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12,139
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24739
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Discharge summary
|
report
|
Admission Date: [**2152-5-22**] Discharge Date: [**2152-6-4**]
Date of Birth: [**2092-1-24**] Sex: M
Service: OME
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 62385**] is a 59-year-old
male with a history of metastatic renal cell carcinoma
admitted for cycle 1/week 1 high-dose IL-2 therapy. His
oncologic history began in [**2148-7-22**] when he underwent right
nephrectomy revealing an 11-cm right kidney mass with clear
cell histology. He did well until he developed hemoptysis in
[**2151-7-23**] with CT scan showing a 3-cm right mediastinal mass
and 2-cm right upper lobe nodule. Bronchoscopy showed a
fungating right upper lobe tumor with biopsy consistent with
metastatic renal cell carcinoma. He underwent radiation
therapy completed in [**2151-11-23**]. During follow-up
bronchoscopy in [**2151-12-23**] at an outside hospital
bronchial washings revealed tuberculosis on [**2152-2-9**];
and he was initiated on tuberculosis medications at that time
including isoniazid and rifampin. He recently had 3 negative
sputum's in [**Month (only) 958**]. He is being admitted today on [**2152-5-22**]
for cycle 1/week 1 high-dose IL-2 therapy.
MEDICAL HISTORY: Metastatic renal cell carcinoma,
hypercholesterolemia, migraines, bilateral inguinal hernia
repair, status post right shoulder arthroscopy, history of TB
as above.
MEDICATIONS ON ADMISSION: Isoniazid 300 mg p.o. daily,
rifampin 600 mg daily, calcium, multivitamin.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: GENERAL: Reveals a well-appearing
male in no acute distress. Performance status 0. VITAL SIGNS:
Stable. HEENT: Normocephalic, atraumatic. Sclerae anicteric.
Moist oral mucosa without lesions. NECK: Supple. LYMPH NODES:
No cervical, supraclavicular, bilateral axillary or bilateral
inguinal lymphadenopathy. HEART: Regular rate and rhythm, S1-
S2 without murmur, rub or gallop. LUNGS: Clear to percussion
bilaterally with a few left basilar crackles. ABDOMEN:
Rounded, positive bowel sounds, soft, nontender. No
hepatosplenomegaly. EXTREMITIES: No lower extremity edema.
SKIN: Three subcutaneous nodules are noted; one on the left
lateral upper arm, one on the left flank and one on the left
lateral lower leg; otherwise skin intact.
ADMISSION LABORATORIES: WBC 9, hemoglobin 13.2, hematocrit
41, platelet count 277,000. BUN 23, creatinine 1.1, sodium
141, potassium 4.5, chloride 106, CO2 of 28, glucose 83, INR
1.1, calcium 9.3, magnesium 2.1, phosphorus 3.2, CK 51.
HOSPITAL COURSE: Mr. [**Known lastname 62385**] was admitted to begin high-dose
IL-2 therapy. He underwent central line placement to begin
therapy. His admission weight was 78.6 kg, and he received
interleuken-2 at 600,000 international units per kilogram
equaling 47.2 mU IV q.8h. x14 potential doses. Given his
history of borderline pulmonary function tests, radiation to
the lung, and tuberculosis history we reduced his intravenous
fluid rate and planned to limit fluid boluses secondary to
concern regarding pulmonary toxicity. During this week he
received [**9-4**] doses with 6 doses held related to hypotension
requiring ICU transfer.
Over the first several days he had the usual IL-2 side
effects including fever, chills, nausea and diarrhea;
improved with supportive medications. However, on treatment
day #4 he developed hypotension and was treated with slight
increase in intravenous fluids as well as a fluid bolus x1.
He required the addition of dopamine to a maximum of 6
mcg/kg/min as well as Neo-Synephrine up to 3.5 mcg/kg/min to
support his blood pressure. Later that day he developed
tachypnea and hypoxia with need for transfer to the intensive
care unit. On treatment day #5, his troponin was elevated -
consistent with myocarditis - and he underwent an
echocardiogram revealing left ventricular ejection fraction
of approximately 25% with global hypokinesis. Cardiology
evaluated the patient and felt this was consistent with
myocarditis rather than acute coronary syndrome. He continued
to require vasopressors and was changed from Neo-Synephrine
and dopamine to Levophed. Later in the day on treatment day
#5 he became more hypoxic and tachypneic and was intubated.
He was weaned off pressors over the next 2 days. He remained
intubated and sedated. On [**2152-5-28**] he developed a fever;
and vancomycin was added with cultures negative. However, on
[**2152-5-29**] he developed increased secretions; and Zosyn was
added for probable pneumonia. His tuberculosis medications
were initially held due to transaminitis and were restarted
with normalization of his liver function tests.
On [**2152-5-30**] he was extubated. An echocardiogram was
repeated on [**2152-5-30**] showing improvement in his ejection
fraction to 45% to 55%. On [**2152-5-31**] he was transferred
back to the floor to continue rehab in order to be discharged
to home. He was initially maintained on vancomycin and Zosyn,
and later changed to levofloxacin when sputum culture grew
Enterobacter with appropriate sensitivities. He remained
afebrile and continued to improve rapidly over the next 4
days and was discharged home on [**2152-6-4**]. His IL-2
toxicities had resolved at this point.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home with his wife.
DISCHARGE DIAGNOSES: Metastatic renal cell carcinoma, status
post cycle 1/week 1 high-dose IL-2 complicated by hypotension
and respiratory failure due to capillary leak syndrome.
DISCHARGE MEDICATIONS: Zantac 150 mg p.o. b.i.d., Ativan 1
mg q.4-6h. p.r.n. nausea/vomiting, Benadryl 25 to 50 mg q.6h.
p.r.n. pruritus, Compazine 10 mg p.o. q.6h. p.r.n.
nausea/vomiting, Lomotil 1 to 2 tablets p.o. q.i.d. p.r.n.
diarrhea, isoniazid 300 mg p.o. daily, rifampin 600 mg p.o.
daily, levofloxacin 500 mg p.o. daily x5 days.
FOLLOW-UP PLANS: Mr. [**Known lastname 62385**] will return to clinic in
approximately 1 month for CT scans to assess disease
response. He will not be returning for week 2 of IL-2 therapy
given significant toxicity.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 19077**]
Dictated By:[**Last Name (NamePattern1) 18853**]
MEDQUIST36
D: [**2152-6-28**] 19:23:32
T: [**2152-6-30**] 15:39:15
Job#: [**Job Number 62386**]
cc:[**Last Name (NamePattern1) 62387**]
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44,065
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36669
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Discharge summary
|
report
|
Admission Date: [**2182-8-24**] Discharge Date: [**2182-9-11**]
Date of Birth: [**2116-3-30**] Sex: M
Service: SURGERY
Allergies:
Percocet
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Ischemic right lower extremity
Major Surgical or Invasive Procedure:
[**2182-8-24**] OPERATION PERFORMED.:
1. Right common femoral to anterior tibial artery bypass
with non-reversed greater saphenous vein.
2. Angioscopy and valve lysis.
3. Ultrasound-guided puncture of left common femoral
artery.
4. Contralateral second-order catheterization of right
common femoral artery.
5. Abdominal aortogram.
6. Serial arteriogram of the right lower extremity.
History of Present Illness:
66 M w/ PVD with rest pain s/p Right [**Name (NI) 1793**] PTA/stent
([**8-5**])-failed. Presented to [**Hospital **] Hosp for urgent R CFA
endarterectomy w/ bovine pericardial patch angioplasty without
improvement in flow. This was followed by a Right BK [**Doctor Last Name **]
endarterectomy and [**Location (un) **] patch and Right proximal CFA to BK [**Doctor Last Name **]
6mm PTFE ([**8-23**]). There was no improvement in rest pain and
patient was transferred to the [**Hospital1 18**] for angiogram and possible
bypass with arm vein.
Pt c/o pain in right lateral calf, worsening. Has parasthesias
chronically bilateral. Denies nausea, vomiting, CP/SOB.
Past Medical History:
1. PVD s/p:
-Right [**Name (NI) 1793**] PTA/stent ([**8-5**])
-R CFA endarterectomy w/ bovine pericardial patch
angioplasty Right BK [**Doctor Last Name **] endarterectomy and [**Location (un) **] patch
and Right proximal CFA to BK [**Doctor Last Name **] 6mm PTFE ([**8-23**])
2. HTN
3. Lipids
4. Hemachromatosis
Social History:
Retired carpenter, 50 pack year smoker, currently smoking, 6-8
beers per day. Married, lives at home
Family History:
N/C
Physical Exam:
VSS
Gen: NAD, A&OX3
Cardiac: RRR
Lungs: CTA
ABD: soft, non tender
RLE wound: mild erythema, mild swelling, staple line intact
Pulses: B/L fem palp, B/L DP/PT dop
Pertinent Results:
[**2182-9-6**] 03:08AM BLOOD WBC-10.7 RBC-3.85* Hgb-12.1* Hct-34.0*
MCV-88 MCH-31.5 MCHC-35.7* RDW-16.5* Plt Ct-384
[**2182-9-5**] 04:00AM BLOOD WBC-12.8* RBC-3.83* Hgb-12.0* Hct-33.9*
MCV-89 MCH-31.3 MCHC-35.4* RDW-16.4* Plt Ct-319
[**2182-9-6**] 03:08AM BLOOD Plt Ct-384
[**2182-9-6**] 10:31PM BLOOD Glucose-134* UreaN-21* Creat-0.9 Na-137
K-4.2 Cl-106 HCO3-24 AnGap-11
[**2182-9-5**] 04:00AM BLOOD ALT-26 AST-26 LD(LDH)-239 AlkPhos-82
Amylase-180* TotBili-0.5
[**2182-9-4**] 05:10AM BLOOD Lipase-549*
[**2182-9-6**] 10:31PM BLOOD Calcium-8.1* Phos-3.5 Mg-2.0
Date: [**2182-9-6**]
Signed by [**First Name8 (NamePattern2) 2620**] [**Last Name (NamePattern1) 2621**], CCC-SLP on [**2182-9-6**] at 8:50 am
Affiliation: [**Hospital1 18**]
BEDSIDE SWALLOWING EVALUATION:
HISTORY:
Thank you for consulting on this 66 y/o male with right sided
[**Name (NI) 1793**]
PTA / stent [**8-5**] that failed admitted on [**2182-8-24**] from OSH
following urgent right CFA enterectomy with bovine pericardial
patch angioplasty without improvement in flow. Pt had right BK
[**Doctor Last Name **] enterectomy and [**Location (un) **] patch and right proximal CFA to BK
[**Doctor Last Name **] [**8-23**]. There was no improvement in rest pain and pt was
transferred to [**Hospital1 18**] for angioplasty and possible bypass with
arm
vein. Pt had continued critical limb ischemia and possible calf
tissue loss and is now s/p right SVG fem-BK [**Doctor Last Name **] graft [**8-24**].
Course has been complicated by DVTs and GI bleed.
Pt has been transferred to the VICU and was advanced to a full
liquid diet. We were consulted to evaluate for oral and
pharyngeal dysphagia. RN reported he has been tolerating well
and
pt denied coughing with meals. He has more concern regarding his
voice and feels he can't increase his volume.
EVALUATION:
The examination was performed while the patient was seated
upright in the chair in the VICU.
Cognition, language, speech, voice:
Pt was awake, alert and oriented x 3 with fluent language.
Speech
was mildly dysarthric. Voice was clear but with reduced volume.
He had difficulty increasing volume with cuing. Pt was able to
follow all basic commands.
Teeth: fair condition - several missing and or cracked
Secretions: wfl in the oral cavity, but intermittent wet vocal
quality
ORAL MOTOR EXAM:
symmetrical facial appearance with adequate lip seal and buccal
tone. Tongue was at midline with functional strength and ROM.
SWALLOWING ASSESSMENT:
Mr. [**Known lastname 65140**] was seen during breakfast with thin liquids (sup,
straw), purees and crackers. Mastication was timely and without
oral cavity residue. He did not have any overt coughing, throat
clearing or changes in vocal quality and denied the sensation of
aspiration or pharyngeal residue. O2 SATs remained stable.
Laryngeal elevation felt timely and wfl to palpation.
SUMMARY / IMPRESSION:
Mr. [**Known lastname 65140**] did not have any overt signs of aspiration and can be
advanced to thin liquids and regular consistency solids once
cleared medically. His voice is somewhat concerning,
particularly
given his prolonged intubation and while I feel he is achieving
adequate closure to prevent aspiration, he may not be achieving
complete adduction. He would likely benefit from an ENT
evaluation to assess vocal cord movement and continued speech
therapy services in rehab.
This swallowing pattern correlates to a Dysphagia Outcome
Severity Scale (DOSS) rating of 6, wfl with modified
independence.
RECOMMENDATIONS:
1. Suggest a PO diet of thin liquids and regular consistency
solids once cleared medically.
2. Pills whole with water.
3. ENT evaluation if possible before d/c and then continued
speech therapy services at rehab.
These recommendations were shared with the patient, nurse and
medical team.
____________________________________
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.S., CCC-SLP
Pager #[**Numeric Identifier 2622**]
Face time: 8:20-8:40
Total time: 50 minutes
_______________________________________________________________
OPERATIVE REPORT
[**Last Name (LF) **],[**First Name3 (LF) **] L.
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) **] on WED [**2182-8-28**]
4:54 PM
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 82933**]
Service: Date: [**2182-8-24**]
Date of Birth: [**2116-3-30**] Sex: M
Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 21890**]
PREOPERATIVE DIAGNOSIS: Acute limb threat of right lower
extremity.
POSTOPERATIVE DIAGNOSES: Acute limb threat of right lower
extremity.
OPERATION PERFORMED.:
1. Right common femoral to anterior tibial artery bypass
with non-reversed greater saphenous vein.
2. Angioscopy and valve lysis.
3. Ultrasound-guided puncture of left common femoral
artery.
4. Contralateral second-order catheterization of right
common femoral artery.
5. Abdominal aortogram.
6. Serial arteriogram of the right lower extremity.
ASSISTANT: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3636**], M.D.
TOTAL FLUOROSCOPY TIME: 2.9 minutes.
CONTRAST: 36 ml of Visipaque.
TOTAL FLUIDS: 2 liters.
ESTIMATED BLOOD LOSS: 200.
SPECIMEN: None.
FINDINGS: Single-vessel runoff into the foot via the
anterior tibial which then perfuses the peroneal artery.
There was an adequate sized greater saphenous vein which was
used to perform the bypass graft in a non-reversed fashion.
DRAINS: None.
COMPLICATIONS: None.
CONDITION: Guarded.
PATIENT ID: This is a 66-year-old man who had previously had
rest pain of the right foot. He had previously undergone a
right femoral patch angioplasty and subsequently right
femoral to below-knee popliteal pro patent bypass graft. He
presents with continued rest pain and evidence of limb threat
with sensory loss in the right foot. Given these findings,
the patient was consented for a arteriogram, possible bypass
graft nerve to achieve limb salvage.
PROCEDURE IN DETAIL: After informed consent was obtained,
the patient was brought to the operating room placed supine
on the operating room table. General endotracheal anesthesia
was started. Vancomycin and gentamicin was given
intravenously prior to skin incision. The right leg, both
groins, and left upper extremity was prepped and draped in
usual sterile fashion. Using the ultrasound, the left common
femoral artery was identified. It was patent. Previously
performed femoral to popliteal bypass graft on the left was
seen and puncture was made above the anastomosis of bypass
graft micro sheath. Hard copy images were stored in the
patient's chart for documentation purposes. Micro sheath was
used to access the left external iliac artery and followed by
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7648**] wire in abdominal aorta and a 4-French short sheath
in the left external iliac artery and Omni Flush catheter in
abdominal aorta.
Abdominal aortogram was performed. Contralateral second-order
catheterization of the right external iliac artery was
achieved with a combination of angled Glidewire and Omni
Flush catheters. Serial arteriogram was then performed to
the right lower extremity. Based on the diagnostic findings,
the decision was made to intervene. We had elected to
proceed with a femoral to contra tibial artery bypass graft.
We cut down the course of the greater saphenous vein.
Dissection was carried down using electrocautery and
saphenous vein was identified by sharp dissection. Dissection
of the greater saphenous vein continued all the way to the
saphenofemoral junction and distally into the mid calf. The
entire length of saphenous vein appeared to be quite usable
and appeared quite healthy. Previously seen tunnel pro patent
was graft is seen. It had no pulse in it and is consistent
with our finding of a firm post bypass pro patent graft. Com
mon femoral artery was identified, dissected from surrounding
structures using sharp dissection. Vessel loops were used to
control the common femoral artery, the superficial femoral,
the profunda femoris artery, and the circumflex femoral
vessels.
Next, exploration of the proximal anterior tibial artery was
achieved via a longitudinal skin incision the lateral aspect
of the leg. Dissection was carried down using electrocautery
and the anterior tibial artery is identified and all side
branches of the anterior tibial artery were carefully
controlled with 2-0 silk ties and proximal and distal control
was controlled with vessel loops on the anterior tibial
artery. The anterior tibial artery appeared quite soft at
this level, although there was some atherosclerosis within
the walls. Once we had proximal distal control in our inflow
and outflow vessels, heparin 6000 units was given
intravenously to maintain activated clotting time for 20-50
seconds throughout the entire case. Vessel control was
achieved via pulling up on the vessel loops and the
previously-placed pro patent graft was disattached from the
common femoral artery. This left a perfect hole on the bovine
pericardial patch that was previously placed. A subcutaneous
tunnel was created in the lateral aspect of the leg and the
greater saphenous vein was harvested via ligating side
branches between 4-0 silk ties. The distal greater saphenous
vein was ligated with 2-0 silk tie and the proximal saphenous
vein at its junction with the saphenofemoral was ligated with
3-0 Vicryl suture. Saphenous vein was removed and an
angioscopy with valve lysis was performed with a [**Doctor Last Name 4048**]
valvulotome. All valves were cut under endoscopic
visualization and with good flow throughout the entire lumen.
Saphenous vein was passed through the subcutaneous tunnel
created to the lateral aspect of the leg and care was taken
to ensure that the graft lay the without kinking or twisting.
A end-to-side anastomosis of the greater saphenous vein graft
to the common femoral artery was achieved with a two running
sutures of 5-0 Prolene. There was excellent hemostasis at the
anastomosis. Proximal and distal clamps were released and
flushing of the graft was performed. There was excellent
pulsatile flow within the distal end of the graft. The graft
was matched to the anterior tibial artery in end-to-side
anastomosis of a spatulated vein and the longitudinal
anterior tibial arteriotomy was performed with two running 6-
0 Prolene sutures. Backflushing and fore flushing of four
vessels were performed prior to completion of the
anastomosis. There appeared to be a flap of tissue within the
anterior tibial artery proximally that was retrieved. A 1.5
mm coronary dilator was passed distally into the anterior
tibial artery which allowed good backbleeding from the
anterior tibial artery. Anastomosis completed, Doppler exam
of the flow vessel showed excellent signal within the vessel
and we were happy with our results. Therefore, hemostasis
achieved at all wounds and the wall incisions in the groin
was closed in three layers with 2-0 Vicryl and staples
distally within the medial incision. The wound was closed
with 2-0 Vicryl in a single deep layer and a 4-0 Monocryl for
the skin and Dermabond for the skin. Lateral incision was
closed with 4-0 Vicryl and Dermabond for the skin. Sterile
dressing was applied. The patient was awakened from
anesthesia, extubated, and brought to the intensive care unit
in guarded condition. Dr. [**Last Name (STitle) **] was scrubbed for the
entire case.
ANGIOGRAPHIC FINDINGS:
1. Normal-appearing abdominal aorta. He had very small
iliac vessels, all of which are widely patent. There are
single patent renal arteries bilaterally.
2. Bilateral common iliac arteries, internal iliac
arteries, and external iliac arteries are very small but
patent.
3. The vein graft is seen coming off the proximal aspect of
the left common femoral artery. This appeared to be
patent with rapid transit of contrast.
4. The right common femoral artery is patent as is the
right profunda femoris artery.
5. The native superficial femoral artery is diffusely
diseased. There is a stent within the mid portion of the
superficial femoral artery. However, the entire
superficial femoral artery is patent.
6. The pro patent graft is seen coming off the proximal
portion of the medial portion of the common femoral
artery and appeared to be patent in its proximal stump.
However, it occludes for the remainder of course and
does not reconstitute even on delayed images.
7. The above-knee popliteal artery occludes before the knee
joint and multiple collateral arteries existed at this
level which does provide some perfusion to the lower
leg.
8. Below-knee steel artery is completely occluded, does not
reconstitute even on delayed images.
9. The anterior tibial artery is heavily diseased in its
proximal portion. However, in the proximal third of its
course, reconstituted, and remains patent into the into
the ankle at which point it abruptly occludes. There is
a large collateral that exists at this level which
helped to perfuse the peroneal artery. Some retrograde
filling of the peroneal artery is seen, although the
peroneal artery is very diseased throughout its proximal
half of its course. Distally the peroneal artery runs
off into the foot with very small plantar and tarsal
vessels.
10.The posterior tibial artery is occluded throughout its
entire length.
11.Within the foot itself, the dorsalis pedis artery was
not seen and is presumed to be occluded. There is a
lateral tarsal vessel that does supply the forefoot and
the plantar circulation provides gives rise to a patent
but very small plantar arch that gives some perfusion to
the forefoot.
ADDENDUM: The distal stump pro patent graft was transected
and ligated with a 3-0 Vicryl suture. There is no evidence
of flow within the distal portion of the pro patent graft.
The entire length of the pro patent graft was removed.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(2) 6039**]
Dictated By:[**Last Name (NamePattern1) 6886**]
EGD report([**2182-9-3**]):
Findings: Esophagus: Normal esophagus.
Stomach:
Mucosa: Localized discontinuous erythema of the mucosa with no
bleeding was noted in the stomach body. These findings are
compatible with mild gastritis and NGT. These findings can not
explain Hct drop and melena.
Duodenum: Normal duodenum
Colonoscopy ([**2182-9-4**]):
Results:
Impression: Friability and erythema in the rectum
Polyp in the sigmoid colon
Grade 1 internal hemorrhoids
Polyps in the rectum
Diverticulosis of the descending colon and sigmoid colon
Otherwise normal colonoscopy to terminal ileum
Wound cultures:right bypass incision:
GRAM STAIN (Final [**2182-9-9**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2182-9-11**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
______________________________________________________
Brief Hospital Course:
This is a 66-year-old man experienced previously rest pain in
his right foot and had undergone surgery for a right femoral
patch angioplasty and subsequently right
femoral to below-knee popliteal pro patent bypass graft at
[**Hospital3 **]([**2182-8-23**]). He presented to the [**Hospital1 18**] with
continued rest pain and evidence of limb threat with sensory
loss in the right foot.The patient was consented for a
arteriogram and possible bypass graft nerve to achieve limb
salvage.
After informed consent was obtained, the patient was brought to
the operating room ([**2182-8-24**]). General endotracheal anesthesia
was started. Vancomycin and gentamicin were given intravenously
prior to skin incision. The right leg, both groins, and left
upper extremity was prepped and draped in usual sterile fashion.
OPERATION PERFORMED.:
1. Right common femoral to anterior tibial artery bypass
with non-reversed greater saphenous vein.
2. Angioscopy and valve lysis.
3. Ultrasound-guided puncture of left common femoral
artery.
4. Contralateral second-order catheterization of right
common femoral artery.
5. Abdominal aortogram.
6. Serial arteriogram of the right lower extremity
After surgery the patient was extubated and transferred to the
ICU for recovery. One day after surgery the patient became
increasingly restless and agitated. Given his history of alcohol
abuse he was put on high dose Ativan and a Dexmedetomidine
drip. Over the course of the next 5 days the patient remained
agitated and delirious requiring large doses of Benzodiazepines.
On postoperative day five the patient was noted to pass dark,
loose, guaiac positive stools. His hematocrit which has been in
the high 20s after surgery dropped to 23/24%. The patient
received 2 units of RBC with a good response. Again his HCT
dropped one day later from 27 to 24 %. Over the course of the
next view days the patient required multiple blood transfusions
to stabilize his hematocrit. An EGD and a colonoscopy were
scheduled after his acute alcohol detoxification on the
([**2182-9-3**]). The performed EGD failed to explain his HCT drop and
melena. Colonoscopy was performed one day later and showed a
diffuse continuous friability and erythema in the rectum however
no bleeding was noted. The patient was weaned and extubated
after colonoscopy. His hematocrit was followed up continuously
over the next couple of days no more bleeding occurred. His
mental status improved and the patient was hemodynamically
stable. No further bleeding occurred so that he was transferred
to the floor on [**2182-9-7**]. DP and PT pulses on both lower
extremities were dopplerable after surgery. Some purulent
discharge and cellulitis was noted over his RLE distal wound.
Wound cultures were sent and the patient was subsequently put on
Vancomycin Ciprofloxacin and Flagyl. Wet to dry dressings have
been changed twice a day. Upon discharge his wound is still with
some drainage. His antibiotic regiment was switched to
Augmentin.
The patients overall condition improved significantly over the
last week. He is hemodynamically stable at the time of
discharge, no shortness of breath and tolerates a regular diet.
Medications on Admission:
Plavix 75', ASA 81', atenolol 50', lisinopril 5', zocor 80',
MTV, folate, fish oil
Discharge Medications:
1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Refill from PCP [**Name9 (PRE) **],[**Name9 (PRE) **]
Phone: [**Telephone/Fax (1) 63941**].
Disp:*30 Tablet(s)* Refills:*0*
7. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 10 days.
Disp:*30 Tablet(s)* Refills:*1*
8. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Refill from PCP [**Name9 (PRE) **],[**Name9 (PRE) **]
Phone: [**Telephone/Fax (1) 63941**]
.
Disp:*30 Tablet(s)* Refills:*0*
10. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily): Refill from PCP [**Name9 (PRE) **],[**Name9 (PRE) **]
Phone: [**Telephone/Fax (1) 63941**].
Disp:*30 Tablet(s)* Refills:*0*
11. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
home med.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Critical RLE ischemia s/p Right common femoral to anterior
tibial artery bypass with non-reversed greater saphenous vein.
PMH:
1. PVD s/p:
-Right [**Name (NI) 1793**] PTA/stent ([**8-5**])
-R CFA endarterectomy w/ bovine pericardial patch
angioplasty Right BK [**Doctor Last Name **] endarterectomy and [**Location (un) **] patch
and Right proximal CFA to BK [**Doctor Last Name **] 6mm PTFE ([**8-23**])
2. HTN
3. Lipids
4. Hemachromatosis
Discharge Condition:
Stable
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**3-12**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2182-9-19**] 10:15
Call PCP for office visit, to be seen in next 2 weeks.
Completed by:[**2182-9-12**]
|
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icd9cm
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[
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icd9pcs
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[
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299, 696
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,907
| 126,131
|
52469
|
Discharge summary
|
report
|
Admission Date: [**2113-1-22**] Discharge Date: [**2113-2-1**]
Date of Birth: [**2064-8-8**] Sex: M
Service: MEDICINE
Allergies:
Gluten
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
CT guided lymphnode biopsy
Bone marrow biopsy
History of Present Illness:
48 M with h/o mild wheat allergy presents with malaise and
shortness of breath. Three weeks ago he felt "flu-ish" with
subjective fevers, headache, fatigue and night sweats. Two
weeks ago he developed a non-productive dry cough which persists
and has become worse. Drenching night sweats became a regular
occurrence as of two weeks ago. He's been more fatigued and
thinks it requires more effort to move around, feeling dyspneic
on exertion and at rest as times. He's noted subjective weight
loss during this time, and loss of appetite. He complains of
daily headaches which come and go, worse at night, but
responsive to Advil. These are new, bifrontal, and not
associated with focal neurologic deficits. He's also developed
LLQ/LUQ pain over the past week, increasing in nature,
non-radiating came to the ER this early morning because of the
abdominal pain.
In the ED, VS 97, HR 110, BP 106/68, RR 16, SpO2 99%. He spike
a temp there and had one set of BCx done. A UA was clear
A CT showed bulky retroperitoneal lymphadenopathy and large
liver lesions.
Past Medical History:
Stress Fracture
Exercise Induced Anaphylaxis after wheat ingestion - ? mild
wheat allergy -- but no GI symtoms
Social History:
Married with one daughter. Is a fashion photographer. No
recetn travel to high-TB endemic areas. Smoked 5 cig/day until
quit 1 month ago. Has 1 alcoholic beverage weekly. Long ago
tried cocaine, no drug use since then.
Family History:
Mo - DM2
Fa - DM2, prostate CA in 50s
[**Last Name (un) **] - prostate CA
Nephew - prostate CA
Physical Exam:
VS: 102.3, 112,
In NAD. Mild dry cough
Anicteric, EOMI, OP clear, no thrush, no lesions
JVP elevated to 8 cm w/o Kussmauls.
Lungs - decreased bs bilat bases, scant crackles L
COR - tachy, s1, s2, (+) Right S3 possible scant systolic murmur
L base
ABD - mild distended, palpable liver edge mildly tender
EXT - no edema
[**Doctor First Name **] - no head, neck, axillary or inguinal lymphadenopathy
NEURO - non focal
SKIN - no rashes
Pertinent Results:
[**2113-1-22**] 09:45AM BLOOD WBC-8.9 RBC-3.58* Hgb-10.7* Hct-33.1*
MCV-93 MCH-30.0 MCHC-32.4 RDW-13.1 Plt Ct-457*
[**2113-1-23**] 06:15AM BLOOD WBC-9.2 RBC-3.26* Hgb-9.9* Hct-30.0*
MCV-92 MCH-30.5 MCHC-33.1 RDW-12.9 Plt Ct-423
[**2113-1-31**] 09:22AM BLOOD WBC-4.8 RBC-3.12* Hgb-9.1* Hct-28.4*
MCV-91 MCH-29.2 MCHC-32.0 RDW-13.6 Plt Ct-480*
[**2113-2-1**] 05:54AM BLOOD WBC-27.9*# RBC-3.32* Hgb-9.4* Hct-30.5*
MCV-92 MCH-28.3 MCHC-30.8* RDW-13.8 Plt Ct-435
[**2113-1-22**] 09:45AM BLOOD Neuts-84.2* Lymphs-9.1* Monos-5.2 Eos-1.2
Baso-0.4
[**2113-1-25**] 07:50AM BLOOD Neuts-84.9* Lymphs-8.6* Monos-6.3 Eos-0.1
Baso-0.1
[**2113-1-31**] 09:22AM BLOOD Neuts-87.9* Lymphs-9.1* Monos-0.8*
Eos-2.1 Baso-0.1
[**2113-2-1**] 05:54AM BLOOD Neuts-97.2* Lymphs-1.6* Monos-0.4*
Eos-0.4 Baso-0.4
[**2113-1-22**] 07:00PM BLOOD PT-16.5* PTT-34.2 INR(PT)-1.5*
[**2113-1-23**] 06:15AM BLOOD PT-16.7* PTT-35.8* INR(PT)-1.5*
[**2113-1-30**] 12:00AM BLOOD PT-13.7* PTT-25.4 INR(PT)-1.2*
[**2113-1-31**] 09:22AM BLOOD PT-14.8* PTT-28.1 INR(PT)-1.3*
[**2113-1-26**] 12:00AM BLOOD Fibrino-1117*
[**2113-1-28**] 06:29AM BLOOD Fibrino-972*#
[**2113-1-31**] 09:22AM BLOOD Fibrino-437*#
[**2113-1-24**] 06:00AM BLOOD ESR-120*
[**2113-1-26**] 12:00AM BLOOD Gran Ct-9050*
[**2113-1-31**] 09:22AM BLOOD Gran Ct-4200
[**2113-2-1**] 05:54AM BLOOD Gran Ct-[**Numeric Identifier **]*
[**2113-1-22**] 09:45AM BLOOD Glucose-103 UreaN-10 Creat-1.0 Na-134
K-4.0 Cl-100 HCO3-24 AnGap-14
[**2113-1-23**] 06:15AM BLOOD Glucose-112* UreaN-10 Creat-0.9 Na-136
K-4.2 Cl-101 HCO3-24 AnGap-15
[**2113-1-31**] 09:22AM BLOOD Glucose-108* UreaN-16 Creat-0.7 Na-139
K-3.5 Cl-102 HCO3-29 AnGap-12
[**2113-2-1**] 05:54AM BLOOD Glucose-85 UreaN-16 Creat-0.7 Na-138
K-4.2 Cl-104 HCO3-26 AnGap-12
[**2113-1-22**] 09:45AM BLOOD ALT-101* AST-77* LD(LDH)-572*
AlkPhos-243* TotBili-0.5
[**2113-1-24**] 06:00AM BLOOD ALT-66* AST-47* LD(LDH)-477* AlkPhos-194*
TotBili-0.5
[**2113-1-31**] 09:22AM BLOOD ALT-193* AST-122* LD(LDH)-258*
AlkPhos-215* TotBili-0.7
[**2113-2-1**] 05:54AM BLOOD ALT-164* AST-82* LD(LDH)-388*
AlkPhos-212* TotBili-0.7
[**2113-1-22**] 09:45AM BLOOD Lipase-15
[**2113-1-27**] 07:57AM BLOOD proBNP-821*
[**2113-1-23**] 06:15AM BLOOD Calcium-7.9* Phos-3.5 Mg-1.9
[**2113-1-24**] 06:00AM BLOOD TotProt-5.3* Albumin-2.7* Globuln-2.6
Phos-1.9*# Mg-2.2 UricAcd-4.7
[**2113-1-31**] 09:22AM BLOOD Calcium-8.2* Phos-2.5* Mg-2.3
UricAcd-2.9*
[**2113-2-1**] 05:54AM BLOOD Calcium-8.4 Phos-3.4 Mg-2.3 UricAcd-3.0*
[**2113-1-23**] 06:15AM BLOOD HCG-<5
[**2113-1-24**] 06:00AM BLOOD CRP-GREATER TH
[**2113-1-23**] 06:15AM BLOOD CEA-<1.0 AFP-<1.0
[**2113-1-24**] 06:00AM BLOOD PEP-NO SPECIFI b2micro-2.4*
[**2113-1-23**] 06:15AM BLOOD HIV Ab-NEGATIVE
[**2113-1-23**] 06:15AM BLOOD tTG-IgA-6
[**2113-1-27**] 01:35PM BLOOD Type-ART pO2-72* pCO2-44 pH-7.53*
calTCO2-38* Base XS-12
[**2113-1-27**] 11:47AM BLOOD Type-ART pO2-57* pCO2-45 pH-7.53*
calTCO2-39* Base XS-12
[**2113-1-27**] 01:35PM BLOOD Lactate-2.9*
[**2113-1-27**] 11:47AM BLOOD Lactate-2.9*
[**2113-1-26**] 02:00PM BLOOD FREE KAPPA AND LAMBDA, WITH K/L
RATIO-Test
[**2113-1-24**] 06:00AM BLOOD EBV PCR, QUANTITATIVE, WHOLE BLOOD-
[**2113-1-24**] 06:00AM BLOOD HISTOPLASMA ANTIBODY (BY CF AND ID)-Test
[**2113-1-24**] 06:00AM BLOOD PARACOCCIDIOIDES BRASILIENSIS
ANTIBODY-Test Name
[**2113-1-24**] 06:00AM BLOOD HTLV I AND II, WITH REFLEX TO WESTERN
BLOT-Test Name
[**2113-1-28**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2113-1-28**] URINE URINE CULTURE-FINAL INPATIENT
[**2113-1-26**] URINE URINE CULTURE-FINAL INPATIENT
[**2113-1-26**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2113-1-26**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2113-1-25**] BONE MARROW FLUID CULTURE-FINAL INPATIENT
[**2113-1-24**] Influenza A/B by DFA DIRECT INFLUENZA A ANTIGEN
TEST-FINAL; DIRECT INFLUENZA B ANTIGEN TEST-FINAL; Respiratory
Viral Culture-FINAL INPATIENT
[**2113-1-24**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2113-1-24**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2113-1-24**] IMMUNOLOGY HIV-1 Viral
Load/Ultrasensitive-FINAL INPATIENT
[**2113-1-24**] Immunology (CMV) CMV Viral Load-FINAL INPATIENT
[**2113-1-24**] Blood (CMV AB) CMV IgG ANTIBODY-FINAL; CMV IgM
ANTIBODY-FINAL INPATIENT
[**2113-1-24**] SEROLOGY/BLOOD RAPID PLASMA REAGIN
TEST-FINAL INPATIENT
[**2113-1-23**] SEROLOGY/BLOOD MONOSPOT-FINAL INPATIENT
[**2113-1-23**] Blood (EBV) [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB-FINAL;
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB-FINAL; [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM
AB-FINAL INPATIENT
[**2113-1-22**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2113-1-22**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2113-1-24**] 03:03AM URINE U-PEP-MULTIPLE P IFE-MONOCLONAL
[**2113-1-26**] 05:20AM URINE Hours-RANDOM Creat-43 TotProt-21
Prot/Cr-0.5*
[**2113-1-24**] 03:03AM URINE Hours-RANDOM Creat-203 TotProt-110
Prot/Cr-0.5*
[**2113-1-23**] 05:53PM OTHER BODY FLUID CD23-DONE CD45-DONE
HLA-DR[**Last Name (STitle) 7735**] [**Name (STitle) 7736**]7-DONE Kappa-DONE CD2-DONE CD7-DONE CD10-DONE
CD19-DONE CD20-DONE Lamba-DONE CD5-DONE
[**2113-1-23**] 05:53PM OTHER BODY FLUID CD3-DONE
[**2113-1-23**] 05:53PM OTHER BODY FLUID IPT-DONE
[**2113-1-25**] 11:00AM BONE MARROW [**Doctor Last Name 4427**]-DONE CD23-DONE CD45-DONE
HLA-DR[**Last Name (STitle) 7735**] [**Name (STitle) 7736**]7-DONE Kappa-DONE CD10-DONE CD19-DONE CD20-DONE
Lambda-DONE CD5-DONE
[**2113-1-25**] 11:00AM BONE MARROW CD3-DONE
[**2113-1-25**] 11:00AM BONE MARROW IPT-DONE
[**2113-1-22**]: CT abd/pel
CT ABDOMEN: The visualized lung bases demonstrate small
dependent effusions
of low-density with associated minor compressive atelectasis.
There are multiple large hypoenhancing mass lesions within the
liver, both the
right and left lobes, these are predominantly peripheral in
location,
suggesting that may be either parenchymal or subcapsular in
location. An 11
mm diameter low-density focus in the hepatic dome is too small
to
characterize. There is no biliary ductal dilatation. The main
portal vein
and hepatic veins are widely patent. The gallbladder is
decompressed.
The spleen is normal in size and appearance. The pancreas,
kidneys, and
adrenal glands are normal.
There is massive confluent retroperitoneal and mesenteric
adenopathy. There
is also thickening of the peritoneum, with omental caking. There
is no free
fluid or free air in the abdomen. The aorta and major mesenteric
vessels are
widely patent.
CT PELVIS: The rectum and sigmoid colon are grossly normal. The
distal
ureters and bladder are unremarkable. The prostate is normal.
There is also
pelvic and deep inguinal lymphadenopathy. There is no free
pelvic fluid.
BONE WINDOWS: There are no suspicious lytic or sclerotic osseous
lesions.
IMPRESSION:
1. Massive retroperitoneal and mesenteric adenopathy, with
peritoneal
thickening and omental caking. Additional precardial nodes are
also noted.
There are also hypodense masses within the liver, peripheral in
location.
While the omental and peritoneal involvement is somewhat
atypical, findings
are overall most suggestive of lymphoma.
2. Small pleural effusions with associated atelectasis.
[**2113-1-22**] CTA:
FINDINGS: The heart is stable in size. A calcification is noted
along the
posterior side of the mitral valve. The pulmonary arteries
opacify normally
without evidence of pulmonary embolism. There is marked
mediastinal, right
hilar, pericardial, and supraclavicular lymphadenopathy. There
is a
superficial lymph node measuring 1.2 cm within the anterior
right neck, in the
supraclavicular region(3:6), which may suitable for percutaneous
biopsy.
Enlarged mediastinal lymph nodes are noted measuring up to 1.9
cm in the
prevascular space, 2.1 cm in short axis within the right
paratracheal space
and up to 1.3 cm in short axis within the subcarinal space.
Right hilar
lymphadenopathy is also identified measuring up to 1.1 cm in
short axis.
Multiple paracardial lymph nodes are identified measuring up to
1.4 cm in
short axis. The tracheobronchial tree is patent to the level of
the
subsegmental bronchi bilaterally. No pulmonary nodules or masses
are
identified. There is bibasilar dependent atelectasis and small
bilateral
pleural effusions. No pneumothorax is identified.
Within the visualized liver is redemonstration of several
low-density
peripherally oriented liver masses, unchanged from the most
recent prior study
of earlier the same day. The visualized spleen is unremarkable.
No
suspicious lytic or sclerotic lesions are identified.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Calcification along the posterior aspect of the mitral valve,
perhaps
along the posterior leaflet, which may be related to the cardiac
abnormalities
noted on physical examination. There is no evidence for venous
compression,
in spite of a large burden of disease in the mediastinum.
3. Bulky mediastinal, supraclavicular, and right hilar
lymphadenopathy,
concerning for lymphoma. A 1.2 cm superficial left
supraclavicular lymph node
may be amenable to percutaneous biopsy.
4. No pulmonary masses or nodules. Small bilateral pleural
effusions and
dependent atelectasis.
5. Partially visualized liver masses, better described and
visualized on
prior CT abdomen dated earlier the same day.
FLOW CYTOMETRY REPORT LYMPH NODE BIOPSY
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: CD2, CD3,
CD5, CD7, CD10, CD19, CD20, FMC7, HLA-DR, Kappa, Lambda, CD45,
CD23.
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize blast/lymphocyte yield. Lymphoma cells comprise 5% of
total gated events. B cells demonstrate a monoclonal lambda
light chain restricted population. They co-express pan-B cell
markers CD19. They do not express any other characteristic
antigens including CD5, CD10.
INTERPRETATION:
Immunophenotypic findings consistent with involvement by a
lambda-restricted B cell lymphoproliferative disorder. See
separate surgical pathology S10-67 for correlation with
morphology.
SPECIMEN: LEFT RETROPERITONEAL LYMPH NODE, CORE NEEDLE BIOPSY.
DIAGNOSIS:
HIGH GRADE DIFFUSE LARGE B-CELL LYMPHOMA WITH PLASMA CELL
DIFFERENTIATION AND CYTOPLASMIC IMMUNOGLOBULIN CRYSTALS. SEE
NOTE.
FLOW CYTOMETRY REPORT BONE MARROW BIOPSY
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: CD3, CD5,
CD10, CD19, CD20, FMC7, HLA-DR, Kappa, lambda, CD45, CD23.
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield. Abnormal cells comprise 2% of total
gated events (50% of events in blast gate) are CD19 positive and
lambda restricted. T cells comprise 74% of lymphoid gated
events.
SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY.
DIAGNOSIS:
HYPERCELLULAR BONE MARROW WITH TRILINEAGE MATURING HEMATOPOIESIS
AND EXTENSIVE INVOLVEMENT WITH LARGE CELL LYMPHOMA.
Note: By immunohistochemistry, the neoplastic lymphoid cells are
diffusely positive for pan B-cell markers CD20, CD79a, PAX-5
(dim), and MUM-1 (dim). CD3 and CD5 highlight scattered admixed
mature T-lymphocytes. CD138 is positive in numerous plasma
cells, which demonstrate cytoplasmic inclusions similar to those
seen in the large cells of the lymphoma. With CD20 staining the
neoplastic infiltrate is estimated to account for approximately
20% of the cellularity, while plasma cells, highlighted by CD138
comprise approximately 10% of marrow cellularity. The plasma
cells and some large lymphocytes are Lambda restricted by Kappa
and Lambda light chain staining. The plasma cells predominantly
express IgM, with scattered cells expressing IgG and IgA. A
MIB-1 stain is difficult to assess do to the admixed
nonneoplastic hemopoietic precursors, but is focally up to 30%.
The above morphologic and immunophenotypic findings are
consistent with involvement by a large B-cell lymphoma with
exhibit peculiar plasma cell differentiation features with many
cells containing crystalline cytoplasmic inclusions, which are
presumably composed of immunoglobulin. The overall features of
this lymphoma are somewhat reminiscent of the so-called
polymorphic immunocytoma of the old [**Location (un) **] classification of
lymphomas.
In addition to lymphoma, there is marked dysppiesis,
particularly in erythroid precursors. The significance of these
findings is uncertain at this time, but needs to be established
by cytogenetics studies and clinical follow up.
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear:
The smear is adequate for evaluation. Erythrocytes are slightly
decreased in number with rouleaux formation, and show occasional
target cells, ovalocytes, and polychromatophils with rare cells
showing basophilic stippling. The white blood cell count
appears normal with scattered atypical, large lymphoid cells,
some of which contain cytoplasmic crystalline inclusions.
Platelet count appears normal. Large forms are seen. Rare
giant forms are present. Differential count shows 80%
neutrophils, 3% bands, 10% monocytes, 5% lymphocytes, 1%
eosinophils, 1% basophils.
Aspirate Smear:
The aspirate material is adequate for evaluation. The M:E ratio
is 2:1. Erythroid precursors are normal in number and show
dyspoietic maturation, karyorrhectic nuclei, nuclear budding,
and micronuclei. Myeloid precursors appear normal in number and
show full spectrum maturation. Megakaryocytes are present in
increased numbers; abnormal forms are seen. Differential shows:
2% Promyelocytes, 13% Myelocytes, 7% Metamyelocytes, 28%
Bands/Neutrophils, 5% Plasma cells, 15% Lymphocytes, 25%
Erythroid, 3% Eosinophils, 2% Basophils.
