pain, no abdominal pain, no diarrhea or
constipation, no headache. EMS was called this AM and he was
noted to be 87% on RA.
.
In ED T 101.8, respiratory distress, improved to 100% on 100%
NRB. An initial ABG showed 7.44/46/126 on NRB. He received
Cefepime for essential neutropenia, Tylenol, and ativan 1 mg.
.
A CTA was negative for PE but showed diffuse centrilobular
nodules b/l and some consolidation in the RML and LL b/l, c/w
infection or mets.
Pt was improving in terms of oxygenation and weaned to nasal
cannula, but started to have increased tachypnea and tachycardia
and with concern for fatigue in setting of myasthenia [**Last Name (un) 2902**],
NIF was checked and found to be -22 and Vital capacity of 1.2L.
Was intubated for impending respiratory fatigue.
Pt underwent bronch on [**3-3**] with positive AFB smear; no evidence
PCP.
Neurology was consulted with concearn for flare-up of his
Myasthenia [**Last Name (un) **]; Tensilon test was positive; neurology
recommended increase Mestinon from 60TID to 80TID and no
indication for IVIG or plasmaphoresis.
Pt was transferred to [**Hospital Unit Name 153**] per onc attending request.
Past Medical History:
1. CLL diagnosed [**2179**], received chemo and was in remission
until [**2189**] when he had recurrence and now on his 4th regimen of
chemotherapy, s/p fludarabine, CPR x4 cycles, Campath
[**Date range (1) 55712**], now on CEPP (cytoxan, etoposide, procarbazine,
prednisone)
2. myasthenia [**Last Name (un) 2902**], on IVIG for the past 3 years
3. anxiety
4. hypertension, now off meds after weight loss
5. BPH
6. h/o grade III internal hemorrhoids
Social History:
Retired science teacher, lives at home w/ wife and son, hx of
tobacco 3 ppd x 20 years, now dc'ed x 34 years, prev 2 ETOH/day,
now dc'ed x 2 years, no IVDU, no illicit drug use
Family History:
Breast cancer in sister, suicide at 67; brother died of lung
cancer at 60; o/w no FH ca, DM2, HTN, CAD
Physical Exam:
VS: 101.0 108/68 136 33 100% NRB
Gen: appears uncomfortable, tachypneic
HEENT: Sclerae anicteric. PERRLA. No oral lesions. Tongue is
well papillated. Shotty cervical and supraclavicular adenopathy.
Large seven by eight centimeter left axillary node is nontender.
NECK: Shotty right axillary adenopathy.
Pulm: + crackles at RLL, no wheezes
CV: tachycardic, regular, nl S1/S2, no murmurs
ABDOMEN: soft, NT/ND, good bowel sounds, spleen is palpable two
centimeters below
the left costal margin, liver edge palpable about 2cm below
costal margin.
EXTREMITIES: Bilateral shotty femoral adenopathy, no edema, 2+
distal pulses.
Pertinent Results:
Admission labs:
[**2191-3-3**] 08:20AM WBC-1.4*# RBC-3.22* HGB-9.8* HCT-27.9* MCV-87
MCH-30.5 MCHC-35.1* RDW-19.0*
[**2191-3-3**] 08:20AM PLT COUNT-119*
[**2191-3-3**] 08:20AM GRAN CT-680*
[**2191-3-3**] 08:20AM GLUCOSE-99 UREA N-21* CREAT-0.6 SODIUM-137
POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-30* ANION GAP-13
[**2191-3-3**] 08:20AM ALT(SGPT)-35 AST(SGOT)-35 CK(CPK)-15* ALK
PHOS-71 AMYLASE-57 TOT BILI-1.4
[**2191-3-3**] 08:20AM PT-12.4 PTT-29.1 INR(PT)-1.0
[**2191-3-3**] 08:41AM LACTATE-1.4
[**2191-3-3**] 09:00AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2191-3-3**] 09:00AM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2191-3-3**] 09:00AM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-RARE
EPI-0-2
[**2191-3-3**] 09:00AM URINE HYALINE-0-2
[**2191-3-3**] 09:46AM TYPE-ART TEMP-38.3 PO2-126* PCO2-46* PH-7.44
TOTAL CO2-32* BASE XS-6 INTUBATED-NOT INTUBA COMMENTS-NON-REBREA
[**2191-3-3**] 09:19PM TYPE-ART O2-100 PO2-506* PCO2-44 PH-7.39
TOTAL CO2-28 BASE XS-1 AADO2-173 REQ O2-38 -ASSIST/CON
INTUBATED-INTUBATED
Imaging:
CXR [**3-3**]:
IMPRESSION:
1) Left lower lobe opacity consistent with pneumonia.
2) Proper placement of the NG tube.
CT angio [**3-3**]:
IMPRESSION:
1) No CT evidence of pulmonary embolism.
2) Interval development of innumerable, diffuse, ill-defined
nodules which appear to be in a centrilobular pattern, some of
which are arranged in a tree and [**Male First Name (un) 239**] pattern. These findings are
most suggestive of a small airways atypical infection, such as
fungal, mycobacterial, or mycoplasma.
3) Multifocal areas of consolidation within the right middle
lobe, right lower lobe, left lower lobe, findings which may
represent atelectasis or multifocal infectious process.
4) Slight interval decrease in size of the right middle lobe
pulmonary mass.
5) Stable appearance of bulky axillary, hilar, or mediastinal
lymphadenopathy.
6) Interval resolution of previously seen effusions.
CT head [**3-15**] (noncontrast):
IMPRESSION: No intracranial hemorrhage or mass effect.
EEG [**3-16**]:
IMPRESSION: Abnormal portable EEG due to the slow and
disorganized
background and bursts of generalized slowing. These findings
indicate a
widespread encephalopathic condition affecting both cortical and
subcortical structures. Medications, metabolic disturbances, and
infection are among the most common causes. There were no areas
of
prominent focal slowing, but encephalopathies may obscure focal
findings. There were no epileptiform features. A tachycardia was
noted.
Brief Hospital Course:
1. Respiratory failure - etiology was multifactorial, due to a
multifocal pneumonia, RSV bronchiolitis, and myasthenia crisis.
Neurology was consulted early, and a tensilon test could not
rule out myasthenia crisis. Pt was therefore treated with 5
days of IVIG. In addition, BAL on [**3-3**] eventually revealed RSV,
which was consistent with the tree-in-[**First Name5 (NamePattern1) 239**] [**Last Name (NamePattern1) 55713**] picture
on chest CT. He was therefore treated with a 5-day course of
ribavirin, as well as Synagis. Further, due to his neutropenia,
pt was placed on broad spectrum antibiotics (cefepime as
febrile/neutropenic, doxycycline for atypicals, and vanco for
possibility of MRSA)for his presumed multifocal pneumonia. On
BAL [**3-3**], a few AFB were noted on concentrated smear; this
proved to be MAC and not thought to be a major player in pt's
respiratory failure. Pt was intubated in the ED and ventilated;
Over the first 2 weeks of his hospitalization, as the above
treatments proceeded, pt required decreasing amounts of
ventilatory support. His NIF was measured daily, and increased
to about -27 without increased effort. Eventually, his mental
status (as detailed below) and ability to manage secretions were
thought to be the major impediments to extubation, he had a
trach placed on [**2191-3-20**]. He did well for a few days off any
ventilatory support, and then on [**2191-3-28**] became hypotensive and
went into hypercarbic respiratory failure.