The lymphocyte count includes many large and atypical cells with
Golgi crystalline inclusions and fragments of lymphocytes in the
background. Several of the plasma cells have the same
inclusions as the lymphocytes.
Clot Section and Biopsy Slides:
The biopsy material is adequate for evaluation. It consists of
a 1.9 cm and a 0.5 cm core biopsy of trabecular bone. The
cellularity is variable, ranging from 50-80%, with an overall
cellularity of 60-70%. There is abnormal localization of
immature precursors. The M:E ratio estimate is decreased.
Erythroid precursors are increased in number and show dysplastic
features including irregular nuclear contours and nuclear
budding. Myeloid elements are normal in number and exhibit full
spectrum maturation. Megakaryocytes are present in markedly
increased numbers. Some show dysmorphic features. There is an
interstitial infiltrate of atypical lymphoid cells associated
with focal fibrosis, which comprises an estimated 20% of marrow
cellularity. These abnormal lymphoid cells span the gamut of
cell sizes and many demonstrate atypical plasmacytoid features
with dense, deep blue cytoplasm and large crystalline
cytoplasmic inclusions.
INTERPRETATION
Immunophenotypic finding consistent with involvement by a lambda
restricted B-cell lymphoproliferative disorder. See separate
surgical pathology report S10-477 for correlation with
morphology.
Clinical: Lymphoma (NHL). B symptoms, possible lymphoma.
KARYOTYPE: SEE BELOW
INTERPRETATION:
Karyotype:
47,XY,add(X)(p22.1),[**Doctor First Name **](2)(q33),+3,add(18)(p11.2)[5]/
46,XY[16]
Five of twenty one cells analyzed showed the anomalies
described above. Additional material of unknown origin is
observed on the terminal 18p and Xp; there is a deletion of
terminal 2q, and an extra chromosome 3 in each of the
abnormal cells. +3 is seen in both B and T cell NHL.
Small chromosome anomalies may not be detectable using the
standard methods employed.
[**2113-1-25**] TTE:
The left atrium is mildly dilated. 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. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Normal regional and global biventricular systolic
function. No pathologic valvular abnormality seen.
[**2113-1-27**] TTE (rule out tamponade):
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 valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Trivial/physiologic pericardial effusion.
[**2113-1-27**] CXR
Basal segments of the right lower lobe are still severely
atelectatic, though
there has been some improved aeration since [**1-25**]. Small
bilateral
pleural effusions persist. Left lung grossly clear. There is
probably new
atelectasis in the right middle lobe. Heart size top normal.
Right lower
paratracheal adenopathy unchanged. Right PIC catheter can be
traced as far as
the superior cavoatrial junction. No pneumothorax.
[**2113-1-27**] KUB
Three views of the abdomen and pelvis including left lateral
decubitus
radiograph demonstrates nonobstructive bowel gas pattern. No
ileus or free
air is identified. Oral contrast from prior CT scan is seen
throughout the
colon to the rectum.
IMPRESSION: No obstruction or free air.
[**2113-1-28**]
BILATERAL LOWER EXTREMITY ULTRASOUND: Grayscale, color, and
Doppler
ultrasound was used to evaluate the bilateral common femoral,
superficial
femoral, and popliteal veins. Calf veins were also interrogated.
There is
normal compressibility, flow, and augmentation throughout.
Augmentation
images of common femoral veins not provided.
IMPRESSION: Slightly limited study with no evidence of DVT of
either lower
extremity.
[**2113-1-29**] CXR
One portable view. Comparison with [**2113-1-27**]. There appears to be
some interval
increase in pleural fluid on the right. The right hemidiaphragm
is obscured.
There is continued evidence of volume loss in the lower right
lung.
Mediastinal structures are unchanged. A PICC line remains in
place on the
right.
IMPRESSION: Interval increase in pleural fluid on the right.
Brief Hospital Course:
48 M with no significant established PMHx presents with 3 wk h/o
fatigue, fevers, night sweats, weight loss, increasing dyspnea,
and abdominal pain now found to have retropertioneal
lymphadenopathy, small pleural effusions and large liver lesions
concerning for possible lymphoma vs. systemic infection.
# Lymphadenopathy/Liver Mass: Patient was found to have large
diffuse lymphadenopathy of the thorax, abdomen and pelvis. He
underwent lymph node biopsy and was diagnosed with diffuse large
B cell lymphoma (see pathology report above for more details).
His liver mass was thought to represent metastatic disease. He
was then transfered to the bone marrow transplant service where
he underwent treatment with chemotherapy using the dose adjusted
R-[**Hospital1 **] regimen. He tolerated the treatment well, but his course
was complicated by acute hypoxic respiratory distress as
explained below. He was discharged in stable condition with
plans to receive the rituxumab portion of the regimen as an
outpatient.
# Abdominal Pain L: Patient had persistent abdominal pain, work
up revealed no evidence of bowel abscess or perforation. This
was thought to be due to lymphoma involvement of the abdominal
lymph nodes and omentum. His pain was treated with long acting
oxycodone and it was well controlled upon discharge.
# Fever: Patient presented with 3 weeks of fevers. On admission
the differential diagnosis included infectious process vs
malignancy. Extensive infection work up was negative and the
patient was diagnosed with diffuse large B cell lymphoma. His
fevers were thought to be part of the B symptoms that manifest
in this disease. Fevers resolved after the patient was started
on [**Hospital1 **].
# Shortness of breath: Patient initially presented with symptoms
of shortness of breath and fatigue. There was no evidence of
pericardial effusion on CT or TTE although he had mildly
distended JVP. PE was ruled out with CTA. While the patient was
on D2 of [**Hospital1 **] he developed acute hypoxic respiratory failure.
The patient was transfered to the [**Hospital Unit Name 153**] on [**2113-1-27**]. In the FIUC
the patient's breathing appeared to be comfortable albeit in the
rate of the mid 20s on non-rebreather. ABG still showed a large
A-a gradient of 300, saturation has been 100% on 10L oxygen.
Initial concern was for tamponade/pericardial effusion however
prelim Echo reported no fluid collection. CXR showed elevated
right hemidiaphragm which on prior reports looks unchanged and
reported as atelectasis. Given the high A-a gradient suspect
either V/Q mismatch or shunt physiology. Primary concern was
possible disease progression, the rate in the decline of his
health status suggests a rapid course. CXR did show changes
within the parenchyma. Other possibilities included Pulmonary
Embolism. Infection currently unlikely given his clinical
status, although he is febrile it is likely due to his
oncological diagnosis given the length of his fevers. Final
echo ruled out tamponade. Lower extremity ultrasound did not
show evidence of deep venous thrombosis. Oxygen saturation
improved prior to diuresis with lasix. Patient was continued on
EPOC for diffuse large B-cell lymphoma, and did not show
evidence of tumor lysis syndrome. An abdominal plain film
showed mild constipation without evidence of obstruction or free
air. Patient was monitored in the ICU and transferred back to
the bone marrow transplant service on [**2113-1-29**] in stable
condition. He was continued on [**Hospital1 **] while in the BMT service
and had no O2 requirement after transfer.
# Abnormal LFTs: Patient was noted to have elevated liver
enzymes on admission. This was thought to be due to metastatic
liver lesion. They began to improve after patient was started on
[**Hospital1 **]. LFT's remained elevated on admission and should be
followed as an outpatient.
# ?Wheat Allergy: Patient has a history of an allergic
(anaphylactic) reaction to wheat while exercising after
ingestion of wheat. He denied celiac type symptoms, but was kept
on a gluten free diet throughout his hospital course. On the day
of discharge the patient was changed to a regular diet, per
patient's request and after a discussion and investigation on
this presumed wheat allergy. The patient had no reactions to
wheat ingestion.
Medications on Admission:
Advil 2tabs q 3-6 hr prn headache
Discharge Medications:
1. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. 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*
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for breakthrough pain for 2 weeks.
Disp:*56 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Large B cell lymphoma
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were admited to the [**Hospital1 18**] becasue you were having fevers.
While in the hospital you were diagnosed with non-hodgkins
lymphoma. We treated you with the first cycle of your
chemotherapy called [**Hospital1 **]. You tolerated this treatment well.
During your hospitalization you had hypoxic respiratory distress
and required transfer to the intensive care unit for 2 days. You
were subsequently transfered back to the hematology/oncology
floor and did well. You will need to have frequent blood count
checks to monitor your disease. The first one will be on [**2113-2-2**]
as explained below. You will resume your chemotherapy as an
outpatient on [**2113-2-10**].
New medications:
START: Allopurinol 300 mg daily
START: Omeprazole 20 mg daily
START: Oxycontin 15 mg twice daily
START: Oxycodone 5 mg every 6-8 hours as needed for pain
START: Docusate 100 mg twice a day as needed for constipation
START: Senna 8.7 mg twice a day as needed for constipation
Followup Instructions:
Provider: [**Name Initial (NameIs) 455**] 1-[**Name Initial (NameIs) **] ONC 7F HEMATOLOGY/ONCOLOGY-7F
Date/Time:[**2113-2-2**] 10:00
Provider: [**Name Initial (NameIs) 455**] 4-[**Name Initial (NameIs) **] ONC 7F HEMATOLOGY/ONCOLOGY-7F
Date/Time:[**2113-2-7**] 12:30
Provider: [**Name10 (NameIs) **] ONC 7F HEMATOLOGY/ONCOLOGY-7F Date/Time:[**2113-2-10**]
9:00
|
[
"276.3",
"790.6",
"276.1",
"E933.1",
"799.02",
"285.9",
"202.83",
"780.60",
"V16.42",
"275.3",
"427.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.25",
"40.11",
"41.31",
"38.93",
"88.01"
] |
icd9pcs
|
[
[
[]
]
] |
26165, 26171
|
20998, 25325
|
293, 341
|
26256, 26256
|
2392, 20975
|
27396, 27763
|
1828, 1924
|
25409, 26142
|
26192, 26192
|
25351, 25386
|
26401, 27373
|
1939, 2373
|
234, 255
|
369, 1437
|
26211, 26235
|
26270, 26377
|
1459, 1571
|
1587, 1812
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,147
| 115,264
|
37208
|
Discharge summary
|
report
|
Admission Date: [**2105-2-18**] Discharge Date: [**2105-2-21**]
Date of Birth: [**2052-9-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
acute shortness of breath and elevated INR s/p
AVR(mechcanical)Ascending Aortic arch replacment on [**2-3**].
Major Surgical or Invasive Procedure:
evacuation of pericardial effusion
History of Present Illness:
SOB onset about 5 days ago, increasing with any movement. Saw
cardiologist yesterday had echo today with effusion.
Past Medical History:
Complete Heart Block(PPM)
Postop DVT in LUE [**2104-3-12**] following lead extraction
Hyperlipidemia
s/p Dual chamber pacemaker placement in [**2087**]
s/p replacement of PM generator [**2096**]
s/p Lead extraction and reimplantation of PPM [**3-/2104**]
Hernia repair as child
s/p AVR(mechcanical)Ascending Aortic arch replacment on [**2-3**].
Social History:
Lives with: Wife in [**Name2 (NI) 1727**]
Occupation: Production manager on ship yard
Tobacco: Quit 1.5 years ago. 40 pack year history
ETOH: [**12-14**] drinks per week
Family History:
non-contributory
Physical Exam:
Physical Exam
Temp 98.6 Pulse: 70 Vpaced Resp: 16 O2 sat: 96% 3LNP
B/P Right: 109/70 Left:
Height: Weight:
General:
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
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ []
Extremities: Warm [x], well-perfused [] Edema 2+ bilat
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: Left:
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Pertinent Results:
[**2105-2-18**] 03:02PM PT-59.9* PTT-34.8 INR(PT)-6.8*
[**2105-2-21**] INR 2.2
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 83779**]Portable TTE
(Focused views) Done [**2105-2-18**] at 5:00:00 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2052-9-21**]
Age (years): 52 M Hgt (in): 70
BP (mm Hg): 130/79 Wgt (lb): 277
HR (bpm): 70 BSA (m2): 2.40 m2
Indication: cath lab pericardiocentesis monitoring.
ICD-9 Codes: 423.3
Test Information
Date/Time: [**2105-2-18**] at 17:00 Interpret MD: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) **], MD
Test Type: Portable TTE (Focused views) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) 4134**]
[**Last Name (NamePattern1) 4135**], RDCS
Doppler: No Doppler Test Location: West Cath/EP Lab
Contrast: None Tech Quality: Adequate
Tape #: 2010W000-: Machine: Vivid i-3
Echocardiographic Measurements
Results Measurements Normal Range
Findings
Limited views were done with sterile probe cover to assess fluid
position during attempted pericardialcentesis.
PERICARDIUM: Large pericardial effusion. RV diastolic collapse,
c/w impaired fillling/tamponade physiology.
Conclusions
There is a large pericardial effusion. There is right
ventricular diastolic collapse, consistent with impaired
fillling/tamponade physiology.
Electronically signed by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2105-2-18**] 17:47
Post-op echo [**2105-2-20**]
Conclusions
Overall left ventricular systolic function is normal (LVEF>55%).
A bileaflet aortic valve prosthesis is present. There is a
moderate sized pericardial effusion. The effusion is echo dense,
consistent with blood, inflammation or other cellular elements.
There are no echocardiographic signs of tamponade. No right
ventricular diastolic collapse is seen.
Compared with the findings of the prior study (images reviewed)
of [**2105-2-18**], the pericardial effusion is smaller, now with
signs of consolidation; no evidence of cardiac tamponade.
Brief Hospital Course:
Mr [**Known lastname **] was admitted on [**2105-2-18**] and taken to the Operating Room
for evacuation of large pericardaicl effusion. See operative
note for details. POst operatively he was transferred to the
CVICU intubated and sedated for hemodynamic and ventilator
management. He awoke neurologically intact and was extubated. He
was tarnsferred from the ICU to the step down unit on POD#1. His
couamdin was resumed for anticoagulation of mechanical aortic
valve. His statin, betablocker and diuretic were also resumed.
He was evaluated by physical therpay for strength and
conditioning and was claered for discharge to home on POD#3.
Medications on Admission:
1. Simvastatin 40'
2. Aspirin 81'
3. Acetaminophen 325-650/PRN
4. Hydromorphone 2-4 mg/Q4H/PRN
6. Warfarin 5QD: **dose will change daily for goal INR 2.5-3.5,
7. Potassium Chloride 20 Q12H (every 12 hours) x5 days.
8. Ranitidine HCl 150'
9. Docusate Sodium 100"
10. Metoprolol Tartrate 25"
11. Furosemide 40"
Discharge Medications:
1. Simvastatin 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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 5 days.
Disp:*20 Capsule(s)* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 10 days.
Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 10
days.
Disp:*20 Tablet(s)* Refills:*0*
10. Coumadin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day:
take 5mg on [**2-22**] then as directed by Dr. [**Last Name (STitle) 83780**].
Disp:*60 Tablet(s)* Refills:*2*
11. Outpatient Lab Work
INR check on [**2105-2-22**] and call results to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4129**] NP
[**Telephone/Fax (1) 170**]
AFTER [**2105-2-22**] INR check and call results to Dr. [**Last Name (STitle) 80724**]
[**Telephone/Fax (1) 8226**]; Fax [**Telephone/Fax (1) 83781**]
Discharge Disposition:
Home With Service
Facility:
VNA of Southern [**State 1727**]
Discharge Diagnosis:
Complete Heart Block(PPM)
Postop DVT in LUE [**2104-3-12**] following lead extraction
Hyperlipidemia
s/p Dual chamber pacemaker placement in [**2087**]
s/p replacement of PM generator [**2096**]
s/p Lead extraction and reimplantation of PPM [**3-/2104**]
Hernia repair as child
Past Surgical History: [**2105-2-3**]
1. Ascending aortic replacement with 28-mm Gelweave graft
under deep hypothermic circulatory arrest.
2. Aortic valve replacement, 25-mm St. [**Hospital 923**] Medical Regent
mechanical valve.
3. Coronary artery bypass grafting x1 of the left internal
mammary artery graft to left anterior descending.
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your 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:
Recommended Follow-up:
Surgeon Dr. [**Last Name (STitle) **] [**2105-3-12**] at 1pm [**Telephone/Fax (1) 170**]
Please call to schedule appointments:
Primary Care Dr. [**Last Name (STitle) 28272**] [**Telephone/Fax (1) 83777**] in [**12-13**] weeks
Cardiologist Dr. [**Last Name (STitle) 80724**] in [**12-13**] weeks.
Dr. [**Last Name (STitle) 80724**] will follow your coumadin starting monday [**2105-2-23**].
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Completed by:[**2105-2-21**]
|
[
"423.3",
"V64.1",
"423.9",
"458.29",
"V45.01",
"V12.51",
"272.4",
"790.92",
"V43.3",
"E879.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.12"
] |
icd9pcs
|
[
[
[]
]
] |
6726, 6789
|
4253, 4895
|
390, 427
|
7451, 7547
|
1805, 4230
|
8028, 8588
|
1146, 1164
|
5255, 6703
|
6810, 7089
|
4921, 5232
|
7571, 8005
|
7112, 7430
|
1179, 1786
|
239, 352
|
455, 572
|
594, 942
|
958, 1130
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,247
| 149,738
|
33304+57843
|
Discharge summary
|
report+addendum
|
Admission Date: [**2163-8-6**] Discharge Date: [**2163-8-24**]
Date of Birth: [**2114-1-16**] Sex: M
Service: SURGERY
Allergies:
Iodine / IV Dye, Iodine Containing Contrast Media / Penicillins
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Fevers, increased abdominal pain, tachycardia
Major Surgical or Invasive Procedure:
[**2163-8-6**]: Exploratory laparotomy, washout, splenectomy,
gastrotomy repair, transgastric jejunostomy.
[**2163-8-16**]: Paracentesis
History of Present Illness:
Pt is 49 y/o M with h/o severe necrotizing alcoholic
pancreatitis on TPN for chronic pancreatitis who presents from
OSH with worsening abdominal pain. Pt initially presented to
OSH one week ago with fevers and abdominal pain. Blood cxs did
grow enterobacter as well as streptococcus and pt was started on
broad
spectrum abx for this. The source for the bacteremia has
remained unclear. Pt did have normal HIDA scan. Pt developed
acute worsening of his abd pain with tachycardia and hypotension
to 90s. Pt was subsequently transferred to [**Hospital1 18**] for further
management.
Past Medical History:
severe necrotizing alcoholic pancreatitis, chronic alcoholic
pancreatitis, possible 1.7 cm IPMN at uncinate process, splenic
vein thrombosis, CBD stricture s/p ERCP with stent placement
[**6-/2163**], malnutrition, depression, anxiety, GERD, [**Doctor Last Name 15532**]
esophagus, DM, spine stenosis
Social History:
History of alcohol abuse, marijuana abuse, cocaine use,
benzodiazepine abuse, 50 pack-year smoker
Family History:
Denies family history of gastrointestinal disorders and cancers.
Denies family history of other cancers.
Physical Exam:
On Admission:
T: 95.9 P: 113 BP: 107/73 RR: 18 O2sat: 97% 2L
General: cachectic, lethargic
HEENT: NCAT, EOMI, no scleral icterus
Heart: RRR, NMRG
Lungs: clear
Abdomen: moderate diffuse tenderness with rebound tenderness and
guarding, nonrigid
Extrem: no edema
On Discharge:
VS:
GEN: Cachetic in NAD, AAO x 3
CV: RRR, no m/r/g
Lungs: Diminished breath sounds bilateraly on bases L > R
Abd: Midline incision open to air with steri strip and c/d/i.
LUQ JP drain to bulb suction, site c/d/i. J-tube - site intact.
Extr: warm, thin, no c/c/e
Pertinent Results:
[**2163-8-24**] 04:29AM BLOOD WBC-16.0* RBC-3.07* Hgb-9.2* Hct-27.2*
MCV-89 MCH-29.9 MCHC-33.7 RDW-14.8 Plt Ct-940*
[**2163-8-24**] 04:29AM BLOOD Glucose-154* UreaN-22* Creat-0.7 Na-137
K-4.1 Cl-96 HCO3-33* AnGap-12
[**2163-8-19**] 11:46AM BLOOD ALT-12 AST-13 AlkPhos-78 TotBili-0.2
[**2163-8-24**] 04:29AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.9
[**2163-8-22**] 04:14AM BLOOD PREALBUMIN-Test
[**2163-8-14**] 10:00AM OTHER BODY FLUID Amylase-[**Numeric Identifier 77311**]
[**2163-8-16**] 02:00PM ASCITES Amylase-37
[**2163-8-6**] 6:30 pm TISSUE Site: SPLEEN INFECTED SPLEEN.
**FINAL REPORT [**2163-8-19**]**
GRAM STAIN (Final [**2163-8-7**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2163-8-10**]):
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2163-8-8**]
8:35AM.
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
ENTEROBACTER CLOACAE. SPARSE GROWTH.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. SPARSE GROWTH.
GRAM NEGATIVE ROD #2. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC CULTURE (Final [**2163-8-10**]): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Final [**2163-8-19**]): NO FUNGUS ISOLATED.
[**2163-8-16**] 2:00 pm PERITONEAL FLUID
**FINAL REPORT [**2163-8-22**]**
GRAM STAIN (Final [**2163-8-16**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2163-8-19**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2163-8-22**]): NO GROWTH.
[**2163-8-14**] 9:25 pm BLOOD CULTURE
**FINAL REPORT [**2163-8-20**]**
Blood Culture, Routine (Final [**2163-8-20**]): NO GROWTH
[**2163-8-6**]: [**Last Name (un) **] ABD:
IMPRESSION:
1. Patent portal vasculature.
2. Gallbladder sludge and stones with negative Son[**Name (NI) 493**]
[**Name2 (NI) 515**] sign.
3. Left lower quadrant ascites and possibly complex fluid
adjacent to the
liver which could be due to hemorrhage or infection.
4. Portal venous gas better seen on recent CT.
5. Bilateral pleural effusions.
6. Multiple splenic infarctions as stated in the provided
history, although given elevated white blood cell count,
infection is not excluded
[**2163-8-15**] ABD CT:
IMPRESSION:
1. Remaining head and body of the pancreas continues to enhance.
The tail is not well visualized; however, the pancreatic tail
was not well seen the
outside hospital MRI and CT of [**2163-6-7**], either.
Calcifications
throughout the remaining pancreas are consistent with history of
chronic
pancreatitis.
2. Moderate amount of intraperitoneal free fluid, stable since
[**2163-8-6**]. Thin, curvilinear configuration of fluid in the
post-splenectomy site; is unclear whether this is an actual
separate fluid collection or in
continuity with the free fluid within the abdomen. It measures
simple fluid density and could represent a small post-operative
seroma versus ascites tracking into the post-splenectomy site.
Percutaneous abdominal drain ending in the left upper quadrant
ends inferiorly to the above described fluid.
3. Small amount of retroperitoneal fluid, likely related to
diffuse anasarca, without a discrete fluid collection.
4. Moderate-sized bilateral pleural effusions with adjacent
compressive
atelectasis, stable.
5. Biliary stent and percutaneous GJ tube are in place.
6. Cholelithiasis.
[**2163-8-19**] CT HEAD:
IMPRESSION:
Normal study. Consider MRI if there is continued clinical
concern and not
otherwise contraindicated.
[**2163-8-20**] EEG:
IMPRESSION: This tracing did not reveal any paroxysmal
epileptiform
activity. While there were a few bursts of theta activity, it
probably
represents drowsiness. The patient did appear to be excessively
drowsy
throughout most of the record. There is also prominent beta
activity
which may be a normal variant or secondary to medication. No
clear
focal activity identified.
Brief Hospital Course:
Pt presented from OSH [**2163-8-6**]. It was evident that the pt had
peritonitis and was developing sepsis. Given the pt's positive
blood cultures at the OSH, there was concern for an
intra-abdominal infectious etiology for the pt's peritonitis.
Pt was subsequently taken to the OR for an exploratory
laparotomy where it was revealed that the pt had a splenic
abscess that had ruptured. Pt subsequently underwent a
splenectomy, repair of gastrotomy, and GJ tube placement which
the pt did tolerate. [**Name (NI) **], pt remained intubated
and required pressors for hypotension and continued to have
volume resuscitation in the SICU. On post-op day 1, pt was able
to be weaned off pressors and urine output did improve. Pt was
able to be extubated on post-op day 2 and was started on trophic
tube feeds through his GJ tube. Pt remained in the SICU for
further monitoring of his respiratory status and was transferred
to the floor on post-op day 5.
The patient arrived on the floor NPO, on TPN, Tube feeds, and
antibiotics, with a foley catheter, and Dilaudid PCA for pain
control. The patient was hemodynamically stable.
Neuro: The patient received Dilaudid PCA with good effect and
adequate pain control. When tolerating oral intake, the patient
was transitioned to oral pain medications.
Delirium: Postoperatively the patient has had waxing and [**Doctor Last Name 688**]
periods of lucidity and confusion. He has usually not been
oriented and unable to have normal conversation. On POD # 8,
patient was found to be more agitated than at baseline, he was
given one dose of Olanzapine and started on Haldol. Psychiatry
was consulted on POD # 10 and they recommended standing doses of
Haldol and continue trazodone and sertraline (home meds). The
patient's delirium continued to deteriorate. On POD # 13, the
patient was found less responsive, with gibberish speech, and
able participate in limited neurological exam only. Haldol was
held and Neurology consult was called. The patient underwent
head CT, which was grossly normal. Haldol and other psych meds
were held per Neurology recommendation. The patient underwent 24
hrs EEG, which was negative for acute seizure activity. Since
Haldol was stopped, patient's mental status gradually returned
to his baseline. He remained stable from neurological standpoint
until discharge.
CV: The patient was required Neo-Synephrine drip postoperatively
to maintain MAP > 60. The drip was discontinued on POD # 2, the
patient remained stable from a cardiovascular standpoint; vital
signs were routinely monitored.
Pulmonary: The patient was extubated on POD # 2, he was found to
have bilateral pulmonary effusions on POD # 3, which were
secondary to multiple transfusions and aggressive fluid
resuscitation. The patient was given Lasix IV to diureses and IS
was encouraged. The patient eventually was weaned form
supplemental O2, and his pulmonary function remained stable.
Good pulmonary toilet, early ambulation and incentive
spirrometry were encouraged throughout hospitalization.
GI: Post-operatively, the patient was continued on TPN, tube
feed was started on POD # 2. The tube feed was advanced to goal
and TPN was discontinued on POD # 5. The patient's diet was
advanced to clear liquids on POD # 5. JP's amylase was sent on
POD # 7 and was high ([**Numeric Identifier 77311**]), diet was changed back to NPO.
Diet was advanced to clears on POD # 14 and was well tolerated.
Diet progressively was advanced to regular on POD # 17, the tube
feed was started to cycle. Patient's intake and output were
closely monitored, electrolytes were routinely followed, and
repleted when necessary.
GU: The patient's urine output was closely monitored in the
immediate post-operative period. The patient was able to
successfully void without issue after Foley catheter was
removed.
ID: The patient underwent 10 days treatment with IV Cipro and
Flagyl for his peritonitis. Surveillance blood and urine
cultures were negative. The patient's white blood count and
fever curves were closely watched. The WBC downwarded
postoperatively from 53 to 16. Wound was evaluated daily and no
signs or symptoms of infection were noticed.
Endocrine: The patient's blood glucose was closely monitored
with Q6 hour glucose checks. Blood glucose levels greater than
120 mg/dL were addressed with an insulin sliding scale. The
Endocrinology service was helping to manage the patient's
insulin requirements and their recommendations were followed.
Hematology: The patient received 6 units of RBC and 3 units of
plasma intraoperatively. Postop complete blood count was
examined routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diabetic diet and tubefeed, ambulating, voiding without
assistance, and pain was well controlled. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
The patient was discharged in long term care facility for
convalescent care less than 30 days.
Medications on Admission:
1. sertraline 50 mg daily
2. trazodone 100 mg qHS prn insomnia
3. fentanyl 25 mcg/hr Patch q72hr
4. nicotine 21 mg/24 hr Patch daily
5. Pancrelipase 5000 5,000-17,000 -27,000 unit Capsule daily
6. insulin aspart sliding scale
7. omeprazole 20 mg [**Hospital1 **]
Discharge Medications:
1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for sleep.
3. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every
eight (8) hours as needed for pain.
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
7. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
8. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Eight
(8) units Subcutaneous at bedtime.
9. insulin lispro 100 unit/mL Insulin Pen Sig: 2-6 units
Subcutaneous before meals and bedtime: please follow sliding
scale instructions.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 931**] House Nursing & Rehabilitation Center - [**Location (un) 932**]
Discharge Diagnosis:
1. Peritonitis secondary to ruptured infected spleen.
2. Necrotizing pancreatitis
3. Delirium
4. Diabetes
5. Bilateral pleural effusions
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires bystand assistance.
Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-10**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain.
Call the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
.
G-tube care:
*Please flush with 30 cc of tap water Q4H.
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Wash the area gently with warm, soapy water or 1/2 strength
hydrogen peroxide followed by saline rinse, pat dry, and place a
drain sponge. Change daily and as needed.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**Telephone/Fax (1) 2998**] Date/Time:[**2163-9-7**]
12:45 [**Location (un) 620**] Office, [**Street Address(2) 3001**], [**Location (un) 620**], [**Numeric Identifier 3002**]
.
Please follow up with Dr. [**Last Name (STitle) 55233**] (PCP) in [**2-3**] weeks after
discharge
Completed by:[**2163-8-24**] Name: [**Known lastname 12532**],[**Known firstname **] Unit No: [**Numeric Identifier 12533**]
Admission Date: [**2163-8-6**] Discharge Date: [**2163-8-24**]
Date of Birth: [**2114-1-16**] Sex: M
Service: SURGERY
Allergies:
Iodine / IV Dye, Iodine Containing Contrast Media / Penicillins
Attending:[**First Name3 (LF) 2674**]
Addendum:
Addendum to final diagnosis:
Splenectomy induced thrombocytosis.
Post op, the patient's PLT count was continued to rise. He was
started on 325 mg of Aspirin PO when PLT count reach [**Numeric Identifier 12534**].
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 2332**] House Nursing & Rehabilitation Center - [**Location (un) 2333**]
[**First Name11 (Name Pattern1) 801**] [**Last Name (NamePattern4) 2675**] MD [**MD Number(1) 2676**]
Completed by:[**2163-8-24**]
|
[
"289.59",
"567.9",
"303.90",
"250.02",
"238.71",
"452",
"995.91",
"038.9",
"511.9",
"577.1",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"41.5",
"99.15",
"96.6",
"54.91",
"46.39",
"44.69"
] |
icd9pcs
|
[
[
[]
]
] |
18136, 18412
|
7650, 12913
|
368, 509
|
14502, 14502
|
2267, 7108
|
17105, 17910
|
1582, 1689
|
13227, 14184
|
14342, 14481
|
12939, 13204
|
17927, 18113
|
14669, 15250
|
15265, 17082
|
1704, 1704
|
1983, 2248
|
283, 330
|
537, 1125
|
7117, 7627
|
1718, 1969
|
14517, 14645
|
1147, 1450
|
1466, 1566
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,258
| 133,098
|
36202
|
Discharge summary
|
report
|
Admission Date: [**2156-2-17**] Discharge Date: [**2156-2-25**]
Date of Birth: [**2088-1-13**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamide Antibiotics) / Adhesive Bandages
Attending:[**First Name3 (LF) 3645**]
Chief Complaint:
Leg pain and weakness
Major Surgical or Invasive Procedure:
Lumbar decompression L2-3.
History of Present Illness:
I had the pleasure of seeing this patient for evaluation and
treatment of his left leg lower extremity weakness. He has a
history of right-sided back pain that goes to his right hip;
however, he has developed significant hip flexure weakness as
well as quadriceps reflex with an inability to go upstairs.
This started approximately started two months ago. He has been
checked with labs and CPK, which was normal. Her PSA and Lyme
titer were within normal limits. He is now using a walker. He
has basically no pain. He is quite limited in terms of his
ambulation. He has a significant history of diabetes. He has a
history of spina bifida and pseudomeningocele repair of
fibrolipomas. This was back in [**2090**]. He has a crush injury to
his toes. He has a history of chronic infections of his left
lower extremity.
Past Medical History:
Diabetes
spina bifida and pseudomeningocele
Chronic history of infections
CAD
Social History:
Currently working as lawyer. Non [**Name2 (NI) 1818**]. Denies EtOH and IVDU
Family History:
N/A
Physical Exam:
On physical examination, this is an alert and oriented male
whose affect is within normal limits. He is quite pleasant.
Cardiac RRR, no M/R/G. Pulm CTA/B. Abdomen is soft, non
tender. He walks with a limp on the left side. His hip
flexures are [**3-18**] at most. His quadriceps are [**3-18**]. He has no
quadriceps reflex on the left side. No clonus. He has no pain
with internal rotation of hips. Negative straight leg raise.
His calves are soft. He has
previous surgery on his left foot. No active ongoing infection
noted at this point.
Pertinent Results:
[**2156-2-17**] 11:32PM BLOOD WBC-7.5 RBC-3.68* Hgb-10.5*# Hct-30.0*#
MCV-82 MCH-28.7 MCHC-35.1* RDW-14.5 Plt Ct-210
[**2156-2-18**] 03:49AM BLOOD WBC-10.1 RBC-3.99* Hgb-11.2* Hct-32.4*
MCV-81* MCH-28.1 MCHC-34.6 RDW-14.7 Plt Ct-254
[**2156-2-19**] 01:58AM BLOOD WBC-9.6 RBC-3.51* Hgb-10.2* Hct-29.1*
MCV-83 MCH-29.1 MCHC-35.1* RDW-14.6 Plt Ct-192
[**2156-2-20**] 01:47AM BLOOD WBC-9.1 RBC-3.38* Hgb-9.7* Hct-27.9*
MCV-83 MCH-28.8 MCHC-34.8 RDW-14.4 Plt Ct-182
[**2156-2-21**] 02:08AM BLOOD WBC-9.1 RBC-3.33* Hgb-9.7* Hct-27.5*
MCV-83 MCH-29.2 MCHC-35.4* RDW-14.1 Plt Ct-237
[**2156-2-22**] 01:44AM BLOOD WBC-8.0 RBC-3.45* Hgb-9.6* Hct-28.1*
MCV-82 MCH-27.8 MCHC-34.1 RDW-14.0 Plt Ct-280
[**2156-2-23**] 04:59AM BLOOD WBC-7.3 RBC-3.76* Hgb-10.6* Hct-31.2*
MCV-83 MCH-28.1 MCHC-33.8 RDW-13.9 Plt Ct-315
[**2156-2-24**] 05:28AM BLOOD Hct-28.8*
[**2156-2-18**] 07:32PM BLOOD Mg-2.2
[**2156-2-19**] 01:58AM BLOOD Calcium-8.1* Phos-3.4 Mg-2.1
[**2156-2-20**] 01:47AM BLOOD Calcium-8.3* Phos-3.7 Mg-2.0
[**2156-2-21**] 02:08AM BLOOD Calcium-8.4 Phos-2.6* Mg-1.7
[**2156-2-22**] 01:44AM BLOOD Calcium-8.7 Phos-2.4* Mg-1.9
[**2156-2-22**] 08:13AM BLOOD Mg-2.0
[**2156-2-23**] 04:59AM BLOOD Calcium-8.9 Phos-3.5 Mg-2.0
[**2156-2-18**] 6:21 pm MRSA SCREEN Site: NARIS (NARE)
Source: Nasal swab.
**FINAL REPORT [**2156-2-22**]**
MRSA SCREEN (Final [**2156-2-22**]): No MRSA isolated.
[**2156-2-23**] 1:35 pm MRSA SCREEN Source: Nasal swab.
MRSA SCREEN (Pending):
Brief Hospital Course:
Mr. [**Known lastname 82076**] was evaluated in clinic with Dr. [**Last Name (STitle) 1352**]. After
discussion of risks and benifits, Mr. [**Known lastname 82076**] signed concents for
elective revision lumbar decompression. He was identified in
the holding area and questions were answered. He was brought
back to the OR. During his procedure, a dural leak occured.
The leak was repaired intraop and a lumbar drain was placed.
Mr. [**Known lastname 82076**] was brought to the PACU and remained intubated
overnight. He was then transfed to the TSICU for observation
and maintainence of his lumbar drain. Mr. [**Known lastname 82076**] was extubated
in the TSICU, the drain remained in place. He had two MRSA
nasopharynx swabs while in the TSICU. The first performed on
[**2156-2-18**] was negative, [**2156-2-23**] was still pending at time of
discharge. The rest of his TSICU course was unremarkable. He
was transfered to the general floor. His pain was controlled
with narcotic medication. He began work with physical therapy
who ultimately recommended discharge to rehab. However, Mr.
[**Known lastname 82076**] rejected rehad and desired discharge home with services.
He ultimately when home with services. Another MRSA swab was
performed on the day of discharge as per Mr. [**Known lastname 82077**] request.
Results were still pending at time of discharge.
Medications on Admission:
Actos
Metformin
Metoprolol
Rosuvastatin
Oxycodone
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Pioglitazone 45 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-16**]
Drops Ophthalmic PRN (as needed).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. OxyContin 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO twice a day as needed for
pain.
Disp:*30 Tablet Sustained Release 12 hr(s)* Refills:*0*
8. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 82078**] Home Health and Hospice
Discharge Diagnosis:
1. Lumbar stenosis L2-L3.
2. Left lower extremity weakness, in particular quadriceps and
hip flexor weakness.
Discharge Condition:
Stable
Discharge Instructions:
Please keep incision clean and dry. You may shower in 48 hours,
but please do not soak the incision. Change the dressing daily
with clean dry gauze. If you notice drainage or redness around
the incision, or if you have a fever greater than 100.5, please
call the office at [**Telephone/Fax (1) **]. Please resume all home
mediciation as prescribed by your primary care physician. [**Name10 (NameIs) **]
have been given additional medication to control pain. Please
allow 72 hours for refills of this medication. Please plan
accordingly. You can either have this prescription mailed to
your home or you may pick this up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in prescriptions for
narcotics to the pharmacy. If you have questions concerning
activity, please refer to the activity sheet.
Physical Therapy:
Activity as tolerated
Treatments Frequency:
Change dressing daily. Please inspect for signs of infection
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1352**] on [**2156-3-18**] at 08.00am. If
you have any questions, please feel free to call [**Telephone/Fax (1) **].
Completed by:[**2156-2-25**]
|
[
"741.90",
"414.01",
"250.00",
"349.31",
"443.9",
"518.5",
"724.02",
"276.8",
"349.2",
"V58.67",
"278.01",
"293.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.59",
"96.71",
"03.09",
"03.51",
"03.90"
] |
icd9pcs
|
[
[
[]
]
] |
5841, 5916
|
3564, 4944
|
338, 367
|
6070, 6079
|
2030, 3541
|
7090, 7287
|
1438, 1443
|
5044, 5818
|
5937, 6049
|
4970, 5021
|
6103, 6942
|
1458, 2011
|
6960, 6982
|
7004, 7067
|
277, 300
|
395, 1225
|
1247, 1326
|
1342, 1422
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,380
| 197,428
|
52341
|
Discharge summary
|
report
|
Admission Date: [**2109-6-3**] Discharge Date: [**2109-6-14**]
Service: MEDICINE
Allergies:
Morphine Sulfate / Lipitor
Attending:[**First Name3 (LF) 10842**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is an 84M h/o CAD, s/p CAGB, h/o VT s/p ICD, ablation,
CHF (EF=20%), with recent hospitalization for decompensated HF
from [**2030-5-16**] after presenting with similar complaints of
shortness of breath and fatigue. His BNP was elevated at >
6000. His chest xray did not show significant pulmonary edema
or evidence of infiltrates. He had a negative CTA to exclude
pulmonary embolism. He had a TTE which showed increasing mitral
and tricuspid regurtitation with increased dilation of the left
ventricle. He had three sets of negative cardiac enzymes. He was
continued on his home dose of lasix 40 mg two times a day,
carvedilol, and lisinopril. He was also started on
spironolactone. The patient reports feeling significantly
improved prior to discharge, without shortness of breath with
exerction and resolution of lower extremity of edema. During
that hospitalization the patient also had an EGD showing
multiple gastric errions with a recent dx of HPylori. Patient
was discharged on flagyl, doxycycline, bismuth and omeprazole.
.
Since discharge, the patient has felt increased fatigue and
worsened dysnpnea on exertion. He also complains of a dialy
cough, producing a clear mucous, but no fever or chills.
Endorses symptoms of LE and scrotal edema, abdominal distension,
and lack of appetite. Has experienced PND, but no change in his
2 pillow orthopnea. While patient was walking [**1-23**] miles daily 3
miles earlier, now unable to walk one city block. He denies
chest pain, palpitations, or lightheadedness. He has had no
change in his medications since discharge, and has taken them
reguarly.
.
Patient was seen in Dr. [**Last Name (STitle) 108210**] office on day of admission,
and was reffered to [**Hospital1 18**] ED for evaluation. In the [**Name (NI) **], pt had
a temperature of 97.2, HR 86, BP 93/60 and was 100% on RA. He
was given 40mg IV lasix and admitted for further manegement.
Past Medical History:
-CAD s/p anterolateral MI & CABG x 3 in '[**84**]
-PCI & Multiple cardiac caths
-CHF with EF of 20%
-VT s/p ICD placement in '[**99**] for sustained VT
-HTN
-Hyperlipidemia.
.
Percutaneous coronary intervention: Multiple cardiac caths
- [**2105-9-23**]: Patent SVG->PDA; RCA, SVG-OM and SVG-LAD were known
occluded. No intervention
- [**2105-8-23**]: 1. Three vessel coronary artery disease. 2. Distolic
dysfunction. 3. Cypher stent was placed in the ostium of RCA
SVG graft which was 95% occluded. c/b ventricular fibrillation
in which his ICD administered shocks did not convert him & he
required external defibrillation.
- [**2101-10-23**]: Successful rotational atherectomy and PTCA of the
upper and lower pole OM1.
- [**2101-8-23**]: three stents were placed in the mid OM1, the
proximal
OM1, and the upper pole of OM1 with good residual flow. The
saphenous vein graft to the PDA was diffusely diseased with 90%
touchdown stenosis and PTCA & stent of this vessel was performed
with good residual flow afterwards.
Pacemaker/ICD, placed in [**2099**] after having monophasic V-tach.
Recent device check [**5-/2108**] with no sustained arrhythmias.
Social History:
SOCIAL and FAMILY HISTORY:
- Lives with his wife, has 2 children, spends 4mo a year in
[**State 108**]
- Used to work as a state policeman
- Enjoys playing golf, works approx 2miles daily
- Denies tobacco or illicit drug use. Reports rare alcohol use.
Family History:
Father with "heart disease"; Mother with CHF
Physical Exam:
vs: HR 68 BP 98/47 O2 100% on RA
Gen: WDWN elderly male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP at mandible
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No r/g. No thrills, lifts. No S3 or S4. ?soft
[**2-27**] blowing systolic murmur heart best at LSB
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. slight crackles at base
L > R.
Abd: soft, non-tender, + FW w/ mild distention, no HSM.
Ext: No c/c. 2+ LE EDEMA to knees.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
[**2109-6-3**] 01:25PM BLOOD WBC-7.2 RBC-5.29 Hgb-14.6 Hct-46.9 MCV-89
MCH-27.7 MCHC-31.3 RDW-14.7 Plt Ct-159
[**2109-6-3**] 01:25PM BLOOD Glucose-167* UreaN-41* Creat-1.8* Na-134
K-3.8 Cl-101 HCO3-20* AnGap-17
[**2109-6-3**] 01:25PM BLOOD CK(CPK)-122
[**2109-6-3**] 01:25PM BLOOD cTropnT-<0.01
[**2109-6-3**] 01:25PM BLOOD CK-MB-7 proBNP-4321*
[**2109-6-3**] 01:25PM BLOOD CK(CPK)-122
SINGLE AP UPRIGHT RADIOGRAPH OF THE CHEST: The right
costophrenic angle is excluded from the field of view. There is
severe cardiomegaly, unchanged. The pulmonary vasculature is
within normal limits without evidence of volume overload. There
is no pleural effusion. There are no focal pulmonary opacities.
There is no pneumothorax.
Unchanged single-lead left-sided cardiac pacer with ventricular
lead in unchanged position. Median sternotomy wires and
mediastinal surgical clips are also unchanged since prior study.
IMPRESSION: No acute cardiopulmonary process.
Percutaneous coronary intervention: Multiple cardiac caths
- [**2105-9-23**]: Patent SVG->PDA; RCA, SVG-OM and SVG-LAD were known
occluded. No intervention
- [**2105-8-23**]: 1. Three vessel coronary artery disease. 2. Distolic
dysfunction. 3. Cypher stent was placed in the ostium of RCA
SVG graft which was 95% occluded. c/b ventricular fibrillation
in which his ICD administered shocks did not convert him & he
required external defibrillation.
- [**2101-10-23**]: Successful rotational atherectomy and PTCA of the
upper and lower pole OM1.
- [**2101-8-23**]: three stents were placed in the mid OM1, the
proximal
OM1, and the upper pole of OM1 with good residual flow. The
saphenous vein graft to the PDA was diffusely diseased with 90%
touchdown stenosis and PTCA & stent of this vessel was performed
with good residual flow afterwards.
Pacemaker/ICD, placed in [**2099**] after having monophasic V-tach.
Recent device check [**5-/2108**] with no sustained arrhythmias.
CT Abd - [**2109-5-17**] - IMPRESSION: Marked injected intravenous
contrast reflux into the IVC and hepatic veins indicating
right-sided cardiac insufficiency. Abdominopelvic ascites could
be related to third- spacing from cardiac dysfunction. No other
abdominopelvic acute pathology is identified.
CTA Chest - [**2109-5-18**] - 1. Negative examination for pulmonary
embolism.
2. Cardiomegaly, pulmonary arterial hypertension and probable
right heart failure.
3. No pericardial or pleural effusion.
4. Limited examination, however, an element of air trapping in
the lung bases which might indicate an airway abnormality.
LLE Leni - [**2109-5-17**] - No evidence of DVT in the left lower
extremity.
ECHO - [**2109-5-18**] - The left atrium is markedly dilated. The right
atrium is markedly dilated. Left ventricular wall thicknesses
are normal. The left ventricular cavity is severely dilated.
Overall left ventricular systolic function is severely depressed
(LVEF= 20 %). The estimated cardiac index is depressed (0.93
L/min/m2). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). There is no
ventricular septal defect. The right ventricular cavity is
dilated with depressed free wall contractility. The aortic arch
is mildly dilated. There are focal calcifications in the aortic
arch. 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 mitral valve leaflets do not
fully coapt. Moderate to severe (3+) mitral regurgitation is
seen. The left ventricular inflow pattern suggests a restrictive
filling abnormality, with elevated left atrial pressure. The
tricuspid valve leaflets are mildly thickened. The supporting
structures of the tricuspid valve are thickened/fibrotic. Severe
[4+] tricuspid regurgitation is seen. There is no pericardial
effusion. Compared with the findings of the prior study (images
reviewed) of [**2109-1-4**], the mitral and tricuspid
regurgitation are further increased, and the left ventricle is
more dilated.
Brief Hospital Course:
A/P Pt is an 84 year old male with a history of coronary artery
disease, ventricular tachycardia and systolic heart failure who
presents with one month of worsening dyspnea on exertion.
# Acute on Chronic Systolic Heart Failure: The patient's
complaints are all consistent with fluid overload, with LE
edema, PND, abdominal discomfort, fatigue, and worsening DOE.
Patient with known poor LV fxn, with EF of 20% and sev TR/MR.
CXR however, does not show marked evidence of pulmonary edema.
BNP of 4500 at presentation. LE per patient already improved to
IV lasix received in ED. Without evidence of hypoxia, may be
simply RH Failure or combination of both.
.
He was diuresed on the regular cardiac floor but unfortunately
became hypotensive. Additionally he had some runs of NSVT on the
floor, for which the electrophysiology service was consulted.
For hypotension, he was transferred to the CCU to start a
milrinone drip. By that time he had already diuresed two liters
off for length of stay. Beta-blockade was continued with
carvedilol 6.25 PO BID, and ACEi was captopril at 18.75 mg PO
TID by the time of transfer back to the floor. Additionally he
was put on a 1500 cc/day fluid restriction. He was 7 liters
negative for length of stay.
.
# Acute Renal Failure: Baseline creatinine of 1.0, last
discharged with rising Cr, at 1.7, 1.8 at presentation. The
patient's creatinine was elevated at arrival at 1.8 and rose
steadily; all things considered, it appeared that his acute
renal failure was most likely secondary to poor forward flow in
the setting of his heart failure. No history of receiving
contrast to explain pump. Noted that patient has dark urine even
with lasix and hyaline casts on UA. His creatinine improved as
diuresis continued, supporting the theory that poor forward flow
was the issue, and his renal function was improving at the time
of transfer from the CCU. A renal ultrasound on the [**1-4**]
showed a small right kidney "raising the question of renal
artery stenosis" but otherwise with no evidence of obstruction
or other pathology.
.
# Epigastric pain: Patient was diagnosed with erosive gastritis,
was guaic positive, and had recent diagnosis of h.pylori. He
has completed bismuth, flagyl, tetracycline regimen today.
However, initial complaints of lack of appetite and bloating
more secondary to right-sided heart failure vs. H.pylori
medication. He had no evidence of acute biliary pathology on
exam and his clinical course did not suggest any evolving
issues.
.
# Coronary Artery Disease: Patient with pronounced history of
CAD. No complaints of chest pain. The team did not feel that
this event was related to new ischemic event. He had one set of
cardiac enzymes in ED and no evidence of ischemia on EKG.
Aspirin was continued, as were beta blocker and ACEi as
tolerated, as above.
.
# Ventricular Tachycardia: The patient has a history of VT and
is s/p AICD placement. Frequent PVCs noted on exam. He had some
runs of NSVT for which EP was consulted on the floor.
.
# Hyperlipidemia: continue on colesevelam. Prior adverse rxn to
statin.
.
# Anxiety: cont outpatient ativan and trazadone for sleep
.
# Full Code
Medications on Admission:
Pantoprazole 40 mg Tablet, Delayed Release (E.C.) PO Q12H
Carvedilol 6.25 mg Tablet PO twice a day.
Colesevelam 625 mg PO BID
Aspirin 81 mg PO DAILY
Lorazepam 0.5 mg Tablet PO TID as needed.
Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension 15-30
MLs PO QID as needed
Spironolactone 25 mg 0.5 Tablet PO DAILY
Furosemide 40 mg PO BID (Please hold every third day).
Enalapril Maleate 10 mg PO daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
3. Colesevelam 625 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
5. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
10. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as
needed for insomnia.
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis:
Acute on chronic decompensated systolic heart failure
Ventricular tachycardia
Acute Renal Failure
Secondary Diagnosis:
CAD
Hypotension
Dyslipidemia
Discharge Condition:
Stable
Discharge Instructions:
You are being discharged from the hospital after admission for
exacerbation of your heart failure with acute renal failure.
Part of your hospitalization was in the intensive care unit in
order to have medications to support your blood pressure while
undergoing diuresis. You had 16 liters of fluid removed, and
have improved renal function. You should continue to your
medication everyday, and weigh yourself every morning. You
should call Dr. [**Last Name (STitle) 1147**] if weight increases > 3 lbs than your
discharge weight.
Please note that your enalapril was changed to lisinopril. Also
note that your spironolactone and lasix doses were increased.
You were also started on a medication for your heart failure
called digoxin.
You have an appointment scheduled with Dr.[**Name (NI) 3536**] Advanced
Heart Failure clinic as well as with Dr. [**Last Name (STitle) 1147**]. We are
setting up physical therapy to come an continue to work with you
at home.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500cc
If you develop worsening shortness of breath, swelling in your
legs, lightheadedness, palpitaitons, chest pain, or any other
concernng symptoms, call your PCP or go to the emergency room.
Followup Instructions:
You have an appointment scheduled with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **]
Advanced Heart Failure Clinic on [**6-24**] at 2:30pm in the [**Hospital Ward Name 23**]
Building [**Location (un) **] [**Hospital1 18**] [**Hospital Ward Name 516**].
You also have an appointment with Dr. [**Last Name (STitle) 1147**] on [**6-27**] at 2:30 pm
in his [**Location (un) 4628**] office.
|
[
"427.1",
"V45.02",
"428.0",
"535.50",
"584.9",
"272.4",
"458.9",
"V45.81",
"300.00",
"414.01",
"428.23"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13318, 13376
|
8602, 11761
|
254, 261
|
13588, 13597
|
4492, 8579
|
14852, 15269
|
3684, 3731
|
12215, 13295
|
13397, 13397
|
11787, 12192
|
13621, 14829
|
3746, 4473
|
195, 216
|
291, 2220
|
13536, 13567
|
13416, 13515
|
2242, 3397
|
3413, 3424
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,317
| 137,433
|
37799
|
Discharge summary
|
report
|
Admission Date: [**2177-10-29**] Discharge Date: [**2177-11-5**]
Date of Birth: [**2133-6-26**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
Distal pancreatectomy and splenectomy
History of Present Illness:
44 year-old male presented as transfer from OSH. He had
recently been admitted to [**Hospital **] for recurrent
pancreatitis. He had a known pseudocyst in his pancreatic tail
that had been followed for some time. The patient was
discharged the day before, and on the day of presentation had
sudden onset of LUQ pain that radiated to his left shoulder. He
denied nausea, vomiting, fever, or chills. He went to [**Hospital **], where his hematocrit was found to be 24 (hematocrit on
[**10-28**] was 33). He was hypotensive to 90's systolic at [**Hospital **]. The CT scan showed possible hemoperitoneum. He was
transferred to [**Hospital1 18**] for further evaluation. At the time of
admission, his pain was slightly improved from what it had been
earlier in the day.
Past Medical History:
HTN, ETOH abuse
Social History:
ETOH abuse - hasn't had a drink in a month but is known to have
[**7-30**] ounces of hard ETOH/night, no tobacco.
Family History:
non-contributory
Physical Exam:
VS: T 99.4, HR 120, BP 96/64, RR 18, 96%2L
GEN: NAD, A&O x 3
LUNGS: Clear B/L
CV: sinus tach, nl s1 and s2
ABD: soft, TTP diffusely with guarding and some rebound, no
hernias, no masses
EXT: no c/c/e
RECTAL: Guaiac positive
Pertinent Results:
[**2177-10-29**] 09:09PM WBC-11.1* RBC-2.50* HGB-7.9* HCT-24.2* MCV-97
MCH-31.5 MCHC-32.4 RDW-14.4
[**2177-10-29**] 09:09PM ALT(SGPT)-27 AST(SGOT)-23 ALK PHOS-70 TOT
BILI-0.8
[**2177-10-29**] 09:09PM LIPASE-90*
[**2177-10-29**] 09:09PM GLUCOSE-119* UREA N-13 CREAT-0.6 SODIUM-137
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-27 ANION GAP-11
[**2177-10-29**] 09:09PM PT-13.7* PTT-24.4 INR(PT)-1.2*
Brief Hospital Course:
The patient was admitted to the ICU, where he was transfused
with packed red blood cells and followed with serial
hematocrits. He was taken to the angiography suite, where
several major branches of the splenic artery were embolized
before going to the operating room. The splenic artery itself
was not completely embolized, but this stopped the majority of
the bleeding from the spleen. In the operating room he
underwent an exploratory laparotomy, distal pancreatectomy,
splenectomy, and finally placement of 2 [**Doctor Last Name 406**] drains. Good
hemostasis was obtained, estimated blood loss 1500 ml. No
complications were reported.
On post-operative day #1 he was transfered from the ICU to the
floor. His diet was advanced over several days, his Foley
discontinued. He continued to have pain post-operatively, but
this improved over the course of his stay, responding to pain
medications. His JP drains decreased in output, draining
sanguinous fluid. He was discharged to home on [**2177-11-5**],
post-operative day #6, with drains in place, instructions to
empty the drains three times daily, recording amounts. He was
instructed to schedule a followup appointment with Dr. [**Last Name (STitle) **] the
following week.
Medications on Admission:
Iron supplements
Discharge Medications:
1. Hydromorphone 4 mg Tablet Sig: 0.5 - 1 Tablet PO every four
(4) hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Take while on narcotics.
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Bleeding pancreatic pseudocyst
Discharge Condition:
Good
Discharge Instructions:
[**Name8 (MD) **] MD if: increased redness, swelling or drainage from
incisions, fever greater than 101.5 degrees, pain not relieved
by pain medication, persistant nausea and vomiting.
You may not shower with drains in place. Do not immerse wound
in water for 4 weeks.
Do not drive while taking narcotics. Avoid strenuous activity
for 4 weeks and do not lift greater than 10 pounds for 2 weeks.
J/P drains: Empty J/P bulbs at least 3 times a day and return
to suction following emptying. Measure the amount of fluid in
each bulb and record the amount for each date. Bring this
information to your follow-up appointment. Keep J/P area dry.
Followup Instructions:
You should call to schedule an appointment with Dr. [**Last Name (STitle) **] for
next Tuesday to have your staples removed. Call [**Telephone/Fax (1) 2359**] to
make an appointment.
|
[
"458.9",
"289.59",
"577.2",
"285.1",
"568.81",
"303.92",
"577.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"52.52",
"54.19",
"39.79",
"41.5"
] |
icd9pcs
|
[
[
[]
]
] |
3623, 3679
|
2060, 3302
|
330, 369
|
3753, 3759
|
1636, 2037
|
4455, 4641
|
1358, 1376
|
3369, 3600
|
3700, 3732
|
3328, 3346
|
3783, 4432
|
1391, 1617
|
276, 292
|
397, 1171
|
1193, 1210
|
1226, 1342
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,054
| 142,399
|
20052
|
Discharge summary
|
report
|
Admission Date: [**2174-1-3**] Discharge Date: [**2174-1-12**]
Date of Birth: [**2148-3-17**] Sex: M
Service:
CHIEF COMPLAINT: [**Known firstname 21258**] [**Known lastname 53988**] was an inpatient under
the care of Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **] of the General Surgery
Purple Service. Chief complaint is esophageal perforation.
HISTORY OF PRESENT ILLNESS: The patient is a 25-year-old man
with a prior medical history of acolasia who received a
laparoscopic hilar myotomy five days prior to admission. He
did well postoperatively with some mild complaints of pain
which was well controlled with narcotics until earlier on the
day of admission when he began having sharp severe abdominal
pain radiating to his back and chest bilaterally.
He complains of chills and nausea. He reports only a small
amount of flatus and diarrhea. He had been tolerating a
normal soft diet until the night prior to admission. He has
no dysuria. The pain that he describes is constant, severe,
sharp, and not relieved by anything.
PAST MEDICAL HISTORY: Acolasia.
PAST SURGICAL HISTORY: Laparoscopic [**Doctor Last Name **] myotomy on
[**2173-12-29**].
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Roxicet as needed.
SOCIAL HISTORY: He smokes half a pack of cigarettes per day
with occasional alcohol use.
PHYSICAL EXAMINATION ON PRESENTATION: His temperature was
94.6, his heart rate was 65, his blood pressure was 135/78,
and his oxygen saturation was 100% on room air. He was
somewhat lethargic with clammy and cool extremities. He was
anicteric. His lungs were clear to auscultation bilaterally
with some subcutaneous emphysema noted in the upper chest and
neck region. His heart was regular rate and rhythm first
heart sounds and second heart sounds. His abdomen was soft
and nondistended but was diffusely tender with no guarding.
His incisions were clean, dry, and intact. His extremities
were well perfused with 2+ dorsalis pedis pulses.
BRIEF SUMMARY OF HOSPITAL COURSE: The concern for an
esophageal perforation following his esophageal surgery was
immediately noted, and the patient was taken upstairs to
Radiology for an emergent upper gastrointestinal contrast
swallowing study to identify suspected leak. The upper
gastrointestinal swallow study with gastrografin did in
fact,demonstrate a leak in the area of the gastroesophageal
junction. The patient
was taken straight to the operating room.
The patient was made nothing by mouth and given intravenous
fluid resuscitation and intravenous antibiotics. He had a Foley
catheter
placed and was consented for this procedure. Please refer to the
dictated Operative Report by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from
[**2174-1-3**].
In brief, a laparoscopic examination of the previous
operative field was performed and a inflamed stomach with
evidence of a leak from the stomach was apparent. At that
point, the surgery was converted to an open procedure.
Inspection of the of the operative field once the surgery was
converted to open revealed approximately a 3-mm perforation
which was closed with interrupted vicryl sutures. In
addition to the sutures, a partial wrap (Dor plication) was
performed of the fundus to help cover the area of esophageal
leak. Finally, a
gastrostomy tube and feeding jejunostomy were placed. Two
[**Location (un) 1661**]- [**Location (un) 1662**] drains were placed in
the region of the esophageal tear.
The patient tolerated the procedure extremely well and was
transferred to the Postanesthesia Care Unit and to the
Intensive Care Unit without complications.
On postoperative day one, after overnight Intensive Care Unit
monitoring, the patient was transferred to the floor in
relatively good condition.
Despite the severity of the patient's disease, his
postoperative course was relatively unremarkable. He was fed
with total parenteral nutrition in the first few days
following surgery and eventually with tube feeds via his
jejunostomy tube. On postoperative days three and four,
respectively, a methylene blue study and an upper
gastrointestinal series revealed showed no evidence of a leak
from the esophagus through the repaired esophageal tear.
On postoperative day five, the patient was started on sips of
clear liquids which he tolerated well. He was slowly
advanced to full liquids and to a soft solid diet which he
tolerated without nausea, vomiting, or abdominal pain.
The only complication during the patient's postoperative
course was a temperature to 101.8 on postoperative day five.
At that time, his cultures were sent and his central venous
line was changed over a wire. On postoperative day nine, the
patient was tolerating a soft solid diet. He had been
afebrile for several days and was without any abdominal pain.
DISCHARGE STATUS: The patient was discharged to home.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE DIAGNOSES: (His discharge diagnoses were as
follows)
1. Esophageal acolasia; status post [**Doctor Last Name **] myotomy.
2. Esophageal perforation/esophageal leak; status post
repair of esophageal leak on [**1-3**].
3. Status post gastrostomy tube placement on [**1-3**].
4. Status post feeding jejunostomy tube placement on
[**1-3**].
5. Hyperalimentation.
6. Central venous line placement.
7. Central venous line exchange.
MEDICATIONS ON DISCHARGE: (He was sent home with the
following discharge medications)
1. Prevacid 30 mg by mouth once per day.
2. Roxicet one to two teaspoons q.4-6h. as needed (for
pain).
3. Colace 100 mg by mouth twice per day as needed (for
constipation).
4. Ativan 0.5 mg by mouth four times per day as needed (for
anxiety).
He was taking Replete tube feeds prior to discharge. If he
is unable to sustain himself, he will take have cycled
Replete tube feeds. Please refer to the discharge paperwork
for the specific strength and rate of these tube feeds.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], M.D. [**MD Number(1) 10637**]
Dictated By:[**Last Name (NamePattern1) 1179**]
MEDQUIST36
D: [**2174-1-11**] 12:24
T: [**2174-1-11**] 14:38
JOB#: [**Job Number 53989**]
|
[
"V64.41",
"998.59",
"567.2",
"530.4",
"997.4",
"300.00",
"780.6",
"530.0",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.39",
"43.19",
"99.15",
"96.6",
"44.66"
] |
icd9pcs
|
[
[
[]
]
] |
5002, 5425
|
5452, 6278
|
1271, 1291
|
1139, 1244
|
2065, 4932
|
4947, 4981
|
144, 391
|
420, 1080
|
1104, 1115
|
1308, 2036
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,129
| 183,176
|
35640
|
Discharge summary
|
report
|
Admission Date: [**2160-1-30**] Discharge Date: [**2160-2-14**]
Service: CARDIOTHORACIC
Allergies:
Penicillins / Lopressor / Indocin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Aortic valve replacement(25mm [**Company 1543**] Mosaic Ultra), Tricuspid
repair, Coronary artery bypass graft times one (LIMA to LAD),
Left atrial ligation [**2160-2-6**]
History of Present Illness:
Mr. [**Known lastname **] is an 84 year old gentleman with a history of
multiple admissions for congestive heart failure exascerbations.
On his most recent admission for this complaint, he underwent a
cardiac catheterization which revealed 70% stenosis of the left
anterior descending artery. He was transferred to [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**]
[**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for evaluation for cardiac surgery
Past Medical History:
severe aortic stenosis
mitral stenosis
coronary artery disease
chronic atrial fibrillation
ascending aortic aneurysm
chronic diastolic congestive heart failure
carotid artery disease
hyperlipidemia
eczema
peripheral vascular disease
duodenal ulcer 30 yrs ago
s/p TURP
Social History:
Mr. [**Known lastname **] lives alone and is retired.
Family History:
His cardiac family health history is unremarkable.
Physical Exam:
On admission Mr. [**Known lastname **] was found to be well nourished.
Multiple bruises were noted on his arms, as was eczema. His
neck was supple with a full range of motion. His lungs were
clear to auscultation bilaterally. A IV/VI holosystolic cardiac
murmur was ausculated. His abdomen was soft, non-tender,
non-distended. 1+ edema was noted and his extremities were
noted to be warm. No varicosities were noted, however there
were bilateral venous stasis ulcers. He was awake, alert, and
oriented times three.
Pertinent Results:
[**2160-2-6**] ECHO
Prebypass
1. The left atrial appendage emptying velocity is depressed
(<0.2m/s). A definite thrombus is seen in the left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
2. There is mild regional left ventricular systolic dysfunction
with hypokinesia of the apex, apical and mid portions of the
inferior and inferoseptal walls.. Overall left ventricular
systolic function is mildly depressed (LVEF= 45 %).
3.Right ventricular chamber size and free wall motion are
normal.
4.The ascending aorta is moderately dilated.
5. There are simple atheroma in the descending thoracic aorta.
6.The aortic valve leaflets are severely thickened/deformed.
There is moderate to severe aortic valve stenosis (area
0.8-1.0cm2). Trace aortic regurgitation is seen.
7. The mitral valve leaflets are moderately thickened. There is
mild valvular mitral stenosis (area 1.5-2.0cm2). Moderate (2+)
mitral regurgitation is seen.
8. The tricuspid valve leaflets are mildly thickened. Severe
[4+] tricuspid regurgitation is seen. Dr. [**Last Name (STitle) 914**] was notified
in person of the results on [**2160-2-6**] at 1030am..
POST-BYPASS: The patient is AV paced and on infusions of
phenylephrine, milrinone and epinephrine.
1. Biventricular function is unchanged.
2. The aorta is intact post decannulation.
3. The aortic valve has been replaced with a tissue valve. The
valve appears well seated and the leaflets move well. There is
no AR. The peak gradient is approximately 20mmHg at a CO of 5
L/m.
4. The opening of the mitral valve leaflets has slightly
improved. The MR is now mild.
5. An annuloplasty ring has been placed around the tricuspid
valve. There is trivial regurgitation.
6. The left atrial appendage has been resected.
The remainder of the examination is unchanged.
Brief Hospital Course:
Upon admission, Mr. [**Known lastname **] was was seen by podiatry for his
extensive bilateral caluses, which they debrided. The dental
service saw him and cleared him for surgery. Carotid ultrasound
was performed and revealed an occluded left internal carotid and
60-69% stenosis of the right internal carotid. Vascular surgery
was consulted given his risk of stroke during bypass with his
carotid disease. The suggested that no carotid endartarectomy
is indicated currently, but they recommended coumadin after
surgery. Vein mapping was performed. A chest radiograph
demonstrated multiple asbestos plaques, so it was followed by a
chest CT. This second study showed stable fusiform ascending
aorta dilation and mediastinal lymphadenopathy from a study on
[**9-28**]. Thoracic surgery recommended continued follow-up as an
outpatient with the patient's pulmonologist. Endocrinology was
consulted for an elevated TSH, which discourage adding synthroid
at this point. Dermatology was consulted for his extensive
eczema and a steroid cream was recommended. He was also seen by
psychiatry for suicidality, and they felt he was not depressed
or suicidal and continued to follow Mr. [**Known lastname **] throughout his
hospitalization.
Incidentally, pt seen by dermatology for chronic eczemtous
dermatitis. Also had biopsy of forhead lesion which tuned out to
be atypical spindle cell neoplasm which warrents further follow
up.
On [**2160-2-6**] he was taken to the operating room and underwent an
aortic valve replacement(25mm [**Company 1543**] Mosaic Ultra), tricuspid
repair, coronary artery bypass graft times one (LIMA to LAD),
left atrial ligation. This procedure was performed by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**]. He tolerated the procedure well and was
transferred intubated in critical but stable condition to the
surgical intensive care unit on Milrinone, amiodarone,
epinephrine, levophed, insulin, propofol.
POD#1 extubated and weaned from pressors and inotropes.
POD# 2 amiodarone stopped due to bradycardia. Electrophysiology
consulted for possible pacer placement. Permanent pacer was
placed on [**2-11**] for ongoing bradycardia -idioventricular rhythm
20-30's off amiodarone.
Decision made by Dr. [**Last Name (STitle) 914**] not to anticoagulate Mr. [**Known lastname **]
due to fakk risk benefit profile.
Chest tubes and pacing wires removed on [**2159-2-11**] after permanent
pacer placed.
Post operatively Mr. [**Known lastname **] [**Last Name (Titles) **] rose to 2.5 from
baseline of 1.2. Nephrology was consulted. Causation thought to
be ATN from hypoprofusion/hypotension. Nephrotoxins were
eliminated and over time creat imporved - presently 1.4-1.6.
Diuresis was resumed after [**Last Name (Titles) **] recovered.
Mr. [**Known lastname **] transferred from the ICU on POD#6 and continued to
make slow and study progress. He was evaluated by Physical
therapy and rehab was recommended.
Medications on Admission:
diltiazem 480mg, lasix 80mg in am and 40mg in pm, aspirin 325mg,
antivert 25mg, digoxin 0.25 every other day, celebrex 200mg,
betamethasone topically as needed for eczema, lipitor 20mg,
serax 15mg, potassium chloride 40meq
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Fluocinolone 0.01 % Solution Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
9. Ammonium Lactate 12 % Liquid Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
10. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
11. Urea 20 % Cream Sig: One (1) Topical [**Hospital1 **] (2 times a day).
12. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day) for 7 days.
13. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
15. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig:
One (1) Inhalation [**Hospital1 **] (2 times a day).
16. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): home med regimen 80mg qam/40mg qpm- totrate accordingly
based on edma and renal function.
17. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily) for 7 days: the decrease to 200mg daily .
18. humalog insulin
per sliding scale fingersticks
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
severe aortic stenosis
mitral stenosis
coronary artery disease
chronic atrial fibrillation
ascending aortic aneurysm
chronic diastolic congestive heart failure
carotid artery disease
hyperlipidemia
eczema
peripheral vascular disease
duodenal ulcer 30 yrs ago
s/p TURP
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**] in 4 weeks ([**Telephone/Fax (1) 11763**] please call for
appointment
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 34547**] in 1 week (cardiologist) please call for
appointment
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6160**] in [**12-25**] weeks ([**Telephone/Fax (1) 81092**] please call for
appointment
Dr. [**Last Name (STitle) **] (podiatry @ [**Hospital1 18**])
Repeat TFTs in 2 months with follow-up by primary care provider.
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2160-2-14**]
|
[
"424.2",
"216.3",
"443.9",
"433.10",
"V58.66",
"272.4",
"398.91",
"396.0",
"414.01",
"692.9",
"441.2",
"427.31",
"584.5",
"427.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.72",
"36.15",
"35.21",
"37.99",
"86.11",
"37.33",
"39.61",
"35.14",
"37.83"
] |
icd9pcs
|
[
[
[]
]
] |
8731, 8798
|
3787, 6755
|
254, 428
|
9110, 9117
|
1953, 3764
|
9629, 10319
|
1345, 1397
|
7028, 8708
|
8819, 9089
|
6781, 7005
|
9141, 9606
|
1412, 1934
|
207, 216
|
456, 966
|
988, 1258
|
1274, 1329
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,247
| 145,564
|
13192
|
Discharge summary
|
report
|
Admission Date: [**2108-5-6**] Discharge Date: [**2108-5-20**]
Date of Birth: [**2029-5-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
VF arrest.
Major Surgical or Invasive Procedure:
1. ICD placement ([**2108-5-17**])
History of Present Illness:
Mr. [**Known lastname 40230**] is a 78 year-old male with a history of SSS s/p PPM,
multiple myeloma c/b CRI, who presented today in Vfib arrest. Pt
was at home surrounded by family today at 2:30pm when he was
found to suddenly lose consciousness and his eyes rolled into
his head. Per family report, he initially had a weak pulse but
was not breathing. CPR was initiated by a family member
approximately 4 minutes into the course. EMS was called who
arrived 5-6 mins later and found patient to be in v-fib arrest.
He was administered one 360J shock ~10 minutes from initial
episode and his paced rhythmn was restored (BP 148/80 in field).
He was intubated in the field and brought into [**Hospital1 18**].
In the ED, initial VS were: HR 68, BP 112/70, RR23, 100% on
vent. He was given ASA 600mg PR x1, Hep gtt bolus, and Plavix
600mg OG x1. He was also given 1L NS and transferred to the cath
lab for urgent cath.
Past Medical History:
1. SSS/2nd degree AV block s/p St. [**Male First Name (un) 923**] Identity ADx pacer in
[**2106**]
2. Multiple Myeloma - initially dx'ed in [**2105**] on BM bx, free
lambda light chain variant. Initially tx'ed with Thalidomide and
cyclical high-dose dexamethasone in the past; now on Dex qweek
and Thalidomide daily.
3. Nephrotic Syndrome/CRI d/t MM (baseline Cr 3.4)
4. DMII
5. HTN
6. Hyperlipidemia
Social History:
Unable to obtain due to being sedated/unresponsive.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: T 97.4 BP 128/72 HR 68 (v-paced) RR 16 O2: 100% on vent
Vent settings: 550x12, PEEP 5, 100% Fi02
Gen: Elderly male; unresponsive to tactile or aural stimulation
or sternal rub.
HEENT: NCAT. Sclera anicteric. Eyes roving horizontally without
fixing gaze. Pupils reactive to light stimulation; 2mm-> 1mm
bilaterally. Conjunctiva were pink, no pallor or cyanosis of the
oral mucosa.
Neck: Supple with JVP of 7 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB anteriorly.
Abd: Soft. No HSM.
Ext: No c/c/e. No spontaneous movements seen, but retracts
somewhat non-purposefully to painful stimuli. Normal bulk and
tone.
NEURO: Downgoing toes bilaterally. Corneal and gag reflexes
present. Pupillary reflex present. Not able to cooperate with
rest of neurologic exam.
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:
ADMIT LABS: [**2108-5-6**]
CBC:
WBC-7.2 RBC-3.75* Hgb-11.5* Hct-35.2* MCV-94 MCH-30.6 MCHC-32.6
RDW-18.7* Plt Ct-241
COAGS:
PT-12.4 PTT-30.6 INR(PT)-1.1
CHEMISTRIES:
Glucose-164* UreaN-60* Creat-3.4* Na-139 K-5.1 Cl-110* HCO3-20*
AnGap-14
Calcium-7.8* Phos-5.6* Mg-1.8
LFTS:
ALT-58* AST-88* LD(LDH)-287* CK(CPK)-95 AlkPhos-61 TotBili-0.2
Albumin-2.8*
CARDIAC ENZYMES:
[**2108-5-6**] 03:25PM CK-MB-NotDone cTropnT-0.06*
[**2108-5-6**] 07:04PM CK-MB-NotDone cTropnT-0.11*
[**2108-5-7**] 04:47AM cTropnT-0.13*
MISC:
[**2108-5-7**] 04:47AM Cortsol-8.0
CXR ([**2108-5-7**]):
Endotracheal tube placement as described. Evidence for
development of mild pulmonary vascular congestion.
CT HEAD ([**2108-5-7**]):
No evidence of intracranial hemorrhage or acute major vascular
territorial infarction.MRI would be more sensitive for acute
ischemia.
CARDIAC CATH ([**2108-5-7**]):
1. Selective coronary angiography of this right dominant system
revealed
no evidence of acute thrombus or flow-limiting coronary artery
disease.
The LMCA was free of critical stenoses. The LAD had a 30% lesion
in the
mid-vessel and 50% stenosis in the D1 branch. The LCx was widely
patent.
The RCA had a 30% lesion in the mid-vessel.
2. Limited views were obtained in an effort to conserved IV dye
given
(30cc) the patient's history of multiple myeloma and chronic
renal
insufficiency.
3. Resting hemodynamics revealed moderately elevated right and
left
heart filling pressures with a mean RA of 14mmHg and mean PCWP
of
21mmHg. The cardiac index was preserved at 3.0 l/min/m2. There
was
systemic arterial hypertension with an aortic SBP of 155mmHg.
4. Left ventriculography was deferred.
FINAL DIAGNOSIS:
1. Vfib arrest
2. Coronary arteries without acute thrombus or flow limiting
disease
3. Moderate diastolic biventricular dysfunction.
ECHO ([**2108-5-8**]):
The left atrium is mildly dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is moderately dilated.
The basal inferolateral wall may be akinetic/hypokinetic but is
not well visualized. Views are technically
suboptimal for assessment of left ventricular function but
global LV systolic function appears grossly preserved. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen in suboptimal views. The mitral valve
leaflets are mildly thickened. No mitral regurgitation is seen
in suboptimal views. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
Brief Hospital Course:
1. s/p VF arrest:
Patient had a witnessed syncopal event, found to be in VF arrest
by EMS and shocked with 360J x1; after shock, was in paced
rhythm with no recurrant episodes of vfib thereafter. Regarding
etiology, there was no clear precipitant as cardiac cath showed
no suspect lesions and while his Troponin was elevated, his
CK-MB was not and his renal disease may confound the utility of
troponin. The echo showed no obvious structural cause.
Electrolytes found within normal limits and while the QRS was
mildly long, it was not felt to be causitive.
On the evening of admission, the patient was started on Artic
Sun cooling x24 hours. While being rewarmed his blood pressure
was transiently low (into 60s systolic) requiring levophed for a
short time ([**Date range (1) 4479**] AM).
He was extubated on [**5-9**], uneventfully and did well from a
respiratory standpoint thereafer. Neurology followed and felt
that his initial exam was re-assuring (intact pupillary, gag and
corneal with movement of BL lower extremities). His neurologic
exam improved throughout his course.
On [**5-17**], an ICD was added to the patient's existing pacemaker
(his ventricular lead was removed and replaced with a pacing/ICD
wire leaving him with 2 wires).
2. Coronary artery disease:
No significant coronary disease was seen on cath to explain VF
arrest. Continued on aspirin, statin and beta-blocker.
3. Pump:
Echo performed was a suboptimal study, but the LV function
appeared normal.
4. Diminshed level of consciousness
As above, neurologic status on arrival with brainstem reflexes
intact (pupillary, gag, corneal) was reassuring. Head CT
negative for bleed, CVA, edema or herniation. Two days after
admission, he was awake (while intubated) and had tracking eye
movements. He was not initially following commands. He quickly
improved over the next days and was alert and oriented to
person, place but did not know the date at the time of
discharge. Follow-up with behavioral neurology was scheduled.
5. Acute on chronic kidney disease:
Underlying renal disease felt to be secondary to amyloidosis and
light chain disease in setting of multiple myeloma. Presented
above baseline of 3.0, at 3.8. This improved after resucitation
and IVF, but worsened (up to 4.4) after hypotensive episode.
Renal was consulted and saw many muddy brown casts, indicitive
of ATN. He had only recieved 30cc of dye at cath, so this was
not felt to be a contributor. He was oliguric for one day (UO
~500cc), but thereafter made good urine. His creatinine
continued to improve and was 3.4 on discharge.
6. Multiple Myeloma:
Discussed with outpt oncologist Dr. [**Last Name (STitle) **] who believed his MM is
in remission. Last BM biopsy [**2108-4-30**] which did not show evidence
of MM. Controlled on weekly Dexamethasone and daily Thalidomide
which were held during the admission.
8. Hyperlipidemia and hypertension: Continued statin;
metoprolol was held during hypotensive episode, but restarted
thereafter.
9. Diabetes: Held antihypoglycemics and covered with sliding
scale insulin.
10. Anemia: Hematocrit 35.2 on admission and trended down
during stay. Partly a component of daily phlebotomy. Did have
OB positive OG output and was placed on IV PPI for a time; this
was transitioned to PO PPI.
Medications on Admission:
Lipitor 20 mg daily
Glipizide 2.5mg daily
Lasix 40 mg q MWF
Allopurinol 300 mg daily
Toprol XL 25 daily
ASA 81mg 3x/week
Gabapentin 300mg tid
Dexamethasone 40mg qMonday
Thalidomide 100mg qhs
Discharge Medications:
1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Glipizide 2.5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO once a day.
4. Lasix 40 mg Tablet Sig: One (1) Tablet PO three times weekly
(Monday, Wednesday and Friday).
Disp:*12 Tablet(s)* Refills:*2*
5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO every other
day.
Disp:*15 Tablet(s)* Refills:*2*
6. Neurontin 300 mg Capsule Sig: One (1) Capsule PO every other
day.
Disp:*15 Capsule(s)* Refills:*2*
7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
Disp:*12 syringes* Refills:*2*
9. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 5 days.
Disp:*15 Capsule(s)* Refills:*0*
10. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: 1 [**1-24**]
Tablet Sustained Release 24 hr PO once a day: total dose 75 mg.
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary:
1. Ventricular fibrillation arrest s/p ICD placement
2. Acute renal failure
3. Septic thrombophlebitis
Secondary:
1. Sick sinus syndrome s/p pacer placement
2. Multiple myeloma
3. Chronic kidney disease
4. Diabetes mellitus
5. Hypertension
6. Hyperlipidemia
Discharge Condition:
Hemodynamically stable.
Discharge Instructions:
You were admitted after a ventricular fibrillation arrest
(vfib). In an attempt to prevent this from happening again, an
internal defibrilator (ICD) was placed.
.
Your dexamethasone and thalidomide were held this admission - do
not restart these until seeing Dr. [**Last Name (STitle) **] in clinic. your
gabapentin and allopurinol were changed to one pill every other
day due to your worsening kidney function. Your Toprol XL dose
was changed to 150 mg . You are now to take an Iron pill daily
and get injections of Erythpoietin (Epo) as an outpatient to
help bring up your blood count. Otherwise continue to take your
medications as you are already doing.
.
After your ICD placement, you cannot lift heavy objects or raise
your arm above your shoulder for 6-8 weeks and you also may not
drive.
Followup Instructions:
Please follow up in the DEVICE CLINIC on [**2108-5-25**] at 9:00am on
[**Hospital Ward Name 23**] [**Location (un) 436**]. Call [**Telephone/Fax (1) 59**] if you have any questions
regarding this appointment.
Please be sure to follow-up with your primary care physician in
the next 2 weeks.
Dr.[**Name (NI) 31656**] office will call you with an appointment in the next
1-2 weeks. His office was faxed your discharge summary. If you
have any questions, please call [**Telephone/Fax (1) 14525**].
Please call Dr.[**Name (NI) 5452**] office at [**Telephone/Fax (1) 31689**] to arrange a follow
up appointment in 2 weeks. He does not want you to restart your
dexamethasone or Thalidomide until that visit. He has started
you on Epogen [**Numeric Identifier **] units per week to increase your hematocrit.
Behavioral neurology (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]) - [**Telephone/Fax (1) 23810**]. You have an
appointment at 1 PM on [**6-6**]. He is located in [**Doctor First Name 40231**] [**Location (un) 1385**] on the [**Hospital Ward Name **] of [**Hospital1 18**] [**Location (un) 86**]
|
[
"427.41",
"203.00",
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icd9cm
|
[
[
[]
]
] |
[
"37.94",
"37.23",
"96.71",
"89.45",
"38.91",
"88.56",
"96.07",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
10322, 10371
|
5631, 8937
|
324, 361
|
10683, 10709
|
3001, 3357
|
11558, 12691
|
1816, 1898
|
9178, 10299
|
10392, 10662
|
8963, 9155
|
4683, 5608
|
10733, 11535
|
1913, 2982
|
3374, 4666
|
274, 286
|
389, 1307
|
1329, 1731
|
1747, 1800
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,265
| 141,586
|
34494
|
Discharge summary
|
report
|
Admission Date: [**2121-5-7**] Discharge Date: [**2121-5-13**]
Service: MEDICINE
Allergies:
Ace Inhibitors / Sulfa (Sulfonamide Antibiotics) / Fish Product
Derivatives
Attending:[**First Name3 (LF) 1928**]
Chief Complaint:
Fall with hematoma to right side of head
Major Surgical or Invasive Procedure:
None
History of Present Illness:
87 year-old woman with chronic atrial fibrillation on Coumadin,
hypertension, hyperlipidemia, and recent left caudate lobe
infarct who presents after unwitnessed fall and an INR of 20.
Pt sustained two falls today while at home with PT/OT/VNA.
First fall was witnessed with no head trauma or LOC. Second
fall was unwitnessed and caused hematoma to right side of head.
Pt does not recall falling or events immediately preceding fall
(she was using her cane). She denies dizziness, lightheadedness
or aura prior to event. No chest pain, palpitations. She was
able to put the hand to prevent hitting her head. She did not
feel very fatigued afterward, there were no abnormal movements.
She has rugs at home, but does not remember tripping. After
falling, pt's next memory is of daughter taking her to her
primary care doctor, where she was found ot have an elevated INR
and administered 10 mg of PO Vitamin K. Pt denies any changes to
her medications including new antibiotics, changes in Coumadin
dosage, diet, or supplements. She denies any current alcohol or
social event. She denies any fever, chills, diarrhea, nausea,
vomit or other signs of infection. She takes her medications by
herself and knows her Coumadin dose (2.5), but is unable to
mention other medications. She lives in an [**Hospital3 **],
where they do not supervise her in terms of her medications, but
has a VNA. Pt was then transferred to [**Hospital1 18**] ER for further care.
In the ER her initial VS: BP 131/53, HR 83, RR 18, 97.7. On
physical exam she was A&OX3, had a hematoma in the right occiput
and lower lip laceration of 0.5 cm. She had C-collar and had
gross blood in the rectal vault. She had labs that were
significant for INR of 20.2 with PTT of 71.4, HCT of 37.7 at her
baseline. She underwent CT scan of the head and c-spine without
any abnormality and CT scan of abdomen and pelvis without acute
pathology. Patient was T&C and received 2 units of FFP. Her VS
were stable throughout the ER course. She was admitted to the
ICU for hemodynamic monitoring. GI was not called from the ER.
Pt was recently hospitalized at [**Hospital1 18**] on [**2121-3-28**] for right
facial and upper lip angioedema, as well as a recent fall. Pt's
daughter reports she was confused and altered from her baseline
mental status on day prior to admission. Angiogedema improved
significantly with IV solumedrol and H1,H2 blockers. A brain
MRI was obtained due to h/o altered mental status in setting of
fall, and was notable for an acute left caudate head infarct.
MRA of the neck demonstrated a 50% stenosis of the left proximal
internal carotid artery and 50% stenosis in both vertebral
arteries in the V2 segment. The TTE on [**2121-3-31**] was negative for
mural thrombus or cardiac source, but etiology of stroke felt
most likely cardioembolic in setting of subtherapeutic INR. Pt
was discharged in stable condition to rehab. On [**2121-4-12**], pt
returned to [**Hospital1 18**] ED with transient dizziness, R arm and face
weakness. Head CT was negative for bleed, and neuro felt most
her presentation was most likely due to recrudescence of prior
caudate infarct in setting of mild dehydration.
Past Medical History:
- Left Caudate Head infarct
- Angioedema: pruritis and periorbital and lip/tongue edema,
previously intubated in MICU ([**12-16**]), etiology thought to be due
to lisinospril, which was subsequenlty discontinued. Recurrence
in [**3-19**] requiring MICU admission, managed with IV steroids and
H1/H2 blockers, no intubation required.
- Atrial fibrillation on Coumadin
- Hypertension
- Hyperlipidemia
- Osteoporosis
- Osteoarthritis
- S/p right hip replacement
- Eczema
- Hayfever as a child
Social History:
She lives by herself in an [**Hospital3 **] in [**Street Address(2) **] in
[**Location (un) **] MA. She cooks for herself often, has a VNA and home
PT. Denies any current or past history of smoking or illegal
substances. Drinks 1 cup of wine occasionally. Uses a walker.
Family History:
- Cousin with peanut allergy developed in his 80s.
- No family history of asthma or eczema
Physical Exam:
VS: T 98.5, BP 146/61, HR 96, RR 16, O2-sat 91% RA
GENERAL: Elderly-appearing woman in NAD, comfortable,
appropriate
HEENT: Hematoma over R occiput (8 cm aprox in diameter), PERRL,
EOMI, sclerae anicteric, MMM, Dry blood over lower lip, good
range of motion of both eyes.
NECK: Supple, no thyromegaly, no JVD, no carotid bruits
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: PMI non-displaced, irregular rate, no MRG, nl S1-S2
ABDOMEN: NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding.
EXTREMITIES: No edema, 2+ peripheral pulses (radials, DPs)
SKIN: Ecchymosis extending from L forearm to L hand, nontender.
Hyperpigmented lesion about 4mm on left nares.
LYMPH: No cervical, axillary, or inguinal LAD
NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**6-11**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
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:
[**2121-5-7**] 04:33PM BLOOD WBC-11.4*# RBC-4.39 Hgb-12.3 Hct-37.7
MCV-86 MCH-28.1 MCHC-32.7 RDW-12.9 Plt Ct-293
[**2121-5-7**] 04:33PM BLOOD PT-150* PTT-71.4* INR(PT)->20.2*
[**2121-5-8**] 12:07AM BLOOD PT-27.6* PTT-35.2* INR(PT)-2.7*
[**2121-5-7**] 04:33PM BLOOD Glucose-164* UreaN-45* Creat-1.4* Na-142
K-3.9 Cl-103 HCO3-25 AnGap-18
[**2121-5-8**] 12:07AM BLOOD Calcium-9.5 Phos-2.4* Mg-1.6
[**2121-5-8**] 03:41AM BLOOD Albumin-3.7 Calcium-8.5 Phos-2.8 Mg-1.6
[**2121-5-8**] 10:37AM BLOOD PT-18.7* INR(PT)-1.7*
[**2121-5-7**] Radiology CT HEAD W/O CONTRAST
IMPRESSION: No acute intracranial process. Unchanged
encephalomalacia and
lacunar infarcts. Chronic microvascular ischemic disease.
Ethmoidal
opacification.
[**2121-5-7**] Radiology CT C-SPINE W/O CONTRAST
IMPRESSION: No acute cervical fracture or malalignment.
Multilevel degenerative changes. Small bilateral thyroid nodules
which could be further evaluated on ultrasound if not previously
and as clinically arranted.
[**2121-5-7**] Radiology CT TORSO With Contrast:
IMPRESSION:
1. Moderate compression of the L3 superior endplate, of
uncertain chronicity.