.
2. Mental status - After propofol was weaned, pt did not clear
his mental status as predicted: he had intact brainstem function
but could not follow commands and did not move his extremities
spontaneously. A head CT did not reveal any acute intracranial
process. An EEG showed changes consistent with encephalopathy,
thought to be due to metabolic causes. An LP was eventually
performed to rule out a meningitis, which was negative. Pt's
mental status continued to improve gradually, but waxed and
waned.
.
3. tachycardia - Pt was noted to be tachycardic, between the
90s-120s during most of his hospitalization. There was no clear
etiology; pt's EKG was consistent with sinus tachycardia. There
was a loose association between his fevers and tachycardia, but
pt remained on the tachycardic side whether or not he was
febrile.
.
4. anemia - Pt's baseline Hct was around 28-30. However, his
Hct dropped to 22-24 during the first few days of
hospitalization. GI was consulted and it was thought that if he
had a true GI bleed, pt would have melena or BRBPR, neither of
which he had. He was transfused and his Hct responded
appropriately. However, later on, around 2 weeks into his
hospitalization, his Hct again dropped to about 26. He was
transfused 2 units again, without significant response
(increased to 29 from 26). Hemolysis and DIC labs were
negative. A reticulocyte count was 1.8%, which pointed to an
underproduction/bone [**Last Name 15482**] problem. Pt was guaiac positive but
not frankly melenic or with BRBPR; this was thought to be due to
the small amount of oral bleeding pt demonstrated in the context
of gum disease.
.
6. myasthenia [**Last Name (un) 2902**] - Due to an equivocal tensilon test, pt
was treated with 5 days of IVIG. He was continued on his
pyridostigmine, which was initially increased to 80mg po tid.
While pt was receiving IVIG and his secretions were increased,
this was lowered to 40mg po tid, and then uptitrated to 60mg po
tid with resolution of these symptoms, after the IVIG was
completed. He was maintained on the pyrdidostigmine throughout
his course and it was felt the myasthenia contributed to his
poor respiratory status.
.
7. fevers - Pt was consistently febrile throughout his
hospitalization. Low-grade fevers were thought to be consistent
with pt's underlying CLL and were consistent with his low-grade
fevers at home. However, he had multiple fever spikes, to the
102s. Blood cultures were repeatedly negative, with the
exception of a myco/lytic blood culture bottle ([**12-27**] blood
cultures from that day, [**3-11**]) grew Enterococcus faecium, which
was sensitive to vancomycin. Pt was therefore placed on
vancomycin for a 2 week course. Pt's sputum cultures did not
grow any bacteria; however, repeated nasopharyngeal aspirates
were positive for RSV antigen and he was treated with ribavirin
and palivizumab x 2. Urine cultures were repeatedly negative.
Pt's nasopharyngeal aspirates grew HSV-1 on viral culture, but
this was not thought to be a pathogenic source. He was treated
with acyclovir for his HSV infection as he had oral ulcers. Pt
developed increasing bilateral pleural effusions. He was covered
with meropenum for possible VAP on [**2191-3-28**].
.
8. adrenal insufficiency - Pt'[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim was borderline
positive, thought likely in the context of sepsis. He was
placed on stress dose steroids, which ere weaned to his
outpatient prednisone dose.
.
9. CLL - pt is s/p recent CEPP chemotherapy, the last dose
being on [**2-28**]. He was pancytopenic as a result, but his ANC
recovered within the first few days, by [**3-8**]. G-CSF and
neutropenic cautions were stopped. Daily ANC revealed a
down-trend, though not to neutropenic levels, but he was felt to
be functionally neutropenic. Pt was also thrombocytopenic and
anemic, thought to be due to his recent chemotherapy. He did
require transfusions of platelets and PRBC.
.
10. FEN - Pt was maintained on tube feeds. He had increased
insensible losses, particularly during the time of ribavirin
treatment due to the tent in place, as well as in the context of
his fevers. He became transiently hypernatremic in this
setting, but this resolved with free water flushes. In
addition, pt was maintained with tight glycemic control (goal
<120) with fingersticks four times daily and an inuslin sliding
scale.
.
11. Goals of care: HIs clinical picture worsened on [**2191-3-28**] when
he became hypotensive and had acute repsiratory failure.
Multiple family meetings were had to discuss his code status and
to discuss goals of care. He was made comfort measures only and
passed away comfortably with his family at his side on [**2191-3-28**].
Medications on Admission:
senna
protonix 40mg po daily
folate 1mg po daily
allopurinol 300mg po daily
acyclovir 800mg po daily
iron sulfate 650mg po daily
bactrim DS MWF
prednisone 50mg po daily
flomax 0.4mg po daily
oxycontin 20mg po bid
restoril 45mg po q4h
CEPP
rituxan weekly
IVIG monthly
albuterol/atrovent nebs
pyridostigmine 180mg po qHS
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
CLL, repsiratory failure, sepsis
Discharge Condition:
Expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"204.10",
"202.80",
"358.01",
"276.2",
"E933.1",
"054.2",
"289.59",
"348.31",
"V58.65",
"584.9",
"041.04",
"466.11",
"458.9",
"480.1",
"255.4",
"288.0",
"427.89",
"707.03",
"285.22",
"V15.82",
"287.4",
"401.9",
"518.81",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"33.24",
"31.1",
"03.31",
"99.14",
"99.05",
"96.04",
"96.72",
"89.14",
"38.91",
"34.91",
"99.04",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
13109, 13118
|
6458, 12710
|
340, 557
|
13194, 13203
|
3825, 3825
|
13255, 13397
|
3053, 3158
|
13080, 13086
|
13139, 13173
|
12736, 13057
|
13227, 13232
|
3173, 3806
|
281, 302
|
585, 2363
|
3842, 6435
|
2385, 2843
|
2859, 3037
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,186
| 101,893
|
7680
|
Discharge summary
|
report
|
Admission Date: [**2141-7-14**] Discharge Date: [**2141-7-20**]
Date of Birth: [**2066-10-6**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
74 years old female admitted, underwent right lobe liver
resection for metastic breast cancer.
Major Surgical or Invasive Procedure:
74 years old female admitted, underwent right lobe liver
resection for metastic breast cancer.
History of Present Illness:
Ms. [**Known lastname 27935**] is a 74-year-old female with a history of breast
cancer approximately 20 years ago who presents with a large
right-sided hepatic tumor. The preoperative biopsy and
immunostaining have characterized this as consistent with a
breast primary. She underwent a CT abdomen/chest, bone scan,
and CT pet, which did not demonstrate any extrahepatic disease.
The
plan is to proceed with right hepatic lobectomy this coming
Friday.
Past Medical History:
Her past medical history is significant for coronary artery
disease. She had a CABG performed in [**2134**]. She had a breast
cancer in the past, hypertension, and osteoporosis. She has
noted previously a CABG, a right breast excision, right mass
excision in the breast, and left lumpectomy with radiation
therapy and chemotherapy in [**2119**] for a stage III breast cancer.