Recommend clinical correlation with site tenderness.
2. No evidence of acute visceral injury in the chest, abdomen,
or pelvis.
3. 2-cm anterior left breast subcutaneous lesion, again seen.
Correlation
with mammogram continues to be recommended if not obtained since
prior study.
5. Diverticulosis without diverticulitis.
6. Multinodular thyroid again seen. Continued follow-up per
thyroid
ultrasound ([**2121-3-31**]) recommendation.
[**2121-5-7**] Radiology HAND (AP, LAT & OBLIQUE
IMPRESSION: Degenerative changes, as above. No definite acute
fracture or
dislocation.
Discharge labs:
[**2121-5-13**] 07:12AM BLOOD WBC-10.8 RBC-3.88* Hgb-11.5* Hct-34.2*
MCV-88 MCH-29.7 MCHC-33.6 RDW-12.8 Plt Ct-314
[**2121-5-13**] 07:12AM BLOOD PT-17.7* PTT-25.1 INR(PT)-1.6*
Brief Hospital Course:
87 year-old woman presents after falling down and hitting head,
admitted with GIB and supratherapeutic INR to ICU. INR was >20
and was reversed with Vitamin K and 2 units of FFP. Coumadin
held. HCT was stable so decision was made not to pursue
colonoscopy. Acute renal failure resolved with IVF. The
patient was transferred to the floor in stable condition for
continued monitoring of HCT and INR.
PROBLEM LIST:
#. Supratherapeutic INR: Unclear exactly why INR went so high.
Nutritional deficiency vs less efficient GI absorption of
Vitamin K vs drug-drug interaction causing decreased metabolism
of Coumadin. She was reversed with Vitamin K and FFP and on
discharge her INR was 1.6. After discussion with her primary
care provider, [**Name10 (NameIs) **] decision was made to restart coumadin at a
lower dose of 1.5mg daily and to have VNA check daily INR until
the levels are therapeutic. After that, she may require INR
checks twice a week until stable.
#. Lower GI Bleed: No active bleeding after reversing
anticoagulation. HCT stable Source most likely either
diverticulosis or hemorrhoids bleeding in the setting of high
INR. After discussions with her PMD, she was restarted on
coumadin at a lower dose at 1.5mg daily
#. Atrial fibrillation: Metoprolol dose reduced because of
bradycardia. As above, her anticoagulation was held until
discharge. She will restart coumadin at a lower dose at 1.5mg
daily. She will need f/u regarding her HR and her BP.
#. Falling down / Gait instability: PT consult to determine
recommended level of home supervision
#. Acute Kidney Injury [**3-11**] GIB resulting in hypovolemia.
Resolved with IVF.
#. Hypertension: On Metoprolol. Held Amlodipine. Restart if
needed for BP control
#. Hyperlipidemia: Continue statin
#. Angioedema: Continue Fexofenadine, Famotidine, and Prednisone
#. Thyroid nodules incidentally seen on CT scan: F/u with PCP.
[**Name10 (NameIs) **] [**Name Initial (NameIs) **] thyroid US on previous admission that recommended f/u
imaging in 6 months.
#. CT torso demonstrated breast nodule which should be follow up
with mammography as an outpatient.
#. Nose skin hyperpigmented skin lesion: Outpatient follow up
#. DVT prophylaxis with pneumoboots
#. Code status - DNR/DNI
#. Contact - [**Name (NI) 553**] (daughter) [**Telephone/Fax (1) 79254**]
Medications on Admission:
Amlodipine 10 mg PO Daily
Fexofenadine 60 mg PO BID
Famotidine 20 mg PO BID
Metoprolol 12.5 mg PO BID
Prednisone 5 mg PO Every other day
Simvastatin 20 mg PO Daily
Vitamin D 1000 IU PO Daily
Warfarin 3 mg PO Daily
Oyster calcium 500 mg PO BID
Alendronate 70 mg PO Weekly
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
2. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Prednisone 5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
7. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
8. Coumadin 1 mg Tablet Sig: 1.5 Tablets PO at bedtime.
Disp:*30 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.25 Tablet PO twice a
day.
Disp:*15 Tablet(s)* Refills:*0*
10. Famotidine 20mg [**Hospital1 **]
11. Fexofenadine 60mg [**Hospital1 **]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 100**] Rehab Home Care
Discharge Diagnosis:
PRIMARY DIAGNOSES:
1. Supratherapeutic INR, corrected
2. Lower gastrointestinal bleeding, stopped
3. Atrial fibrillation
4. Anemia from acute blood loss
5. Acute kidney injury, resolved
6. Thyroid nodule
7. Breast nodule
8. Gait instability
SECONDARY DIAGNOSES:
1. Hypertension
2. Hyperlipidemia
3. Angioedema
4. History of left caudate infarct
5. Osteoporosis
6. Osteoarthritis s/p right hip replacement
7. Eczema
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 after falling down and hitting your head. You
were found to have an very elevated INR (>20) which is the
reason you had GI bleeding. CT scans were performed and you did
not have any head or neck fractures. Your INR was corrected
with Vitamin K and transfusion of plasma. Your bleeding stopped
and your blood counts remained stable.
We recommend that you stop taking Coumadin until [**2121-5-13**]. You
should restart Coumadin at a lower dose of 1.5mg daily. You
should restart this tonight. You will need to call your primary
care provider's office at [**Telephone/Fax (1) 79255**] to get follow up
appointmen with your Dr. [**Name (NI) **].
CT scans showed incidental findings of thyroid nodule and breast
nodule. These issues should be addressed with your primary care
physician.
MEDICATION CHANGES:
1. Restart coumadin 1.5mg daily. You will need daily INRs drawn
and these will be faxed to your primary care [**Provider Number 34259**]. DECREASE DOSE of Metoprolol to 6.25mg twice a day (The dose
was decreased because your heart rate was too slow)
3. STOP Amlodipine (This was stopped because your high blood
pressure is not currently requiring this medication to be
controlled)
Followup Instructions:
Name/NP: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Location: [**Hospital1 **] SENIOR HEALTH
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**Telephone/Fax (1) 60246**]
Appt: Tomorrow, [**5-14**] at 1:00pm.
|
[
"995.1",
"781.2",
"427.31",
"241.0",
"401.9",
"272.4",
"V58.61",
"578.9",
"285.1",
"709.9",
"733.00",
"V12.54",
"E934.2",
"793.89",
"715.90",
"E888.9",
"873.43",
"584.9",
"V43.64",
"920"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10927, 10992
|
7455, 7859
|
323, 329
|
11452, 11452
|
5536, 7238
|
12872, 13151
|
4352, 4444
|
10112, 10904
|
11013, 11255
|
9817, 10089
|
11635, 12446
|
7255, 7432
|
4459, 5517
|
11276, 11431
|
12466, 12849
|
243, 285
|
357, 3535
|
7873, 9791
|
11467, 11611
|
3557, 4048
|
4064, 4336
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,579
| 131,928
|
43478
|
Discharge summary
|
report
|
Admission Date: [**2184-10-20**] Discharge Date: [**2184-11-2**]
Date of Birth: [**2128-10-9**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Cryptogenic Cirrhosis with encephalopathy
Major Surgical or Invasive Procedure:
Orthotopic Liver Transplantation
History of Present Illness:
Mr. [**Known lastname **] is a 56yo M w/hx of cryptogenic cirrhosis c/b
encephalopathy, ascites, SBP, on the transplant list, who
presents from clinic with encephalopathy. He was recently
admitted from [**Date range (1) 60609**] for renal failure which improved with
albumin, midodrine and octreotide. He presented to clinic on the
day of admission and was directly admitted for encephalopathy.
Per patient, he has been feeling more confused over the past few
days. However, today he drove himself into the clinic. He denied
any abdominal pain, cough, or fevers/nightsweats. No urinary
symptoms or back pain. He does report feeling chilled for the
past few days.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, 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.
On floor, patient was sleepy but able to converse in complete
sentence, hemodynamically stable. A diagnostic paracentesis was
performed. Patient tolerated it well.
Past Medical History:
- IPMN (Intraductal papillary mucinous neoplasm of the pancreas)
- Cryptogenic cirrhosis dx on biospy [**5-2**] c/b enceophalopathy,
ascites, SBP, on transplant list
- Pulmonary nodules
- HBV
- DM
Social History:
- Married with 4 children
- Works in a chemical company
- Tobacco: Smokes 2 to 3 cigarettes a day for the past 20 years,
quit 5 days ago
- Alcohol: pt states that he has not drank alcohol in 20-30
years
- IVDU: denies
Family History:
- Father died of lung cancer and was a heavy smoker
- Mother died of a CVA
- Sister with chronic renal insufficiency, PVD, and s/p CABG
Physical Exam:
Physical exam on admission:
VS - 95.3 127/71 66 18 98% RA
GENERAL - African-American man, in no acute distress
HEENT - EOMI, icteric, MMM, OP clear
LUNGS - good air movement, diffuse bibasilar crackles
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - +bs, soft, distended, + fluid wave, no
rebound/guarding
EXTREMITIES - WWP, 2+ edema to ankle, 2+ DP
NEURO - awake, A&Ox3, CNs II-XII grossly intact, positive
asterexis
Physical exam on discharge:
Pertinent Results:
1. Labs on admission:
[**2184-10-20**] 12:00PM BLOOD WBC-7.6 RBC-3.16* Hgb-10.1* Hct-30.7*
MCV-97 MCH-32.1* MCHC-33.0 RDW-15.3 Plt Ct-142*
[**2184-10-20**] Neuts-65.1 Lymphs-20.9 Monos-11.2* Eos-2.1 Baso-0.7
[**2184-10-20**] PT-18.7* INR(PT)-1.7*
[**2184-10-20**] UreaN-40* Creat-3.0*# Na-138 K-4.7 Cl-104 HCO3-21*
AnGap-18
[**2184-10-20**] ALT-33 AST-54* AlkPhos-129 TotBili-6.0*
[**2184-10-20**] Albumin-3.5 Calcium-9.6 Phos-3.8# Mg-2.0
.
2. Labs on discharge: [**2184-11-2**]
WBC-8.7 RBC-3.08* Hgb-9.7* Hct-27.6* MCV-90 MCH-31.6 MCHC-35.3*
RDW-16.3* Plt Ct-115*
PT-13.1 PTT-26.8 INR(PT)-1.1
Glucose-109* UreaN-28* Creat-1.4* Na-137 K-4.6 Cl-106 HCO3-27
AnGap-9
ALT-39 AST-31 AlkPhos-121 TotBili-1.7*
Calcium-7.8* Phos-1.7* Mg-2.2
HBsAg-NEGATIVE HBsAb-POSITIVE
BLOOD tacroFK-11.8
<<< >>>
.
3. Imaging/diagnostics:
- Liver/gallbladder ultrasound ([**2184-10-20**]): Cirrhosis, ascites
and splenomegaly. No detectable flow within the portal venous
system. This could be due to slow flow although thrombosis
cannot be excluded. A CT could be obtained for further
evaluation if clinically indicated.
- Abdominal ultrasound ([**2184-10-21**]):The portal veins and splenic
vein are patent and demonstrate reversed flow. The SMV is
patent and demonstrates forward flow.
- CXR ([**2184-10-21**]):Stable lung opacities. No acute cardiopulmonary
findings
Brief Hospital Course:
56 yo M with cryptogenic cirrhosis complicated by
encephalopathy, ascites, SBP, currently on liver transplant
list, admitted from clinic for encephalopathy.
Encephalopathy: Diagnostics paracentesis was negative for SBP.
Patient was placed on lactulose and rifaximin. Abdominal
ultrasound showed no flow in the portal system, which was a
progression since [**2184-9-29**]. Blood and urine cultures were no
growth to date. Mental status improved after bowel movements.
On [**2184-10-21**], he underwent an orthotopic liver transplant. The
donor was a brain-dead, 66-year-old deceased donor who was
hepatitis B surface antigen negative, hepatitis B core antibody
positive, and hepatitis B NAT-positive. He received
intra-operative HBIg 10,000 units and 5000 units daily through
POD 5. He converted to HBSAb positive > 500 after the initial
dose. The HBSAg was negative throughout. He will continue on
HBIg post operatively as an outpatient.
He underwent routine transplant induction immunosuppression with
Solumedrol and Cellcept. The steroid taper is per protocol,
Prograf was started on the evening of POD 1. Levels were
followed daily, dosage was variable. Because his fluconazole was
increased once his kidney function improved, the dose was
slightly lowered prior to discharge and will require close
follow up.
Post operatively, he was transferred to the ICU and was
extubated on post op day 1. He remained in the SICU until POD 5.
The patient was almost 30 kg above his admission weight, urine
output was initially low and his creatinine rose daily to a
maximum of 4.1 on POD 6. Over the rest of the hospitalization
the urine output increased daily and his creatinine came down to
1.4.
He was transferred to the regular surgical floor on POD 5. He
received several doses of Lasix, and his weight, maximum 110 kg
was 98 kg on discharge and he was sent home on [**Hospital1 **] Lasix.
Duplex ultrasounds x 2 demonstrated normal hepatic flow in all
vessels. The medial drain was having large output daily. The
lateral drain was scant and was pulled early in his course. On
POD 11 the medial drain was pulled and site sutured with no
leakage noted.
The patient was ambulating, tolerating regular diet and had
return of bowel function. Mental status had clearly improved,
the patient participated in his mediation teaching sessions.
Medications on Admission:
1. ursodiol 300 mg PO BID
2. nadolol 40 mg PO DAILY
3. ciprofloxacin 250 mg PO Q24H - pt states he was told to take
cipro [**Hospital1 **]
4. insulin sliding scale
5. lactulose 30 gram PO TID - pt is taking this once per day
6. vitamin D oral
7. omeprazole E.C. 40 mg Capsule PO DAILY
8. ferrous sulfate 300 mg (60 mg Iron) PO DAILY
9. lisinopril 2.5 mg PO DAILY
10. clotrimazole Mucous membrane
11. Lasix 20 mg PO DAILY
12. spironolactone 50 mg PO DAILY
Discharge Medications:
1. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
2. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*40 Capsule(s)* Refills:*2*
5. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. insulin glargine 100 unit/mL Solution Sig: One (1) 20
Subcutaneous once a day.
Disp:*2 bottles* Refills:*2*
7. prednisone 5 mg Tablet Sig: Four (4) Tablet PO once a day:
Follow transplant clinic recommended taper of this medication.
8. valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
11. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day.
12. Novolog 100 unit/mL Solution Sig: per sliding scale
Subcutaneous four times a day: Per sliding scale.
13. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours) for 3 days: Then start 2 mg twice a day
starting Friday.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Cryptogenic cirrhosis with encephalopathy s/p Orthotopic liver
transplantation.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call up the transplant office at [**Telephone/Fax (1) 11086**] For fever,
chills, nausea, vomiting, diarrhea, increased abdominal pain,
yellowing of eyes or skin, inability to take or keep down food,
fluids or medications.
You will have labwork drawn every Monday and Thursday to be done
at the [**Hospital **] Medical Office Building Lab on [**Last Name (NamePattern1) **].
No heavy lifting
No driving if taking narcotic pain medication
Take 3 mg twice daily of the Prograf through Thursday evening
and then start taking 2 mg daily on Friday morning.
Weigh yourself daily. If you lose or gain more than 3 pounds in
a day or feel very thirsty or notice your urine output dropping
down, please call the transplant clinic as your lasix may need
to be adjusted.
Followup Instructions:
PHERESIS,BED SIX PHERESIS ROOMS Date/Time:[**2184-11-4**] 7:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2184-11-10**]
10:40
[**Last Name (LF) **],[**First Name3 (LF) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2184-11-10**] 11:30
Labs Monday and Thursdays
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2184-11-5**]
|
[
"584.5",
"572.2",
"789.59",
"572.3",
"155.0",
"250.00",
"571.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.59",
"38.93",
"00.93"
] |
icd9pcs
|
[
[
[]
]
] |
8230, 8287
|
4128, 6467
|
356, 391
|
8411, 8411
|
2745, 2753
|
9353, 9868
|
2114, 2252
|
6975, 8207
|
8308, 8390
|
6493, 6952
|
8562, 9330
|
2267, 2281
|
2726, 2726
|
275, 318
|
3208, 4105
|
1104, 1641
|
419, 1086
|
2767, 3189
|
8426, 8538
|
1663, 1862
|
1878, 2098
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,152
| 183,298
|
3122+55444
|
Discharge summary
|
report+addendum
|
Admission Date: [**2177-3-4**] Discharge Date: [**2177-3-14**]
Date of Birth: [**2106-6-10**] Sex: F
Service: [**Hospital Unit Name 196**]
CHIEF COMPLAINT: Back pain.
HISTORY OF PRESENT ILLNESS: A 70-year-old female with a
history of scleroderma, osteoarthritis, dermatomyositis who
was admitted to an outside hospital back on [**2-24**] with
inability to walk and low back pain, mild fevers, and
questionable stool incontinence in the setting of colchicine.
Was also noted to have a white count of 14,000 and an ESR of
111. The primary medical team at that point was concerned
for epidural abscess, however, the neurological examination
at that time did not clearly demonstrate evidence for
abscess, and MR of the spine was reported negative for
abscess. However, this MR showed L3-L4 cord compression and
was seen by Neurosurgery at the outside hospital, which
commented that they felt that this was a diffuse process and
nonfocal, and recommended following up with Rheumatology.
She was given an empiric course of ceftriaxone and
doxycycline at the outside hospital. She was also scheduled
to get a bone scan, but at that time was found to be in rapid
atrial fibrillation and was sent to the CCU. She was started
on an amiodarone drip for rate control, and was successfully
cardioverted to normal sinus rhythm. She was placed on to
Lovenox 60 mg subQ [**Hospital1 **].
Upon arrival to [**Hospital1 69**], her
vital signs are stable, but unable to provide any reliable
history.
PAST MEDICAL HISTORY:
1. Scleroderma with interstitial lung disease.
2. Raynaud's disorder.
3. Digital calcinosis.
4. Inflammatory arthritis.
5. Dermatomyositis.
6. Osteoarthritis.
7. History of atrial fibrillation/atrial flutter since [**10-21**].
8. Congestive heart failure with intact ejection fraction.
9. Hypothyroidism status post thyroidectomy.
10. Coccydynia status post injection.
11. Gout.
12. Status post left medial meniscus tear.
13. Chronic low back pain status post laminectomy.
ALLERGIES: Hydroxychloroquine.
MEDICATIONS ON TRANSFER:
1. Amiodarone 400 mg po q day.
2. Solu-Medrol 60 mg IV q8h.
3. Vicodin prn.
4. Rocaltrol 0.25 mg po q day.
5. Calcium carbonate 500 mg po tid.
6. Duragesic 50 mcg transdermal patch q72h.
7. Ceftriaxone 2 grams IV q24h.
8. Doxycycline 100 mg po bid.
9. Magnesium oxide 400 mg po bid.
10. Lopressor 25 mg po bid.
11. Protonix 40 mg po q day.
12. Synthroid 175 mcg po q day.
13. Lisinopril 20 mg po q day.
14. Soma 350 mg po tid.
15. Lovenox 50 mg po subQ [**Hospital1 **].
PHYSICAL EXAMINATION: Temperature 98.3, blood pressure
140/54, heart rate of 56, respiratory rate of 20, and 94% on
room air. In general, the patient is sleeping and
comfortable, alert, and oriented to self and place. HEENT:
anicteric sclerae. Extraocular muscles are intact. Pupils
are equal, round, and reactive to light. Neck: No jugular
venous distention and supple. Cardiovascular examination:
S1, S2 with a regular rate, no murmurs, rubs, or gallops.
Lung examination: Scattered crackles throughout the lung
fields, no wheezes. Abdominal examination: Bowel sounds
present, soft, nontender, nondistended, no guarding,
tenderness, or rebound. Extremities: Sclerodactyly with a
swollen left fourth digit. Neurological examination:
Cranial nerves II through XII intact. Intact strength
bilaterally lower extremities. No focal deficits. Back with
positive spinal tenderness at L2-L3.
LABORATORY DATA FROM OUTSIDE HOSPITAL: White count 15.6,
hematocrit 32.0, platelets 357. Sodium 135, potassium 4.7,
chloride 104, CO2 21, creatinine 1.1, digoxin of 1.8, TSH of
1.4. Blood cultures were no growth to date.
HOSPITAL COURSE:
1. Back pain: Patient was noted to be disoriented which was
felt secondary to excessive narcotics. Her narcotics were
discontinued with the resolution in her mental status. A
Neurology consult was obtained for further evaluation of the
questionable L3-L4 cord compression seen at the outside
hospital MRI scan. Repeat MR [**First Name (Titles) 7837**] [**Last Name (Titles) 14796**]
degenerative and postoperative changes most prominent in the
lower lumbar spine as well as impingement on the exiting left
L3 root. There was notable mild disk bulging in the lumbar
spine as well as osseous effusion of the vertebral bodies
with Grade I anterolisthesis of L5 upon S1.
The Neurology Service felt that this compression of L3-L4 was
a chronic process and not consistent with her intact
neurological examination. However, given the hyperreflexia
of the left side, they recommended pursuing brain MRI. This
MRI revealed mild microvascular changes in the cerebral white
matter, but no evidence of recent infarct. The back pain did
not improve throughout her admission. The Chronic Pain
Service was consulted for palliative treatment with steroid
injection.
A sacrococcygeal steroid injection was performed with
improvement of her low back pain approximately 48-72 hours
later with increase in her daily activities and increased
ambulation as well as significant improvement in her Physical
Therapy.
She will be discharged to an acute rehabilitation facility
for further physical therapy sessions and will only have
Tylenol with codeine as her only narcotic which seemed to
minimize her mental status changes.
2. Paroxysmal atrial fibrillation: The patient was admitted
in normal sinus rhythm, however, during her hospital course,
she reverted back to atrial fibrillation with a ventricular
response of approximately 100-150 beats per minute. She was
discontinued on her beta blocker for fear of exacerbation of
her scleroderma, and was placed on maximum dose of diltiazem
CD 360 mg po q day, and the patient converted spontaneously
back to normal sinus rhythm. However, after approximately 72
hours, the patient reverted back to atrial fibrillation.
Flecainide 100 mg po q12h was started, but was not successful
with chemical cardioversion. She was then brought to the
Electrophysiology Laboratory for transesophageal
echocardiogram and electric cardioversion which was
successful, and reverted her to normal sinus rhythm. She
continues on diltiazem CD 360 mg po q day as well as
flecainide 100 mg po q12h. Her Lovenox 60 mg subQ q12h was
continued while she was Coumadin loaded with 5 mg po q hs.
However, it was noted that on the second day of her Coumadin,
she had an INR of 5.4 and her Coumadin was held. She will
need close followup of her INR as the patient is in acute
rehabilitation.
3. Scleroderma: The patient was admitted with IV steroids
for her scleroderma. A Rheumatology consult was obtained for
optimization of her steroids. They recommended following a
hand x-ray to further evaluate the swelling of the left
fourth digit which revealed extensive soft tissue
calcifications, joint space narrowing, sclerosis, and
subluxations in the DIP and PIP joints consistent with
scleroderma.
Her IV steroids were changed to po prednisone and was tapered
10 mg po q day down to her baseline of 10 mg of prednisone po
q day. She is to followup with her rheumatologist once
discharged from her acute rehabilitation facility.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: [**Hospital3 4419**] in [**Location (un) 6251**],
[**State 350**].
FOLLOW-UP INSTRUCTIONS: She was to followup with her primary
care physician and her rheumatologist, as well as her
cardiologist upon discharge to her acute rehab facility.
DISCHARGE MEDICATIONS:
1. Calcitriol 0.25 mcg po q day.
2. Calcium carbonate 500 mg po tid.
3. Amoxil 175 mcg po q day.
4. Tylenol with codeine 1-2 tablets po q6h prn.
5. Diltiazem 360 mg po q day.
6. Flecainide 100 mg po q12h.
7. Prednisone 10 mg po q day.
8. Lisinopril 10 mg po q day.
9. Her Coumadin will be held until her INR is therapeutic
between 2 and 3.
DISCHARGE DIAGNOSES:
1. Scleroderma.
2. Paroxysmal atrial fibrillation.
3. Chronic back pain secondary to spondylolisthesis.
4. Hypothyroidism.
5. Gout.
6. Dermatomyositis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10477**], MD [**MD Number(2) 11775**]
Dictated By:[**Name8 (MD) 5406**]
MEDQUIST36
D: [**2177-3-14**] 02:40
T: [**2177-3-14**] 04:50
JOB#: [**Job Number 14797**]
ADDENDUM: Please note that this clinical summary does not
reflect events subsequent to [**2177-3-14**]. Briefly, Ms. [**Known lastname 14798**]
developed progressive dyspnea requiring MICU transfer on [**2177-3-18**],
with rapid progression to respiratory failure and intubation.
During prolonged MICU stay, pt. was determined to have diffuse
alveolar hemorrhage; scleroderma renal crisis; systemic fungemia;
and progressive acidosis eventually leading to her demise.
Please refer to the separate MICU discharge summary for details
of her protracted MICU course.
Name: [**Known lastname 2345**], [**Known firstname 1940**] Unit No: [**Numeric Identifier 2346**]
Admission Date: [**2177-3-4**] Discharge Date: [**2177-4-6**]
Date of Birth: [**2106-6-10**] Sex: F
Service: MICU
ADDENDUM: This is an addendum to the discharge summary from
[**3-14**] to [**4-6**].
HOSPITAL COURSE: 1. Pulmonary: Around [**3-14**] the patient
was noted to have slow onset progressive desaturation on room
air and was requiring 2 liters of oxygen by the end of the
day on [**3-14**] and was noted to be significantly more
hypoxic on ambulation with O2 sats dropping to the mid 80s.
Concurrent with this the patient was noted to have a drop in
her hematocrit from a baseline of around 30 to 25.5 on
[**3-14**] and by the following day her oxygen saturation
continued to drop requiring increasing amounts of oxygen.
Chest x-ray was concerning for interstitial edema consistent
with congestive heart failure and the patient was diuresed
with intravenous Lasix and was transfused with 1 unit of
packed red blood cells as her hematocrit had dropped to 25.
By the next day her oxygen saturations continued to drop
despite diuresis and a pulmonary consult was obtained.
Recommendation was made to obtain a CT of the chest with
intravenous contrast, which was revealing for diffuse
interstitial edema including the alveoli and recommendation
was made to proceed with bronchoscopy. As the patient was
recently weaned from steroids the thinking was that this
could possibly represent PCP given [**Name Initial (PRE) **] relative
immunosuppressed state and Bactrim was started as empiric
therapy. Bronchoscopy was postponed as the patient developed
a bradyarrhythmia with frequent pauses as well as rates in
the 30s and 40s. By [**3-19**] oxygen requirement had
increased to 100% FIO2 on a nonrebreather with sats being
maintained in the mid 90% range. An induced sputum was sent
by respiratory therapy for a PCP, [**Name10 (NameIs) 2347**], later that day the
patient's oxygenation continued to worsen, began to develop
mental status changes. An arterial blood gas was sent, which
showed a PAO2 of 35 and the patient was emergently intubated
with initially difficult oxygenation either with 100% FIO2
and PEEP was gradually increased to about 15 bringing the
PAO2 to above 70. The following day bronchoscopy was
performed, which showed evidence of diffuse alveolar
hemorrhage. No evidence of pus or other infectious process.
PAL was negative for any growth. No evidence of PCP. [**Name10 (NameIs) **]
evidence of fungal infections. The antibiotics were
discontinued and the patient was started on pulse dose
steroids for diffuse alveolar hemorrhage.
Over the following several days oxygen requirement did
actually decrease with decreased need for PEEP as well as for
FIO2. Appearance on chest x-ray appeared to be that of a
resolving diffuse alveolar hemorrhage. By [**3-25**] the
patient's volume status due to her acute renal failure began
to effect oxygenation with increasing PEEP as well as FIO2
requirement. By [**3-27**] there was evidence of ongoing diffuse
alveolar hemorrhage with increasing bloody secretions
draining from the ET tube as well as drop in hematocrit.
Oxygen requirement continued to increase. The patient was
restarted on pulse dose steroids and was also started on
plasmapheresis. Data did support the use of plasmaphoresis
in diffuse alveolar hemorrhage secondary to scleroderma is
unfortunately scant, however, given the patient's critical
illness it was felt that a trial of plasmaphoresis would be
worthwhile. This was initiated on [**2177-3-28**] along with
Solu-Medrol 250 mg q 6 hours. Over the course of the next
five days the patient's oxygenation significantly improved
with stabilization of the hematocrit and FIO2 weaned down to
.45 as well as a decrease of the PEEP down to 5. Dialysis
initiated during this time also was able to take off a
significant amount of fluid contributing to the decrease in
oxygen requirement. On [**4-2**] the patient's oxygen
requirement began to climb with an increase in PEEP as well
as FIO2 with some evidence of diffuse alveolar hemorrhage
could once again be occurring given the drop in hematocrit
and appearance on chest x-ray. Bronchoscopy was performed
once again, which showed evidence of ongoing diffuse alveolar
hemorrhage. No clear evidence of an infectious process as
contributing to this current worsening as gram stain as well
as cultures were negative for any growth of organisms.
Given the recurrence of these findings despite treatment with
pulse dose steroids as well as plasmaphoresis, it was felt
that plasmaphoresis would be of limited utility and would be
continued on a q.o.d. basis and the pulse dose steroids would
be reduced once again to baseline of 100 mg of Solu-Medrol q
8 hours. By [**4-5**] the patient's pulmonary status continued
to worsen with an oxygen requirement now of 100% FIO2 with 17
of PEEP. The family discussed these findings and were all in
agreement that further care at this point would be futile and
not in the patient's best interest. On [**4-6**] they elected
to withdraw support and opted to extubate the patient. On
[**4-6**] this was done with the family all present and within
several minutes of extubation the patient became apneic and
expired.
2. Atrial fibrillation: The patient continued to be in
paroxysmal atrial fibrillation throughout her hospital stay
on both the floor as well as in the Medical Intensive Care
Unit. She was initially started on a Diltiazem drip, which
was discontinued due to bradycardia during the initial stay
in the Medical Intensive Care Unit. However, it was
restarted due to rapid atrial fibrillation with rates as high
as 140s and 150s with adequate rate control achieved with
about 10 to 15 mg intravenous q hour of Diltiazem.
3. Renal failure: Initially the etiology of the renal
failure was unclear. It was felt that it was likely due to
the aggresive diuresis and reducing volume overload that was
evident on chest x-ray. Possibly with the addition of sulfa
crystals from the Bactrim that was used for PCP. [**Name10 (NameIs) 2348**] the
patient was discontinued from the Bactrim she a Swan-Ganz
catheterization was performed in order to ascertain the
preload pressures. It was evident that the patient had mild
pulmonary hypertension with systolic PA pressures in the 50
to 60 range with a pulmonary capillary wedge pressure of
approximately 25 giving evidence that the etiology of the
renal failure was unlikely to be prerenal. Urine
electrolytes, however, did give the appearance of the
prerenal failure of being prerenal and for this reason the
diagnosis of sclerodermal renal crisis was entertained along
with the findings of hypertension. A renal biopsy was
performed on [**3-22**] the results of which were not diagnostic
for sclerodermal renal crisis, however, the size of tissue
used was likely inadequate. For this reason on [**2177-3-27**]
the biopsy was repeated once again done under CT guidance
under the supervision of Dr. [**Last Name (STitle) 2349**] in nephrology. This
time the biopsy results returned with findings of fibrinoid
necrosis consistent with sclerodermal renal crisis. The
recommendation made around the time of the first biopsy was
to begin ace inhibitor therapy as this was a treatment of
choice for sclerodermal renal crisis and this was continued
and a higher dose after the second biopsy results came back
with Enalapril intravenous with goals to keep the systolic
blood pressure in the range of 100 to 120. The patient
required dialysis as she continued to have volume overload
that was not amenable to medical therapy as well as
continuously rising BUN and creatinine concerning for uremia.
Dialysis was changed over to CVVH over the course of the
last three to four days prior to patient's death as goals
were to get as much fluid off as possible as there was
thinking that this volume overload could be contributing to
her hypoxic respiratory failure.
4. Hematology: The patient had evidence of DIC starting as
early as the second day of her hospitalization in the Medical
Intensive Care Unit with D-dimers greater then [**2173**] as well
as thrombocytopenia elevated FDP and decreased fibrinogen.
These findings were also consistent with a microangiopathic
hemolytic anemia likely due to the sclerodermal renal crisis
in the kidneys. Treatment was supportive with fresh frozen
platelets given for elevated INR and platelets given during
periprocedural bleeding. The patient also developed HLA
antibodies, which necessitated the treatment with HLA
specific platelets. The patient also had evidence of a
hemolytic anemia, which could be due in part to resorptive
hemosiderin and blood break down products from the lungs due
to the diffuse alveolar hemorrhage, however, were also likely
due in part to a microangiopathic hemolytic anemia.
Treatment was largely supportive with blood products being
given for hematocrits that showed evidence of continued
decline or hematocrits below 30.
5. Infectious disease: Throughout the course of her
hospital stay multiple blood cultures were taken, which
showed no evidence of bacterial growth in the blood. There
was one culture that was positive for diphtheroids, however,
this was likely a contaminant given all negative blood
cultures prior to and after that with no antibiotic dosing
being given at that time. There was one bottle also that
grew out yeast, however, this was likely also a colonizer as
after the line was changed there was no evidence of fungemia
by follow up blood cultures or by clinical status.
6. Scleroderma: As this was likely the underlying etiology
of the patient's diffuse alveolar hemorrhage, rheumatology
consult was obtained who recommended treatment with pulse
dose steroids and agreed with the utilization of the
plasmaphoresis. Cytoxan was discussed as a possible therapy
for the diffuse alveolar hemorrhage, however, it was felt
that given the patient's thrombocytopenia and likely period
of ongoing infections being possible in her somewhat
immunocompromised state it was decided that Cytoxan would
likely be riskier to use then its potential benefits and
therapy was continued with pulse dose steroids along with
plasmapheresis.
7. Posterior oropharyngeal hematoma: On [**4-2**] the patient
began to have some bleeding from her posterior oropharynx
during an attempted transesophageal echocardiogram. It is
likely due in part to trauma to the procedure as well as the
underlying thrombocytopenia and coagulation disorder. The
blood had to be transfused as her hematocrit dropped fairly
significant. Packing was put in place and the patient was
evaluated by otolaryngology who recommended placing packing
in addition to the packing in place and were planning on
removing the packing on Monday [**4-7**], to have a reevaluation
of the wound site. However, due to worsening alveolar
hemorrhage the patient expired on [**4-6**].
DISCHARGE DIAGNOSES:
1. Sclerodermal renal crisis.
2. Diffuse alveolar hemorrhage.
3. Atrial fibrillation.
4. DIC.
5. Anemia.
6. Posterior pharyngeal hematoma.
7. Acute renal failure.
8. Hypoxic respiratory failure.
DISCHARGE CONDITION: Expired.
[**Name6 (MD) 73**] [**Name8 (MD) 72**], M.D. [**MD Number(1) 352**]
Dictated By:[**Name8 (MD) 2350**]
MEDQUIST36
D: [**2177-4-6**] 04:05
T: [**2177-4-10**] 13:37
JOB#: [**Job Number 2351**]
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icd9cm
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20067, 20308
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7450, 7791
|
9155, 19820
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2561, 3666
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178, 190
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219, 1512
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,253
| 170,829
|
2441
|
Discharge summary
|
report
|
Admission Date: [**2150-8-20**] Discharge Date: [**2150-8-26**]
Date of Birth: [**2095-2-23**] Sex: M
Service: SURGERY
Allergies:
Levaquin
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Hypoglycemia & renal insufficiency
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr [**Known lastname **] is 55yo re-admitted for hypoglycemia & leukocytosis of
14.9 after undergoing an open fistula takedown and sigmoid
colectomy with Dr. [**Last Name (STitle) 1120**]. During his previous admission, he had
an increase in Creatinine due to post-op anastomotic leak &
sepsis. Due to his decreased kidney function, the patient & wife
were advised to hold renal-toxic medications including:
Metformin, glyburide, indomethacin, and lisinopril temporarily.
Prior to being discharged during last admission, sugery service
spoke with pt's PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] who approved re-starting PO
Metformin. At that time, patient's Creatinine was 2.8. The
patient & wife were advised of this instruction.
.
On [**2150-8-20**]: The patient's wife [**Name (NI) 653**] Dr. [**Last Name (STitle) 1120**] reporting
patient was unresponsive. EMT's called. Blood sugar-20, treated
with dextrose, and patient responded well. He was transferred
via ambulance to [**Hospital1 18**] for further management. In addition, Mrs.
[**Known lastname **] [**Last Name (STitle) 12533**] that Mr. [**Known lastname **] had taken 2 tabs of his
metformin/glyburide combination pill the day before per
recommendation of PCP for [**Name9 (PRE) 444**] of blood sugar in 280's.
Past Medical History:
DM II hyperlipidemia, HTN, spinal effusion cervical spine, knee
surgery, diverticulosis/itis
.
PSX:diverticulitis c/b colovesicular fistula s/p open fistula
takedown and sigmoid colectomy with leak of anterior aspect of
bladder, reexplored [**8-10**] for sepsis and found to have
anastomotic leak
Social History:
SOCIAL HISTORY: Married, no children. Smokes 3 to 5 cigars per
day. Social alcohol. Two cups of coffee per day. He is a
retired state police officer retired because of his neck injury
Family History:
FAMILY HISTORY: Diverticulosis
Physical Exam:
At Discharge:
Vitals: T-98, HR-83, BP-132/76, RR-20, RA-98%
Blood sugars: 188,158,158
GEN:NAD, A/Ox3, flat affect at times.
CV:RRR, no m/r/g
RESP:CTAB
ABD:+BS,large,appropriately TTP
Incision: surgical midline adbominal with intermittent retention
sutures. Packed loosely with [**Last Name (un) 12534**] AMD kerlix, moistened W-D.
Stoma beefy red & viable with soft brown effluence, pouch
intact.
EXTREM: no c/c/e
Pertinent Results:
[**2150-8-21**] 07:30AM BLOOD WBC-11.6* RBC-2.86* Hgb-7.7* Hct-24.5*
MCV-86 MCH-27.0 MCHC-31.6 RDW-14.1 Plt Ct-682*
[**2150-8-22**] 03:07AM BLOOD WBC-12.6* RBC-2.79* Hgb-7.7* Hct-23.8*
MCV-85 MCH-27.5 MCHC-32.2 RDW-14.1 Plt Ct-530*
[**2150-8-23**] 06:35AM BLOOD WBC-10.8 RBC-2.74* Hgb-7.9* Hct-23.4*
MCV-86 MCH-28.7 MCHC-33.6 RDW-13.9 Plt Ct-550*
[**2150-8-20**] 10:00AM BLOOD PT-16.7* PTT-31.2 INR(PT)-1.5*
[**2150-8-24**] 07:10AM BLOOD Glucose-124* UreaN-30* Creat-3.0* Na-140
K-4.5 Cl-109* HCO3-21* AnGap-15
[**2150-8-23**] 06:35AM BLOOD Glucose-159* UreaN-28* Creat-3.2* Na-141
K-4.4 Cl-112* HCO3-20* AnGap-13
[**2150-8-22**] 03:07AM BLOOD Glucose-113* UreaN-29* Creat-3.2* Na-138
K-4.1 Cl-107 HCO3-21* AnGap-14
[**2150-8-22**] 03:07AM BLOOD ALT-10 AST-26 AlkPhos-49 TotBili-0.3
[**2150-8-24**] 07:10AM BLOOD Albumin-2.5* Calcium-7.8* Phos-4.2 Mg-2.0
[**2150-8-21**] 01:18PM BLOOD %HbA1c-6.2*
[**2150-8-24**] 07:10AM BLOOD PTH-121*
[**2150-8-20**] 10:09AM BLOOD Glucose-83 Lactate-1.3 Na-140 K-3.9
[**2150-8-20**] 10:09AM BLOOD Hgb-8.6* calcHCT-26
[**2150-8-25**] 07:55AM BLOOD WBC-8.6 RBC-3.14* Hgb-8.6* Hct-26.3*
MCV-84 MCH-27.5 MCHC-32.8 RDW-14.5 Plt Ct-445*
[**2150-8-25**] 07:55AM BLOOD Glucose-118* UreaN-30* Creat-2.8* Na-143
K-4.7 Cl-111* HCO3-22 AnGap-15
[**2150-8-25**] 07:55AM BLOOD Calcium-8.2* Phos-4.3 Mg-2.0
.
[**2150-8-21**] 7:30 am URINE Site: CATHETER Source: Catheter.
**FINAL REPORT [**2150-8-22**]**
URINE CULTURE (Final [**2150-8-22**]):
YEAST. >100,000 ORGANISMS/ML..
.
[**2150-8-24**]-CT Cystogram
IMPRESSION:
1. Small linear anterior bladder wall defect significantly
smaller than the prior study without associated extravasation of
contrast in the perivesical region.
2. Partially imaged right renal lower pole cyst, incompletely
characterized in the non-contrast imaging, however, based on
prior imaging, likely represents a simple cyst.
3. Generalized soft tissue anasarca and pelvic free fluid could
represent
third spacing.
Brief Hospital Course:
[**8-20**]: Presented emergently to [**Hospital1 18**] ED for management of acute
hypoglycemia. Found to be unresponsive & unarousable at home.
EMT reports blood sugar of 20. Responded well to IV Dextrose.
Unable to maintain adequate glucose control in the ED. Admitted
to [**Hospital Unit Name 153**] for close blood sugar monitoring.
.
[**Date range (1) 12535**]: Maintained in ICU for close blood sugar monitoring.
Blood sugars gradually stabilized with dextrose. WBC decreased.
Creatinine increased to 3's. Patient transferred back to 12
[**Hospital Ward Name **] for continued monitoring.
.
[**8-24**]: Tolerating a regular, diabetic diet. Continues with calorie
counts due to decreased PO intake. Requires encouragement.
Sugar-free shake supplements added to diet. Blood sugars
stabilized, ranging from 138-188. Managedon RISS. Oral
weekend. Recommended temporary home insulin per sliding scale.
Patient adamantly refuses to learn insulin at home. Wants to
resume oral agents. Explained he can not temporarily due to
chronically elevated creatinine, CR today 3.0, down from 3.2.
[**Name8 (MD) **] MD will follow patient on [**8-25**] to continue education and
consider possible oral [**Doctor Last Name 360**] for discharge home.
.
Patient underwent repeat CT Cystogram to re-evaluate leak of
anterior aspect of bladder from original surgery due to
adhesions. No leak noted per Final read. Received PO
Fluconazole to treat yeast in urine x 3 days total. Foley
removed on [**2150-8-25**]. Patient able to urinate without difficulty on
various occasions. Flomax PO started to empirically managed
bladder function.
.
[**8-25**]: Tolerating regular food. PO intake at baseline per patient.
Nutritional instruction provided regarding increased protein to
aid in wound healing. Seen [**First Name8 (NamePattern2) **] [**Last Name (un) **], Dr.[**Last Name (STitle) 9978**]. Recommended
starting PO Prandin out-patient with more aggressive blood sugar
monitoring per patient. Patient agreed to this plan. He has a
glucometer at home. In addition, he was screened per Physical
Therapy and found to have NO PT needs for home. He ambulates
independently.
.
[**8-26**]: He was seen by ostomy RN prior to discharge home today.
Stoma beefy red & viable with adequate soft brown effluence. He
was re-connected with a "new" VNA agency per the wife's request
for follow-up of blood sugars, serum creatinine checks, &
wound/ostomy care. Prescriptions for "new" medications were
provided including [**Doctor Last Name 12536**] AMD kerlix for wound packing per
recommendation of OStomy RN. In addition, patient will complete
total 14 days of PO Ciprofloxacin and Flagyl. Cipro prescription
was provided. Patient has Flagyl at home. Discharge instructions
were reviewed in detail with patient and wife. [**Name (NI) 6419**] also met
with LICSW prior to leaving hospital.
Medications on Admission:
[**Doctor First Name 130**] 60 prn, atenolol 50', simvatain 40', levofloxacin,
flagyl, glyburide/metformin 5/500'
.
HELD DUE TO ELEVATED CREATININE:
indomethacin 50qhs, lisinopril 20'
Discharge Medications:
1. Prandin 0.5 mg Tablet Sig: One (1) Tablet PO Pre-breakfast &
Pre-dinner.
Disp:*60 Tablet(s)* Refills:*2*
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO at bedtime.
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
4. [**Doctor First Name **] 30 mg Tablet Sig: Two (2) Tablet PO twice a day.
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every 4-6 hours
as needed for fever or pain.
7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Outpatient Lab Work
Please check serum creatinine on Friday [**2150-8-28**], Monday [**2150-8-31**]
and as instructed per Physician.
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours for 6 days: Expected completion on Monday. .
Disp:*12 Tablet(s)* Refills:*0*
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 6 days: Take with Food.
Expected completion on Monday.
11. Wound Care
[**Doctor Last Name 12536**] Company - Kerlix Amd-Antimicrobial Gauze Dressing
Bandage Roll - 4.5"X4.1yds Sterile.
Disp-6 Refill-11
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
Hypoglycemia
Renal insufficiency
Leukocystosis
.
Secondary:
S/P s/p open fistula takedown and sigmoid colectomy, reexplored
[**8-10**] for sepsis and found to have anastomotic leak.
DMII, hyperlipidemia, HTN, spinal effusion cervical spine, knee
surgery, diverticulosis/itis
Discharge Condition:
Stable
Tolerating a Regular diabetic diet
Adequate pain control with oral medication
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat or feeling dizzy or faint when standing.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Continue to ambulate several times per day.
* Monitor your incision for signs of infection.
* It is OK to shower and wash. No tub baths or swimming. Keep
incision clean and dry.
.
Incision Care:
-Your dressing will be changed once a day per the Visiting
Nurse.
-Pack with Kerlix AMD gauze daily.
-You will be instructed on dressing changes.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
Monitoring Ostomy output/Prevention of Dehydration:
-Keep well hydrated.
-Replace fluid [**Known lastname **] from ostomy daily.
-Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
-Try to maintain ostomy output between 1000mL to 1500mL per day.
-If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with
each episode of loose stool. Do not exceed 16mg/24 hours.
.
Kidney Function/Medications to be HELD:
-Please HOLD your Metformin & Glyburide [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD
recommendations.
-You will be starting Prandin orally as your mangement of blood
sugars.
-Please do NOT continue taking your Lisinopril and Indomethacin
until your kidney function has returned to [**Location 213**].
-Your blood pressure and creatinine will be checked per the
Visiting Nurse, and called into Dr.[**Name (NI) 3377**] office.
-You will be advised as to when to resume these medications.
.
Urination:
-Please call Dr. [**Last Name (STitle) 1120**] or your Primary Doctor if you have any
concerns or changes in your urinary pattern.
-You will be referred to a Urologist as needed.
-Continue taking the Flomax to assist in urinating.
Followup Instructions:
1. Please make a follow-up appointment with Dr. [**Last Name (STitle) 1120**]
[**Telephone/Fax (1) 160**] in [**1-21**] weeks.
2. Follow-up with [**Last Name (un) **] Diabetes, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9978**]
[**Telephone/Fax (1) 2378**] in 1 week.
3. Follow-up with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**0-0-**] in 1
week and as needed.
.
Previous appointments:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2150-8-28**] 10:00
NEITHER DICTATED NOR READ BY ME
Completed by:[**2150-8-26**]
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|
1989, 2163
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7,223
| 108,294
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19851
|
Discharge summary
|
report
|
Admission Date: [**2159-8-17**] Discharge Date: [**2159-8-17**]
Date of Birth: [**2109-7-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Iodixanol
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
? ruptured pseudoaneurysm
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 53636**] is a 50 y/o s/p type A dissection repair in [**2151**]
with complicated post op course, multiple bowel surgeries and
most recently very resistent chronic VRE BSI since [**5-/2158**] who
has been off and on palliative antibiotics. He was admitted to
[**Hospital1 18**] [**7-30**] w/pre-syncope, found to have positive blood cultures
for VRE sensitive only to daptomycin, and was found to have a
pulsitile mass on his chest wall that was found to be likely a
partially thrombosed pseudoaneurysm in the right presternal
location measuring 2.7x7cm, the inferior aspect closely
associated with the ascending aorta and demonstrates an apparent
tract which was present 2/[**2158**]. At the time, the patient
refused surgical intervention. The patient reports that the
pulsatile mass has been growing in size over the last couple of
weeks and became
tender and burst tonight draining moderate amout of foul
smelling bloody fluid.
Past Medical History:
MRSA, VRE colonization
++ Type A acute aortic arch dissection, admit [**10/2152**]/[**2152**]
- suspected secondary to cocaine use
- multiple post-operative cardiac arrests
- femoral-femoral artery bypass
- subsequent CVA (watershed infarcts) --> bilateral occiptal
infarcts, optic neuropathy, blindness
- bowel ischemia s/p right hemicolectomy and ileostomy
* ileostomy reversal [**10/2154**]
* ileocolonic anastomosis resection (wound dehiscence)
* end ileostomy [**12/2153**]
* Bowel perforation on attempted ileostomy takedown in [**2154**]
* Colostomy takedown, lysis of adhesions, hernia repair,
wound revision, ileocolonic anastomosis resection, end
ileostomy,
fascial closure, VAC placement (continues with colostomy) [**3-/2157**]
- renal ischemia
* renal artery stent placement (L, [**3-/2154**])
* mid-ureteral stone --> L ureteral stent (fall/[**2153**])
* ARF due to L stone --> L percut nephrostomy tube ([**12/2154**])
- liver necrosis (>75%)
- tracheostomy --> hemoptysis (trach since removed)
- MRSA pneumonia
- VRE wound infection and bacteremia (coccyx/occipital decub
ulcer)
++ C. diff toxin in stool ([**12/2152**])
++ Klebsiella bacteriuria (early [**2155**])
++ Enterococcal bacteremia, [**1-/2156**] --> Daptomycin x6wks
++ Enterococcal bacteremia, [**3-/2156**]
++ VRE.faecium endocarditis, [**5-/2157**] and [**5-/2158**]
- tx: daptomycin x6 weeks
++ Klebsiella, Pseudomonal bacteriuria ([**5-/2157**])
- tx: ciprofloxacin x8d
++ Hypertension
++ hyperlipidemia
++ Chronic kidney disease
- prior ureteral stent
- renal artery stenting
++ Anemia
++ Myoclonus
++ aortic regurgitation with dilated LV
++ depression
Social History:
On disability currently, used to work for Caterpillar as
mechanic. Lives alone, his children visit during the weekends.
Lives in [**Location 4047**]. Denies tobacco or drug use currently. ~2
drinks/month Past history of cocaine use, precipitating aortic
dissection.
Family History:
Adopted, no history of immediate family known.
Physical Exam:
Admission Physical Exam
Temp 101.3 Pulse:73 regular Resp: 18 O2 sat: 97 on RA
B/P Right:113/58 Left:
Height: Weight:
General:
Skin: Dry [x] intact [x]
[**Location 4459**]: PERRLA [x] EOMI []
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Murmur [**3-6**] holosystolic murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] ileostomy pink, large healed abdominal wall defect
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: blind R eye, otherwise grosely intact
Pulses:
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right: 2+ Left:2+
upper mid sternum 1cm opening in skin, area non pulsitile but
w/palpable thrill, draining turbid/murky bloody fluid, 2-3 cm
surrounding w/fluctuance, able to express same murky fluid.
Labs:
10.5 >----<303
22.5(21 on [**8-15**]-transfused 1u PRBC)
PT:12.9 PTT: 27.5 INR:1.1
130 106 26
----I----I----<105
4.5 16 2.4
U/A:negative
Impression:50 yo s/p type A disection repair [**2151**] w/long
standing
VRE bacteremia and recent development of pulsitile mass on chest
wall which was thought to be a partially thrombosed
pseudoaneurysm of the aorta, began draining tonight.
Plan:Need contrast study of aorta to define pseudoaneurysm.
Will
need pre contrast hydration, pre-medication vs tagged red cell
scan due to chronic kidney disease and contrast allergy
Non contrast CT scan tonight.
continue antihypertensives
NPO until plan established
FEEN:gentle hydration D5W w/150mEq bicarb at 75cc/hr
heme:transfuse 1u PRBC
continue daptomycin-consult ID in am
code status:pt wishes to be DNR/DNI
Pertinent Results:
[**2159-8-17**] 03:59AM BLOOD WBC-8.2 RBC-2.83* Hgb-7.5* Hct-22.4*
MCV-79* MCH-26.6* MCHC-33.6 RDW-16.8* Plt Ct-282
[**2159-8-16**] 10:10PM BLOOD WBC-10.5 RBC-2.85* Hgb-7.5* Hct-22.5*
MCV-79* MCH-26.2* MCHC-33.3 RDW-16.7* Plt Ct-303
[**2159-8-17**] 03:59AM BLOOD Neuts-77.5* Lymphs-16.2* Monos-2.7
Eos-2.5 Baso-1.2
[**2159-8-16**] 10:10PM BLOOD Neuts-81.1* Lymphs-13.4* Monos-2.9
Eos-1.8 Baso-0.9
[**2159-8-17**] 03:59AM BLOOD PT-12.8 PTT-27.2 INR(PT)-1.1
[**2159-8-16**] 10:10PM BLOOD PT-12.9 PTT-27.5 INR(PT)-1.1
[**2159-8-17**] 03:59AM BLOOD Glucose-98 UreaN-24* Creat-2.4* Na-135
K-4.3 Cl-109* HCO3-17* AnGap-13
[**2159-8-16**] 10:10PM BLOOD Glucose-105* UreaN-26* Creat-2.4* Na-130*
K-4.5 Cl-106 HCO3-16* AnGap-13
[**Known lastname **],[**Known firstname **] [**Medical Record Number 53647**] M 50 [**2109-7-17**]
Radiology Report CT CHEST W/O CONTRAST Study Date of [**2159-8-17**]
2:06 AM
[**Last Name (LF) **],[**First Name3 (LF) **] EU [**2159-8-17**] 2:06 AM
CT CHEST W/O CONTRAST Clip # [**Clip Number (Radiology) 53652**]
Reason: eval for pseudoaneurysm
Field of view: 38
[**Hospital 93**] MEDICAL CONDITION:
50 year old man with cocern for ruptured aortic
pseudoaneurysm
REASON FOR THIS EXAMINATION:
eval for pseudoaneurysm
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: DLrc FRI [**2159-8-17**] 4:07 AM
1. Interval decrease in size of right presternal anterior chest
wall
low-attenuation fluid collection compatible with clinically
known rupture.
There is still low-attenuation fluid that is seen tracking
posteriorly with a
neck immediately adjacent to the ascending thoracic aorta.
Overall, the
appearance within the mediastinum of this region is stable since
[**2159-7-31**].
The differential still includes the possibility of
pseudoaneurysm formation or
infection.
2. Stable 4-mm right lower lobe pulmonary nodule.
3. Bibasilar atelectasis. New nodular density in the left upper
lobe, seen
perifissurally, that is non-specific.
4. Stable cardiomegaly.
5. Right PICC now in right atrium.
Wet Read Audit # 1 DLrc FRI [**2159-8-17**] 2:37 AM
Collection has now decreased in size compatible with clinically
known rupture
with overall stable appearance of soft tissue density in the
anterior chest
wall which tracks posteriorly immediately adjacent to the aorta
as has been
described previously. New right dependent atelectasis and
nodular
opacification, likely atelectasis though infection is not
excluded.
Wet Read Audit # 2 DLrc FRI [**2159-8-17**] 3:07 AM
Collection has now decreased in size compatible with clinically
known rupture
with overall stable appearance of soft tissue density in the
anterior chest
wall which tracks posteriorly immediately adjacent to the aorta
as has been
described previously. New right dependent atelectasis and
nodular
opacification, likely atelectasis though infection is not
excluded.
Right PICC now in right atrium.
Final Report
INDICATION: Patient is a 50-year-old male with concern for
ruptured aortic
pseudoaneurysm. Evaluate for pseudoaneurysm.
EXAMINATION: NON-CONTRAST CHEST CT.
COMPARISONS: [**2159-7-31**] and [**2159-1-11**].
TECHNIQUE: Helically acquired axial images were obtained from
the thoracic
inlet to the mid abdomen without the administration of oral or
intravenous
contrast. Coronal and sagittal reformations are provided for
review.
Intravenous contrast was contraindicated secondary to chronic
renal
sufficiency and documented allergy to both iodine and gadolinium
contrast
agents.
FINDINGS:
CT OF THE CHEST WITHOUT INTRAVENOUS CONTRAST:
Since the most recent prior chest CT from [**2159-7-31**], the
anterior chest wall
low-attenuation collection in the right presternal space has now
decreased in
extent, compatible with clinically known rupture of collection.
This
low-attenuation collection now is in direct contiguity with the
skin (2:25).
Low-attenuation components continue to track posteriorly (2:26),
with a tract
or neck seen that enters the anterior mediastinum to the middle
mediastinum
adjacent to the right aspect of the sternum. This tract is
intimately
associated with the ascending aorta. Overall, the configuration
of the
posterior aspect are unchanged since examination from [**2159-7-31**].
Redemonstrated are postsurgical changes from the ascending
aortic repair with
the presence of a graft noted. The main pulmonary trunk is
enlarged measuring
up to 3.4 cm. There is stable cardiomegaly. A right approach
PICC is now
terminating within the right atrium.
There is no axillary, mediastinal, or hilar lymphadenopathy,
with a stably
prominent mediastinal lymph node in a pretracheal station
demonstrating a
fatty hilum. The central airways are patent to the subsegmental
levels.
There is dependent bilateral atelectasis with increase in
atelectasis
involving the left hemithorax. A right lower lobe 4-mm pulmonary
nodule
(series 2:26) is stable. There is a new 5 x 10-mm pulmonary
nodular density
seen perifissurally along the left upper lobe, likely
atelectasis. There are
trace bilateral pleural effusions.
This examination is not tailored for subdiaphragmatic
evaluation. The
partially imaged upper abdomen redemonstrates extensive [**Year (4 digits) 1106**]
calcification, multiple splenules in the left upper quadrant,
and an atrophic
right kidney with dystrophic parenchymal calcification.
BONE WINDOWS: The visualized osseous structures are unremarkable
with no new
suspicious lytic or sclerotic foci.
IMPRESSION:
1. Interval decrease in size of right presternal anterior chest
wall
low-attenuation fluid collection compatible with clinically
known rupture of
collection. There is still low-attenuation fluid that is seen
tracking
posteriorly immediately adjacent to the ascending thoracic
aorta. Overall,
the appearance within the mediastinum of this region is stable
since
[**2159-7-31**].
2. Stable 4-mm right lower lobe pulmonary nodule.
3. Bibasilar atelectasis and bilateral trace effusions.
4. Stable cardiomegaly.
5. Right PICC now in right atrium.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] LI
DR. [**First Name (STitle) 5432**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Approved: FRI [**2159-8-17**] 8:39 AM
Imaging Lab
Brief Hospital Course:
50 yo s/p type A disection repair [**2151**] w/long standing VRE
bacteremia and recent development of pulsitile mass on chest
wall which was thought to be a partially thrombosed
pseudoaneurysm of the aorta, began draining [**2159-8-16**]. He was
transferred to [**Hospital1 18**] for further evaluation. Chest contrast
study of aorta to define pseudoaneurysm was performed. Pre
contrast hydration was initiated with IV Bicarbonate for
possible CT scan with contrast vs tagged red cell scan due to
chronic kidney disease and contrast allergy .Non contrast CT
scan performed.
This patient is well known to Dr.[**Last Name (STitle) 914**] and the cardiac
surgical service. About a year ago he went over Mr. [**Known lastname 53653**]
options which basically included chronic suppressive antibiotic
treatment for his chronic graft infection/endocarditis vs redo
surgery which would involve replacement of all prosthetic
material (graft from
sinotubular junction to include the total aortic arch) plus AVR
or more likely full Bentall procedure which would most likely
entail a prolonged hospital stay and likely lead to chronic
hemodialysis postoperatively. Approximately one year ago, an
ethics consult and a long family meeting with ID and cardiac
surgery presented to discuss these options and he chose to
pursue
suppressive antibiotic therapy and was adamant about not
pursuing surgery. Dr.[**Last Name (STitle) 914**] was in agreement with that
decision as he felt he had a good understanding of the
morbidity/mortality associated with the surgery and he actually
has done quite well with this plan until his antibiotics were
discontinued
approximatley 3-4 weeks ago. This most likely allowed the
chronic well controlled infection to flair up and produce his
symptoms. His options are no different now and Dr.[**Last Name (STitle) 914**]
reiterated them to the patient and his sister, [**Name (NI) **], and they
again do not wish to proceed with surgery. He is very aware
that his infected
aortic graft/pseudoaneurysm may rutpure at any point producing
almost certain death and still does not want to pursue surgery.
ID was reconsulted for their recomendations regarding
suppressive antibiotic therapy. [**2159-8-17**] Pt was cleared for
discharge back to Twin Oaks Rehabilitative Care for further
management. Follow up appointments were advised.
Medications on Admission:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
6. Labetalol 200 mg Tablet Sig: 2.5 Tablets PO TID (3 times a
day).
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash,itch.
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
10. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
13. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO QID
(4 times a day).
14. Daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q48H (every 48 hours).
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
5. Labetalol 200 mg Tablet Sig: 2.5 Tablets PO TID (3 times a
day).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
8. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
10. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Daptomycin 500 mg Recon Soln Sig: 680 mg Intravenous Q48H
(every 48 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2857**] - Twin Oaks - [**Location (un) 4047**]
Discharge Diagnosis:
Infected Aortic graft and native Aortic valve endocarditis (VRE)
s/p emergent Aortic Dissection repair in [**2151**].Probable fistula
from graft to presternal area.
Chronic kidney disease
Discharge Condition:
Alert & oreinted, NAD
stable
Discharge Instructions:
-Resume preadmission care.
-While hospitalized your IV antibiotics were restarted to treat
the chronic infection you have in your blood stream and on
your heart valves in hopes this will improve symptoms for a
short time.Antibiotics are palliative, not curative.
Unfortunately surgery, which isn't a viable option, is the only
option to completely eradicate infection.
-Sternal wound incision: NS wet->dry [**Hospital1 **] for life
Followup Instructions:
Per Dr.[**Last Name (STitle) 914**], no follow up with cardiac surgery necessary.
Followup Instructions:
Weekly CBC with dirreferntial/BUN/Cr/CPK results to be FAXED to
Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12081**] (Infectious Disease) FAX#[**Telephone/Fax (1) 432**]
Follow UP :
Department: INFECTIOUS DISEASE
When: FRIDAY [**2159-8-31**] at 9:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], 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: TRANSPLANT CENTER
When: THURSDAY [**2159-9-13**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2159-8-17**]
|
[
"V44.3",
"518.89",
"424.1",
"585.9",
"V12.54",
"311",
"041.04",
"421.0",
"285.9",
"996.62",
"996.74",
"V44.2",
"V09.80",
"E878.2",
"403.90",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
15846, 15932
|
11390, 13747
|
301, 308
|
16164, 16195
|
5100, 6200
|
16782, 17657
|
3323, 3371
|
14959, 15823
|
6240, 6303
|
15953, 16143
|
13773, 14936
|
16219, 16654
|
3386, 5081
|
236, 263
|
6335, 11367
|
336, 1294
|
1316, 3023
|
3039, 3307
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,701
| 134,527
|
46365
|
Discharge summary
|
report
|
Admission Date: [**2108-11-18**] Discharge Date: [**2108-12-1**]
Date of Birth: [**2054-2-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Erythromycin/Sulfisoxazole
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
[**11-20**] Mitral Valve Repair with 30mm [**Company 1543**] CG future ring
History of Present Illness:
54 y/o male with shortness of breath and decreased exercise
tolerance over 1 year progressively getting worse. Has known MR
with echo in [**4-11**] showing moderate to severe MR, severely
dilated LV with an EF of 20%. Cardiac cath in [**2108-9-18**] showed
moderate MR with clean coronaries.
Past Medical History:
Mitral Regurgitation, Atrial Fibrillation s/p Cardioversion
[**2107**], Ventricular Tachycardia s/p ICD/pacer [**07**], Non-ischemic
dilated cardiomyopathy, Hypertension, Hyperlipidemia, Deep Vein
Thrombosis, Drug Induced renal failure, Hepatitis C, Benign
Prostatic Hypertrophy, h/o burns s/p STSG approx. 30 yrs ago
Social History:
lives alone. on disability
Tob: 1ppd x 1yr, quit 15yrs ago
EtOH: h/o abuse, quit 10yrs ago
illicits: h/o cocaine use [**2096**]-[**2099**]
Family History:
Mother d. MI 50yrs, h/o CABG in 20s
Father d. 30yrs, unknown cause
Physical Exam:
VS: 95.8 70 120/72 18
HEENT: Facial scars from STSG
Heart: RRR 2/6 syst. murmur
Lungs: CTAB -w/r/r
Abd: Soft, NT?ND
Ext: warm, well-perfused, 2+ pulses
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
[**11-20**] Echo: PRE-CPB:1. The left atrium is markedly dilated. No
spontaneous echo contrast is seen in the body of the left
atrium. No thrombus is seen in the left atrial appendage. No
atrial septal defect is seen by 2D or color Doppler. 2. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity is severely dilated. No left ventricular
aneurysm is seen. Overall left ventricular systolic function is
severely depressed (LVEF= 20 %). 3. The right ventricular free
wall is hypertrophied. Right ventricular chamber size is normal.
Right ventricular systolic function is normal. 4. There are
three aortic valve leaflets. The aortic valve leaflets are
mildly thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. 5. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve.
There is a minimally increased gradient consistent with trivial
mitral stenosis. Moderate to severe (3+) mitral regurgitation is
seen. The mitral annulus measures 3.8 cm. POST-CPB: On infusions
of levo, epi, milrinone. Well-seated annuloplasty ring in the
mitral position. No MR. [**First Name8 (NamePattern2) **] [**Last Name (Titles) **]. LVEF now 25% on inotropic
support.
[**11-27**] Abd US: Cholelithiasis. No ultrasound evidence of acute
cholecystitis; however, a stone is identified within the neck of
the gallbladder.
[**11-27**] Abd x-ray: Air is seen in the colon with no evidence of
small-bowel dilatation or obstruction. No intra-abdominal free
air is seen.
[**2108-11-18**] 07:43PM BLOOD WBC-8.3 RBC-5.30 Hgb-13.7* Hct-41.6
MCV-79* MCH-25.9* MCHC-33.0 RDW-14.8 Plt Ct-296
[**2108-11-28**] 06:55AM BLOOD WBC-10.8 RBC-4.25* Hgb-11.1* Hct-33.9*
MCV-80* MCH-26.2* MCHC-32.7 RDW-15.4 Plt Ct-416
[**2108-11-18**] 07:43PM BLOOD PT-17.4* PTT-39.6* INR(PT)-1.6*
[**2108-11-28**] 06:55AM BLOOD PT-12.3 PTT-62.9* INR(PT)-1.1
[**2108-11-18**] 07:43PM BLOOD Glucose-114* UreaN-21* Creat-1.0 Na-139
K-4.1 Cl-104 HCO3-24 AnGap-15
[**2108-11-28**] 06:55AM BLOOD Glucose-110* UreaN-16 Creat-0.9 Na-137
K-4.0 Cl-102 HCO3-29 AnGap-10
Brief Hospital Course:
[**11-18**]
Mr. [**Known lastname 98537**],[**Known firstname **] was admitted with with SOB anf fatigue. A echo
was obtained which showerd mod to severe MR.
He agreed to have an elective surgery. Pre-operatively, he was
consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were
obtained, all other preperations were made.
It was decided that she would undergo a Mitral valve repair with
a size 30 [**Company 1543**] CG ring.
.
[**11-20**]
He was prepped, and brought down to the operating room for
surgery. Intra-operatively, he was closely monitored and
remained hemodynamically stable. He tolerated the procedure well
without any difficulty or complication.
Post-operatively, he was transferred to the CVICU for further
stabilization and monitoring. While i nthe CVICU he required
pressure support post operative course
[**11-21**]
EP was consulted for interigation of ICD
[**11-24**]
Pt extubate CT out / post cxr no pnuemothorax
EP interrigation of ICD again for lower rate
When stable he was delined. His diet was advanced.
[**11-25**]
Pt transfered to [**Hospital Ward Name 121**] 2 for further recovery. A PT consult was
obtained.
On the floor, he remained hemodynamically stable with his pain
controlled. He progressed with physical therapy to improve her
strength and mobility. He continues to make steady progress.
[**11-26**]
Coumadin started for his histiry of a fib / INR monitered. INR
is 1.3 on DC. To note his INR has increased x 3 days.
[**11-27**] - [**11-30**]
Pt c/o N/V with abdominal pain . Seen by General Surgery.
originally pt mad NPO. Pt was also febrile. Pt pan cx. Started
in Kefzol. On Dc he is afebrile. Home on keflex PO. All cx's
negative. Pt with found to have mild pancreatitis / amylase and
lipase trending down on DC.
[**12-1**]
pt stable for DC
Medications on Admission:
Digoxin 0.25mg qd, Amiodarone 200mg qd, Doxazosin 2mg qd,
Carvedilol 25mg [**Hospital1 **], Lisinopril 15mg [**Hospital1 **], Lasix 40mg [**Hospital1 **],
Aldactone 25mg qd, Protonix 40mg qd, NTG prn, Viagra prn,
Coumadin, Magnesium
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
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:*1*
3. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*1*
4. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO ONCE (Once): INR
goal is [**3-10**].
Disp:*60 Tablet(s)* Refills:*2*
6. Cephalexin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 10 days.
Disp:*40 Capsule(s)* Refills:*0*
7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
8. Doxazosin 2 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
Mitral Regurgitation s/p Mitral Valve Repair
PMH: Atrial Fibrillation s/p Cardioversion [**2107**], Ventricular
Tachycardia s/p ICD/pacer [**07**], Non-ischemic dilated
cardiomyopathy, Hypertension, Hyperlipidemia, Deep Vein
Thrombosis, Drug Induced renal failure, Hepatitis C, h/o burns
s/p STSG approx. 30 yrs ago
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
[**Last Name (NamePattern4) **] Instructions:
Dr. [**Last Name (STitle) **] [**Last Name (Prefixes) 53724**] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 **] heart center
[**Telephone/Fax (2) 6256**] Thrusday [**12-6**] at 930am
Please go to radiology for chest xray prior to post op visit,
please ask for copy of films to take to appointment with you
Dr. [**Last Name (STitle) 23070**] in [**2-7**] weeks
Dr. [**Last Name (STitle) 20222**] in [**3-10**] weeks
Please call to schedule appointments
Completed by:[**2108-12-1**]
|
[
"577.0",
"427.32",
"272.4",
"428.0",
"424.0",
"401.9",
"V45.02",
"427.31",
"425.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.60",
"35.33",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
6697, 6759
|
3633, 5437
|
313, 390
|
7118, 7124
|
1514, 3610
|
1228, 1296
|
5720, 6674
|
6780, 7097
|
5463, 5697
|
7148, 8412
|
1311, 1495
|
254, 275
|
418, 711
|
733, 1052
|
1068, 1212
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,603
| 197,065
|
20762
|
Discharge summary
|
report
|
Admission Date: [**2167-6-21**] Discharge Date: [**2167-6-23**]
Date of Birth: [**2111-10-17**] Sex: M
Service: SURGERY
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
Hepatic encephalopathy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
55yo incarcerated man, HCV cirrhosis, hepatic encephalopathy,
esophageal and gastric varices, history of pancreatitis,
polysubstance abuse and psychiatric history, presenting on
[**2167-6-21**] with 2 week history of constant epigastric abdominal pain
and dyspnea. Initially presented to [**Hospital1 **] ED, where he was
having [**9-23**] abdominal pain. Labs showed chronic anemia,
thrombocytopenia, as well as smoldering transaminases and a
lipase of 193. Given the elevated LFTs and lipase, he was
transferred to [**Hospital1 18**] for abdominal ultrasound and surgical
consultation for possible acute cholecystitis and/or gallstone
pancreatitis.
In the ED at [**Hospital1 18**], he was tremulous, confused with
epigastric/RUQ tenderness and a positive [**Doctor Last Name 515**] sign. Repeat
labs were similar to those at [**Hospital1 **]-N. RUQ U/S showed gallstones
with a positive son[**Name (NI) 493**] [**Name (NI) **] sign but no wall thickening
or pericholecystic fluid, concerning for but not diagnostic of
acute cholecystitis. Surgery was consulted, and he is admitted
to the SICU for further care. In the SICU, he was continued on
lactulose, rifaximin, and ruled out for infectious causes of
presentation. Per report, he was at his baseline mental status
per prison guards account. US was not diagnostic for acute
cholecystitis or gallstone pancreatitis, and patient's
presentation was thought to be a manifestation of underlying
viral hepatitis. Given no acute surgical issues, he was called
out to the [**Doctor Last Name 3271**] [**Doctor Last Name 679**] service. VS prior to transfer were 98.4
60 118/78 12 100%ra.
Past Medical History:
- HCV cirrhosis, c/b hepatic encephalopathy, esophageal and
gastric varices
- pancreatitis (? gallstone)
- hypertension
- hypothyroidism
- GERD
- schizophrenia, bipolar disorder
- polysubstance abuse
- s/p abdominal surgery for stab wound along left abdomen 20
years ago
- s/p right leg surgery [**84**] years ago
Social History:
Currently incarcerated. Tobacco: 30 pack years.
EtOH: Daily x40 years. Prior heroin and ? cocaine use, last use
within one year. Per his guards, he is homeless and likely gets
medical care at [**Hospital1 **]. He has had multiple incarcerations in
the past, usually 3-6 months long at a time, between which he
returns to the streets and uses EtOH, cocaine, and heroin
frequently.
Family History:
Mother and father are deceased. Mother passed
away after h/o alcoholism. He has a sister in [**Name (NI) 1474**], MA.
Physical Exam:
Admission exam
VS: 98.4 60 118/78 12 100%ra.
GENERAL: Disheveled AA in NAD.
HEENT: Sclera anicteric. MMM.
CARDIAC: RRR with no excess sounds appreciated
LUNGS: CTA b/l with no wheezing, rales, or rhonchi.
ABDOMEN: Distended but Soft, non-tender to palpation. Dullness
to percussion over dependent areas but tympanic anteriorly. No
HSM or tenderness appreciated.
EXTREMITIES: 1+ edema b/l. Warm and well perfused, no clubbing
or cyanosis.
NEUROLOGY: asterixis present. A+Ox1. CN2-12 intact. Sensation
grossly intact
Discharge exam
VS: 98.0 68-78, 104-117/70-81, 97%ra.
GENERAL: Disheveled AA in NAD. Not oriented to place, or time.
HEENT: Sclera anicteric. MMM.
CARDIAC: RRR with no m/r/g.
LUNGS: Unlabored, CTA b/l.
ABDOMEN: Distended, Soft, non-tender. Dullness to percussion
over dependent areas but tympanic anteriorly. Minimal tenderness
appreciated over epigastrium.
EXTREMITIES: 1+ edema b/l. Warm and well perfused.
NEUROLOGY: asterixis present. A+Ox1. CN2-12 intact. Sensation
grossly intact
Pertinent Results:
Admission labs
[**2167-6-21**] 01:10PM BLOOD WBC-3.1*# RBC-3.93* Hgb-10.4* Hct-32.7*
MCV-83 MCH-26.5* MCHC-31.9 RDW-16.5* Plt Ct-80*
[**2167-6-21**] 01:10PM BLOOD PT-15.4* PTT-37.8* INR(PT)-1.4*
[**2167-6-21**] 01:10PM BLOOD Glucose-102* UreaN-11 Creat-0.7 Na-135
K-3.6 Cl-107 HCO3-22 AnGap-10
[**2167-6-21**] 01:10PM BLOOD ALT-75* AST-97* AlkPhos-191* TotBili-1.1
[**2167-6-21**] 01:10PM BLOOD Amylase-220*
[**2167-6-21**] 01:10PM BLOOD Lipase-106*
[**2167-6-21**] 01:10PM BLOOD Albumin-3.7 Calcium-9.3 Phos-3.4 Mg-2.0
[**2167-6-21**] 01:10PM BLOOD Lithium-1.3
Discharge labs
[**2167-6-23**] 05:40AM BLOOD WBC-2.7* RBC-3.56* Hgb-9.2* Hct-29.9*
MCV-84 MCH-25.8* MCHC-30.8* RDW-16.2* Plt Ct-75*
[**2167-6-23**] 05:40AM BLOOD PT-15.8* PTT-40.5* INR(PT)-1.5*
[**2167-6-23**] 05:40AM BLOOD Glucose-95 UreaN-7 Creat-0.7 Na-136 K-3.6
Cl-110* HCO3-22 AnGap-8
[**2167-6-23**] 05:40AM BLOOD ALT-56* AST-74* AlkPhos-153* TotBili-0.6
[**2167-6-23**] 05:40AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.7
Micro: none
Studies:
RUQ U/S: Transabdominal son[**Name (NI) 493**] images were obtained of the
right upper quadrant. The liver is normal in echotexture
without focal lesions. Ill-defined echogenic foci are not
confirmed when scanning in both transverse and sagittal planes.
The gallbladder is mildly distended and contains gallstones, but
there is no gallbladder wall thickening or pericholecystic
fluid. There is no intrahepatic biliary ductal dilatation. The
common bile duct measures 4 mm. Hepatopetal flow is seen within
the main portal vein. Limited images of the head and body of
the pancreas are unremarkable. Limited images of the right
kidney demonstrate no hydronephrosis.
IMPRESSION: Gallstones with a positive son[**Name (NI) 493**] [**Name (NI) **] sign
but no wall thickening or pericholecystic fluid is concerning
for but not diagnostic of acute cholecystitis. Further imaging
with HIDA scan is recommended to aid in this differentiation, if
clinically indicated.
Brief Hospital Course:
Mr [**Known lastname **] is a 55yo with h/o HCV/EtOH cirrhosis, hepatic
encephalopathy, esophageal and gastric varices, pancreatitis,
polysubstance abuse, and schizophrenia, who presents with
abdominal pain, abnormal LFTs and abnormal lipase.
.
#) Abdominal pain: History of similar pain in past. Improving
without therapy. Tolerating full diet well. Constant epigastic
pain, mild tenderness on exam. Etiology unclear, DDx includes
hepatitis, acute cholecystitis, pancreatitis, gastritis, peptic
ulcer disease, etc. LFTs and lipase are mild and trending down,
unclear that these would account for his pain. Gastritis and PUD
also unlikely if he has been compliant with PPI. After
discussion w/ outpatient provider, [**Name10 (NameIs) 55398**] that these complaints
were very chronic in nature, and extensive work-up has been
unrevealing. He is transferred to that provider's care, at the
infirmary at his Correctional Facility.
.
#) Hepatic encephalopathy: He was A+Ox1, lacking executive
function, and had asterixis on exam. Per outpatient provider, [**Name10 (NameIs) **]
is non-compliant with his lactulose, and this likely explains
his HE presention. Culture were negative. No evidence of GI
bleed. Lithium levels were normal. His lactulose was increased
to Q2 hours for now, and can be reduced to every 4 afters after
HE resolves. He is also on rifaxamin 550mg [**Hospital1 **], and should
remain on this. He should f/u with his PCP/GI doctors once [**Name5 (PTitle) **]
gets out of the correctional facility infirmary.
#) Cirrhosis: Likely [**1-15**] combination of HCV and EtOH.
Complicated by ascites, h/o SBP, and HE. We continued nadolol,
multivitamin, and folate. His diuretics (lasix and
spironolactone) were initially held, but then restarted.
.
#) Hypothyroidism: continued home levothyroxine
.
#) Schizophrenia/Bipolar disorder: continued home lithium and
risperidone.
.
#) GERD: continued home omeprazole
.
==================================================
TRANSITIONAL ISSUES
# needs to take lactulose every 2 hours
Medications on Admission:
- furosemide 40 mg alternating with 20 mg daily
- spironolactone 100 mg daily
- nadolol 80 mg daily
- lactulose 20 gms 4x/day
- rifaximin 600 mg QAM, 400 mg QPM
- levothyroxine 125 mcg daily
- omeprazole 20 mg daily
- multivitamin daily
- folic acid 1 mg daily
- risperidone 3 mg QHS
- lithium 1200 mg QHS
Discharge Medications:
1. Lactulose 30 mL PO Q2H
2. Furosemide 40 mg PO DAILY
alternating with 20mg daily
3. Spironolactone 100 mg PO DAILY
4. Nadolol 80 mg PO DAILY
5. Rifaximin 550 mg PO BID
6. Levothyroxine Sodium 125 mcg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Risperidone 3 mg PO HS
10. Lithium Carbonate 1200 mg PO QHS
Discharge Disposition:
Extended Care
Discharge Diagnosis:
- Hepatic encephalopathy
- HCV
- cirrhosis
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
for abdominal pain. You also had hepatic encephalopathy
(confusion from liver disease), and this was treated with
lactulose.
The following changes have been made to your medications:
** INCREASE lactulose to 30mL every 2 hours. It is VERY
important that you take your lactulose as prescribed.
Followup Instructions:
Please follow up with the Correctional Facility doctor as soon
as possible upon transfer.
|
[
"305.53",
"244.9",
"303.93",
"070.71",
"530.81",
"789.06",
"285.9",
"305.63",
"338.29",
"296.80",
"571.2",
"295.90",
"V15.82",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8652, 8667
|
5899, 7935
|
310, 317
|
8754, 8754
|
3901, 5876
|
9332, 9425
|
2741, 2861
|
8292, 8629
|
8688, 8733
|
7961, 8269
|
8904, 9309
|
2876, 3882
|
247, 272
|
345, 1989
|
8769, 8880
|
2011, 2326
|
2342, 2725
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,526
| 145,171
|
20742+20743
|
Discharge summary
|
report+report
|
Admission Date: [**2136-3-19**] Discharge Date: [**2136-3-27**]
Date of Birth: [**2093-7-17**] Sex: M
Service: .
ADMITTING DIAGNOSIS: Non-Hodgkin's lymphoma, IL2 therapy.
DISCHARGE DIAGNOSES:
1. VT cardiac monitoring.
HISTORY OF PRESENT ILLNESS: The patient is a 42 year old
male with a history of metastatic renal cancer admitted
[**2136-3-19**], to [**Hospital1 69**] for IL2
biologic therapy.
Dictation ended
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], M.D. [**MD Number(1) 7782**]
Dictated By:[**Last Name (NamePattern1) 201**]
MEDQUIST36
D: [**2136-3-27**] 11:48
T: [**2136-3-28**] 18:41
JOB#: [**Job Number 55347**]
Admission Date: [**2136-3-19**] Discharge Date: [**2136-3-27**]
Date of Birth: Sex: M
Service: Biologics
HISTORY OF PRESENT ILLNESS: Patient is a 42-year-old male
with a history of metastatic renal cell carcinoma admitted
for cycle one week one of high-dose IL-2. His oncologic
history began in [**2135-1-15**] when he developed fatigue
and by [**2135-4-14**], he had developed anemia. CT of his
abdomen revealed a large right kidney mass. He underwent a
right radical nephrectomy on [**2135-5-25**] revealing
adenocarcinoma with predominant clear cell type with
anaplastic spindle cell areas firm and grade 4. There was
tumor invasion of the renal vein and metastases to the
adrenal. Staging workup was otherwise negative.
He was followed closely and developed a cough in [**2136-4-14**]. Chest CT in [**2136-2-13**] revealed large lung nodules
consistent with renal cell metastases. Patient was evaluated
here for high-dose IL-2 treatment program and found to meet
eligibility criteria.
PAST MEDICAL HISTORY:
1. Metastatic renal cell carcinoma.
2. Bilateral inguinal hernia repairs.
3. Vasectomy.
ALLERGIES: No known drug allergies.
ADMISSION MEDICATIONS:
1. Percocet prn.
2. MS Contin 30 mg p.o. b.i.d.
3. Multivitamin.
PHYSICAL EXAM ON ADMISSION: Reveals a well appearing
middle-age male in no acute distress. Performance status 0.
Vital signs: 98.6, 76, 18, 113/68, and O2 saturation 98% on
room air. Head, eyes, ears, nose, and throat: Normocephalic
and atraumatic. Pupils are equal, round, and reactive to
light. Moist oral mucosa without lesions. Neck is supple,
no JVD. Heart: Regular, rate, and rhythm, S1, S2. Lungs
clear. Abdomen is rounded, positive bowel sounds, soft.
Mild tenderness over the right nephrectomy scar area.
Extremities without edema. Neurologic is nonfocal.
ADMISSION LABORATORIES: WBC 5.0, hematocrit 29.3, platelet
count 332,000. BUN 19, creatinine 1.2, sodium 142, potassium
4.1, chloride 105, CO2 30. ALT 26, AST 13, CPK 60, alkaline
phosphatase 75, total bilirubin 0.3, albumin 3.4, calcium
8.4, phosphorus 5.1, magnesium 2.0, uric acid 6.
HOSPITAL COURSE: Patient was admitted. Admission weight was
noted to be 83.8 kg and he was dosed with IL-2 600,000 IU/kg
equaling 50.3 mIU IV q.8h. for 14 planned doses, [**11-27**]
scheduled doses with dose #11 held due to hypotension and
doses 13 and 14 held related to mild neurotoxicity and severe
constitutional side-effects.
His course was notable for early hypotension initially
responding to fluid boluses later requiring dopamine and
Neo-Synephrine, vasopressor support. He was eventually
weaned from his pressors on day 11, but was noted to have a
CPK of 475 at that time. CK MB and troponin values were also
elevated. As per protocol, he was placed on a cardiac
monitor, and on [**3-26**] at 7 a.m., he had a run of question of
ventricular tachycardia. He was transferred to the Intensive
Care Unit for closer monitoring.
Cardiology felt his rhythm strip was from artifact rather
than true ventricular tachycardia. He had no acute ischemic
changes on EKG. Echocardiogram revealed mild aortic
regurgitation and mild mitral regurgitation with a left
ventricular ejection fraction slightly decreased at 50-55%.
Cardiac enzymes continued to trend downward and he remained
without any arrhythmia on telemetry. He was felt to have an
IL-2-induced myocarditis without myocardial infarction. He
was planned for an outpatient stress test to further evaluate
cardiac function. He was discharged to home on [**2136-3-27**]
with a normal CPK and no cardiac symptoms.
Other side-effects during his course included fevers and
chills, and an erythematous skin rash. He also had some
nausea and vomiting treated with antiemetic therapy. His
hemoglobin and hematocrit on [**2136-3-21**] were 9.4 and 28.9
respectively, and he was transfused with 2 units of packed
red blood cells to help support his blood pressure. He had a
mild thrombocytopenia with a minimum platelet count of 72,000
thought related to IL-2, which had improved to 98,000 on the
day of discharge and developed hyperbilirubinemia with a peak
bilirubin of 4.3 on [**3-24**], improved to 1.5 on [**3-24**]; mild
transaminitis with an ALT of 46 and an AST of 63 on
[**2136-3-24**] again improved before discharge.
He developed a mild metabolic acidosis with a CO2 of 19 on
[**3-24**], treated with bicarb and his maintenance IV fluids. He
had a mild renal insufficiency with a peak creatinine of 1.8
improved to 1.1 on the day of discharge. The side-effects
included mild diarrhea treated with antidiarrheals.
By [**2136-3-27**], he had recovered from myocarditis and other
side-effects to allow for discharge to home.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home with his wife.
DISCHARGE INSTRUCTIONS: The patient is to notify us for
fever or cardiac symptoms. He will have an outpatient
thallium stress test performed prior to his next planned week
of IL-2 therapy.
DISCHARGE MEDICATIONS:
1. Keflex 500 mg p.o. b.i.d. x5 days.
2. Ranitidine 150 mg p.o. b.i.d. prn nausea, acid stomach, or
while on NSAIDs.
3. Lomotil two tablets p.o. q.6h. prn diarrhea.
4. Compazine 10 mg p.o. q.6h. prn nausea.
5. Ativan 1 mg q.6h. prn nausea, or anxiety, or for sleep.
6. Benadryl 25-50 mg q.6h. prn pruritus.
7. Tylenol 650 mg p.o. q.4h. prn fever or pain.
8. Motrin 400 mg p.o. q.4h. prn pain.
9. Oxycodone 5-10 mg p.o. q.4h. prn pain.
10. Colace 100 mg p.o. b.i.d. prn constipation.
DIAGNOSIS: Status post cycle one, week one high-dose IL-2
for metastatic renal cell carcinoma with course complicated
by myocarditis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], M.D. [**MD Number(1) 7782**]
Dictated By:[**Last Name (NamePattern1) 43757**]
MEDQUIST36
D: [**2136-4-3**] 13:27
T: [**2136-4-5**] 07:21
JOB#: [**Job Number 55348**]
cc:[**Numeric Identifier 55349**]
|
[
"197.0",
"429.0",
"458.29",
"428.0",
"189.0",
"V58.1",
"276.2",
"396.3",
"287.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"00.15",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
211, 239
|
5744, 6674
|
2870, 5452
|
5554, 5721
|
1916, 1996
|
879, 1744
|
2011, 2852
|
152, 190
|
1766, 1893
|
5477, 5529
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,492
| 142,259
|
14761
|
Discharge summary
|
report
|
Admission Date: [**2193-1-9**] Discharge Date: [**2193-2-18**]
Date of Birth: [**2154-6-8**] Sex: F
Service: MEDICINE
Allergies:
Cefepime / Aztreonam / Levaquin
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Reinduction MEC therapy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Known firstname **] [**Known lastname **] is a 38-year-old Chinese-speaking female with a history
of secondary AML from her treatment for breast cancer, is
currently day 165 status post allogeneic stem cell transplant
from an unrelated donor for TBI and Cytoxan for conditioning
regimen. The donor was noted to be an antigen B mismatch, noted
to have an antigen mismatch as well as to B core positive
hepatitis B. The donor had a negative viral load. Ms. [**Known lastname **] had
been on lamivudine prophylactically. The patient had been doing
very well as an outpatient until a couple of weeks ago when she
is noted to have some blasts in the peripheral smear. Bone
marrow biopsy and aspirate revealed full both morphological and
cytogenetic evidence of disease relapse, noted at that to be 98%
donor. She was rapidly tapered off immunosuppression in order to
stimulate the donor T cells to hopefully initiated graft versus
leukemia effect. She has had no clear evidence of GVH at this
time, did develop a maculopapular rash and spotty areas around
the neck, back, torso, arms, and legs, which was very pruritic,
was evaluated by dermatology who thought that perhaps it was an
eczematous process possibly brought on by MRI contrast and was
not thought to be GVH, treated empirically initially with Lidex
ointment and then switched to triamcinolone cream with almost
complete resolution of the rash.
.