Social History:
Pt lives alone in [**Hospital3 **].
Family History:
non-contributory
Physical Exam:
AVSS
NAD, comfortable
alert, follows commands
neck supple
PERRLA EOMI
CTA bilaterlly
RRR no MRG nl s1 s2
soft, incision c/d/i, JP intact
no c/c/e pulses 2+
Pertinent Results:
CBC:
[**2141-7-14**] 03:19PM BLOOD WBC-11.1* RBC-3.79* Hgb-11.6* Hct-34.5*
MCV-91 MCH-30.7 MCHC-33.7 RDW-13.3 Plt Ct-188
[**2141-7-19**] 06:20AM BLOOD WBC-14.2* RBC-3.07* Hgb-9.0* Hct-28.0*
MCV-91 MCH-29.3 MCHC-32.2 RDW-13.6 Plt Ct-264
P7:
[**2141-7-14**] 03:19PM BLOOD Glucose-129* UreaN-15 Creat-0.6 Na-141
K-4.0 Cl-112* HCO3-21* AnGap-12
[**2141-7-19**] 06:00PM BLOOD K-3.5
COAGS:
[**2141-7-14**] 03:19PM BLOOD PT-13.0 PTT-25.1 INR(PT)-1.1
LFT's:
[**2141-7-14**] 03:19PM BLOOD ALT-317* AST-333* AlkPhos-48 TotBili-0.5
[**2141-7-19**] 06:20AM BLOOD ALT-234* AST-100* AlkPhos-96 TotBili-0.8
SPECIMEN SUBMITTED: FNA LIVER CORE BX.
Procedure date Tissue received Report Date Diagnosed
by
[**2141-5-23**] [**2141-5-23**] [**2141-5-26**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 18795**]/cwg
Liver, core needle biopsy:
Adenocarcinoma; see note.
Note: Immunohistochemistry stains are positive for estrogen
receptor and cytokeratin CK-7, and negative for cytokeratin
CK20. GCDFP shows no definite specific staining. This
immunophenotype is most consistent with metastatic breast
carcinoma in the appropriate clinical setting. Clinical
correlation is suggested. Trichrome stain confirms the presence
of fibrosis surrounding foci of cancer. Iron stain is
non-contributory.
Path [**2141-7-14**]: pending @ discharge - preliminary read -
metastatic CA, negative margins.
Brief Hospital Course:
This is a 74 yo Female admitted to [**Hospital1 18**] s/p R hepatic lobectomy
for metastatic lobectomy on [**2141-7-14**]. Operation was uncomplicated
with EBL=600. She received 1unit PRBC and 4 L crystalloid. Pt
was extubated in stable condition to the PACU awake and alert on
POD#0. Pain was well controlled on morphine PCA. Epidural was
d/c'd [**12-28**] hypotension and Pt was transfered to the SICU.
On POD#1 pt was comfortable with pain well controlled, lungs
were clear, and pt tolerated sips of clears. Her NGT was d/c'd
and she was transferred to the floor. On POD#2 her JP continued
to have serosanguinous drainage. On POD#3 pt was ambulatory with
PT and continued to do well. She had poor strength and mobility
anticipated rehab placement versus home with PT services. By
POD#5, Pt passed flatus but had still not moved her bowel. Her
PCA and Foley were d/c'd and her diet was advanced to a regular
diet. On POD#6 pt was ambulatory, comfortable, tolerated a
regular diet, and discharged to rehab.
Medications on Admission:
Evista *NF* 60 mg Oral daily
Atorvastatin 20 mg PO DAILY
Atenolol
Discharge Medications:
Oxycodone-Acetaminophen [**11-27**] TAB PO Q4-6H:PRN
Evista *NF* 60 mg Oral daily
Atorvastatin 20 mg PO DAILY
Atenolol 25 PO Daily
Discharge Disposition:
Extended Care
Facility:
[**Hospital 24806**] Care Center - [**Hospital1 1562**]
Discharge Diagnosis:
Metastatic Breast CA
Discharge Condition:
Stable
Discharge Instructions:
Please [**Name8 (MD) 138**] M.D. for Temp>101.5, breakdown of abdominal wound,
redness or increased pain at incision site, or change in
symptoms.
No heavy lifting, no driving while on narcotics.
Followup Instructions:
Follow-up w/ Dr. [**First Name (STitle) **] in [**11-27**] weeks in [**Hospital Ward Name **] 7. Please call
[**Hospital 18**] [**Hospital 1326**] clinic to schedule.
Completed by:[**2141-7-19**]
|
[
"424.0",
"733.00",
"272.0",
"197.7",
"575.11",
"V45.81",
"V10.3",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.3",
"45.34",
"51.22",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
4368, 4450
|
3088, 4097
|
408, 504
|
4514, 4522
|
1670, 3065
|
4766, 4964
|
1460, 1478
|
4213, 4345
|
4471, 4493
|
4123, 4190
|
4546, 4743
|
1493, 1651
|
274, 370
|
532, 988
|
1010, 1391
|
1407, 1444
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,282
| 163,377
|
21291
|
Discharge summary
|
report
|
Admission Date: [**2138-5-18**] Discharge Date: [**2138-5-20**]
Date of Birth: [**2085-1-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
BRBPR x 2 days
.
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
The patient is a 53 year old male with a history of HTN, HL, no
known CAD who presents s/p polypectomy of benign cecal polyp
[**2138-5-14**] with the chief complaint of rectal bleeding since
[**2138-5-17**]. The patient underwent routine screening colonoscopy on
[**2138-5-14**] and states that he experienced bright red bloody BM
beginning on Saturday- Bright red blood [**12-3**] cup to 1 cup of
blood "spurting out" x 3 on Sat. As he continued to have
bleeding, he called the GI fellow page who recommended further
evaluation in the ER. He denies lightheadedness/headache before
presentation to ED, CP/SOB, fever/chills. Denies hematuria.
Denies any syncope/presyncope.
.
Of note, the patient recently underwent a right ankle ORIF on
[**2138-2-14**] with a pre-op Hct of 44 (no documented post-op with
small EBL intra-operatively).
.
In the [**Name (NI) **], pt was typed and screened 2 units PRBCs. He was cross
matched for 4 units. INR 1.2. 2 PIV's were placed. His Hct was
found to be 29 (down from 44 pre-op). He was not transfused any
blood but received 1 liter of NS and transferred to the floor.
.
The patient currently denies abdominal pain/nausea/vomiting,
cough, fatigue. No CP/SOB.
.
On the floor, the patient had HR up to the 140s on telemetry
with a BP 120-130s. Given his tachycardia and acute blood loss,
the patient was transferred to the MICU for further monitoring.
The patient had received a total of 2 units on the floor with a
Hct that bumped from 23 to 24 checked immediately after 2 units
of PRBC.
.
Past Medical History:
ORIF of his Right ankle [**2138-2-14**]
LVEF>55%, Normal regional and global LV systolic function
[**2138-5-16**], echo, eval by Dr. [**First Name (STitle) **] [**Name (STitle) **]
h/o cecal Polyp s/p polypectomy [**2138-5-14**]
childhood seizures age [**3-10**], none since
seasonal allergies
hypertension
Hyperlipidemia
Social History:
He consumes 1 drink per day (vodka or beer) and uses marijuana
occasionally.
Family History:
mother age 87 with hypertension but otherwise in
good health; father died age 41 from kidney disease; 3 sisters
and 5 brothers in good health. He is married with no children.
He works for [**Company 56315**] Energy and does civil engineering survey
mapping.
Physical Exam:
VS: 97.4 P 94 BP 136/90 RR 18 O2sat 100%RA
.
general: Comfortable, NAD
HEENT: pale sclera, anicteric, EOMI; OP clear and MMM
Heart: RRR no MRG, nl s1, s2
Lungs: CTAB No rales, rhonchi, or wheezes
Abd: Soft, NT, ND Normoactive BS, no HSM
Ext: Warm, Well perfused, no CCE
Neuro: CN2-12 intact, Strength 5/5 bilateral upper and lower
extremities. Alert and oriented x3
Skin: warm, dry, no rash
Pertinent Results:
[**2138-5-18**] 08:56PM HCT-22.5*
[**2138-5-18**] 06:00PM GLUCOSE-138* UREA N-18 CREAT-1.3* SODIUM-140
POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-21* ANION GAP-16
[**2138-5-18**] 06:00PM WBC-8.6 RBC-3.56*# HGB-10.5*# HCT-29.4*#
MCV-83 MCH-29.5 MCHC-35.7* RDW-14.2
[**2138-5-18**] 06:00PM PT-13.5* PTT-23.7 INR(PT)-1.2*
.
Cardiology Report ECG Study Date of [**2138-5-18**] 8:46:54 PM
Sinus tachycardia. Probable old inferior wall myocardial
infarction. Possible left atrial abnormality. Compared to
tracing of [**2138-2-13**] there is no significant diagnostic change.
.
Colonoscopy [**2138-5-14**]:
A single sessile 10 mm polyp of benign appearance was found in
the cecum. A single-piece polypectomy was performed using a hot
snare. The polyp was completely removed.
.
Impression: Polyp in the cecum (polypectomy)
Otherwise normal colonoscopy to cecum
.
Recommendations: Follow-up with Dr [**Last Name (STitle) 349**] within 1 week for
pathology report. Follow-up with referring physician as
necessary
[**Name9 (PRE) **] Fiber, low fat Diet. Colonoscopy in 5 years if the polyp(s)
are adenoma(s), otherwise in 10 years.
.
Colonoscopy [**2138-5-19**]:
.
The cecal polypectomy site was located. There was no active
bleeding. There was a large clot over the cecal polypectomy
site. After injection of epinephrine, the majority of the clot
was removed. There was no bleeding noted. (injection). Otherwise
normal colonoscopy to cecum . Recommendations: NPO. If further
bleeding -> repeat colonoscopy. If not further bleeding, advance
diet Tuesday morning. No ASA or NSAIDs for 14 days.
Brief Hospital Course:
A/P: 53 year old male s/p polypectomy of benign cecal polyp
[**2138-5-14**] p/w with chief complaint of bright red blood per rectum
with acute Hct drop from 44 to 23 being transferred to the MICU
on [**2138-5-19**] for hemodynamic monitoring.
.
# GIB- The patient had a polypectomy for a 10 mm
benign-appearing cecal polyp on colonoscopy [**2138-5-14**]. Otherwise,
the patient had [**Doctor First Name **] otherwise normal colonoscopy. - The patient
remained hemodynamically stable without evidence of end-organ
ischemia.
- No central line required.
- The patient received a total of 5 units of blood. Colonscopy
on [**2138-5-19**] showed blood clot at polypectomy site with no active
bleed. Given epi at the site with no further bleeding during his
stay.
- The patient was instructed to hold ASA and refrain from NSAIDs
for 2 weeks.
Medications on Admission:
None.
Discharge Medications:
None.
Discharge Disposition:
Home
Discharge Diagnosis:
Bleeding from prior polypectomy site
Discharge Condition:
Medically stable to be discharged home.
Discharge Instructions:
You had bleeding at the site of your polyp removal. Please
avoid Aspirin and all other anti-inflammatory medications
(Ibuprofen, Motrin, Aleve, etc) for 2 weeks.
If you develop repeat bleeding from below, chest pain, shortness
of breath, dizziness, passing out, or any other worrisome
symptoms, please call your doctor or report to the nearest ER.
Followup Instructions:
Call Dr. [**Last Name (STitle) 56316**] office at [**Telephone/Fax (1) **] to schedule a follow up
appointment [**12-3**] weeks after discharge.
Your previously scheduled appointments:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 20141**], M.D. Phone:[**Telephone/Fax (1) 4022**]
Date/Time:[**2138-6-12**] 10:20
Provider: [**Name Initial (NameIs) 10081**]/EXERCISE LAB Phone:[**Telephone/Fax (1) 1566**]
Date/Time:[**2138-6-23**] 1:45
Provider: [**Name10 (NameIs) 5865**] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2138-8-7**] 2:05
|
[
"276.2",
"280.0",
"569.3",
"401.9",
"998.11",
"584.9",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.43",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
5580, 5586
|
4658, 5494
|
332, 346
|
5667, 5709
|
3046, 4635
|
6107, 6664
|
2359, 2619
|
5550, 5557
|
5607, 5646
|
5520, 5527
|
5733, 6084
|
2634, 3027
|
275, 294
|
374, 1902
|
1924, 2248
|
2264, 2342
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,843
| 157,086
|
50362
|
Discharge summary
|
report
|
Admission Date: [**2139-7-25**] Discharge Date: [**2139-7-30**]
Date of Birth: [**2060-11-2**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Zestril / Diovan / Hydrochlorothiazide / Univasc /
Verapamil / Cimetidine / Bactrim / Ketoconazole
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Lightheaded
Major Surgical or Invasive Procedure:
[**2139-7-27**]- pacemaker placement: [**Company 1543**] ADAPTA ADDRL1
History of Present Illness:
Patient is a 78 yo female with PMHx of a-fib, hypertension,
benign bladder tumor presenting with light-headedness and
bradycardia. It began on [**7-13**] when patient first noticed
symptoms. She was placed on KOH monitor the following week,
which captured an abnormal rhythm. In addition, this AM, she
woke up dizzy with a pulse she measured to be 38. Daughter was
called, captured event on KOH and brought patient to ED after
talking to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Captured event was a junctional
rhythm. Patient denied any chest pain, shortness of breath,
headaches, syncope, fever, chills.
.
In the ED vitals were HR 50, RR 17, BP 138/34, Sa02 of 95%.
Patient was stable. Developed some nausea after receiving
atropine- was given zofran and ativan. Nausea subsided and
patient's anxiety was relieved. She was given dopamine 10mg in
ED which converted her back to sinus rhythm. Attempt was made
to wean patient off dopamine but she converted back into
junctional rhythm. Dopamine restarted and patient returned to
sinus rhythm.
.
On arrival to the CCU, the patient was sleeping. Comfortable.