She has required periodic blood and platelet support since her
relapse. She recently has not had any evidence of circulating
blasts in her peripheral smear. She did have a bone marrow
biopsy and aspirate last week; the results are currently
pending. The patient reports that the rash had almost completely
resolved until a day or so ago when she had recrudescence of
some of her symptoms, started to use the triamcinolone cream
again and her symptoms have improved. She does continue to have
some mild pruritus in her chest and back. She notes that over
the last couple of days her eyes felt tired and dry. She notes
some pressure behind her right eye and has not really had any
headaches over the last couple of days but did have some
headaches a few weeks ago. We did an MRI which was essentially
negative. She continues to report significant fatigue and lack
of appetite. She denies any further back pain. Otherwise, denies
any nausea, vomiting, diarrhea, or constipation. Denies any
bleeding or bruising difficulties. Denies any fever, chills, or
night sweats. Denies any cough, shortness of breath, chest pain,
palpitations, or any other cardiac or respiratory difficulties.
Denies any lightheadedness or dizziness.
.
Past Medical History:
Past Medical History:
Secondary AML 11q23 mutation
breast CA
Graves' disease status post radioactive iodine treatment on
[**2190-9-14**] with subsequent hypothyroidism.
.
ONC Hx: She was diagnosed with Stage I (T1C, N0, M0) of right
breast diagnosed in [**2189**] and ductal in situ of the left breast
diagnosed in [**2189**].(LVI negative, ER positive, HER-2/neu
negative) She underwent wide excision with sentinel lymph node
procedure on the right along with wide excision of the left
breast. She also received four cycles of Adriamycin and Cytoxan
chemotherapy (completed in [**2190-11-3**]). Bilateral
mastectomies were performed in [**2191-1-26**]. Tamoxifen was
initiated in [**2191-2-1**] though was taken off at time of
diagnosis of AML.
Social History:
She is originally from [**Country 651**], moved here in [**2183**]. She lives in
[**Location 86**] with her parents. She denies tobacco, alcohol or illicit
drug use. She does not have children and is single.
Family History:
Sister with DM, no history of malignancy
Physical Exam:
PE: Young asain woman in NAD
VS: T 98.6 BP 120/65 HR 97 RR 18 97%RA
HEENT: PERRL, OP clear
Neck: No LAD
Lungs: CTAB
Cards: tachycardic, regular rhythm, 2/6 SEM at LUSB
ABD: +BS, scaphoid, ND, tender to deep palpation mcburney's pt,
no rebound, no guarding.
Ext: +2 pulses, no edema
Neuro: Nonfocal, 5/5 strength, sensation intact
Skin: No visible rashes
Pertinent Results:
Notable Admission Labs:
WBC 0.6
ANC 110
Hgb/Hct: 11.1/30.4
plts 9
BONE MARROW BIOPSY
Note: Myeloblasts in the aspirate account for 70% of the marrow
cellularity.
.
MICROSCOPIC DESCRIPTION
Peripheral Blood Smears:
The smear is adequate for evaluation. Erythrocytes show
anisopoikilocytosis with ovalocytes, dacrocytes. The white blood
cell count appears decreased. Hypogranular neutrophils are
present. Platelet count appears normal. Large forms are seen.
Giant forms are not present. The differential shows: 13%
neutrophils, 1% bands, 2% monocytes, 90% lymphocytes, <1%
eosinophils, <1% basophils, 3% blasts.
.
Aspirate Smears
The aspirated material is adequate for evaluation. The M:E ratio
is 3.6. Erythroid precursors are markedly decreased with
megaloblastic changes. Myeloid precursors appear markedly
decreased in number and show a left-shift in maturation.
Megakaryocytes are virtually absent. The differential shows: 70%
Blasts, 4% Promyelocytes, 4% Myelocytes, 2% Metamyelocytes, 1%
Bands/Neutrophils, 2% Plasma cells, 11% Lymphocytes, 3%
Erythroid, 3% of Promonocytes/Monocytes.
.
Clot Section and Biopsy Slides
The biopsy material is adequate for evaluation. The marrow
cellularity is approximately 10-20%. Hemosiderin-laden
macrophages are noted. The predominant population consists of
interstitial blasts greater than 70% of the marrow cellularity.
Erythroid precursors are decreased and present in small
clusters. Myeloid elements are decreased. Maturing myeloid
elements are greatly decreased. Megakaryocytes are decreased
with hypolobated forms and cells with disjointed nuclei. Marrow
clot section is not submitted. Touch prep is not submitted.
.
TTE [**1-10**]:
The left atrium is normal in size. There is borderline left
ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
leaflets are mildly thickened. No mitral regurgitation is seen.
There is a small pericardial effusion. There are no
echocardiographic signs of tamponade. Compared with the prior
study images reviewed) of [**2192-6-27**], there is now a small
pericardial effusion.
.
CT head [**1-24**]:
1. No intracranial hemorrhage or mass effect.
2. Persistent opacification of the right frontal sinus, anterior
right ethmoid air cell, and right maxillary sinus, the latter of
which is not completely included in the field of view.
.
CTA [**2193-2-3**]: No evidence of PE. Large pericardial and pleural
effusion.
.
Echo [**2193-2-3**]: Moderate circumferential pericardial effusion with
evidence of mildly increased pericardial pressures and global
biventricular hypokinesis. Mild mitral regurgitation. Compared
with the prior study (images reviewed) of [**2193-1-9**], the
pericardial effusion is larger (previously very small) and
global biventricular systolic dysfunction are now evident. These
findings are suggestive of myopericarditis or other diffuse
process. Serial evaluation is suggested.
.
Echo [**2193-2-8**]: The estimated right atrial pressure is 5-10 mmHg.
LV systolic function appears depressed. Right ventricular
chamber size and free wall motion are normal. There is a
moderate sized pericardial effusion (maximal posteriorly @ 1.9
cm, minimal anteriorly at 0.8 cm). No right ventricular
diastolic collapse is seen. There is brief right atrial
collapse, consistent with low filling pressures or early
tamponade. Compared to the prior study dated [**2193-2-6**], there is no
change. These findings are suggestive of elevated
intrapericardial pressures. Given the samll IVC
size and normal respirophasic variation, a component of
intravascular volume depletion should be considered.
Brief Hospital Course:
.
# Relapsed AML: Given the extent of disease involvement the
patient was admitted to the hospital to reinduce her with MEC in
order to cytoreduce her disease prior to receiving DLI. The
patient received 5 days of MEC therapy which she tolerated well.
She had an echo prior to starting treatment which showed normal
LV function. She has been pancytopenic and has required platelet
and blood transfusions to keep her crit > 25 and plt > [**9-21**].
After MEC a bone marrow was performed which showed a
hypocellular marrow with 85-90% blasts. Despite the aggressive
nature of the disease, a discussion was made with the family to
continue with DLI. DLI was not given after the patient became
hemodynamically unstable [**1-4**] pericardial tamponade and bilateral
pulmonary edema. A decision was made to make the patient
comfort measures and not pursue further aggressive treatment
given worsening bilateral pleural effusions and persistent
tamponade in the setting of disease recurrence. The patient
passed away peacefully with family at bedside.
.
# Febrile Neutopenia: Granulocyte count of 110 on admission.
Patient remained neutropenic thoughout this admission and
started to spike fever >102 on [**1-15**] and was started on
vancomycin and meropenem. She was already on fluconazole and
acyclovir already for prophylaxis given her neutropenia. All
culture data has been negative to date except for a urine cx
with 10,000-100,000 proteus mirabilis microorganisms. Repeat
urine cultures have been negative. On [**1-21**], pt developed a rash
and it was thought to be due to meropenem although the patient
had meropenem in the past without problem. Of note she does have
rash with aztreonam. She was taken off meropenem and started on
gentamicin. The rash was still present but not getting worse. On
[**1-26**] gentamycin was stopped and meropenem was restarted to
better cover gram negative bacteria as the patient was still
spiking fevers. On [**1-24**], the patient developed diarrhea and c
dif cultures were sent and are pending. At that time, pt was
started on flagyl. In addition, head CT showed some
opacification of ethmoid and frontal sinuses. Fungal cx sent and
is pending. CMV viral loads sent weekly have been negative. The
patient was switched briefly to Aztreonam but this too worsened
her rash and she was switched back to Gentamicin for gram
negative coverage. Her left subclavian line was discontinued
given that it was thought to be contributing to her fevers but
the patient continued to spike despite the line being removed.
She was eventually broadened to
Posaconazole/Gentamicin/Vancomycin/Flagyl but continued to spike
fevers of unclear etiology despite multiple blood cultures.
Upon transfer to the [**Hospital Unit Name 153**] for pericardial tamponade, the patient
continued to spike fevers up to 102. Voriconazole was added for
empiric fungal coverage. Voriconazole was switched to
Posaconazole for mucor coverage by ID recommendation and
switching Vancomycin to Daptomycin to avoid renal toxicity. A
repeat bone marrow biopsy was performed when the patient's
counts showed no signs of recovery. She was found to have
recurrent disease in her bone marrow. No source was identified
for her fevers. A discussion with the patient and her family
was held and a decision was made to make the patient comfort
care given her aggressive disease and worsening clinical course
with worsening respiratory distress from her pulmonary edema and
pericardial tamponade. She was given standing Tylenol to
prevent fevers and make the patient comfortable. She passed
peacefully with family at bedside.
.
# Skin rash- Thought to be due to meropenem which was stopped
[**1-23**] and restarted on [**1-26**] for better gram neg coverage as she
was still spiking temps. She was briefly switched to Aztreonam
which also seemed to worsen the rash. Dermatology saw the
patient and a biopsy showed spongiotic changes which were
thought to be more likely consistent with drug rash although
GVHD could not be ruled out. She was given Triamcinolone cream
for symptomatic relief and the rash slowly improved when she was
switched off Meropenem/Aztreonam to Gentamicin.
.
# Mucositis- Patient developed mucositis after reinduction with
MEC. She was given mouth care with nystatin, caphasol,
clotrimazole troches prior to mucositis. She was also being
covered for viral and fungal causes with fluconazole and
acyclovir. The fluconazole was switched to caspofungin when she
was still spiking fevers. Her pain was well-controlled with a
fentanyl pca and improved during her stay. Patient was start on
TPN since it was difficult for her to eat [**1-4**] mouth pain.
.
# Hypothyroidism- Continued on home dose of levothyroxine.
.
# History of Hep B positive donor- Continued prophylaxis with
lamivudine. Her Hepatitis B viral load was negative. This was
checked as her LFTS were elevated with MEC. They trended down to
normal after MEC was completed.
.
# Epistaxis- This occured in setting of plt count < 20 K. She
was given plts to keep goal > 35,000 and afrin nasal spray. ENT
consulted and nose was never packed. This did not happen again
during this admission.
.
# Pericardial effusion and Tamponade Physiology: On the day of
transfer to the [**Hospital Unit Name 153**], the patient was found to have increased
SOB and increasing O2 requirement. A chest CT showed evidence
of a pericardial effusion and TTE showing RA/RV collapse in
diastole. In the [**Hospital Unit Name 153**], the patient was monitored with serial
echos which showed persistent evidence of tamponade physiology.
The etiology of her pericardial effusion was unclear. The fluid
collection was not thought to be drainable given its posterior
location. She was diuresed as needed for volume overload
demonstrated on CXR. Ambisome was added for empiric fungal
coverage. Her echo continued to show evidence of worsening
tamponade physiology. Upon transfer back to the floor, the
patient's respiratory status worsened with tachycardia to the
150s, severe pulmonary edema and increased O2 requirement
despite diuresis. A discussion with the patient and her family
was held and the patient did not want to return to the ICU.
Instead, comfort care measures were pursued. The patient was
eventually placed on a Fentanyl gtt for respiratory distress and
made comfortable. She passed away peacefully with family at
bedside.
.
# Dispo: Please see above for details of hospital course. The
patient was found to have aggressive disease with recurrence of
AML in the marrow after the patient underwent MEC.
Concurrently, a large pericardial effusion was identified with
tamponade physiology and worsening pulmonary edema. A
discussion with the patient and her family was held and a
decision was made to make the patient comfort measures. She was
made comfortable on a Fentanyl gtt and passed peacefully with
her family at bedside.
.
Medications on Admission:
levothyroxine
lamivudine
Discharge Medications:
N/A
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
1. Secondary AML
2. H/O breast cancer
3. Pancytopenia
4. Pericardial effusion and Tamponade
5. Pleural effusions
.
Secondary
1. Hypothyroidism
Discharge Condition:
Patient passed away peacefully with her family at bedside.
Completed by:[**2193-2-18**]
|
[
"V42.82",
"692.9",
"780.6",
"428.0",
"288.09",
"V58.11",
"423.9",
"693.0",
"473.9",
"285.22",
"244.9",
"V10.3",
"599.0",
"518.81",
"784.7",
"787.91",
"379.91",
"E930.8",
"205.00",
"V02.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.25",
"00.14",
"99.04",
"41.31",
"99.05",
"99.15",
"86.11"
] |
icd9pcs
|
[
[
[]
]
] |
15317, 15323
|
8304, 15214
|
314, 320
|
15518, 15607
|
4424, 4432
|
3991, 4034
|
15289, 15294
|
15344, 15497
|
15240, 15266
|
4049, 4405
|
251, 276
|
348, 2979
|
4448, 8281
|
3023, 3749
|
3765, 3975
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,058
| 146,725
|
40258
|
Discharge summary
|
report
|
Admission Date: [**2196-2-23**] Discharge Date: [**2196-2-29**]
Date of Birth: [**2114-8-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2196-2-23**] - Aortic Valve Replacement (23mm St. [**Male First Name (un) 923**]
porcine)/Coronary [**Last Name (un) **] bypass graft x 1 (Left internal mammary
artery to left anterior descending)
History of Present Illness:
This is an 81 year old male with known coronary artery disease
and severe aortic stenosis. He is s/p drug eluting stent to the
LAD in [**2194-4-30**]. He has recently noted exercise intolerance,
increasing fatigue and dyspnea on exertion. Given echo and
cardiac catheterization findings, he has been referred for
surgical intervention.
Past Medical History:
Aortic Stenosis
Coronary Artery Disease
s/p DES to LAD [**2194-4-30**]
Hypertension
Hyperlipidemia
Hearing Loss
Osteoarthritis
Chronic Constipation
Torn Right Rotator Cuff
Social History:
Last Dental Exam: Full dentures
Lives with: married has 4 children, 7 grand-children
Occupation: retired
Tobacco: quit [**2162**], approx 30 PYH
ETOH: occasional beer, no history of ETOH abuse
Family History:
Denies premature coronary artery disease
Physical Exam:
BP: 146/60 Pulse: 77 Resp: 16 O2 sat: 98% room air
General: Elderly male in no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x] - full dentures noted
Neck: Supple [x] Full ROM [x] - no JVD
Chest: Lungs clear bilaterally [x], slightly decreased at bases
Heart: RRR [x] Irregular [] Murmur 4/6 SEM ejection murmur
radiating to carotids and precordium
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema 1+ L>R
Varicosities: None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: 2 Left: 2
DP Right: 1 Left: 1
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 2 Left: 2
Carotid Bruit: transmitted murmurs noted
Pertinent Results:
[**2196-2-29**] 06:40AM BLOOD WBC-8.7 RBC-3.28* Hgb-9.7* Hct-28.3*
MCV-86 MCH-29.6 MCHC-34.4 RDW-13.9 Plt Ct-202
[**2196-2-26**] 05:16PM BLOOD WBC-11.0 RBC-3.57* Hgb-10.6* Hct-30.7*
MCV-86 MCH-29.7 MCHC-34.5 RDW-14.4 Plt Ct-129*
[**2196-2-24**] 02:09AM BLOOD WBC-12.0* RBC-2.70* Hgb-8.2* Hct-23.0*
MCV-85 MCH-30.6 MCHC-35.8* RDW-13.6 Plt Ct-135*
[**2196-2-26**] 12:09AM BLOOD PT-13.2 PTT-28.4 INR(PT)-1.1
[**2196-2-29**] 06:40AM BLOOD UreaN-27* Creat-1.0 Na-138 K-4.0 Cl-103
[**2196-2-28**] 04:50AM BLOOD Glucose-112* UreaN-29* Creat-1.2 Na-139
K-3.7 Cl-102 HCO3-30 AnGap-11
[**2196-2-23**] 01:11PM BLOOD UreaN-22* Creat-1.1 Na-139 K-3.5 Cl-111*
HCO3-26 AnGap-6*
Brief Hospital Course:
Mr. [**Known lastname 88365**] was admitted to the [**Hospital1 18**] on [**2196-2-23**] for surgical
management of his cardiac disease. He was taken to the Operating
Room where he underwent coronary artery bypass grafting to one
vessel and replacement of his aortic valve. Please see operative
note for details. Postoperatively he was taken to the intensive
care unit for monitoring. He was transfused with red blood cells
for postoperative anemia. On postoperative day one, he awoke
neurologically intact and was extubated. He developed rate
controlled atrial fibrillation which was monitored. His
electrolytes were repleted. Beta blockade, aspirin, statin and
diuretics were resumed. He was gently diuresed towards his
pre-op weight. Chest tubes and epicardial pacing wires were
removed per protocol.
He was transferred to the step-down floor on post-op day three
for further care. On post-op day four he complained of double
vision (has h/o glaucoma) and Ophthalmology was consulted. The
following day Neurology was consulted and he underwent a
head/neck MRI/MRA which demonstrated extensive microvascular
calcification and atherosclerosis. The ventricles were dilated
as well, however, there were no acute changes and his vision
improved somewhat.
He was transfered to [**Location (un) 38076**] House in [**Location (un) 47**] for further
recovery on [**2-29**].
Medications on Admission:
Zocor 40mg daily, Aspirin 81mg daily, Xalatan eye gtts, HCTZ
12.5mg daily, Diovan 80mg daily
Discharge Medications:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
5. influenza vaccine tr-s 10 (PF) 45 mcg (15 mcg x 3)/0.5 mL
Syringe Sig: One (1) ML Intramuscular NOW X1 (Now Times One
Dose).
6. pneumococcal 23-valps vaccine 25 mcg/0.5 mL Injectable Sig:
0.5 ML Injection NOW X1 (Now Times One Dose).
7. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2
times a day): one tablet [**Hospital1 **] for two weeks then one tablet
daily.
9. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
10. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7
days.
11. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
12. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime): OU.
13. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for fever or pain.
14. warfarin 1 mg Tablet Sig: as ordered Tablet PO once a day:
INR goal 2-2.5.
15. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours for
4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 38076**] House - [**Location (un) 47**]
Discharge Diagnosis:
Aortic Stenosis and Coronary Artery Disease s/p Aortic Valve
Replacement and Coronary artery bypass graft x 1
Past medical history:
s/p DES to LAD [**2194-4-30**]
Hypertension
Hyperlipidemia
History of Epistaxis, s/p cauterization
Hearing Loss
Osteoarthritis
Chronic Constipation, requires laxatives frequently
Torn Right Rotator Cuff
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema - trace
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 provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on: [**3-24**] at 9am at [**Hospital1 **] Heart Center
[**Telephone/Fax (2) 6256**]
Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] on [**4-1**] at 12 noon [**Telephone/Fax (1) 6256**]
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] in [**5-3**] weeks [**Telephone/Fax (1) 20261**]
**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:[**2196-2-29**]
|
[
"414.01",
"424.1",
"368.2",
"389.9",
"458.29",
"V45.82",
"E878.2",
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"427.31",
"434.11",
"564.00",
"272.4",
"401.9",
"285.1",
"V15.82",
"997.02",
"998.11",
"715.90",
"V70.7",
"365.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"36.15",
"39.61",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
5824, 5907
|
2779, 4151
|
296, 497
|
6286, 6467
|
2092, 2756
|
7355, 8003
|
1286, 1328
|
4294, 5801
|
5928, 6039
|
4177, 4271
|
6491, 7332
|
1343, 2073
|
237, 258
|
525, 865
|
6061, 6265
|
1076, 1270
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,743
| 109,381
|
35163
|
Discharge summary
|
report
|
Admission Date: [**2134-5-6**] Discharge Date: [**2134-6-6**]
Date of Birth: [**2058-2-27**] Sex: M
Service: MEDICINE
Allergies:
Nadolol / Propranolol / Lidocaine Hcl/Epinephrine
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
Central Venous Line Placement
Arterial Line Placement
Intubation
Mechanical Intubation
Tracheostomy
Lumbar Puncture
Temporary hemodialysis catheter placement
History of Present Illness:
Mr. [**Known lastname 80259**] is a 76M with DM and cirrhosis who presented to an
OSH on [**5-3**] with 3d of lethargy, headache, and diarrhea. Patient
was reportedly well until the week prior to transfer when he
developed a watery diarrhea. Family noticed that he seemed to be
more lethargic toward the end of the week. Over the weekend,
complained of a frontal headache -- intense, unusual for him.
His headache worsened over the weekend and by [**5-3**] was severe.
Family noticed that gait was abnormal and he was "shuffling." He
felt shaky and cold, and had difficulty standing. At that point,
wife brought him to another hospital. No travel or known sick
contacts, but he had eaten a cheese/seafood dish which was
unusual for him. No n/v, abdominal pain, melena, hematochezia,
neck stiffness, photophobia, chest discomfort, dyspnea, dysuria.
Denies any travel.
.
At the OSH, empiric ceftriaxone, vancomycin, flagyl, and
acyclovir were initiated upon admission. His respiratory status
remained poor. He was intubated due to respiratory distress the
morning of [**5-4**]. He was started on pressors and admitted to the
CCU. Blood cultures subsequently grew out listeria, and
ampicillin was initiated on [**5-4**], ceftriaxone was continued.
.
Hemodynamically he improved and neosynephrine was weaned off by
[**5-6**] AM. Hospital course notable for Cr rise to 3.3, and
elevation of transaminases to 1000s. He underwent a paracentesis
on [**5-5**] with removal of 900cc of fluid. Albumin was initiated at
25mg [**Hospital1 **]. He was also found to have a troponin elevation to 17,
and echocardiogram showed an EF depressed to 15%. His mental
status remained poor. No LP was done. CXR and CT head were
apparently unremarkable, CT abdomen on admission showed ascites.
.
Given deteriorating liver and kidney function transferred to
[**Hospital1 18**] for further workup.
Past Medical History:
Crytogenic cirrhosis ?[**1-25**] NASH - Grade 2 varices s/p banding.
h/o hypotension with betablockers
DM
Diverticulosis
HTN
Hyperlipidemia
Chronic low back pain
s/p appendectomy
s/p tonsillectomy
h/o L hydrocele repair
+PPD
Social History:
Married. Former smoker, h/o heavy EtoH. Per d/w son he is still
drinking fairly regularly.
Family History:
no liver disease
Physical Exam:
Vitals 97.2 96 107/80 19 98% on PSV
HEENT conjugate gaze, PEARL, +scleral icterus
Neck supple
CV regular s1 s2 no m/r/g
Pulm lungs clear bilaterally
Abd soft nontender +bowel sounds no hsm
Extrem feet cool with diminished pulses, cyanotic however radial
pulses are palpable. dopplerable L PT, R PT and DP. 1+ edema
Neuro intubated and sedated. PEARL. toes downgoing bilaterally.
Derm jaundiced no rash
Lines/tubes/drains R groin line without exudate or erythema
Pertinent Results:
ADMISSION LABS
[**2134-5-6**] 09:30PM WBC-10.9# RBC-5.01 HGB-12.9* HCT-38.9*
MCV-78* MCH-25.8* MCHC-33.2 RDW-17.1*
[**2134-5-6**] 09:30PM NEUTS-89.8* LYMPHS-5.7* MONOS-4.1 EOS-0.1
BASOS-0.3
[**2134-5-6**] 09:30PM PLT SMR-VERY LOW PLT COUNT-74*
[**2134-5-6**] 09:30PM PT-24.3* PTT-44.1* INR(PT)-2.4*
[**2134-5-6**] 09:30PM ALT(SGPT)-1050* AST(SGOT)-[**2118**]* ALK PHOS-93
TOT BILI-2.9* DIR BILI-1.9* INDIR BIL-1.0
[**2134-5-6**] 09:30PM CALCIUM-8.0* PHOSPHATE-7.6* MAGNESIUM-2.4
[**2134-5-6**] 09:30PM GLUCOSE-140* UREA N-84* CREAT-4.2*#
SODIUM-135 POTASSIUM-5.2* CHLORIDE-103 TOTAL CO2-10* ANION
GAP-27*
[**2134-5-6**] 09:36PM LACTATE-6.1*
[**2134-5-6**] 09:36PM TYPE-[**Last Name (un) **] PO2-183* PCO2-26* PH-7.22* TOTAL
CO2-11* BASE XS--15 COMMENTS-GREEN-TOP
Brief Hospital Course:
Patient was admitted to [**Hospital1 18**] on [**2134-5-7**] with lethargy,
headache, diarrhea, and confusion.
OSH COURSE:
He originally presented to an OSH on [**5-3**] with 3 days of these
symptoms. He had developed watery diarrhea 1 week prior to
transfer to [**Hospital1 18**]. His family noted that his gait was abnormal
and "shuffling." At OSH, empiric ceftriaxone, vancomycin,
Flagyl, and acyclovir were initiated upon admission. He was
intubated due to poor respiratory status on [**2134-5-4**] at OSH. He
was started on pressors and admitted to the CCU. Blood cultures
subsequently grew out listeria, and ampicillin was initiated on
[**2134-5-4**]. Ceftriaxone was continued. Hemodynamically, he
improved at OSH, and neo synephrine was weaned off by [**2134-5-6**]
AM; however, his Cr rose to 3.3 and transaminitis to 1000s. 900
cc Para on [**2134-5-5**]. Troponin elevated to 17 and echo showed
depressed EF of 15%. Mental status remained poor. No LP was
done. CT on admission with ascites. Given deteriorating liver
and kidney function, he was transferred to [**Hospital1 18**] on [**2134-5-7**].
[**Hospital 18**] HOSPITAL COURSE:
# Pulm: The patient remained intubated and on mechanical
ventilation while at [**Hospital1 18**]. During his hospitalization, his
course was complicated by aspiration pneumonia, which was
treated with antibiotics. He ultimately had a tracheostomy.
# ID: The patient's listeriosis was treated with ampicillin and
bactrim for prolonged course. Infectious disease was consulted
and helped in management of his antibiotics. MRI showed small
abscesses in his brain and signals consistent with
cerebritis/meningitis. On [**2134-5-25**], his blood cultures grew out
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 29361**]. All of his lines were cultured and resited.
These line cultures also grew out yeast. He was treated for
fungemia. TTE was negative for vegetations. LP was performed
by IR on [**2134-5-31**] thus far with unrevealing results. He was on
antibiotics for the duration of his hospitalization until CMO
status was decided.
# Renal: Renal assisted in management of his acute renal
failure, which was thought to be due to ATN. The patient had
temporary HD lines placed for CVVH. He continued on CVVH while
hospitalized.
# CV: Patient noted to have troponin leak which was likely
demand ischemia in the setting of acute illness rather than a
primary plaque rupture event. Cardiology was initially
consulted. The patient's troponins were trended.
# Neuro: During his hospitalization, his neurological status was
complicated by seizures which were likely due to small abscesses
[**1-25**] his infection. Neurology was consulted and assisted in
management of his anti-epileptic medication. Additionally, EEGs
were performed which showed moderate diffuse cerebral
dysfunction.
# GI: Liver team consulted due to transamnitis likely in the
setting of sepsis. Trended LFTs daily. Held spirinolactone.
The patient expired on [**2134-6-6**] at 0115 with family at bedside
after having been made comfort measures only. Primary cause of
death due to sepsis secondary to listeriosis and fungemia.
Medications on Admission:
Home:
HCTZ 25mg daily
Metformin 1000mg [**Hospital1 **]
Omeprazole 40mg [**Hospital1 **]
Spironolactone 25mg TID
Cholestyramine 4g daily
Ursodiol 500mg [**Hospital1 **]
Ferrous sulfate 325mg daily
MVT
Fish oil tablets
.
Albumin 50g IV BID
ampicillin 2g Iv q8h
ceftriaxone 1g [**Hospital1 **]
protonix 40 IV BID
lactulose 30mL q8h
aspirin 81mg daily
meoprolol 2.5mg IV q6h
combivent prn
humalog insulin sliding scale
dulcolax, zofran, albututerol, dulcolax prn
Discharge Medications:
None - Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnosis:
1. Sepsis secondary to listeriosis and fungemia
2. Aspiration pneumonia
3. Seizures
4. Anuric Renal Failure
Secondary Diagnosis:
1. Diabetes
2. Alcoholic Cirrhosis
Discharge Condition:
Expired
Discharge Instructions:
Expired.
Followup Instructions:
Expired.
Completed by:[**2134-6-6**]
|
[
"410.71",
"428.0",
"507.0",
"785.52",
"780.39",
"112.5",
"571.2",
"572.3",
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"320.7",
"572.2",
"285.1",
"250.00",
"570",
"584.5",
"401.9",
"324.0",
"996.62",
"027.0",
"286.6",
"276.7",
"414.8",
"428.21",
"276.2",
"995.92",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.93",
"43.11",
"33.22",
"38.95",
"96.72",
"44.13",
"96.6",
"39.95",
"31.1",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
7808, 7817
|
4074, 5215
|
315, 475
|
8045, 8055
|
3269, 4051
|
8112, 8151
|
2752, 2770
|
7769, 7785
|
7838, 7838
|
7285, 7746
|
5232, 7259
|
8079, 8089
|
2785, 3250
|
269, 277
|
503, 2378
|
7987, 8024
|
7857, 7966
|
2400, 2628
|
2644, 2736
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,145
| 191,289
|
791
|
Discharge summary
|
report
|
Admission Date: [**2190-3-8**] Discharge Date: [**2190-3-16**]
Date of Birth: [**2107-11-21**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
N-G tube placement
History of Present Illness:
Mr. [**Known lastname **] is an 82 yo male s/p prolonged hospital and
rehabilitation course following XRT for [**Location (un) 5668**] cell carcinoma
who presents with acute onset shortness of breath at [**Hospital 100**]
Rehab earlier today. Per report, oxygen saturation dropped to
84-85% on 4L NC from baseline in the mid 90's. He was
hypotensive with SBP's in the 80's, which resolved with IVF. Per
report from [**Hospital 100**] Rehab, patient was noted to have new thick
brown sputum with difficulty swallowing. He was recently started
on levofloxacin/flagyl three days ago for treatment of a
presumed aspiration pneumonia.
.
Of note, he was admitted to NEBH in [**Month (only) 1096**] for ? pneumonia,
then discharged to rehab and readmitted for dyspnea and
hemoptysis. He was placed on BiPAP and later intubated with a
two-week course complicated by ARDS, ARF requiring temporary HD,
acute delirium, and thrombocytopenia. He was treated with a
steroid taper for COPD exacerbation and broad spectrum
antibiotics. He was discharged to [**Hospital 100**] Rehab on [**1-29**].
Per his wife, he has made significant gains over the past month
while at [**Hospital 100**] Rehab.
.
On arrival to the ED, SpO2 95% on NRB, RR 32, HR 96, BP 121/47.
He received vancomycin 1 g IV, Cefepime 2 g IV, solumedrol 125
mg IV, and a combivent neb.
Past Medical History:
COPD
CAD
Anemia of chronic disease
Chronic dementia
Chronic renal insuffciency
h/o alcohol abuse
Recent treatment for aspiration pneumonia
Hypertension
Hyptothyroidism
Pancytopenia
[**Location (un) 5668**] cell skin cancer of right temple s/p resection + XRT
x/p laser TURP
s/p spine surgeries in the [**2172**]'s
Social History:
Until recent fall and spine surgery, patient lived with his wife
and was independent with [**Name (NI) 5669**]. He smoked until [**2189-12-10**]
(1.5 PPD) and has a h/o alcohol abuse, quit 5-10 years ago. At
baseline he ambulates with a rolling walker.
Family History:
NC
Physical Exam:
PHYSICAL EXAM:
VS: T 98, BP 119/51, HR 88, SpO2 93% on 50% shovel mask, RR 30
Gen: elderly [**Male First Name (un) 4746**], resting comfortably, slightly diaphoretic
HEENT: multiple actinic keratoses over scalp, MMM, sclerae
anicteric
CV: RRR, difficult to auscultate [**3-13**] upper airway sounds
Resp: coarse rhonchi throughout lung fields. No abdominal
accessory muscle use, no nasal flaring.
Abdomen: soft nt/nd, normoactive BS
Extrem: diffuse muscle wasting, no peripheral edema, calf
tenderness, cords
Pertinent Results:
[**2190-3-8**] 03:15AM WBC-17.7*# RBC-3.62* HGB-11.1* HCT-34.5*
MCV-95# MCH-30.5 MCHC-32.1 RDW-15.5
[**2190-3-8**] 03:15AM NEUTS-75* BANDS-10* LYMPHS-9* MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2190-3-8**] 03:15AM PLT SMR-NORMAL PLT COUNT-373#
[**2190-3-8**] 03:15AM PT-17.4* PTT-31.9 INR(PT)-1.6*
[**2190-3-8**] 03:23AM LACTATE-1.1
[**2190-3-8**] 03:31AM proBNP-2673*
[**2190-3-8**] 03:31AM GLUCOSE-128* UREA N-48* CREAT-1.8* SODIUM-145
POTASSIUM-5.2* CHLORIDE-112* TOTAL CO2-22 ANION GAP-16
[**2190-3-8**] 04:15AM PO2-36* PCO2-51* PH-7.31* TOTAL CO2-27 BASE
XS--1
[**2190-3-8**] 08:41AM O2 SAT-99
[**2190-3-8**] 08:41AM LACTATE-0.6
[**2190-3-8**] 08:41AM TYPE-ART PO2-189* PCO2-45 PH-7.32* TOTAL
CO2-24 BASE XS--3
[**2190-3-8**] 10:27AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-LG
[**2190-3-8**] 10:27AM URINE RBC-1 WBC-74* BACTERIA-FEW YEAST-MANY
EPI-0
[**2190-3-8**] 10:27AM URINE HOURS-RANDOM CREAT-70 SODIUM-16
POTASSIUM-43
[**2190-3-8**] 03:48PM GLUCOSE-168* UREA N-46* CREAT-1.6*
SODIUM-148* POTASSIUM-4.3 CHLORIDE-116* TOTAL CO2-23 ANION
GAP-13
[**2190-3-8**] 03:48PM CALCIUM-7.8* PHOSPHATE-3.9 MAGNESIUM-2.0
[**2190-3-13**] 06:05AM BLOOD WBC-26.3* RBC-3.32* Hgb-10.1* Hct-31.4*
MCV-95 MCH-30.5 MCHC-32.2 RDW-16.3* Plt Ct-330
[**2190-3-13**] 06:05AM BLOOD Neuts-93* Bands-0 Lymphs-4* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2190-3-16**] 03:06AM BLOOD WBC-26.2* RBC-3.56* Hgb-10.4* Hct-33.9*
MCV-95 MCH-29.3 MCHC-30.7* RDW-16.8* Plt Ct-376
[**2190-3-13**] 06:05AM BLOOD PT-15.1* PTT-34.7 INR(PT)-1.3*
[**2190-3-16**] 03:06AM BLOOD Glucose-139* UreaN-26* Creat-1.6* Na-146*
K-4.1 Cl-114* HCO3-25 AnGap-11
[**2190-3-16**] 03:06AM BLOOD CK(CPK)-15*
[**2190-3-16**] 03:06AM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2190-3-16**] 03:06AM BLOOD Calcium-7.8* Phos-3.7 Mg-2.3
[**2190-3-13**] 06:05AM BLOOD Calcium-7.2* Phos-2.5* Mg-1.7 Iron-36*
[**2190-3-9**] 03:20AM BLOOD Albumin-1.9* Calcium-7.5* Phos-3.9 Mg-2.0
[**2190-3-13**] 06:05AM BLOOD calTIBC-73* VitB12-1530* Folate-8.6
Hapto-321* Ferritn-1214* TRF-56*
[**2190-3-12**] 05:30AM BLOOD Type-ART pO2-62* pCO2-49* pH-7.25*
calTCO2-23 Base XS--5
[**2190-3-16**] 02:23AM BLOOD Type-ART pO2-81* pCO2-78* pH-7.11*
calTCO2-26 Base XS--6
[**2190-3-16**] 04:15AM BLOOD Type-ART pO2-76* pCO2-53* pH-7.26*
calTCO2-25 Base XS--3 Intubat-NOT INTUBA Comment-BIPAP
[**2190-3-16**] 02:23AM BLOOD Glucose-137* Lactate-0.7 Na-141 K-3.8
Cl-111
[**2190-3-8**] 08:41AM BLOOD O2 Sat-99
[**2190-3-13**] 09:46AM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2190-3-13**] 09:46AM URINE RBC-0-2 WBC->50 Bacteri-FEW Yeast-MOD
Epi-0 RenalEp-0-2
.
Micro:
BCx: negative x 4
UCx: yeast x 2
Urine negative for legionella
Stool Cx: cdiff positive
Sputum: MRSA
MRSA screen + x 2
.
Reports:
CHEST (PORTABLE AP) [**2190-3-8**] 3:20 AM
AP PORTABLE CHEST: Heart size, mediastinal contours are within
normal limits. The aorta is mildly tortuous and there are
atherosclerotic calcifications of the arch. There is patchy
airspace consolidation at the right lung base which partially
obscures the hemidiaphragm consistent with right lower lobe
pneumonia. There is no pleural effusion on this radiograph that
does not fully include the right costophrenic sulcus. Left lung
is clear. No pneumothorax. The acromioclavicular joints appear
narrowed bilaterally.
IMPRESSION: Right lower lobe pneumonia.
.
ECG Study Date of [**2190-3-8**] 3:20:30 AM
Sinus rhythm. Atrial ectopy. Ventricular ectopy. Non-specific
inferior
ST-T wave changes. Compared to the previous tracing the rate is
faster and
ectopy is present.
TRACING #1
.
ECG Study Date of [**2190-3-8**] 8:47:02 AM
Sinus rhythm. Atrial ectopy. Non-specific inferior ST-T wave
changes.
Compared to the previous tracing ventricular ectopy is no longer
present.
TRACING #2
.
CHEST (PORTABLE AP) [**2190-3-9**] 5:17 AM
FINDINGS: In comparison with the study of [**3-8**], there is poor
definition of the left hemidiaphragm with some increased
opacification suggesting atelectasis or pneumonia at the left
base. The right basilar opacification is again seen and probably
is of little change.
The upper lung zones are clear.
.
[**2190-3-9**] 2:07 PM CHEST (PORTABLE AP)
CHEST, SUPINE PORTABLE: Comparison is made to earlier on the
same day. A new nasogastric tube terminates in the stomach.
However, the sidehole lies only immediately beyond the expected
site of the gastroesophageal junction. The mediastinal and hilar
contours are unchanged. Bibasilar parenchymal opacities are also
unchanged.
IMPRESSION: New nasogastric tube terminating in the stomach.
However, the tube could be advanced further in order to gain
greater purchase, as the side hole lies near the
gastroesophageal junction.
.
[**2190-3-9**] 4:26 PM CHEST (PORTABLE AP)
FINDINGS: In comparison with earlier study of this date, there
is little change in the position of the nasogastric tube. The
side port remains in the region of the GE junction, and the tube
should be advanced 6-10 cm for optimal positioning.
Little change in the appearance of the heart and lungs.
.
ECHO [**2190-3-9**]:
Conclusions
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. Regional left ventricular wall
motion is normal. There is mild global left ventricular
hypokinesis (LVEF = 50%), which may be partially due to rhythm
(appears to be atrial fibrillation based on the transmitral
Doppler profile). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Mild global left ventricular systolic dysfunction.
Mild mitral regurgitation.
.
CHEST (PORTABLE AP) [**2190-3-10**] 10:34 AM
Nasogastric tube terminates below the diaphragm within the
stomach. Cardiomediastinal contours are unchanged. Right
perihilar and bibasilar opacities appear similar to the previous
examination. Bilateral small-to- moderate pleural effusions are
partially layering on this semi-upright radiograph, and there
are possible calcified pleural plaques. PA and lateral
radiograph prior to discharge may be helpful to confirm this
impression.
.
[**2190-3-12**] 7:20 PM
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST
CT OF THE ABDOMEN WITHOUT IV CONTRAST: Incompletely visualized
are small-to- moderate sized bilateral pleural effusions with
associated atelectasis of the dependent lower lobes. Coronary
artery calcifications are present.
Evaluation of the solid organs is limited by the non- contrast
technique.
Numerous punctate calcifications are noted scattered throughout
the liver and spleen consistent with old granulomatous disease.
There is a small splenule adjacent to the spleen. There are
extensive abdominal arterial vascular calcifications due to
atherosclerosis. There are cysts of the left kidney and other
small hypodensities too small to characterize. The right kidney
is abnormally small, cystic, and atrophic with coarse
calcification along its medial aspect from old insult. There is
no hydronephrosis. The pancreas is atrophic. The gallbladder is
unremarkable.
Extensive soft tissue and mesenteric edema and a small amount of
ascites is noted. Oral contrast has passed through to the
splenic flexure of colon. There are no dilated loops of small or
large bowel. There is no evidence of obstruction or
pneumoperitoneum. There are numerous colonic diverticula. The
descending and sigmoid colon are not well evaluated due to lack
of oral contrast opacification and distention. Extensive
mesenteric edema and small amount of ascites also complicates
assessment for wall thickening; however, there is apparent wall
thickening of the sigmoid and lower descending colon, as well as
the cecum. There is no loculated fluid collection or abscess.
CT OF THE PELVIS WITHOUT IV CONTRAST: The right hip arthroplasty
causes streak artifact which somewhat obscures the pelvis. Small
amount of ascites layers into the pelvis. Stool is present in
the rectum. Foley catheter is in the bladder.
BONE WINDOWS: There are extensive degenerative changes of the
visualized spine. Patient is status post laminectomy.
IMPRESSION:
1. Wall thickening involving the sigmoid colon and possibly
cecum consistent with colitis, more likely infectious. No
evidence of megacolon or pneumoperitoneum. No abscess
identified, within the limits of noncontrast examination.
2. Diverticulosis.
3. Extensive atherosclerosis of the abdominal aorta and
arteries.
4. Atrophic right kidney.
5. Anasarca.
6. Small-to-moderate bilateral pleural effusions.
.
CHEST (PORTABLE AP) [**2190-3-12**] 5:08 AM
IMPRESSION: AP chest compared to [**3-9**] and 30:
Moderate bilateral pleural effusion right greater than left has
increased more substantially on the right than the left since
[**3-9**]. Mild cardiomegaly and mediastinal vascular
engorgement have worsened. Right lower lung is obscured by
effusion, left shows increasing atelectasis. Upper lungs are
clear aside from mild vascular engorgement. Nasogastric tube
ends in the stomach. No pneumothorax.
Sequence of changes suggests earlier left heart failure has
progressed to biventricular or predominantly right-sided
decompensation.
.
ECG Study Date of [**2190-3-12**] 5:14:32 AM
Sinus rhythm and occasional atrial ectopy. Diffuse non-specific
ST-T wave
changes. Compared to the previous tracing of [**2190-3-8**] no
diagnostic interim
change.
.
CHEST PORT. LINE PLACEMENT [**2190-3-13**] 2:40 PM
FINDINGS: There is a new right PICC line with tip in the right
atrium. There is an NG tube coiled in the stomach. There are
moderate bilateral pleural effusions with bilateral lower lobe
volume loss. An underlying infectious infiltrate cannot be
excluded. The appearance of the lungs is not significantly
changed compared to the film from the prior day.
.
CHEST (PORTABLE AP) [**2190-3-14**] 12:45 PM
FINDINGS: The NG tube tip is in the stomach. There is moderate
bilateral pleural effusions and bilateral lower lobe volume
loss. An underlying infiltrate cannot be excluded. There is
pulmonary vascular redistribution and perihilar haze, suggesting
CHF. The right PICC line is unchanged.
.
CHEST (PORTABLE AP) [**2190-3-15**] 11:27 AM
FINDINGS: In comparison to the previous examination, the size of
the cardiac silhouette is slightly decreased. The extent of the
bilateral pleural effusions is stable. Moderate bibasilar
atelectasis, no secure evidence of pneumonia. The nasogastric
tube is in unchanged position.
IMPRESSION: Otherwise, no relevant changes.
.
ECG Study Date of [**2190-3-15**] 11:30:46 AM
Sinus rhythm. P-R interval is 110 milliseconds. Poor R wave
progression
across the anterior precordial leads, probably a normal variant.
Non-specifc inferior and lateral ST-T wave changes. Compared to
the previous tracing of [**2190-3-12**] no atrial ectopy is seen. The
other findings are similar.
.
CHEST (PORTABLE AP) [**2190-3-16**] 2:17 AM
SINGLE VIEW, CHEST: Moderate bilateral pleural effusion
unchanged. No focal consolidation. Lung fields are clear. No
pneumothorax. Unchanged aortic knob calcification. Hilar
contour, cardiomediastinal silhouettes are within normal limits.
The heart size is upper limit of normal. NG tube with tip in the
stomach is noted.
IMPRESSION: Unchanged moderate layering bilateral pleural
effusion. No acute cardiopulmonary process or significant
changes since prior radiograph.
Brief Hospital Course:
The patient was admitted to the medical ICU with a diagnosis of
pnemonia, likely aspiration. He was given broad spectrum
antibiotics including Vancomycin and Zosyn. His course was
notable for decreased urine output, which responded well to
fluid boluses. Also, he developed atrial fibrillation on the
evening of the 28th. This was managed with Digoxin and
metoprolol. He had difficulty swallowing and an NG tube was
placed. A stool culture was positive for C-Difficile and he was
started on metronidazole. He has a baseline dementia and he did
become agitated with placement of the NG tube necessitating
restraints. He was transferred to the floor, where he remained
on vanc/zosyn. He continued to have intermittent desats thought
to be [**3-13**] to mucous plugging, and his floor course was notable
for significant pulmonary congestion. Sputum grew out MRSA,
urine grew out yeast. CT abdomen was suspicious for colitis.