Still in sinus rhythm with HR of 58. SBP of 138. Satting at
92% on 2L NC.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope. Reports light-headedness
and dizziness.
Past Medical History:
****** CARDIAC HISTORY: *****
# Paroxysmal a-fib/flutter/tachy s/p multiple cardioversions
(last in [**Month (only) 216**] and then [**2138-5-9**] at [**Hospital1 18**])
- followed by Dr [**Last Name (STitle) **]
- on coumadin and dofetilide
- prior amio, but stopped d/t pulmonary and thyroid toxicity
# Valvular disease - Followed by Dr. [**First Name (STitle) **].
# CAD - Cardiac cath in [**2130**] with 2VD, mild MR, mod systolic and
diastolic dysfunction
# Transient CHF in setting of LAD ischemia
# -Diabetes, -Dyslipidemia, +Hypertension (baseline SBP in the
150s)
.
***** OTHER PAST MEDICAL HISTORY: *******
# Bladder tumor - CTU on [**2135-1-13**] with likely TCC, s/p cystoscopy
[**2135-1-18**] and cystoscopy [**2135-1-24**] for excision
# H/O + PPD
# Amiodarone induced pulmonary fibrosis - restrictive
ventilatory defect in [**8-23**] with FEV1/FVC on 115% predicted
# Adrenal adenoma ('[**31**])
# Hemorrhoids
# Constipation
# H/o pulmonary edema ('[**29**])
# Chronic pericardial effusions - not amenable to bx, no
tamponade
# Temporal lobe epilepsy with single seizure ('[**13**]) and none
since with carbamazepine therapy
# Gastritis (hx h.pylori)
Social History:
Pt lives with husband; she immigrated from [**Country 651**] in [**2091**],
minimal English speaking, speaks Cantonese; no
IVDU/ETOH/Tobacco; independent of ADLs. Daughter works at [**Hospital1 **] as
nurse in employee health.
Family History:
Non-contributory
Physical Exam:
GENERAL: In NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 2 cm above clavicle.
CARDIAC: Bradycardic. Regular rhythm. 3/6 systolic murmur
heard best at right sternal border. PMI located in 5th
intercostal space, midclavicular line. Normal S1, S2. No
thrills, lifts. No S3 or S4.
LUNGS: Bilateral inspiratory crackles to apex. No chest wall
deformities, scoliosis or kyphosis. Resp were unlabored, no
accessory muscle use. No wheezes.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
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:
[**2139-7-25**] 02:00PM BLOOD WBC-7.5 RBC-3.51* Hgb-11.4* Hct-34.6*
MCV-99* MCH-32.5* MCHC-32.9 RDW-12.6 Plt Ct-179
[**2139-7-26**] 08:55AM BLOOD WBC-6.9 RBC-3.27* Hgb-10.9* Hct-32.1*
MCV-98 MCH-33.4* MCHC-34.1 RDW-12.7 Plt Ct-142*
[**2139-7-27**] 05:21AM BLOOD WBC-6.4 RBC-3.12* Hgb-10.2* Hct-31.0*
MCV-99* MCH-32.8* MCHC-33.0 RDW-12.7 Plt Ct-148*
[**2139-7-28**] 05:20AM BLOOD WBC-7.6 RBC-3.26* Hgb-10.5* Hct-32.2*
MCV-99* MCH-32.3* MCHC-32.7 RDW-12.6 Plt Ct-161
[**2139-7-29**] 06:00AM BLOOD WBC-6.8 RBC-3.30* Hgb-10.9* Hct-32.8*
MCV-99* MCH-33.1* MCHC-33.3 RDW-12.6 Plt Ct-183
[**2139-7-30**] 05:20AM BLOOD WBC-5.9 RBC-3.04* Hgb-9.9* Hct-29.8*
MCV-98 MCH-32.5* MCHC-33.3 RDW-12.5 Plt Ct-166
[**2139-7-25**] 02:00PM BLOOD Neuts-50.9 Lymphs-42.0 Monos-6.2 Eos-0.6
Baso-0.4
[**2139-7-25**] 02:00PM BLOOD PT-26.6* PTT-35.9* INR(PT)-2.6*
[**2139-7-25**] 02:00PM BLOOD Plt Ct-179
[**2139-7-26**] 08:55AM BLOOD PT-20.6* PTT-33.0 INR(PT)-1.9*
[**2139-7-26**] 08:55AM BLOOD Plt Ct-142*
[**2139-7-26**] 06:23PM BLOOD PT-19.4* PTT-82.4* INR(PT)-1.8*
[**2139-7-27**] 05:21AM BLOOD PT-16.5* PTT-31.2 INR(PT)-1.5*
[**2139-7-27**] 05:21AM BLOOD Plt Ct-148*
[**2139-7-28**] 05:20AM BLOOD PT-14.4* PTT-29.1 INR(PT)-1.2*
[**2139-7-28**] 05:20AM BLOOD Plt Ct-161
[**2139-7-28**] 04:00PM BLOOD PTT-110.5*
[**2139-7-28**] 10:45PM BLOOD PTT-133.3*
[**2139-7-29**] 06:00AM BLOOD PT-15.8* PTT-80.1* INR(PT)-1.4*
[**2139-7-29**] 06:00AM BLOOD Plt Ct-183
[**2139-7-29**] 01:00PM BLOOD PTT-69.4*
[**2139-7-30**] 05:20AM BLOOD PT-15.7* PTT-91.6* INR(PT)-1.4*
[**2139-7-30**] 05:20AM BLOOD Plt Ct-166
[**2139-7-25**] 02:00PM BLOOD Glucose-104 UreaN-24* Creat-2.2*# Na-130*
K-4.8 Cl-96 HCO3-26 AnGap-13
[**2139-7-25**] 11:28PM BLOOD Glucose-134* UreaN-16 Creat-1.0# Na-139
K-4.0 Cl-102 HCO3-25 AnGap-16
[**2139-7-26**] 08:55AM BLOOD Glucose-163* UreaN-15 Creat-1.0 Na-136
K-3.9 Cl-102 HCO3-23 AnGap-15
[**2139-7-26**] 06:23PM BLOOD K-3.7
[**2139-7-27**] 05:21AM BLOOD Glucose-93 UreaN-15 Creat-0.8 Na-139
K-4.6 Cl-106 HCO3-26 AnGap-12
[**2139-7-28**] 05:20AM BLOOD Glucose-87 UreaN-15 Creat-0.8 Na-135
K-4.0 Cl-101 HCO3-27 AnGap-11
[**2139-7-29**] 06:00AM BLOOD Glucose-106* UreaN-21* Creat-0.8 Na-138
K-4.1 Cl-100 HCO3-27 AnGap-15
[**2139-7-30**] 05:20AM BLOOD Glucose-100 UreaN-16 Creat-0.8 Na-138
K-4.4 Cl-104 HCO3-28 AnGap-10
[**2139-7-25**] 02:00PM BLOOD Calcium-8.9 Phos-5.3*# Mg-2.2
[**2139-7-25**] 11:28PM BLOOD Calcium-9.0 Phos-3.6# Mg-2.3
[**2139-7-26**] 08:55AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.0
[**2139-7-27**] 05:21AM BLOOD Calcium-8.7 Phos-2.9 Mg-2.2
[**2139-7-28**] 05:20AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.0
[**2139-7-29**] 06:00AM BLOOD Calcium-9.1 Phos-3.9 Mg-2.2
Brief Hospital Course:
This is a 78 year old female with a-fib, aortic stenosis,
hypertension who presented with light-headedness and symptomatic
junctional rhythm which required pacemaker placement.
.
# RHYTHM: History of paroxysmal a-fib/flutter/tachy. Admitted
for symptomatic (light-headed) junctional rhythm.
Hemodynamically stable. Initially started on dopamine 10mcg in
ED. Converted to sinus rhythm. Attempted to stop dopamine but
she went back into junctional rhythm. Was seen by cardiology
fellow on admission. Patient was placed on telemetry and
maintained on dopamine 10mcg on arrival to CCU.
That night, she had prolonged pauses on tele ranging from
2.83-3.11 seconds but remained asymptomatic. Increased dopamine
to 15mcg/min. BP elevated (SBP in 170s). Gave 50mg PO
hydralazine (home dose) and checked pressure before increasing
dopamine drip. Permanent pacemaker placed on [**7-27**]. Post-op CXR
showed appropriate lead placement, no pneumothorax and no
pleural effusion. Home metoprolol, dofetilide, and coumadin
restarted after procedure. Pressures were monitored closely.
On [**7-28**] AM she had a burst of elevated HR (150s). Increased
metoprolol to 50mg [**Hospital1 **] and temporarily held her hydralazine
until she returned to sinus rhythm given her SBP of 100s. Since
then she has remained in a paced rhythm with a rate of 70.
Denied any complaints except for pain at the pacemaker site.
Denied chest pain, shortness of breath, lightheadedness,
palpitations, dizziness. Upon discharge, patient was in paced
rhythm and stable.
# Syncope- Had syncopal episode at on [**7-28**] 12:28pm while in
radiology holding. Per daughter, felt dizzy and passed out.
Unarousable for 30 seconds then came to. AAO x 3. Denied chest
pain, shortness of breath. Taken back to floor- EKG, portable
chest x-ray, orthostatics were checked. All were within normal
limits. No other sycopal episodes during admission. On
discharge, patient denied any lightheadedness, dizziness,
headache, chest pain, or shortness of breath.
# CORONARIES: Had cath in [**2130**] that showed 2VD. Not on home
statin given normal lipid panel. Denied any chest pain or
shortness of breath during admission. Aspirin was initially
continued but was held while patient was receiving coumadin and
heparin gtt. Will restart aspirin 81mg one week after
discharge.
# PUMP: History of HTN. EF normal. Has pulmonary hypertension
caused by LV diastolic dysfunction. Initially held home
antihypertensives given low HR and relatively low BP on
admission (normally runs in 150s). BP rose on admission day so
she received her hydralazine. Restarted on home metoprolol,
felodipine and losartan. Hydralazine was held again after low
BP readings on [**7-28**]. Upon discharge, BP stable in 150's
(baseline). Patient had no symptomatic complaints during
admission.
# Anticoagulation- Patient on coumadin 5mg daily at home. INR
on admission was 2.6. Coumadin initially held for pacemaker
placement. Restarted afterward at home dose. INR monitored.
Bridged with heparin gtt with goal INR of 2.0. INR trended up
slowly. Was 1.4 on day of discharge. Gave an extra one time
dose of 3mg on day before and day of discharge. Since her
pacemaker site was oozing, it was decided not to bridge her with
Lovenox at home due to the increased risk this poses for
surgical site bleeding. She is at low risk for thromboembolic
event at this time since she is in a paced sinus rhythm, but has
a history of PAF and could go into Afib at home. The risks were
discussed with patient and daughter with full understanding.
They agree with and prefer the plan as opposed to bridge with
heparin and staying in hospital until INR is 2.0. Given strict
instructions on INR follow-up for Saturday AM as well as
monitoring pacemaker placement site for bleed.
# Acute renal failure- Inital Cr in ED was 2.2. Thought to be
pre-renal given low HR (and CO). However, we re-checked Cr in
PM and it was 1.0. Repeated and again was 1.0. Determined that
lab from ED was an error. Good UOP and stable BUN/Cr over
course of admission. No signs of fluid overload. Cr on
discharge is .8.
# Hyponatremia- Initial Na+ in ED was 130. Thought to be due
to low circulating volume given cardiac status. However, it was
re-checked in PM and came back to be 139. Determined that it
was also a lab error. Na+ remained within normal limits
throughout admission.
# Anemia- Hct 34 on admission. Trended down slightly while in
hospital. Most likely due to phlebotomy. No signs of bleed in
stool. Patient stable with no complaints on discharge.
# Nausea/Vomiting- Patient experienced nausea/vomting in ED
after receiving atropine. Did not give
zofran/compazine/phenergan due to QT-prolongation. No more
complaints of nausea/vomiting during admission.
# Pain- Patient experienced pain at pacemaker site. Was given
prn tylenol and oxycontin during admission with symptomatic
relief.
CODE: Full code- discussed with daughter [**Name (NI) **].
COMM: [**Name (NI) **] (daughter)- [**Telephone/Fax (1) 104974**]
[**Name (NI) **] (son)- [**Telephone/Fax (1) 104975**]
DISPO: Home
Medications on Admission:
Carbamazepine 200mg PO daily
Clonazepam 0.5mg Qam, 1mg QHS PRN
Dofetilide 250mcg [**Hospital1 **]
Felodipine 10mg Q24
Furosemide 10mg Qam
Hydralazine 50mg TID
Losartan 100mg Daily
Metoprolol 50mg daily
Trazadone 50mg QHS
Warfarin 5mg daily
ASA 81mg daily
Calcium/vit D [**Hospital1 **]
Metamucil daily
Discharge Medications:
1. Carbamazepine 200 mg Tablet Sustained Release 12 hr Sig: One
(1) Tablet Sustained Release 12 hr PO DAILY (Daily).
2. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)): 2 pills at bedtime.
3. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Metamucil Powder Sig: One (1) packet PO once a day.
5. Losartan 100 mg Tablet Sig: One (1) Tablet PO once a day.
6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
7. Felodipine 10 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
8. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO once a day.
9. Dofetilide 250 mcg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H
(every 8 hours) as needed for pain: for pain at the pacer site.
11. Calcium Citrate + D 315-200 mg-unit Tablet Sig: Two (2)
Tablet PO twice a day.
12. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
13. Outpatient Lab Work
Please check PT/INR on Saturday [**7-31**], call results to Dr.
[**Last Name (STitle) 9006**] at [**Telephone/Fax (1) 250**]
Discharge Disposition:
Home
Discharge Diagnosis:
Junctional Rhythm
Hypertension
Acute Renal Failure
Chronic Diastolic Dysfunction: EF 55%
Atrial Fibrillation
Discharge Condition:
stable
Discharge Instructions:
You had a slow heart rate and required a pacemaker. No pools or
showers for one week. You may take a bath but the pacer dressing
needs to stay dry. No lifting your left arm over your head or
carrying anything heavier than 5 pounds for 6 weeks. WE have put
a pressure dressing over the pacer site. You may remove this in
[**12-19**] days if there is no more bleeding.