His flagyl was changed to PO vancomycin. He was maintained on
metoprolol 12.5 [**Hospital1 **] for rate control of his afib. He then
experienced acute hypoxia, and was transferred to the MICU on
[**2190-3-16**]. This was likely another aspiration event. There, his
wife requested [**Name (NI) 3225**] status, his non-comfort medications were
discontinued, and he subsequently expired on [**2190-3-16**].
.
[**Last Name **] problem list:
.
#) Chronic renal insufficiency: He had low urine output during
his stay, responsive to IVF. Per report, baseline creatine s/p
prolonged ICU course in [**Month (only) 1096**] is ~1.8. His Cr ranged from 1.5
to 1.8 during his stay.
.
#) Anemia: consistent with anemia of chronic inflammation
.
#) CAD: Unknown anatomy. Continued on ASA 81 mg daily. ECHO as
above.
.
#) Hypothyroidism: Continued on Synthroid.
.
#) PPx: Pneumoboots, PPI. Per report, patient has a history of
thrombocytopenia, presumed secondary to heparin products, but no
documented HIT-antibody. Wife reports heparin as an allergy. Per
lab, HIT antibody is low yield when platelets are not low.
.
#) FEN: failed speech and swallow with recommendations for NPO.
Possible PEG tube, though PEG tube not likely to stop
aspiration. Family did not seem to be interested in PEG tube, so
one was never placed. He received tube feeds though NGT during
his stay.
.
#) Contact: [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 5670**].
Medications on Admission:
Metronidazole 500 mg IV q8 hours
Levofloxacin 750 mg qOD
Colace 250 mg daily
Ferrous sulfate 325 mg daily
Advair 250/50 diskus
Synthroid 50 mcg daily
Senna 2 tabs qHS
Tiotropium 18 mcg daily
Acetaminophen 650 mg q4 hours PRN
Robitussin 10 mL TID
Discharge Disposition:
Expired
Discharge Diagnosis:
aspiration pneumonia
MRSA pneumonia
Discharge Condition:
expired
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"276.0",
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"276.2",
"008.45",
"507.0",
"518.81",
"707.07",
"294.8",
"428.22",
"458.9",
"427.31",
"585.9",
"112.2",
"285.21",
"496",
"244.9",
"414.01",
"584.9",
"272.0",
"707.03",
"428.0",
"263.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.07"
] |
icd9pcs
|
[
[
[]
]
] |
17236, 17245
|
14571, 15924
|
283, 303
|
17324, 17460
|
2843, 14548
|
2294, 2298
|
17266, 17303
|
16965, 17213
|
2328, 2824
|
236, 245
|
331, 1670
|
15938, 16939
|
1692, 2008
|
2024, 2278
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,565
| 181,839
|
35128
|
Discharge summary
|
report
|
Admission Date: [**2146-11-23**] Discharge Date: [**2146-12-15**]
Date of Birth: [**2072-4-16**] Sex: M
Service: EMERGENCY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 2565**]
Chief Complaint:
Colitis/diarrhea
Major Surgical or Invasive Procedure:
flexible sigmoidoscopy x2
Intubation
Bronchoscopy
IVC filter
History of Present Illness:
Patient is a 74 yo man with h/o non-specific colitisi in [**2-18**],
PMH CAD s/p MI, s/p prostatectomy, lung nodule/NSCLC s/p VATs
removal in [**10-19**] now with recurrent colitis, transferred to
[**Hospital1 18**] for further management of his colitis. History obtained
from records, patient, and his wife.
[**Name (NI) **] has a history of colitis (deemed ulcerative colitis),
diagnosed in [**2146-1-12**] after having bout of diarrhea at that time,
per report, diagnosed by colonoscopy (see below in PMH). At
that time, was treated with prednisone with improvment in
symptoms. Was symptom free until [**7-19**] when again developed
diarrhea, gas, urgency. Otherwise no abdominal pain,
nausea/vomiting, fevers/chills. Had progression of symptoms
from [**7-19**] to [**10-19**] with increased urgency, going to bathroom up
to every 15 minutes, awaking at night to go to bathroom,
diarrhea, gas, non-bloody bowel movements. In [**2146-9-21**] per
report had a CT scan that was negative for colitis, stool
studies that were negative.
Patient was then admitted to the [**Location (un) **]/[**Hospital 1459**] hospital for
removal of lung nodule via VATS procedure on [**2146-11-4**], symptoms
of diarrhea/urgency were still ongoing at this time.
Post-procedure patient developed escalating amounts of diarrhea,
without any unstable vital signs, but also developed severe
abdominal distension. This required NGT placement and rectal
tube placement. Repeat CT scan per report demonstrated colitis,
most prominent in sigmoid and left sided colon, without evidence
of mechanical obstruction or ischemic bowel (per one report -
but also demonstrated dilation of bowel loops in large and small
intestine, no noted mechanical obstruction, per another report -
awaiting fax of CT scan report). The patient was started on
solumedrol, questran, and made NPO and started on TPN. Stool
studies for c diff have been negative multiple times, but he was
also started on IV flagyl. His symptoms improved with these
measures and the NGT/rectal tube per report had a lot of
drainage, and after a couple of days he had his NGT and rectal
tube removed.
However, he is still having loose bowel movements, poor PO
intake, urgency. Patient is therefore transferred to [**Hospital1 18**] for
further evaluation and management of his colitis.
Besides the above complaints, pt denies nausea/vomiting. Does
report chills, denies fevers. Also states has developed lower
extremity edema during prolonged hospital course. Also reports
some dyspnea on exertion which he attributes to deconditioning,
denies CP/pressure, orthopnea, PND.
Past Medical History:
- Colitis, ?UC, diagnosed in [**1-18**] with colonoscopy (by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 40066**]) after presenting with diarrhea. Per report that
examination demonstrated colitis involving the rectum, sigmoid
colon and left colon, with edema and erythema. Inflammatory
changes extended up to transverse colon with less involvement of
the right colon, ileum not examined. Left colon biopsies
demonstrated active chronic colitis with low-grade dysplasia
involving the left colon. Right colon biopsies demonstrated
focal mild acute colitis without dysplasia. Of note, 2 prior
colonoscopies performed by Dr. [**Last Name (STitle) 80206**] in [**5-16**] and [**6-/2138**] showed
only diverticulosis of sigmoid colon and a diminutive
adenomatous polyp at 20cm. Following colonoscopy in [**1-18**], pt
was treated with prednisone at that time with improvement of
symptoms.
- Non-small cell lung cancer s/p left upper lobe lobectomy in
[**10-19**], clean margins
- CAD s/p MI and LAD stent in 10/97 at [**Hospital1 2025**]
- Hypothyroid
- Tobacco use
- Possible history of pancreatitis
- H/o prostate ca s/p removal (?)
Social History:
Patient is married, has 1 daughter. 80 pack year smoking
history, occasional alcohol use.
Family History:
1 daughter died at age 35 from metastatic lung cancer. 1
brother died of MI at age 45. Family history of colon cancer in
his father who died at age 59.
Physical Exam:
Vitals - T 96.5, HR 77, BP 112/78, RR 22, O2 96% RA
General - Patient is an ill appearing man, no acute distress
ENT - moist mucous membranes
CVS - RRR, no noted m/r/g
Lungs - CTA b/l
Abd - slightly distended, soft, midline scar noted (per patient
from prostate removal for prostate ca), non-tender to palpation,
hyperactive bowel sounds
Ext - 3+ lower extremity edema, doughy texture
Pertinent Results:
OSH labs: Na 137, K 4.2, Cl 110, CO2 20, Ca 7.7, Phos 3.2, TG
116, Mg 2.3, BUN 37, Cr 0.7
WBC 10.4, Hct 29.4, Plt 335
Somatostatin 18
TTG IgG 1.4, tissue trans 0.7
Gastrin 52
.
OSH microbiology:
[**11-6**], [**11-8**], [**11-16**] c diff - negative
Stool for O+P - negative
.
OSH imaging:
[**2146-11-15**] CT scan: Diffuse small and large bowel dilation with
mild wall thickening. The stomach is distended as well. There
is trace amount of peri-hepatic ascites. Ileus or infectious
colitis are favored over obstruction. There is probably chronic
pancreatitis. No adenopathy, no free air.
Admission:
[**2146-11-23**] 06:10PM BLOOD WBC-12.7* RBC-3.48* Hgb-10.5* Hct-31.3*
MCV-90 MCH-30.3 MCHC-33.7 RDW-15.4 Plt Ct-357
[**2146-11-23**] 06:10PM BLOOD Neuts-91.7* Lymphs-5.7* Monos-2.4 Eos-0.1
Baso-0.1
[**2146-11-23**] 06:10PM BLOOD PT-15.4* PTT-27.6 INR(PT)-1.4*
[**2146-11-23**] 06:10PM BLOOD Glucose-100 UreaN-38* Creat-0.7 Na-140
K-4.2 Cl-114* HCO3-19* AnGap-11
[**2146-11-23**] 06:10PM BLOOD ALT-13 AST-13 LD(LDH)-216 AlkPhos-78
TotBili-0.3
[**2146-11-23**] 06:10PM BLOOD Albumin-2.1* Calcium-7.3* Phos-3.1 Mg-2.2
[**2146-11-23**] 06:10PM BLOOD TSH-4.1
[**2146-11-23**] 06:10PM BLOOD Free T4-1.0
[**2146-11-23**] 06:10PM BLOOD tTG-IgA-9
Studies:
[**2146-11-23**]
CT ABDOMEN WITH IV CONTRAST: IMPRESSION:
1. Diffuse wall thickening and loss of haustra from splenic
flexure to anus with adjacent fatty proliferation. Findings
consistent with ulcerative colitis, of indeterminate chronicity.
No free air, free fluid or bowel obstruction seen.
2. Status post prostatectomy.
3. Small-to-moderate right pleural effusion with related
atelectasis.
4. Bilateral peripheral reticular honeycombing in the visualized
lung bases. Comparison with prior study is recommended if
available.
5. Right lower lobe bronchiectasis with region of consolidation
which could represent aspiration, atelectasis or infection.
6. Region of spiculated nodular opacity in the right lower lobe
and also
subpleural nodule in the right middle lobe. Again comparison
with prior study would be useful for establishing stability.
7. Scattered punctate calcifications in the pancreas could be
related to
chronic pancreatitis.
8. Sub-millimeter hypodensities in the liver, too small to
accurately
characterize.
9. Rounded hypodensity in the right common femoral vein,
consistent with DVT, and appearing to extend from the deep
femoral branch at the level of the greater saphenous origin. No
evidence of thrombosis is seen in the common femoral vein below
this level in the visualized distal common femoral vein.
10. Sclerotic and lucent lesions in vertebral bodies. In this
patient with
history of prostate cancer, correlation with bone scan would be
recommended in the absence of prior study to establish
stability.
[**11-25**]: rectal bx: Chronic active colitis with ulceration; no
granulomas or dysplasia are identified.
.
CT a/p c contrast [**11-30**]
1. Diffuse wall thickening and loss of haustra from splenic
flexure to anus, consistent with ulcerative colitis, of
indeterminate chronicity, stable. There is no free air, no free
fluid or bowel obstruction seen. No siginificant change in bowel
apperance since [**2146-11-24**].
2. Status post prostatectomy.
3. Left stable pleural effusion. There is adjacent atelectasis,
but
superimposed consolidation cannot be excluded. There are two
tiny air pockets within the pleural fluid on the left, might be
related to history of procedure in this area, but superinfection
cannot be excluded.
4. Bilateral peripheral reticular honeycombing in the lung
bases, stable.
5. Stable right lower lobe bronchiectasis.
6. Scattered punctate calcification in the pancreas could be
related to chronic pancreatitis.
7. Stable tiny hypodensities in the liver, too small to
characterize.
8. Rounded hypodensity in the right femoral vein, seen also on
the previous study, likely consistent with DVT, unchanged.
9. Sclerotic and lucent lesions in the vertebral bodies in this
patient with history of prostate cancer, correlation with bone
scan is recommended for further followup.
10. Nodular prominence in the left adrenal gland. Attention on
next follow up.
Colonoscopy [**11-25**]:
DIAGNOSIS:
Rectum:
Chronic active colitis with ulceration; no granulomas or
dysplasia are identified.
Clinical: Ulcerative colitis.
Gross: The specimen is received in one formalin container,
labeled with the patient's name, "[**Known lastname 35714**], [**Known firstname **] R", the
medical record number and additionally labeled "rectal biopsy".
It consists of multiple tissue fragments measuring up to 0.4 cm,
entirely submitted in cassette A.
==================
[**2146-11-27**]
CXR
FINDINGS: In comparison with the earlier study of this date,
there has been placement of a right subclavian PICC line that
extends to the mid portion of the SVC. The patient has taken a
better inspiration and there is still prominence of interstitial
markings with elevation of the left hemidiaphragm.
ABD plain film [**2146-11-30**]
IMPRESSION: Marked gaseous distention of the colon, with the
transverse colon measuring up to 8 cm. No free air or
pneumatosis. Continued followup
recommended to assess for interval changes.
[**12-5**] CXR Right lung is clear. Left hemidiaphragm remains
elevated. Opacification in the left lower lung could be
atelectasis. There is no large pleural effusion or pneumothorax.
Heart size is normal
[**12-5**]: KUB 1. Little interval change in appearance of multiple
dilated, air-filled colonic loops. Featureless appearance of the
descending and sigmoid colon are consistent with chronic
ulcerative colitis.
2. There is no bowel wall thickening, pneumatosis, or free air
appreciated.
.
[**12-6**] Chest CT noncontrast:
1. Left hydropneumothorax raises concern for bronchial stump
leak. No evidence of recurrent malignancy.
2. Multifocal pneumonia, probably aspiration.
3. Very small cavities in the right upper and middle lobe
require followup. There is no evidence of active tuberculosis.
4. Severe emphysema. Possible pulmonary arterial hypertension.
.
.
Bone Scan [**12-5**]
1. Focal focus of left anterior rib uptake which may correspond
to a rib fracture. Anatomic imaging is recommended as clinically
indicated.
2. No corresponding abnormal uptake in the lower thoracic or
lumbar spine to correlate with CT findings.
3. Some limited assessment of the pelvis as described above.
Brief Hospital Course:
Patient is a 74 year old man with history of CAD, NSCLC, who
presents with evidence of chronic diarrhea/colitis, transferred
from outside hospital after worsening of symptoms after
lobectomy (for NSCLC).
1. Colitis/Diarrhea: On transfer here, patient was initially
maintained on solumedrol (for ?ulcerative colitis flare), IV
flagyl (for ?c diff colitis, ruled out by c.diff toxin x3
negative), and GI was consulted and involved throughout his
hospital course. He had a repeat CT scan here that demonstrated
bowel wall edema from anus to sigmoid colon. He therefore
underwent a sigmoidoscopy for further evaluation that
demonstrated very friable erythematous mucosa consistent with
colitis. He continued on bowel rest and IV solumedrol until
[**2146-12-1**], when repeat flexible sigmoidoscopy showed worsened
friable mucosa and colitis. Cyclosprine was initiated at that
time at 1.5mg/kg/day divided in two doses and then discontinued
and steroids were decreased. On [**12-15**], the patient had
significant lower GI bleed (approx 4-5L blood pouring from
rectum). At that time the patient's family was contact[**Name (NI) **] and we
discussed the difficulty of resusitating him and necessity of
pressors and large volume transfusion. Given the patient's very
grave situation and family discussion, the patient was not
resusitated with blood.
2. ARDS/Hypoxia: Pt had increasing O2 requirement and on HD 3
required transfer to ICU. CT chest with multifocal opacities
thought due to infection. On [**12-8**] the patient had a witnessed
aspiration and required intubation on [**12-10**] for tachypnea.
Eventually the patient's hypoxia was thought to be due to ARDS
secondary to pneumonia and intraabdominal inflammation. The
patient was managed with IV antibiotics, but the patient's poor
pulmonary status persisted. Additionally, the patient was
difficult to ventilate being frequently asynchronous with the
vent except in the case of high amounts of sedation. His
respiratory status remained tenuous. Sputum cultures were
positive for Aspergillous. Bronchoscopy was performed and BAL
was negative for PCP. [**Name10 (NameIs) **] was started on caspofungin for
treatment of his fungal infection.
3. DVT, RLE: incidental finding on CT scan. The patient was
started on coumadin but this was discontinued in the setting of
his continued GI blood loss. Once stable, he was started on
heparin, but noted to have low platelet count and transitioned
to argatroban for possible HIT.
4. Malnutrition/Stage II sacral/buttock decubitus: Noted on
admission. Pt was started on wound care, turn q2, nutrition, on
vitamin C and zinc
TPN at 75cc/hr. give small PO liquids only if pt is awake.
5. Hypothyroid: continue synthroid
6. Coronary artery disease s/p myocardial infarction: During the
hospital course he was kept on ASA 81 and beta-blocker when he
tolerated it.
7. NSCLC s/p resection: His lung cancer was not an active issue.
End of life care: As the patient continued his hospital course
he had several episodes of massive GI bleeding. The GI team was
consulted and felt that the patient required immediate surgical
intervention. The surgery team evaluated the patient and found
that the patient was too unstable and ill to undergo surgical
intervention. On HD 22, a family meeting was held and goals of
care were discussed. That evening, the patient again developed
extensive GI bleeding. The family was consulted and requested
that no resusitation measures be made.
Medications on Admission:
Outpatient medications:
Asacol 800mg TID
Prednisone PRN for colitis symptoms
Synthroid 88mcg daily
ASA 325mg daily
loratidine 10mg daily
simvastatin 40mg daily
lopressor 50mg [**Hospital1 **]
.
Medications on transfer:
Ceftriaxone 1gm IV daily (started [**2146-11-8**])
Metronidazole 500mg IV q 8hr (started [**2146-11-16**])
Solu-medrol 60mg IV q 8hr (started [**2146-11-16**])
Cholestyramine 4gm packet PO TID
Epo 4000 units SC q week
Guafenesin PRN
SC heparin
Levothyroxine 0.088mg daily
Metoprolol 50mg PO BID
Nystatin cream to buttocks
Omeprazole 20mg daily
Trypsin ointment to back
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiopulmoary arrest
Massive GI bleed
Severe colitis
ARDS
Discharge Condition:
Deceased
|
[
"287.5",
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"453.41",
"560.1",
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"V45.82",
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icd9cm
|
[
[
[]
]
] |
[
"96.72",
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"33.22",
"99.15",
"96.04",
"45.24",
"38.7",
"99.05",
"38.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
15482, 15491
|
11348, 14843
|
334, 397
|
15593, 15604
|
4927, 11325
|
4350, 4506
|
15512, 15572
|
14869, 14869
|
4521, 4908
|
14893, 15063
|
278, 296
|
425, 3045
|
15088, 15459
|
3067, 4225
|
4241, 4334
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,587
| 198,345
|
7620
|
Discharge summary
|
report
|
Service: NICU/GREEN Date: [**2150-5-21**]
Date of Birth: [**2077-8-1**] Sex: M
Surgeon: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
CHIEF COMPLAINT: The patient was admitted for shortness of
breath, hypoxia, and hypotension.
HISTORY OF THE PRESENT ILLNESS: The patient is a 72-year-old
male with a complicated recent medical course including a
long hospitalization beginning in [**Month (only) 404**] for respiratory
failure, CHF, and urosepsis. He subsequently had current
episodes of gastrointestinal bleeding secondary to ischemic
colitis in [**Month (only) 956**] and [**Month (only) 958**]. He was transferred from the
nursing home on [**5-19**], for evaluation of hypotension,
hypoxia, and lethargy. His family states that over the past
three days, he had been developing cough and shortness of
breath. At dialysis, he was noted to have coarse crackles.
On his respiratory examination, an oxygen requirement. When
he arrived in the ER, he was hypotensive with systolic
pressures in the 70s, which was managed initially with
dopamine. In the ER also it was noted that he did not wish
to be intubated because of his difficulty with extubation in
the past. Mask ventilation was initiated because of
hypocarbic respiratory failure.
PAST MEDICAL HISTORY:
1. End-stage renal disease on hemodialysis.
2. Coronary artery disease status post large LAD infarct
[**2149-12-9**]. EF approximately 20%.
3. Type 2 diabetes mellitus.
4. Peripheral vascular disease.
5. Obstructive sleep apnea.
6. Pseudomonas UTI.
7. Atrial fibrillation.
8. Recent gastrointestinal bleeds.
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS:
1. Captopril.
2. Aspirin.
3. Amiodarone.
4. Lipitor.
5. Calcium.
6. Reglan.
7. Paxil.
8. Nephrocaps.
9. Colace.
10. Epogen.
11. Prevacid.
SOCIAL HISTORY: The patient has prior tobacco use. He
currently resides at the Brianwood Nursing Home. He is
married to his wife named [**Name (NI) **]. [**Name2 (NI) **] has three daughters and
one son who live in the area.
PHYSICAL EXAMINATION: Examination revealed the following:
VITAL SIGNS: Temperature 100.4, blood pressure 90/50
initially, now 120/70 on dopamine. Heart rate in the 80s;
100% oxygen saturation on mask ventilation. GENERAL: The
patient is somnolent, but arousable. NECK: No JVD. LUNGS:
Coarse breath sounds bilaterally. HEART: Distal regular
rhythm. No murmurs, rubs, or gallops. ABDOMEN: Soft,
nontender, nondistended, normoactive bowel sounds.
EXTREMITIES: 1+ lower extremity edema. Right subclavian
dialysis catheter site looks fine. Bilateral heel decubitus
ulcers, which were dry. BACK: He has a stage I decubitus
ulcer. NEUROLOGICAL: Examination was briskly nonfocal.
LABORATORY DATA: Initial laboratory values revealed the
following: White blood cell 36,000, 87 neutrophils, 4 bands,
hematocrit 39, platelet count 521,000, sodium 137, potassium
4.7, chloride 103, bicarbonate 19, BUN 28, creatinine 2.9,
glucose 153. Initial blood gas revealed the pH of 7.29, CO2
49, pO2 72.
Chest x-ray: Edema versus chronic interstitial disease and a
right lower lobe pneumonia. No effusions. Blood culture
grew group B Strep.
HOSPITAL COURSE: The patient received aggressive
antibiotics, as well as blood pressure supporting medications
in the emergency room. After the patient was admitted to the
MICU a family meeting was held and it was determined that the
patient would not be happy returning to the quality of life
from which he came which was unable to walk and unable to
feed himself living in a nursing home. It was unlikely that
he would be able to regain a high level of functioning if he
had aggressive therapy. He was made comfort oriented shortly
after admission. At that time he was maintained on a
morphine drip with close attention being pain to his symptom
relief. His family remained at the bedside and he died
comfortably on the morning of [**2150-5-21**]. Autopsy was
offered and discussed, but declined.
DIAGNOSES:
1. Respiratory failure most likely secondary to pneumonia in
the setting of end-stage renal disease requiring
hemodialysis.
2. Coronary artery disease status post MI.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Name8 (MD) 22927**]
MEDQUIST36
D: [**2150-5-21**] 11:33
T: [**2150-5-28**] 13:56
JOB#: [**Job Number 27794**]
|
[
"486",
"276.2",
"428.0",
"458.9",
"585",
"250.00",
"518.81",
"707.0",
"038.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
1806, 4711
|
1407, 1783
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,994
| 162,338
|
36578+36579+36580
|
Discharge summary
|
report+report+report
|
Admission Date: [**2160-1-14**] Discharge Date: [**2160-1-18**]
Date of Birth: [**2077-3-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
Mr. [**Known lastname 724**] is a 82 yo [**Known lastname 8230**]-speaking man w/h/o COPD, ESRD/HD
w/ some residual urine production, and chronic diastolic CHF (EF
60% in [**12-4**]) with multiple recent admissions for PNA and CHF
exacerbations. He presented today to the ED with SOB.
.
VS in the ED were 97.6, 166/69, 79, 23, 100% on 10L. He was
transiently on a BIPAP (<30 min per flowsheet) with good relief
and was going to go to the ICU. However, he responded well to an
albuterol/ipratroium neb and solumedrol 125 mg. He had already
receive dlasix 40 mg IV in the ambulance with urine output. O2
requirement improved to 4L NC on transfer to the floor. ABG
showed 7.41/44/447 on NRB.
.
He was given zosyn 4.5g and levofloxacin 750 mg IV; vancomycin 1
g IV was ordered but not yet given.
.
On the floor, he appears to be breathing well and is comfortable
with the NC barely in his nose and O2 sats listed at 96% on
4LNC. He denies pain and says his breathing is improved after
treatment compared to the ED, via an interpreter. He is unable
to give much more history than that.
.
NOTE: Last HD session should have been [**1-12**] (~48 hours PTA). Ic
oudl not verify this overnight. Also, per DCS from [**2160-1-2**], team
treated for CAP (and CHF exacerbation) with similar presentation
of no fever, no WBC, minimal sputum and difficult to interpret
CXR for infiltrate vs. atalectasis vs. effusion.
Past Medical History:
* ESRD on HD (T/Th/Sat schedule)
* Diabetes Mellitus Type 2
* Hypertension
* Diastolic CHF: Last ECHO [**2159-12-6**] showed LVEF>55%, mild
symmetric left ventricular hypertrophy with preserved global and
regional biventricular systolic function. Diastolic dysfunction.
Dilated aortic sinus.
* Hypercholesterolemia
* Asthma
* ?COPD
Social History:
Lives with caretaker (mainly [**Name (NI) 8230**] speaking only) who takes
care of him. Also has son who lives nearby and involved in his
care (occasionally goes to hemodialysis with him). Other son
loves out of state and is also involved in his care (visits him
1-2 times a week, sets his medications out for him and pre-draws
his insulin, fixed dose). Denies alcohol use or illicit drugs.
Does smoke 1 pack/2-3 days X years.
Family History:
Unknown. Per OMR, noncontributory
Physical Exam:
VS: weight 86.2 kg, T96.2, 148/80, 84 (83-95), 20 (20-32), 98%
on 2LNC --> Patient was agitated when this House Office saw
patient secondary to audible wheezing. O2sat 95% on 2L -->
increased to 4L for symptomatic relief and administered
Albuterol nebs with good effect
GENERAL: Elderly man, agitated and trying to get out of bed
HEENT: Poor dentition, clear oro/nasopharynx, anicteric sclera,
?JVD (difficult to assess with pt movement)
LUNGS: Audible expiratory wheezing --> decreased with neb
treatment, bilateral crackles (L>R), moving good air
CV: RRR, no murmurs/gallops/rubs
ABD: + BS, obese, non-tender/non-distended
EXTREMITIES: [**1-30**]+ pitting emeda, symmetric, no ertyehma or skin
breakdown, WWP, +DP/PT pulses
Pertinent Results:
Notable for Na 131, AG 10, K 4.6, BNP 8100 (last 4300 on
[**2159-12-29**]), lactate 1.8
ABG 7.41/44/447 on NRB
at 6:45 on [**1-13**], trop 0.05 (baseline), CK 99, MB "not done"
.
MICROBIOLOGY: none
.
ADMISSION EKG: NSR at 80, RAD, poor RWP, V1 TWI seen in priors,
no ST changes
.
IMAGING:
Follow-up CXR: As compared to the previous radiograph, the
extent of the
pre-existing left-sided pleural effusion has slightly decreased.
On the other hand, the pre-existing right basal atelectasis has
slightly increased in extent, and a minimal right-sided pleural
effusion might have newly occurred. Unchanged is the
retrocardiac atelectasis and the evidence of moderate pulmonary
edema. No evidence of pneumonia in the inflated parts of the
lung parenchyma.
.
[**2160-1-14**] ADMISSION CXR (PORTABLE): Congestive heart failure,
large left effusion with left basilar consolidation most likely
atelectasis, though pneumonia cannot be excluded.
.
[**2159-12-30**] CXR (PA/LAT):
There is again seen a left retrocardiac opacity as well as a
left-sided pleural effusion with blunting of the CP angle.
Moreover, since the prior study, there has been development of a
right basilar opacity. These findings can be seen with
aspiration or pneumonia. Followup to resolution is recommended.
Pulmonary interstitial markings are minimally prominent
consistent with mild fluid overload; however, there is no overt
pulmonary edema. These findings are stable. Calcifications in
thoracic aorta is also seen.
.
[**11/2159**] TTE:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Tissue Doppler
imaging suggests an ncreased left ventricular filling pressure
(PCWP>18mmHg). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
right ventricular free wall is hypertrophied. The aortic root is
mildly dilated at the sinus level. The aortic valve leaflets (3)
are mildly thickened but aortic tenosis 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 mildu
plmonary artery systolic hypertension. There is an anterior
space which most likely represents a fat pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Diastolic dysfunction. Dilated aortic sinus.
Brief Hospital Course:
#. ACUTE ON CHRONIC DIASTOLIC CHF: Last EF 60% in [**12-4**];
respiratory sx likely [**1-29**] volume overload in setting of
?suboptimal volume removal at HD; BNP slightly high on amdission
but no evidence that HR or BP were uncontrolled at any point. No
WBC or fever suggesting PNA though difficult to tell on CXR due
to effusion (which is worse but noted on prior admission).
Patient underwent regular hemodialysis with significant
improvement in his breathing, lower extremity edema and blood
pressures.
Patient was started on Lasix 80mg PO on non-dialysis days for
better management of his volume status. Patient was continued on
a strict renal, diabetic, low-sodium diet. He was continued on
his home olmesartan, beta blocker, aspirin and simvastatin.
.
#. Delirium: On second and third days of admission, patient
would sun-down around 8pm. He responded best to Trazodone and
low-doses of Haldol. Continued to try to reorient patient during
the day, maintain sleep wake cycle, keep his glasses nearby etc.
with good effect during the day.
.
#. DM: As per prior admission, home regimen uncertain. Patient
was continued on an insulin sliding scale in house which was
tightened accordingly.
.
#. HYPERTENSION: Patient's blood pressures were initially high
(SBP170s) but responded well to hemodialysis, strict diet and
home medications: Labetolol 600 mg [**Hospital1 **], Amlodipine 10 mg QD,
Olmesartan 40 mg QD. Of note, Olmesartan was not formulary so
patient was switched over to an equivalent dose of Valsartan.
.
#. ANEMIA: Remained stable at ~38.0, which is baseline for the
patient, who has chronic disease.
-- monitor
Medications on Admission:
Senna
Colace
Sevelamer 400 TID
Famotidine 20 QD
Fluticasone-salmeterol 250/50 [**Hospital1 **]
Albuterol PRN
Ipratropium PRN
Nephrocaps
Labetolol 600 mg [**Hospital1 **]
Amlodipine 10 mg QD
Olmesartan 40 mg QD
ASA 81 mg
Simvastatin 20 mg QD
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Sevelamer HCl 400 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO once a day as needed for
constipation.
9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
11. Olmesartan 40 mg Tablet Sig: One (1) Tablet PO once a day.
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
vial Inhalation Q6H (every 6 hours) as needed for SOB, wheezing.
Disp:*30 vials* Refills:*0*
13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer vial Inhalation every four
(4) hours as needed for SOB, wheezing.
Disp:*30 vials* Refills:*0*
14. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 2 days: Last day: [**1-20**], [**Month (only) 1017**].
Disp:*4 Tablet(s)* Refills:*0*
15. Insulin
Please resume your home insulin regimen
16. Nebulizer & Compressor For Neb Device Sig: One (1)
device Miscellaneous every 4-6 hours as needed for shortness of
breath or wheezing.
Disp:*1 device* Refills:*0*
17. Lasix 40 mg Tablet Sig: Three (3) Tablet PO Sun/Mon/Wed/Fri:
120mg daily, on NON-DIALYSIS DAYS (Sun/Mon/Wed/Fri).
Disp:*48 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary: Congestive Heart Failure (CHF) exacerbation, Chronic
Obstructive Pulmonary Disease (COPD) exacerbation, End Stage
Renal Disease on Hemodialysis
Secondary: Type 2 Diabetes Mellitus, Hypertension
Discharge Condition:
Mental Status:Confused - sometimes
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - should use assistance or aid
(walker or cane)
Discharge Instructions:
-You were admitted with shortness of breath. Your heart, which
is weaker than normal, was having difficulty circulating blood
and fluid (CHF exacerbation). You were also felt to be having a
flare of your chronic, obstructive lung disease (COPD
exacerbation). You were treated with hemodialysis, steroids and
nebulized medications, which improved your breathing. You were
also put on a strict diet (low sodium, diabetic, renal), which
decreased fluid build-up in your body.
.
-It is important that you continue to take your medications as
directed. We made the following changes to your medications
during this admission:
--> START Prednisone 40mg daily for 2 more days. (Last day:
[**Last Name (LF) 1017**], [**1-20**])
--> START Lasix 120mg daily ON NON-DIALYSIS DAYS
(Sun/Mon/Wed/Fri)
--> START Albuterol and Ipratroprium nebulizers every 4-6 hours
as needed for shortness of breath and wheeze
.
-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 care doctor, Dr. [**First Name8 (NamePattern2) 803**]
[**Last Name (NamePattern1) **]. You have an appointment to see her on [**2-1**] at 9:40am.
You can reach her office at: [**Telephone/Fax (1) 2115**]
Location: [**University/College 70860**], [**Location (un) 86**] MA
.
** Please plan on your caretaker going with you to your
hemodialysis sessions. Your son, [**Name (NI) **] [**Name (NI) 724**], [**First Name3 (LF) **] also accompany
you to your Thursday hemodialysis sessions. He will work with
you, your caretaker and a dietician on how you can adhere to
your strict diet, to better help your episodes of shortness of
breath.
Admission Date: [**2160-1-20**] Discharge Date: [**2160-1-25**]
Date of Birth: [**2077-3-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Intubation for mechanical ventilation
Hemodialysis
History of Present Illness:
Mr. [**Known lastname 724**] is a 82 yo [**Known lastname 8230**]-speaking man with a history of
COPD, ESRD on HD w/ some residual urine production, asthma/COPD,
and chronic diastolic CHF (EF 60% in [**12-4**]) with multiple recent
admissions for PNA and CHF exacerbations, who presented from
rehab with respiratory distress.
Per report, at rehab he was found tripoding with sats in the 70s
and very wheezy. He was also hypertensive to 200s. He was given
O2 by NRB. He was sent to the [**Hospital1 18**] ED for further workup.
Of note, he was recently admitted from [**Date range (3) 82787**] for acute
dyspnea that improved with lasix and dialysis. He was also
admitted from [**Date range (1) 19970**] for dyspnea thought to be [**1-29**] volume
overload, and from [**Date range (1) 82788**] for SOB in the setting of fluid
overload and missing HD. On prior admissions, there have been
extensive discussions regarding the optimal setting for the
patient and whether he would benefit from an LTAC facility.
However the patient and family have refused.
.
In the emergency department, initial vitals were: 140/90 HR 36
100% NRB, AF HR 80s. He was unresponsive when he got to ED.
Given his respiratory distress, a trial of Bipap was initiated.
ABG was 7.30/67/357. BNP was [**Numeric Identifier **]. The patient was subsequently
intubated given his failure to improve and altered mental
status. Patient was thought to have a COPD exacerbation given
extensive wheezing and received methlprednisolone. He got
Vancomycin and Zosyn for presumed HAP. He had a head CT for his
unresponsiveness which showed ICH.
He also received 600mg PR ASA.
.
Urine Cx and BCx sent.
.
.
.
On the floor, patient is intubated and sedated.
.
Review of systems:
(+) Per HPI
(-) Unable to complete.
Past Medical History:
* ESRD on HD (T/Th/Sat schedule)
* Diabetes Mellitus Type 2
* Hypertension
* Diastolic CHF: Last ECHO [**2159-12-6**] showed LVEF>55%, mild
symmetric left ventricular hypertrophy with preserved global and
regional biventricular systolic function. Diastolic dysfunction.
Dilated aortic sinus.
* Hypercholesterolemia
* Asthma
* ?COPD
Social History:
Lives with caretaker (mainly [**Name (NI) 8230**] speaking only) who takes
care of him. Also has son who lives nearby and involved in his
care (occasionally goes to hemodialysis with him). Other son
lives out of state and is also involved in his care (visits him
1-2 times a week, sets his medications out for him and pre-draws
his insulin, fixed dose). Denies alcohol use or illicit drugs.
Does smoke 1 pack/2-3 days X years.
Family History:
Unknown. Per OMR, noncontributory
Physical Exam:
Vitals: T:97.1 BP: 167/99 P:68 R: 15 O2: 98%
General: Intubated and sedated
HEENT: Pupils non reactive. Sclera anicteric, MMM, oropharynx
clear
Neck: supple, JVP not elevated, no LAD
Lungs: Mild wheezes on anterior exam
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Withdraws to pain
.
Upon transfer out to regular Medicine Floor:
O: T97.6, BP148/54, HR77, RR20, 90% RA <-- 97% 2L
.
General: NAD, alert and oriented. Interactive.
HEENT: Pupils minimally reactive. Sclera anicteric, MMM,
[**Last Name (un) **]/oropharynx clear and normal. Poor dentition
Neck: Soft, supple. No JVD/LAD appreciated.
Lungs: Mild expiratory wheeze anteriorly, bilaterally.
?Decreased breath sounds in left lower lobe. No rhonchi/rales.
No dullness to percussion appreciated.
CV: Regular rate and rhythm, normal S1 + S2, I/VI murmer at
LUSB.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused; +DP/PT pulses but with 1+ pitting
edema of bilateral lower extremities. No cyanosis, ecchymosis.
Neuro: CN2-12 grossly intact. Motor strength and sensation
grossly sensation.
Pertinent Results:
Labs on Admission: WBC 13.4, 79.6% polys
HCT 38.9
nl coags
Na 132
Cr 3.6
AG 11
ABG: 7.30/67/357/34
lactate 1.1
CK 95
CKMB not done
Trop 0.09
BNP [**Numeric Identifier **]
UA 3-5 WBCs, leukocyte and nitrite negative
.
Micro: Blood cultures X2 no growth to date; Urine culture no
growth to date
.
Studies:
CXR ([**2160-1-23**]): The cardiomediastinal silhouette is currently
more clearly identified consistent with mild cardiac
enlargement. The mediastinum is unremarkable. Bilateral pleural
effusions are moderate. There is bilateral atelectasis,
involving left lower lobe and most likely right lower lobe at
least partially. Currently, there is no evidence of pulmonary
edema, just minimal vascular engorgement.
CXR ([**1-21**]): Moderate left pleural effusion has worsened. Left
lower lobe remains consolidated or collapsed. Moderate right
pleural effusion increased. Heart size is obscured by adjacent
pleural and parenchymal abnormality. No pneumothorax. ET tube in
standard placement. Nasogastric tube passes below the diaphragm
and out of view. No pneumothorax.
CXR ([**1-20**]): Endotracheal tube terminates at the thoracic inlet.
Nasogastric tube terminates in the stomach. Heart and
mediastinum are likely within normal limits, although aorta is
calcified. There is a moderate left-sided pleural effusion.
There is left lower lobe atelectasis. There is mild atelectasis
at the right lung base with a small right pleural effusion. This
has mildly increased since prior study.
.
Renal Ultrasound with Dopplers: 1. No hydronephrosis. Small
bilateral renal cysts. 2. Doppler examination could not be
performed as the patient was unable to hold his breath for the
examination.
.
CT head: 1. No intracranial hemorrhage.
2. Ventriculomegaly, out of proportion to sulcal enlargement,
correlate
clinically for NPH.
3. Focal hypodensities consistent with old lacunar infarcts in
the right
cerebellum and left basal ganglia.
4. Chronic small vessel ischemic change.
Brief Hospital Course:
82 year old male with a history of dCHF, COPD, ESRD on HD and
multiple recent admissions (4 at [**Hospital1 18**] since mid-[**11-26**] at
[**Hospital6 **]) for pneumonia and pulmonary edema, who
presents from homw with hypoxia.
.
#. Hypoxemic respiratory failure: Differential includes COPD
exacerbation (wheezy on exam initially), volume overload
(noncompliance with HD and medications), acute on chronic
diastolic CHF exacerbation (non-compliance with low-sodium diet
and has BNP 21,224 with L pleural effusion), pneumonia +/-
aspiration (elevated WBC and suggestion of consolidation of LLL
on early CXR). Given multiple recent hospitalizations, patient
was felt at high risk of health care acquired pneumonia and
initially treated with Vancomycin, Zosyn, Levofloxacin. The
third chest xray performed after extubation and sufficient
diuresis showed no concerning infiltrates/[**Last Name (LF) 75026**], [**First Name3 (LF) **] the
antibiotics were discontinued. There was also lower suspicion
for COPD exacerbation given patient's intermittent wheeziness so
his steroids were also discontinued. Of note, patient had
received high dose IV steroids in the MICU/ED given concern for
COPD exacerbation initially. Patient's Prednisone was
discontinued without issues. Ultimately, patient's nebulizers
were ordered standing and PRN and patient did not require much.
For management of his CHF exacerbation, he was aggressively
diuresed, fluid restricted, kept on a strict diet and ultimately
did well. Cardiac enzymes were negative (baseline slightly
elevated troponin given renal disease) for concern of myocardial
ischemia causing CHF exacerbation. He was also kept on Lasix
120mg daily on nonhemodialysis days, with some urine diuresis.
He was saturating ~93% on room air by time of discharge
- Continue nebulizers as needed for symptomatic relief. Please
note that patient does get very agitated when he is wheezy,
especially when audibly so. Also continue home Flovent.
- Supplement oxygen as needed
- Ensure aggressive hemodialysis (patient's respiratory status
very sensitive to volume overload)
- Continue Lasix 120mg on NON-HEMODIALYSIS DAYS (Mon, Wed, [**First Name3 (LF) **],
Sun)
- Patient requires a very strict low sodium (<2 grams), renal,
diabetic diet
.
# Delirium: Patient has a history of sundowning, especially [**1-30**]
days after being in an unfamiliar environment. Has not been an
issue during this admission. Patient has significant dementia at
baseline, with difficulty remembering things hour by hour.
- Please maintain geriatric precautions for delirium: Maintain
sleep/wake cycle, reorient frequently, family at bedside when
possible, keep his glasses on, out of bed to chair/ambulation,
[**Month/Day (3) 8230**] speakers when feasible
- Note: Patient does smoke at home and can be agitated regarding
this. Please continue nicotine patch and consider nicotine
inhaler if would be helpful for habitual aspect of smoking
- Responds well to Trazodone 25mg before bed
- Also responds well to Haldol IM/IV 0.5mg. Can consider Zydis
(disintegrating form of Zyprexa) 5mg as well.
.
# Hyponatremia: Patient has been intermittently hyponatremic,
occasionally to the 120s. This, however, responded well to
hemodialysis and although is a poor prognostic indicator, did
not require further intervention.
.
#. ESRD on HD: Renal physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], is aware of patient
and his complicated psychosocial situation.
- Patient needs aggressive hemodialysis
- Continue nephrocaps, sevelamer (1600mg three times daily now)
.
#. DM2: Patient was continued on his home dose of NPH 8 units
with breakfast, with moderate blood sugar control. Patient
apparently has a history of becoming too hypoglycemic on lantus,
especially overnight when his blood sugars tend to run low. -
Continue home insulin dose (Novolin N 8 units with breakfast)
.
#. HTN: Was not well controlled this admission, with SBP
140-160s and not responsive to hemodialysis.
- Increased Labetalol from 600 to 800mg three times daily
- Continue Olmesartan and increase if necessary
Medications on Admission:
MEDICATIONS upon d/c on [**1-18**]:
Famotidine 20 mg PO Q24H
Fluticasone-Salmeterol 250-50 mcg/Dose [**Hospital1 **]
B Complex-Vitamin C-Folic Acid 1 mg Capsule PO DAILY
Labetalol 600 mg PO TID
Simvastatin 20 mg PO DAILY
Amlodipine 10 mg PO DAILY
Sevelamer HCl 400 mg PO TID W/MEALS
Bisacodyl 10 mg PO once a day as needed for constipation.
Aspirin 81 mg PO once a day.
Senna 8.6 mg PO twice a day as needed for constipation.
Olmesartan 40 mg PO once a day.
Ipratropium Bromide 0.02 % Solution Q6H (every 6 hours) prn
Albuterol Sulfate 2.5 mg /3 mL every four hours prn
Prednisone 40mg PO DAILY for 2 days: Last day: [**1-20**],
[**Month (only) 1017**].
Insulin
Lasix 120 mg PO daily on NON-DIALYSIS DAYS (Sun/Mon/Wed/[**Month (only) **])
Discharge Medications:
1. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day as needed for constipation.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Furosemide 80 mg Tablet Sig: 1.5 Tablets PO QMWFSU (): On
non-hemodialysis days: Mon, Wed, [**Last Name (LF) **], [**First Name3 (LF) **].
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb vial Inhalation every four (4)
hours as needed for wheezing, SOB.
8. Sevelamer Carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times
a day).
11. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb vial
Inhalation every six (6) hours.
13. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
14. Olmesartan 40 mg Tablet Sig: One (1) Tablet PO once a day.
15. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
16. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
17. Novolin N 100 unit/mL Suspension Sig: Eight (8) units
Subcutaneous qAM.
18. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) inhalation Inhalation twice a day.
19. Zyprexa Zydis 5 mg Tablet, Rapid Dissolve Sig: One (1)
Tablet, Rapid Dissolve PO once a day as needed for agitation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1643**]
Discharge Diagnosis:
Primary: Respiratory distress likely secondary to acute on
chronic diastolic CHF exacerbation and volume overload
.