.
Medication changes:
1. Do not take aspirin for one week. Please restart on [**2139-8-7**].
2. Take warfarin 5 mg Friday and Saturday. Check the INR on
Saturday and follow the directions of Dr. [**Last Name (STitle) 9006**] (or covering
physician)
3. Stop taking hydralazine
4. Increase the Toprol XL to 100 mg daily
.
Please call Dr. [**Last Name (STitle) **] if you notice increasing bleeding at
the pacer site, more pain
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day
or 6 pounds in 3 days.
Adhere to 2 gm sodium diet
Followup Instructions:
DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2139-8-5**] 11:00
.
Cardiology:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] NP with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 62**]
Date/Time: [**9-25**] at 10:00 am.
.
Primary Care:
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] Phone: [**Telephone/Fax (1) 250**] Date/time: Wednesday
[**8-5**] at 9:40am.
|
[
"V58.61",
"515",
"272.4",
"428.32",
"427.81",
"427.31",
"416.8",
"428.0",
"414.01",
"E942.0",
"780.2",
"285.9",
"584.9",
"345.40",
"401.9",
"427.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.72",
"37.83"
] |
icd9pcs
|
[
[
[]
]
] |
14135, 14141
|
7356, 12503
|
385, 458
|
14294, 14303
|
4677, 7333
|
15276, 15734
|
3722, 3740
|
12855, 14112
|
14162, 14273
|
12529, 12832
|
14327, 14696
|
3755, 4658
|
14716, 15253
|
334, 347
|
486, 2268
|
2901, 3461
|
3477, 3706
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,662
| 162,046
|
45399
|
Discharge summary
|
report
|
Admission Date: [**2171-10-15**] Discharge Date: [**2171-10-19**]
Date of Birth: [**2091-5-8**] Sex: F
Service: MEDICINE
Allergies:
Compazine / Lisinopril / Ativan
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
SOB, CP
Major Surgical or Invasive Procedure:
R IJ
History of Present Illness:
Pt is 80 yo f with h/o pancreatic CA s/p Whipple in [**2160**],
dementia, recurrent UTI's, and chronic R pleural effusion, who
was d/c'd yesterday after admission for fever, delirium, and LLQ
tenderness thought [**1-3**] colitis. Pt was d/c'd with instructions
to complete 14 day course of cipro/flagyl. Pt now presents with
CP/SOB, increasing pedal edema, and bilateral pleural effusions
(R>L). Per pt's daughter, she was SOB at the time of discharge
yesterday after receiving continuous IVF. This AM, pt became
more wheezy and tachypnic. She also c/o several hours of vague,
R sided/sub-sternal chest pain, which has now resolved.
.
In the [**Name (NI) **], pt was reportedly tachypnic and had O2sat in the 70's
on arrival, which improved spontaneously to 90's on RA. She was
hypertensive with SBP's in the 190's, which also improved
spontaneously. A right IJ line was placed, with return of some
clear fluid, so a chest CT was ordered to r/o PTX (was negative
for PTX).
.
Pt currently denies CP, SOB, N/V, diarrhea.
Past Medical History:
- h/o pancreatic adenocarcinoma s/p Whipple in [**2160**] and L
hepatic lobectomy with feeding jejunostomy [**10-6**] c/b
postoperative nonconvulsive seizures, chronic biliary leak, and
pleural effusion
- endoscopic myotomy for upper esophageal achalasia and a
Zenker's diverticulum
- h/o urosepsis
- VRE
- h/o pleural effusion ([**2-4**] tap: +WBC, culture negative,
cytology negative, [**9-6**] tap: +WBC, culture negative, cytology
negative)
- HTN
- pAfib
Social History:
Lives in [**Location 745**] with her husband. [**Name (NI) **] a personal care attending
who helps her walk and dress. No tobacco, EtOH, or IVDU.
Family History:
noncontributory
Physical Exam:
Vitals: T 97.9 BP 140/62 HR 67 RR 23 O2 98% 2L NC
Gen: thin, elderly female in NAD
HEENT: PERRL.
Neck: R IJ in place
Cardio: RRR, nl S1S2, 2/6 SEM
Resp: decreased breath sounds [**2-2**] way up bilaterally. No wheeze.
Abd: soft, +BS, J-tube in place, mild distension, non-tender. No
rebound/guarding.
Ext: no c/c/e
Neuro: A&Ox1 (knows she's in hospital, but does not know [**Hospital1 **] or
date)
Pertinent Results:
[**2171-10-15**] 08:14PM CK(CPK)-43
[**2171-10-15**] 08:14PM CK-MB-5 cTropnT-0.03*
[**2171-10-15**] 01:27PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.036*
[**2171-10-15**] 01:27PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR
[**2171-10-15**] 01:27PM URINE RBC-0 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-[**2-3**]
[**2171-10-15**] 11:38AM LACTATE-2.2*
[**2171-10-15**] 11:00AM GLUCOSE-148* UREA N-21* CREAT-1.1 SODIUM-138
POTASSIUM-3.8 CHLORIDE-110* TOTAL CO2-19* ANION GAP-13
[**2171-10-15**] 11:00AM CK(CPK)-68
[**2171-10-15**] 11:00AM cTropnT-<0.01
[**2171-10-15**] 11:00AM CK-MB-NotDone
[**2171-10-15**] 11:00AM CALCIUM-8.3* PHOSPHATE-2.3* MAGNESIUM-2.0
[**2171-10-15**] 11:00AM WBC-10.4 RBC-3.29* HGB-10.5* HCT-31.1* MCV-94
MCH-31.8 MCHC-33.6 RDW-16.5*
[**2171-10-15**] 11:00AM NEUTS-87.8* LYMPHS-7.8* MONOS-2.7 EOS-0.6
BASOS-1.1
[**2171-10-15**] 11:00AM ANISOCYT-1+ MACROCYT-1+
[**2171-10-15**] 11:00AM PLT COUNT-246
[**2171-10-14**] 06:05AM GLUCOSE-147* UREA N-22* CREAT-1.1 SODIUM-136
POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-15* ANION GAP-18
[**2171-10-14**] 06:05AM CALCIUM-8.6 PHOSPHATE-3.2 MAGNESIUM-2.1
[**2171-10-14**] 06:05AM WBC-10.7 RBC-3.51* HGB-11.3* HCT-32.8* MCV-93
MCH-32.3* MCHC-34.6 RDW-16.3*
[**2171-10-14**] 06:05AM PLT COUNT-235
.
1. No evidence of small bowel obstruction. Notably, however,
contrast that was presumably injected through the patient's
J-tube fills the stomach, and refluxes into a moderate-sized
hiatal hernia. This raises the possibility for aspiration. This
was discussed with Dr. [**Last Name (STitle) 1071**] at 6am on [**2171-10-19**].
2. Interval increase in ascites compared to the previous exam,
possibly accounting for increase in abdominal distension.
3. Bilateral pleural effusions with associated compressive
atelectasis. Additionally, there are patchy areas of
ground-glass and reticular opacities in both lower lobes that
could represent areas of aspiration, with pneumonia difficult to
entirely exclude.
4. Diffuse ascites and mesenteric stranding limits evaluation
for bowel wall thickening, there does, however, appear to be
possible thickening of the cecum, that was also seen on the
previous exam.
5. Air in the bladder is present, presumably secondary to Foley
catheterization. If indicated, correlation with a urinalysis
could be performed to exclude cystitis.
6. Stable hypodense lesions in the right kidney, too small to
characterize, that may represent cysts.
Brief Hospital Course:
80 yo f with h/o pancreatic CA s/p Whipple in [**2160**], dementia,
recurrent UTI's, and chronic R pleural effusion, s/p recent
admission for colitis, now presenting with CP/SOB and worsening
bilateral pleural effusions, s/p thoracentesis on right side,
now with much improved breathing.
.
1) SOB: most likely secondary to large bilateral pleural
effusions (R>L). Pt has had a chronic large R pleural effusion,
but L pleural effusion has worsened over the past several days.
Likely [**1-3**] large amount of intravenous fluids during previous
admission. s/p bilateral thoracentesis, with 1200cc removed
from right side, 800cc removed from other. Fluid was sent for
analysis, cytology, pending on discharge. Her breathing
improved symptomatically and she no longer required oxygen on
discharge. She will undergo pleuredesis by interventional
pulmonary next week. Still unclear whether or not patient's
episode of SOB was caused by effusions (which are chronic) or if
pt had episode of flash pulm edema (pt's sob resolved
spontaneously before getting diuresed or any other interventions
making transient ischemia and diastolic dysfunction more
likely). Avoided excessive IVF, given hx of volume overload.
.
2) CP: Pt with vague c/o chest pain x several hours. EKG
unchanged. Possible [**1-3**] pleural effusions vs. pulm edema as
cardiac enzymes remained flat, although she had a slight
troponin bump. She was continued on ASA, BB and ACE-I. Echo
was unchanged.
.
3) Abdominal Distension/Vomiting: Patient had an interval
increase in abdominal girth as well as three episodes of
vomiting. Subsequent KUBs showed possible obstruction. CT scan
of the abdomen showed no obstruction, but stable colonic
thickening as well as interval increase in ascites. She was
observed to be inducing vomiting, which was confirmed with the
daughter that she does that on occasion when anxious. Tube
feeds were restarted at low rate, with no other episodes of
emesis. She was started on Reglan to help with motility.
.
4) H/o fever and colonic thickening: continued cipro/flagyl for
presumed colitis. Possible C. dif, sending stool cx
.
5) ARF: baseline Cr 0.7-0.8, up to 1.1 on admission. Careful
IVF hydration given large effusions (resp status was stable
overnight)
.
6) Anemia: Baseline 29-33. Previous iron studies c/w ACD.
Stable.
.
7) h/o seizures: had been tapered off Keppra. No seizure
activity currently.
.
8) HTN: pt hypertensive on admission, now normotensive on
transfer to the floor. Anxiety may play a component as well.
Continued BB, ACE-I
.
9) h/o UTI's: Bactrim d/c'd yesterday, presumably for UTI ppx.
.
10) Elevated INR: likely [**1-3**] poor nutrition. also recent partial
hepatectomy with elevated alk phos indicates element of hepatic
dysfunction. Given Vitamin K to assess INR response, with no
interval decrease.
.
11) Diarrhea: chronic since Whipple. Continue loperamide prn.
.
12) FEN: J-tube feedings.
.
13) PPX: PPI, Hep SC, no bowel regimen given chronic diarrhea
.
14) Dispo: To floor today after tap
.
15) Access: RIJ (pulled back to aortocaval junction; confirmed
with radiology overnight); Line will have to be pulled bc ED did
not complete line checklist.
.
16) Code: DNR/DNI (confirmed with daughter [**Name (NI) **] [**Name (NI) **], pager
[**Telephone/Fax (1) 96918**])
Medications on Admission:
Acetaminophen 325-650 mg Q4-6H prn
Aspirin 325 mg qd
Amylase-Lipase-Protease 468 mg TID before meals
Sertraline 50 mg qd
Loperamide 2 mg qid prn
Metronidazole 500 mg tid (day #[**2-12**])
Ciprofloxacin 500 mg qd (day #[**2-12**])
Metoprolol Tartrate 12.5 mg [**Hospital1 **]
Trimethoprim-Sulfamethoxazole 160-800 mg qd
Captopril 6.25 mg tid
Discharge Medications:
1. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
2. Amylase-Lipase-Protease 468 mg Tablet [**Hospital1 **]: One (1) Tablet PO
TID (3 times a day).
3. Loperamide 2 mg Capsule [**Hospital1 **]: One (1) Capsule PO QID (4 times
a day) as needed.
4. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID (2
times a day).
5. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily).
6. Sertraline 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
7. Captopril 12.5 mg Tablet [**Hospital1 **]: 0.5 Tablet PO TID (3 times a
day).
8. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain.
9. Simethicone 80 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet,
Chewable PO TID (3 times a day) as needed for bloating.
Disp:*60 Tablet, Chewable(s)* Refills:*2*
10. Metronidazole 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3
times a day) for 8 days.
Disp:*24 Tablet(s)* Refills:*0*
11. Ciprofloxacin 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q24H
(every 24 hours) for 8 days.
Disp:*8 Tablet(s)* Refills:*0*
12. Metoclopramide 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
13. Calcium Carbonate 500 mg Tablet, Chewable [**Hospital1 **]: One (1)
Tablet, Chewable PO ONCE (Once).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis:
Pulmonary effusions
Ascites
.
Secondary diagnoses:
History of pancreatic adenocarcinoma s/p Whipple
+ VRE
paroxysmal atrial fibrillation
Discharge Condition:
Good
Discharge Instructions:
You were admitted for worsening shortness of breath and found to
have large bilateral pleural effusions. These were drained by
thoracentesis and your oxygen level has improved.
.
Please call your primary care doctor if you continue to have
vomiting, fevers, chills, abdominal distension, abdominal pain,
chest pain, shortness of breath.
Followup Instructions:
You should call on Monday morning to make an appointment to see
the interventional pulmonary Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] ([**Telephone/Fax (1) 514**]
.
You have an appointment to see your primary care doctor, Dr.
[**Last Name (STitle) 172**], on Monday [**10-28**] at 1:45pm, if you need to change
this appointment please call [**Telephone/Fax (1) 133**].
.
You have the following appointments already scheduled:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2171-10-30**]
11:00
|
[
"V44.4",
"276.52",
"790.92",
"V10.09",
"584.9",
"511.9",
"599.0",
"427.31",
"518.0",
"401.9",
"294.8",
"558.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"88.73",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
10144, 10202
|
5027, 8331
|
300, 306
|
10402, 10409
|
2470, 5004
|
10795, 11428
|
2018, 2035
|
8723, 10121
|
10223, 10223
|
8357, 8700
|
10433, 10772
|
2050, 2451
|
10293, 10381
|
253, 262
|
334, 1355
|
10242, 10272
|
1377, 1838
|
1854, 2002
|
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