Secondary: End-stage renal disease on hemodialysis, Type 2
Diabetes, hypertension, dementia, asthma/COPD
Discharge Condition:
Mental Status:Clear and coherent, but poor short term memory
(dementia)
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
-You were admitted with sudden, severe shortness of breath. You
temporarily required a breathing tube and machine to help you
oxygenate your lungs. You responded well to hemodialysis and
nebulizers, as well as some steroids and antibiotics. It was
felt that you likely became volume overloaded at home.
.
-It is important that you continue to take your medications as
directed. We made the following changes to your medications
during this admission:
--> START Omeprazole 20mg daily instead of Famotidine 20mg daily
--> INCREASE Sevelamer 400mg to 1600mg three times daily
--> INCREASE Labetalol 600mg to 800mg three times daily
--> START Zydis 5mg daily as needed for agitation
--> RESUME Nephrocaps daily
--> RESUME home Flovent 1 puff twice daily
--> RESUME home Olmesartan 40mg daily
--> RESUME Albuterol/Ipratropium nebulizers every 4 hours as
needed for shortness of breath, wheeze
.
-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 care doctor, Dr. [**First Name8 (NamePattern2) 803**]
[**Last Name (NamePattern1) **], within 2 weeks. You can reach her office at: [**Telephone/Fax (1) 2115**]
Admission Date: [**2160-2-3**] Discharge Date: [**2160-2-7**]
Date of Birth: [**2077-3-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
Intubation/extubation and mechanical ventilation
Hemodialysis
Brochoscopy
History of Present Illness:
Information obtained [**Last Name (un) 7245**] from ED records and prior OMR notes
as patient is intubated and family is not present. PMH of ERSD
on HD, dCHF, COPD, DM.
Patient is well known to ICU and renal service and has been
admitted several times to the MICU over the last month with
respiratory failure from presumed diet non-compliance. Today he
was at home and was found in respiratory distress with sats in
the 70's on room air.
He was intubated in the field by EMS and brought here to the ED.
In the ED, initial vs were: 186/78, 98.3, 74 and intubated
sating 100% on 40% FiO2. CXR showed ? LLL infiltrate and he
received a dose of CTX, vanc and levo. He also received a dose
of solumedrol for possible COPD exacerbation. Trop 0.1 (priors
0.04-0.2).
On the floor, patient is intuabted and sedated. Unable to
complete reivew of systems.
Review of systems:
(+) Per HPI
Past Medical History:
ESRD on HD (T/Th/Sat schedule)
Diabetes Mellitus Type 2
Hypertension
Diastolic CHF: Last ECHO [**2159-12-6**] showed LVEF>55%, mild
symmetric left ventricular hypertrophy with preserved global and
regional biventricular systolic function. Diastolic dysfunction.
Dilated aortic sinus
Hypercholesterolemia
Asthma
COPD
Social History:
Lives with caretaker (mainly [**Name (NI) 8230**] speaking only) who takes
care of him. Also has son who lives nearby and involved in his
care (occasionally goes to hemodialysis with him). Other son
lives out of state and is also involved in his care (visits him
1-2 times a week, sets his medications out for him and pre-draws
his insulin, fixed dose). Denies alcohol use or illicit drugs.
Does smoke 1 pack/2-3 days X years.
Family History:
Unknown. Per OMR, noncontributory
Physical Exam:
Vitals: 96.7 162/62 63 100% on 600x16 PEEP 5 FiO2 0.3
General: intubated, sedated, does not follow commands
HEENT: Surgical L pupil, pinpoint R pupil difficult to assess
for reactivity. Intubated.
Neck: supple
Lungs: Clear anteriorly, good breath sounds throughout. No
crackles or wheezes appreciated.
CV: Regular rate, no MRG
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, 2+ pitting edema to knees
Skin: 8cm healing ecchymosis on lower abdomen
Pertinent Results:
Labs on admission:
[**2160-2-3**] 08:25AM PLT COUNT-183
[**2160-2-3**] 08:25AM PT-11.4 PTT-25.9 INR(PT)-0.9
[**2160-2-3**] 08:25AM NEUTS-89.3* LYMPHS-6.6* MONOS-2.7 EOS-1.4
BASOS-0
[**2160-2-3**] 08:25AM WBC-11.5* RBC-3.52* HGB-10.2* HCT-32.9*
MCV-94 MCH-29.0 MCHC-31.0 RDW-15.4
[**2160-2-3**] 08:25AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2160-2-3**] 08:25AM CALCIUM-6.8* PHOSPHATE-3.1 MAGNESIUM-1.5*
[**2160-2-3**] 08:25AM CK-MB-NotDone cTropnT-0.10* proBNP-[**Numeric Identifier **]*
[**2160-2-3**] 08:25AM CK(CPK)-77
[**2160-2-3**] 08:25AM estGFR-Using this
[**2160-2-3**] 08:25AM GLUCOSE-250* UREA N-21* CREAT-3.3* SODIUM-140
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-31 ANION GAP-11
[**2160-2-3**] 08:32AM GLUCOSE-234* LACTATE-1.8 K+-4.0
[**2160-2-3**] 08:32AM TYPE-[**Last Name (un) **] TEMP-37.2 PO2-154* PCO2-51* PH-7.40
TOTAL CO2-33* BASE XS-5
[**2160-2-3**] 01:14PM freeCa-0.90*
[**2160-2-3**] 01:14PM O2 SAT-97
[**2160-2-3**] 01:14PM LACTATE-1.2
[**2160-2-3**] 01:14PM TYPE-ART TEMP-37.6 PO2-102 PCO2-42 PH-7.51*
TOTAL CO2-35* BASE XS-9 INTUBATED-INTUBATED
[**2160-2-3**] 09:37PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-500
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2160-2-3**] 09:37PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2160-2-3**] 09:42PM cTropnT-0.16*
[**2160-2-3**] 09:42PM CK(CPK)-47
[**2160-2-3**] 10:52PM freeCa-0.99*
[**2160-2-3**] 10:52PM O2 SAT-87
[**2160-2-3**] 10:52PM LACTATE-1.9
[**2160-2-3**] 10:52PM TYPE-ART TEMP-36.7 PEEP-5 O2-30 PO2-54*
PCO2-49* PH-7.41 TOTAL CO2-32* BASE XS-4 INTUBATED-INTUBATED
[**2160-2-4**] 04:11AM BLOOD proBNP-[**Numeric Identifier **]*
Labs on discharge:
[**2160-2-7**] 07:15AM BLOOD WBC-4.7 RBC-3.26* Hgb-9.7* Hct-29.9*
MCV-92 MCH-29.8 MCHC-32.5 RDW-15.1 Plt Ct-170
[**2160-2-7**] 07:15AM BLOOD Glucose-192* UreaN-39* Creat-4.5* Na-133
K-3.9 Cl-94* HCO3-31 AnGap-12
[**2160-2-7**] 07:15AM BLOOD Calcium-6.7* Phos-3.8 Mg-2.0
ECG [**2160-2-3**]: Sinus rhythm. Right axis deviation. Possible
anterior myocardial infarction of undetermined age. Non-specific
T wave flattening in lead aVL. No previous tracing available for
comparison.
ECG [**2160-2-3**]: Sinus rhythm. Possible anteroseptal myocardial
infarction of undetermined age. Non-specific T wave flattening
in lead aVL. Compared to tracing #1 no significant difference.
CXR [**2160-2-3**]: SINGLE AP VIEW OF THE CHEST: An endotracheal tube
tip lies 4.2 cm from the carina. The heart is upper limits of
normal in size, with markedly atherosclerotic calcifications of
the aortic arch and descending aorta. Opacity at the left lower
lobe likely relates to atelectasis given leftward shift of the
mediastinum, although underlying smaller effusion and/or
consolidation is not excluded. The right lung is clear.
IMPRESSION:
1. Endotracheal tube tip 4 cm from the carina.
2. Left base opacity with leftward shift of the mediastinum
suggest left lower lobe collapse/atelectasis. Underlying pleural
effusion and/or consolidation not excluded.
Echocardiogram [**2160-2-5**]: There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF 60%). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size and free
wall motion are normal. The ascending aorta is mildly dilated.
There are focal calcifications in the aortic arch. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion. There is an
anterior space which most likely represents a fat pad. Compared
with the findings of the prior study (images reviewed) of [**2159-12-6**], the findings are similar.
CXR [**2160-2-5**]: The patient was extubated in the meantime interval
with removal of the NG tube. There is worsening of the left
lower lobe opacity which has a triangular shape accompanied by
mediastinal shift and is most likely consistent with left lower
lobe complete atelectasis accompanied by pleural effusion. Small
amount of right pleural effusion is most likely unchanged. Upper
lungs are essentially clear and the cardiomediastinal silhouette
is unremarkable as much as it can be assessed.
CXR [**2160-2-6**]: Left lower lobe collapse and moderate left pleural
effusion have been present to more or less the same degree more
than a month. Small right pleural effusion and milder right
basal atelectasis are also longstanding. Heart size is normal.
Upper lobes grossly clear. Thoracic aorta very heavily calcified
but not dilated. No pulmonary edema. No pneumothorax.
Brief Hospital Course:
84 yo M with ESRD on HD, dCHF, COPD here with hypoxic
respiratory failure.
# Hypoxic respiratory Failure: 70% RA on at home per EMS report.
Intubated in field. Now sating 100% on 30% FiO2. CXR without
volume overload - there was suspicion for mucous plugging
contributing to atelectasis or possible aspiration event.
Patient was initially treated with vancomycin, cefepime,
ciprofloxacin for double pseudomonas coverage, but given no
localizing symptoms, leukocytosis, or temperatures suggestive of
pneumonia, the antibiotics were discontinued. Patient underwent
bronchoscopy with good symptomatic relief. Post-bronchoscopy
chest xray showed improved reinflation of lower lobes. Patient
was successfully extubated the day following admission, BNP
continued to be stably elevated. The etiology of recurrent
hypoxia/respiratory failure remains unclear: dietary
non-compliance vs. flash pulmonary edema vs. volume overload
from renal disease vs. CHF exacerbation. Of note, patient's left
lower lung has been collapsed since last admission, giving him
low pulmonary reserve. An ECHO was performed while in the ICU to
assess for the possibility of episodic ventricle non-compliance
causing these episodes. The ECHO was within normal limits -
unchanged from prior.
# Psychosocial: Social Work met with the patient who re-iterated
his strong preference to be at home, where he has a 24 hour
caregiver, Chinese television, familiar surroundings etc.
Patient has repeatedly left from rehab/nursing home facilities
against medical advice. Patient's family has requested closer
communication between the hospital staff and patient's primary
care provider. [**Name10 (NameIs) 20282**] have also discussed the patient's family's
strong preference for setting up hospice care for this patient
given his poor prognosis and repeated hospitalizations (6 in the
last 6-8 weeks). [**Hospital 2188**] saw patient while in the MICU
and felt he would be a good candidate for their services.
Hospice was discussed at length with the patient's son [**Name (NI) **]
(HCP) at this time, but no interpreter was present. A second
meeting was conducted with an interpreter to explain Hospice to
the patient (social worker, case manager, and two [**Hospital 2188**]
team members were present). The patient was able to express his
desire to be kept comfortable and at home, but it was not clear
that he fully understood that home with Hospice means that
future hospitalizations will be actively avoided. He made
statements such as "If I need to be admitted in the future, that
is fine, it is up to the doctors." However, it was the general
consensus of the Hospice team, SW and CM that the patient's
interests would be best met by sending him home with Hospice
services. He will have a [**Hospital 8230**]-speaking nurse to meet with
him daily. The Hospice team will work with the patient and his
caregiver [**First Name (Titles) **] [**Last Name (Titles) 82789**] that should the patient become ill, they
should call the Hospice team rather than 911. If the patient
develops life-threatening hypoxia, he may ultimately still be
transferred to the hospital for admission if this best meets his
needs at that time.
# Hospice criteria. This patient meets criteria for NYHA class
IV heart failure (symptomatic at rest or with minimal exertion).
BNP during this admission was > 32,000. His heart failure is
exacerbated by volume shifts related to his end stage renal
disease (patient is on dialysis, and tends to have increasing O2
requirement the longer it has been since his last session). The
patient also has COPD which contributes to hypoxia even in the
absence of volume overload. As above, he may also have mucous
plugging or other lung pathology causing lung collapse and
contributing to his SOB.
Medications on Admission:
1. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day as needed for constipation.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Furosemide 80 mg Tablet Sig: 1.5 Tablets PO QMWFSU (): On
non-hemodialysis days: Mon, Wed, [**Last Name (LF) **], [**First Name3 (LF) **].
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb vial Inhalation every four (4)
hours as needed for wheezing, SOB.
8. Sevelamer Carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times
a day).
11. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb vial
Inhalation every six (6) hours.
13. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
14. Olmesartan 40 mg Tablet Sig: One (1) Tablet PO once a day.
15. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
16. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
17. Novolin N 100 unit/mL Suspension Sig: Eight (8) units
Subcutaneous qAM.
18. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) inhalation Inhalation twice a day.
19. Zyprexa Zydis 5 mg Tablet, Rapid Dissolve Sig: One (1)
Tablet, Rapid Dissolve PO once a day as needed for agitation.
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Sevelamer Carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO three times a
day.
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for fever or pain.
8. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO QMOWEFRSU
(NON HD DAYS) (): Take on non-dialysis days.
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every six (6) hours as
needed for shortness of breath or wheezing.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
every six (6) hours.
11. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Transdermal
once a day.
12. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
13. Olmesartan 40 mg Tablet Sig: One (1) Tablet PO once a day.
14. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
15. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
16. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
17. Novolin N 100 unit/mL Suspension Sig: Eight (8) units
Subcutaneous every morning.
18. Zyprexa 5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for agitation.
19. Hospice care
Please admit patient to Hospice ([**Hospital 2188**]).
20. Home oxygen
Awaiting patient at home, supplied by Hospice. Titrate to
patient comfort or oxygen saturation > 90%.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **]
Discharge Diagnosis:
Primary:
- Hypoxia requiring intubation
- Atelectasis
- End stage renal disease, dialysis-dependent
Secondary:
- Diastolic heart failure
- COPD
- Type II diabetes mellitus
- Hypertension
Discharge Condition:
Mental Status: Confused - sometimes
Level of Consciousness: Alert and interactive
Activity Status: Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
You were admitted to [**Hospital1 69**] after
you were found very short of breath and had to have a breathing
tube placed. When you came to the hospital, you were admitted to
the intensive care unit. You underwent dialysis and your
breathing improved.
Give the frequency of your recent hospitalizations and your
desire to remain out of the hospital, a Hospice service was
consulted to talk about other options for care. You agreed to go
home with Hopsice with goals to keep you out of the hospital and
maximize your comfort.
Followup Instructions:
Please discuss any active health issues with your Hospice team.
If you would like additional health care, please call to
schedule an appointment with your PCP [**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) **] at
[**Telephone/Fax (1) 2115**].
Completed by:[**2160-2-7**]
|
[
"518.0",
"585.6",
"428.0",
"V15.81",
"250.00",
"403.91",
"493.22",
"428.33"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
42238, 42289
|
34774, 38549
|
27258, 27333
|
42521, 42521
|
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27361, 28209
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18083, 18357
|
29697, 31408
|
42536, 42672
|
28264, 28582
|
28598, 29027
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,829
| 139,621
|
43616
|
Discharge summary
|
report
|
Admission Date: [**2103-8-30**] Discharge Date: [**2103-10-8**]
Date of Birth: [**2063-4-23**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
found down unconscious
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 40 W with AIDS, last CD4 count of 8 in [**1-19**], who is
non-compliant with f/u and not on HAART, presented to the ED
with lethargy, fever, hypotension, and a cough productive of
thick greenish-yellow sputum. Per ED records, the patient was
noticed sitting on her doorstep, apparently unconscious, and a
bystander called 911.
.
Of note, patient is not cooperative with interview or
examination.
She refused to answer questions about her medical history or
social situation and is uncooperative with physical exam.
.
In the ED patient was found to be febrile (101.9), hypotensive
(80/50), tachycardiac, and severely anemic with Hct 12, and
guaiac positive. Patient was transfused with 2 Units PRBCs and
blood and urine cultures were sent. An LP was performed and
patient was started on 2 grams ceftriaxone, 1 gram vanco, 500 mg
IV flagyl, and Decadron 10 mg IV.
Past Medical History:
AIDS
ITP
HSV rash
abnormal PAP s/p LEEP for squamous intraepithelial lesions
Social History:
The patient had been living with her 22-year-old daughter for
the six months prior to the admission. Before Feburary [**2103**], the
patient had difficulty meeting her living expenses and spent
some time in shelters. Before being diagnosed with HIV, she
worked at [**Hospital3 1810**] and was a notary public. She is
estranged from her husband.
Family History:
NC
Physical Exam:
VS: T: 99.2 HR: 71 BP: 101/63
GEN: cachectic woman lying in bed, refusing to open her eyes, in
NAD
HEENT: [**5-18**] eyelid strength, otherwise unable to assess
CV: RRR, no m/r/g
CHEST: CTAB no c/w/r
ABD: thin, unable to assess
EXT: no edema, + 2 distal pulses BL
NEURO: awake, uncooperative, answers to some questions
appropriately
Pertinent Results:
[**2103-8-30**] 11:47PM CORTISOL-30.8*
[**2103-8-30**] 11:47PM URINE HOURS-RANDOM CREAT-118 SODIUM-31
[**2103-8-30**] 08:45PM CEREBROSPINAL FLUID (CSF) PROTEIN-27
GLUCOSE-64
[**2103-8-30**] 08:45PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-6* POLYS-0
LYMPHS-0 MONOS-0
[**2103-8-30**] 04:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2103-8-30**] 04:00PM URINE RBC-0-2 WBC-[**3-18**] BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2103-8-30**] 04:00PM URINE HYALINE-[**12-3**]*
[**2103-8-30**] 01:11PM GLUCOSE-81 UREA N-49* CREAT-2.0*# SODIUM-138
POTASSIUM-3.7 CHLORIDE-92* TOTAL CO2-34* ANION GAP-16
[**2103-8-30**] 01:33PM LACTATE-2.1*
[**2103-8-30**] 01:11PM CALCIUM-8.8 PHOSPHATE-4.7* MAGNESIUM-2.6
[**2103-8-30**] 01:11PM WBC-3.9* RBC-1.59*# HGB-4.2*# HCT-12.5*#
MCV-79* MCH-26.6*# MCHC-33.8 RDW-18.5*
[**2103-8-30**] 01:11PM PLT COUNT-407
[**2103-8-30**] 01:11PM PT-12.3 PTT-29.6 INR(PT)-1.1
.
CXR ([**9-3**]): Persistent bibasilar opacities. Development of new
opacity in the right upper lobe as described above. Given the
current clinical situation, multifocal pneumonia would be the
likely cause.
.
MRI ([**9-5**]): IMPRESSION. 1. No mass or abnormal enhancement in
the brain or meninges. 2. Findings consistent with bilateral
mastoiditis and mucosal thickening in both sphenoid sinuses. 3.
Generalized brain atrophy.
.
EEG ([**9-7**]): No focal abnormalities or epileptiform features were
seen.
.
CT of Head ([**9-10**]): IMPRESSION: Severe destruction and fluid
replacement of bilateral mastoid air cells, right greater than
left. In the right petrous bone there is osseous destruction
anteriorly that might indicate possible spread to the
intracranial
compartment. Demineralization of the sigmoid plate is present
posteriorly. We recommend MRI of the brain and also MRV.
.
MRI ([**9-11**]): IMPRESSION: 1. Increased enhancement of bilateral
mastoids and part of the petrous bones, opacified with complex
fluid, most likely due to infection. 2. New small subdural
complex fluid collections in bilateral frontal regions with
meningeal enhancement. These findings are worrisome for
meningeal spread of the infection. 3. No obvious
intraparenchymal abnormality at this stage.
.
MRI ([**9-13**]) IMPRESSION:
1. Acute left putaminal infarct, new in the interval.
2. Unchanged appearance of bilateral mastoiditis with small
bilateral subdural fluid collections, with enhancement of the
surrounding meninges.
.
[**9-19**] EEG: IMPRESSION: Markedly abnormal EEG due to the very
frequent generalized sharp wave discharges with a left
hemisphere predominance. These discharges were generally
occurring every one to two seconds but not particularly
rhythmically. The suppressed background suggests a widespread
and severe encephalopathy affecting all areas. There was more
cortical dysfunction on the right, with lower voltage activity,
but the discharges suggest an area of increased cortical
hypersynchrony on the left with epileptogenic potential. These
discharges did not constitute a seizure at the time of the
recording, but they are worrisome for seizures at other times.
.
[**9-20**] EEG: This 24 hour video EEG telemetry demonstrated periodic
lateralized sharp epileptiform discharges most prominantly seen
over the left frontocentral and frontotemporal leads. The
background also
demonstrated a diffuse low voltage slowing. These findings are
suggestive of a left hemispheric focus superimposed on a more
widespread encephalopathy.
.
[**9-20**] CXR: Stable appearance of small bilateral pleural effusions
and small bibasilar consolidation which could represent
pneumonia or atelectasis.
.
[**9-21**] MR head: IMPRESSION:
1. Bilateral extensive mastoid soft tissue changes. Decrease
in meningeal enhancement seen on the previous MRI study. No new
areas of signal abnormality or enhancement or fluid collection
seen.
2. Evolution of left putaminal infarct.
3. Diffuse brain atrophy could be related to HIV
encephalopathy.
4. No new areas of enhancement.
.
[**9-24**] head CT IMPRESSION:
1. No new infarct or hemorrhage.
2. Status post right mastoidectomy with persistent opacification
in the region of surgery. Increased opacification in the left
mastoid air cell/middle ear cavity consistent with worsening
mastoiditis.
.
[**9-26**] Renal USN: Increased echogenicity in relation to the
kidneys bilaterally consistent with HIV nephropathy.
Brief Hospital Course:
This is a 40 y.o. woman with AIDS admitted with hypotension,
fever, pneumonia, anemia, UTI, and acute renal failure. During
this hospitalization, the patient was transferred to the MICU on
several occasions for hypotension. After a long hospital stay
with a consistently declining status, the patient was made CMO
and expired while on the wards. The following issues were
addressed:
.
1. Infectious disease: The patient presented with b/l PNA and
developed a mastoiditis with extension into the subdural space.
Upon presentation an LP was done which was negative for
meningitis. Blood cultures, urine cultures, and ear drainage was
cultured. Viral cultures and stool cultures were also sent. The
patient grew out MSSA and pseudomonas from her sputum and coag
negative staph from her R ear. A right mastoidectomy was
performed. The patient was treated empirically with Vanco,
Ceftazadime, caspofungin, and acyclovir. As viral and fungal
cultures came back negative, the acyclovir and caspofungin were
stopped. ID was involved throughout the hospitalization and
suggested a 4 week course of the vanco and ceftazadime from the
time of debridement of the R mastoid. A repeat head CT on [**9-26**]
showed increasing L sided mastoiditis despite maximum medical
therapy. On [**10-2**], all antibiotics were stopped as the patient
had been anuric for three days and the antibiotics were
contributing to fluid overload and respiratory distress. The
patient was made CMO at that point and finally expired on [**10-8**].
.
A. Pneumonia: The patient presented with CXR and CT findings
consistent with a bilateral multi-focal pneumonia. A cavitary
lung lesion was also seen in the right LL on chest CT. Given
patient's CD4 count of 8, and subsequent immunocompromised
state, the patient was susceptible to opportunistic infections
and the ddx was extremely broad and included bacterial, viral,
fungal, parasitic infections. Three consecutive induced sputum
samples were negative for acid fast bacteria. Culture of these
sputum samples revealed pseudomonas aeruginosa, MSSA, and yeast.
Her sputum was negative for PCP, [**Name10 (NameIs) 11381**], and nocardia. She was
treated with an antibiotic regimen to cover gram +, gram -,
particularly pseudomonas. As stated above she was treated with
Vancomycin, ceftazidime, and caspofungin. The patient was kept
on bactrim for PCP [**Name Initial (PRE) 1102**]. The patient also was found to
have b/l pleural effusions after being fluid repleted in the
ICU. A thoracocentesis was considered but ultimately was not
pursued as the patient was satting well and had an overall poor
prognosis. As part of a workup for the cavitary RLL lesion, ANCA
was sent to r/o Wegener's granulomatosis. The ANCA was found to
be mildly positive with a pattern not typical of patient's with
HIV. Rheumatology was consulted and did not think a vasculitic
process was likely given ANCA is commonly positive in AIDS and
also in the setting of infection. No further workup or treatment
was done for this finding.
.
B. Bilateral otitis media/mastoiditis: Patient was noted to have
opacification of mastoid air cells on head CT. On the third day
of her admission, her right ear drum ruptured and was oozing an
opaque, thick fluid. Her ear infections were noted to be
bilateral. ENT was consulted several times during the course of
this admission. Tympanostomy tubes were placed to drain any
residual infection and to prevent intracranial infiltration. The
drainage from her R ear was cultured and grew coag negative
staph and some yeast. The patient was treated with vancomycin
and caspofungin. A repeat MRI showed bilateral fluid collections
in the frontal region with meningeal enhancement that were
concerning for meningeal spread of the infection. A right sided
mastoidectomy was done to remove the fluid from the right
mastoid cavity. A CT head on [**9-24**] later showed increasing L
sided mastoiditis despite the broad antibiotic coverage. ENT was
consulted but no further intervention was recommended.
.
C.UTI: Her UTI was treated with the broad spectrum antibiotics
(for PNA and mastoiditis) and subsequent UA was negative as were
urine cultures.
.
2. Seizures: On day six of her hospital admission, the patient
had a witnessed tonic-clonic seizure. Her antibiotics and
antipsychotic medications that may have lowered the seizure
threshold were stopped. Neurology was consulted and the patient
was started on phenytoin for seizure management (goal 15-20).
The patient continued to have seizures and Keppra was added. An
EEG was done which showed seizure activity. By the end of her
hospitalization, the seizures appeared to be controlled on
phenytoin and Keppra. However, non-convulsant seizures could not
be ruled out. The patient was continued on the seizure
prophylaxis while she was CMO.
.
3. Acute left putaminal infarct: This infarct was found s/p R
mastoidectomy and thought to be secondary to a hypercoagulable
state during surgery and/or hypotension during surgery. The
patient exhibited diminished movement of her RUE and was not
seen to move her lower extremities. The patient was often
uncooperative with the exam and it was unclear if these
perceived motor deficits were secondary to a hemiparesis vs MS
decline secondary to post-ictal states vs lack of voluntary
cooperation by the patient. The patient was started on an
aspirin and her HCT was trended given her history of OB positive
stool.
.
4. Pericardial effusion: For evaluation of the patient's
tachycardia and hypotension, the patient had a ETT which showed
a pericardial effusion. Cardiology was consulted and did not
feel that the patient had clinical signs of tamponade (no JVD
and pulsus= [**6-23**]). Cardiology did not recommend
pericardiocentesis. The fellow spoke to the daughter and she
agreed not to pursue with the procedure.
.
5. hyperchloremic metabolic acidosis: The patient developed a
non-gap metabolic acidosis initially thought to be secondary to
fluid boluses with NS used to keep the patient's BP WNL in
addition to bicarb loss via diarrhea induced by the tube feeds.
The boluses were changed to LR but the acidosis continued. A
c.diff was ordered but the patient's status was changed to CMO
before it was sent.
.
6. hypothyroidism: The patient's thyroid function was initially
WNL at the beginning of her hospitalization. Thyroid function
was reassessed when the patient developed hypothermia. The TSH
was increased and T3 T4 were decreased, likely secondary to her
infected state. This may have also contributed to her declining
MS, pericardial effusion and LE edema. The patient was started
on levothyroxine 25 mcg QD without any improvement in her
hypothermia or edema.
.
7. MS changes: Throughout the [**Hospital 228**] hospital stay her mental
status fluctuated on a day to day basis. However, as the
patient's overall condition worsened, her mental status
declined. The ddx for this change includes the numerous seizures
and a post-ictal state, the infarct, AIDS dementia, and
overwhelming infection.
.
8. Hypotension: In the ED SBP transiently improved to 90's -low
100's with IVF. Given the signs of infection, the hypotension
was concerning for sepsis. The patient was normotensive for some
time after transfer to the medicine service. She later developed
hypotension in the setting of tachycardia and was transferred to
the ICU because of the concern for sepsis. She was treated with
4L IV normal saline. When her hypotension resolved, she was
transferred back to the medicine service for management. After a
few days on the medicine service, the patient again became
hypotensive and had multiple seizures, requiring a dilantin load
which tended to exacerbate the hypotension. The patient was
again admitted to the ICU, fluid repleted, and returned to the
floor for further management. Multiple blood cultures were drawn
throughout the [**Hospital 228**] hospital stay. None of the blood
cultures every grew out any organisms.
.
9. Anemia: While the patient's hct measured in the ED was 12.5,
the patient received 3 units packed RBCs after which her hct
stabilized to 28-29. GI was consulted, but the patient declined
to have endoscopy performed. Her stool was guaic + in the ED.
The patient was transfused multiple times during her
hospitalization to keep her hct>21.
.
10. TCP: The patient's platelets began to drop during the
admission. The ddx included BM suppression from her HIV and/or
overwhelming infection. DIC was also possible but thought to be
less likely. Drug toxicity was also considered possible and
drugs causing TCP were stopped (protonix). Given the patient was
on heparin, HIT was also deemed a possibility and SC heparin was
stopped. Pneumoboots were used instead. The patient did not show
any signs of bleeding and never needed platelet transfusions.
All lab draws were discontinued on [**9-28**] secondary to her poor
prognosis and the desire to move the patient to comfort care
only.
.
11. AIDS: Not on HAART [**2-15**] non-compliance. Pt was felt to be too
ill/decompensated with multiple areas of infection to start
HAART as an inpatient.
.
12. ARF: Her initial serum creatinine was 2.0. After receiving
IV fluids, it resolved to 0.7, making it likely that her
elevated creatinine was the result of dehydration. The patient's
Cr was stable throughout her admission. However, towards the end
of the admission the patient's creatinine began to increase.
Urine lytes did not show a picture consistent with a pre-renal
etiology as FEna was 1.7%. Renal USN did not show any signs of
obstruction. Med toxicity was considered and all nephrotoxic
agents were stopped. The patient's vanco level was
supratherapuetic and was held. There were no eos in her urine or
peripherally. The patient's renal failure continued to progress
and she eventually became anuric. It was decided that dialysis
would not be pursued and no further workup would be done given
her poor prognosis. The patient was anuric for >7 days prior to
expiration.
.
13. PPX: PPI and SC heparin were given until TCP developed and
then pneumoboots were used thereafter.
.
14. FEN: An NGT was placed and the patient was started on tube
feeds to improve nutrition. When the patient's code status was
changed to comfort care only, the NGT was pulled and tube feeds
were stopped.
Medications on Admission:
Bactrim
MVI
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
Completed by:[**2103-10-16**]
|
[
"041.11",
"482.41",
"042",
"345.3",
"324.0",
"997.02",
"518.89",
"423.9",
"789.5",
"482.1",
"578.9",
"244.9",
"383.02",
"584.5",
"434.01",
"383.1",
"280.0",
"511.9",
"381.00",
"320.3",
"294.10",
"383.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"99.04",
"03.31",
"20.01",
"20.41",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
16858, 16867
|
6516, 16796
|
295, 301
|
16918, 17079
|
2054, 6493
|
1681, 1685
|
16888, 16897
|
16822, 16835
|
1700, 2035
|
233, 257
|
329, 1202
|
1224, 1303
|
1319, 1665
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,165
| 191,152
|
5783
|
Discharge summary
|
report
|
Admission Date: [**2199-10-13**] Discharge Date: [**2199-10-25**]
Date of Birth: [**2125-10-3**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Massive diaphragmatic hernia
with infarcted small bowel, corresponding small bowel
obstruction, pericarditis, cardiac adhesions to pericardium.
PHYSICAL EXAMINATION: The patient is a well developed, well
nourished male, appearance appropriate to age, in no acute
distress. HEENT: Mucus membranes moist, no oral ulcers,
sclera is anicteric. Cranial nerves II through XII are
intact, no cervical lymphadenopathy. Chest clear to
auscultation bilaterally. Cardiac, regular rate and rhythm,
no murmurs. Abdomen soft, non distended, Steri-Strips were
intact, no evidence of cellulitis, no evidence of masses, no
tenderness on palpation, no rebound noted.
LABORATORY DATA: On the day of discharge patient's labs were
within normal range.
HOSPITAL COURSE: Mr. [**Known lastname 22994**] is a 74-year-old male with
past medical history remarkable for aortic valve replacement
in [**2194-5-11**] and asthma, who presented with bowel herniation
into the left hemithorax via anterior diaphragm. The patient
was emergently reversed in his anticoagulation and started on
IV Zosyn with operative inter-exploration on [**2199-10-13**].
Operatively, massive diaphragmatic hernia with infarcted
small bowel was found. The patient underwent a reduction of
diaphragmatic hernia, division of cardiac adhesions to
pericardium and pericarditis, drainage of right chest pleural
effusion and repair of diaphragmatic hernia with small bowel
resection and left chest tube placement. The patient
received two units of packed red blood cells and two units of
FFP during the operation with immediate transfer to the CSRU
postoperatively. On [**10-14**] the patient was extubated and with
100% O2 sat on face mask. By postoperative day #2 the
patient was transferred to the floor whereupon three issues
emerged.
First, the patient's tachycardia was managed with beta
blockade after hypovolemia and pain as cause was ruled out.
Secondly, the patient was anticoagulated to prevent adverse
consequence from aortic valve replacement. The patient was
transitioned to oral Coumadin by the date of discharge.
Third, patient's postoperative ileus resolved and diet was
appropriately advanced. By [**10-24**] decision was made to
discharge patient with home VNA and physical therapy for
endurance training.
DISCHARGE STATUS: Stable.
DISCHARGE DIAGNOSIS: Status post diaphragmatic hernia
repair, infarcted small bowel resection, division of cardiac
adhesions to pericardium, drainage of right chest pleural
effusion and insertion of left chest tube.
DISCHARGE MEDICATIONS: The patient was instructed to
continue his prior home medications which included Coumadin
and beta blockers.
FOLLOW-UP: The patient was instructed to follow-up with Dr.
[**Last Name (STitle) **] in [**1-14**] weeks after discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 18153**], M.D. [**MD Number(1) 18154**]
Dictated By:[**Name8 (MD) 11079**]
MEDQUIST36
D: [**2199-11-19**] 16:52
T: [**2199-11-19**] 19:26
JOB#: [**Job Number 22995**]
|
[
"557.0",
"V43.3",
"423.1",
"553.3",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.10",
"45.62",
"53.7",
"34.09"
] |
icd9pcs
|
[
[
[]
]
] |
2722, 3227
|
2502, 2698
|
922, 2480
|
330, 904
|
162, 307
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,320
| 168,090
|
990
|
Discharge summary
|
report
|
Admission Date: [**2117-8-11**] Discharge Date: [**2117-8-24**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
hyperkalemia, chest pain,
Ischemic Colitis
Chronic Renal Insufficiency
Major Surgical or Invasive Procedure:
1. Exploratory laparotomy.
2. Extensive lysis of adhesions.
3. Repair of small bowel serosal injury.
4. Right and left component ventral herniorrhaphy.
History of Present Illness:
87 yo F with h/o chronic renal insuficiency, nephrectomy for
renal cell carcinoma, and hypertensive nephrosclerosis who
presents to the ED after being found in her doctor's office to
be hyperkalemic. At the ED, ECG changes consistent with
hyperkalemia were found.
.
Patient reported history through mother and phone interpreter.
She has not been feeling well for a while now, with chest pain,
fatigue and SOB. These symptoms have been present for many
months, but the CP and SOB have been more severe over the last
couple days. Two days ago she started experiencing a squeezing,
pressure pain on the left side of the chest and left shoulder,
which at times radiated down the left arm. The pain occurs at
rest and nothing, except for nitroglycerin, improves or resolve
this pain. This episode she had two weeks ago lasted for about
two hours. Pt took nitro, which decreased the pain but did not
resolve it completely. After two hours the pain resolved on its
own. She is not experiencing CP, SOB now.
.
In the ED, VS were T 97.1, HR 64, BP 192/48, RR 16, O2sat 98%. K
was 6.6 on admission to ED. She was given calcuim gluconate,
sodium bicarbonate, dextrose, insulin, Kayexelate 30 g. At time
of admission to the medicine service her K was 5.3.
.
ROS:
Ms. [**Known lastname **] has had a 20 pound weight loss over the last 6 months
because of loss of appetite. She mostly drinks tea during the
day. She has had chronic abdominal pain not related to eating,
last colonoscopy in [**2114**]. Denied nausea, vomiting, hematochezia,
orthopnea, PND. Has had bilateral leg swelling for many years,
but no pain or worsening edema now.
Past Medical History:
1. Diabetes
2. HTN
3. Hypercholesterolemia
4. Arthritis
5. Hypothyroid
6. S/p nephrectomy for renal cell ca done in 94 at BU
7. MRegurgitation
8. Chronic abdominal pain
9. H/o pancreatitis
10. pancreas divisum
11. hiatal hernia repair
12. left colectomy [**3-12**] [**Location (un) 6553**] b 2 colon cancer with neg nodes
13. ccy
Social History:
no tob, no etoh, no narcotics, lives by self in [**Hospital3 4634**]
Family History:
NC
Physical Exam:
VS: HR 64 BP 181/87 RR 16 O2 sat 99%
GEN: NAD
HEENT: PERRLA, EOMI, sclera anicteric, OP clear, MMM, no LAD,
bilateral carotid bruits. No JVD.
CV: regular, nl s1, s2, holosystolic murmur [**4-13**] on LSB
CHEST: no pain with palpation
PULM: CTA Bl, no r/r/w.
ABD: soft, tender throughout more on the LLQ, ND, + BS, no HSM.
EXT: warm, 1+ dp/radial pulses BL, edema up to the knees
bilaterally.
NEURO: alert & oriented x 3, CN II-XII grossly intact.
Pertinent Results:
[**2117-8-10**] 03:00PM BLOOD WBC-4.5 RBC-2.70* Hgb-8.5* Hct-27.3*
MCV-101*# MCH-31.6 MCHC-31.3 RDW-14.8 Plt Ct-148*
[**2117-8-12**] 09:11PM BLOOD WBC-12.0*# RBC-2.50* Hgb-7.7* Hct-24.3*
MCV-97 MCH-30.9 MCHC-31.7 RDW-14.9 Plt Ct-134*
[**2117-8-10**] 03:00PM BLOOD UreaN-37* Creat-1.7* Na-144 K-6.3*
Cl-116* HCO3-17* AnGap-17
[**2117-8-13**] 09:30PM BLOOD Glucose-123* UreaN-34* Creat-1.9* Na-143
K-4.2 Cl-119* HCO3-17* AnGap-11
[**2117-8-19**] 02:05AM BLOOD Glucose-120* UreaN-71* Creat-3.2* Na-141
K-3.8 Cl-111* HCO3-20* AnGap-14
[**2117-8-10**] 03:00PM BLOOD ALT-13 AST-16 AlkPhos-46 TotBili-0.2
DirBili-0.1 IndBili-0.1
[**2117-8-12**] 07:35AM BLOOD Lipase-44
[**2117-8-11**] 04:30PM BLOOD Lipase-50
[**2117-8-17**] 06:33PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2117-8-10**] 03:00PM BLOOD TotProt-6.0* Albumin-3.6 Globuln-2.4
Calcium-7.9* Cholest-116
[**2117-8-19**] 02:05AM BLOOD Calcium-7.0* Phos-4.7* Mg-2.2
[**2117-8-10**] 03:00PM BLOOD %HbA1c-5.5
.
CT ABDOMEN W/CONTRAST [**2117-8-12**] 1:20 PM
IMPRESSION: Free fluid and large amount of fat stranding seen
within the abdomen, particularly in the region of the splenic
flexure. Relative narrowing of the SMA. Findings are concerning
for ischemic colitis. 2) No evidence of obstruction or
intra-abdominal mass. 3) Status post left nephrectomy. Multiple
small rounded low attenuation lesions seen within the right
kidney, possibly representing cysts but incompletely
characterized on this single-phase study.
.
PORTABLE ABDOMEN [**2117-8-13**] 7:31 AM
IMPRESSION:
1. Unchanged appearance of the multiple massively dilated loops
of large bowel.
2. Unusual appearance of a loop of bowel projecting within the
mid pelvis, probably air filled small bowel--continued followup
advised.
.
[**2117-8-13**] [**2117-8-13**] [**2117-8-17**] DR. [**Last Name (STitle) **]. [**Doctor Last Name 2336**]/kg
DIAGNOSIS:
Fibroadipose tissue and mesothelium with reactive changes,
consistent with hernial sac.
.
RENAL U.S. PORT [**2117-8-14**] 12:22 AM
IMPRESSION:
Mild prominence of the collecting system suggestive of a very
mild hydronephrosis. Probable non-obstructive 4 mm right upper
pole renal calculi.
.
CHEST (PORTABLE AP) [**2117-8-16**] 4:20 PM
IMPRESSION:
1. Low position of endotracheal tube as communicated to Dr.
[**Last Name (STitle) **].
2. Left lower lobe atelectasis.
Brief Hospital Course:
A/P: 87 yo F with h/o chronic renal insuficiency, nephrectomy
for renal cell carcinoma, and hypertensive nephrosclerosis who
presents with hyperkalemia and ECG changes.
.
.
1. Hyperkalemia: Pt's h/o of CRI and hypertensive
nephrosclerosis are most concerning for an etiology. She also
has a history of MGUS. Pt has been eating poorly which would
suggest a component of decreased effective circulating volume.
Given these conditions it is likely that decreased urinary
potassium excretion (from all these separate causes) is the
underlying process. It is unclear how compliant patient is with
meds and this could be contributing as well.
- Give IV fluids
- check K q6h; give kayexelate if K elevated
- Maintain on telemetry
- Reorder ECG
- Check SPEP, UPEP - to check for multiple myeloma
- Hold ACE inhibitor
- low K diet
- nutrition consult
.
2. CRI: baseline creat 2.0, pt at baseline now.
- IV fluids
- check creat
- renal consult was obtained
.
3. Hypertension: Patient with history of poorly controlled
hypertension.
- Will continue home BP meds, and uptitrate as tolerated.
- Hold ACEI
.
4. Chest pain: Patient with episode of chest pain two days
prior, with multiple RF including high cholesterol, DM2, age,
hypertension. Although pain resolved at this time, will check
for cardiac origin.
- Will check CE
- EKG shows no acute ST-T changes
- Continue labetolol, aspirin. Hold ACEI for now.
- Check lipid panel, A1c
- Check repeat echocardiogram
.
5. Weight loss: Patient endorses recent 20# weight loss, and has
history of colon cancer. Overdue for colonoscopy. Also noted to
have abdominal pain, but without acute abdomen.
- Check LFTs, amylase, lipase
- Needs outpatient colonoscopy
- Guaiac all stools.
- Nutrition consult as above
.
6. Anemia: baseline HCT per records has been in low 30s. Now at
28. Might be anemia of chronic disease or secondary to
malnutrition given reported poor PO intake in last months. No
obvious bleeding, but will like to check stool.
- guiaic all stools
- Fe studies.
.
7 Hyperlipidemia: history of hyperlipidemia on record, but
current lipid panel results were within normal levels
.
8 Chronic LE edema: long time issue. Stable now. No pain,
erythema or skin color changes. CHF a possibility and will be
explored.
- check Echocardiogram for EF
.
9 Hypothyroid: stable condition
- continue Levothyroxine
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
================================================================
She was transfered to the Surgery service and went to the OR on
[**2117-8-13**] for:
1. Exploratory laparotomy.
2. Extensive lysis of adhesions.
3. Repair of small bowel serosal injury.
4. Right and left component ventral herniorrhaphy.
She remained in the ICU for 6 days.
CRI: She had post-op low urine output with ATN. She continued on
IVF and occasional Lasix and Diuril. Once her urine output
picked up, the Diuretics were held. She had autodiuresis and her
Cr began to fall as she mobilized fluids. She continued on D5
1/2NS for several day and we then encouraged PO intake. Her
Foleuy was removed as her urine output picked up.
Abd/GI: She was NPO with a NGT. Her incision was intact with a
moderate amount of serosanguinous drainage. She had a
surrounding area of ecchymosis around the incision. She had
abdominal JP drains in place with high output (>1000cc
drainage).
She was started on a PO diet on POD 5. Her PO intake was
marginal and we encouraged additional PO's. The drain output was
still high from drain #2 at time of discharge (1000-2000cc/day).
The drains will remain in place until follow-up.
CV: She was in normal sinus rhythm with frequent PVC's. She was
started on an Amiodarone drip. She had occasional bradycardia.
She had a episode of rapid Afib while repostioning the patient
on POD 4 with a rate in the 150's. She converted shortly
thereafter with a rate in the 60's. She continued on PO
Amiodarone once back on a diet.
Resp: She remained intubated and on the vent. She was extubated
on [**8-17**] and tolerated this.
ID: She was on Cipro/Flagyl and Ampicillin antibiotics for
peritonitis and ischemic bowel. Stop antibiotics on [**8-27**].
Medications on Admission:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
4. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
6. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
7. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
9. Quinine Sulfate 325 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
10. Metformin 500 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Sliding Scale Injection ASDIR (AS DIRECTED).
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) for 1 days.
4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 1 weeks: Start [**8-26**]. Then transition to maintenance.
5. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): Please hold for SBP<100 and HR<60.
7. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily): Hold for SBP < 100 and HR <
60.
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 3 days: Stop on [**8-27**].
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days: Stop on [**8-27**].
11. Ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q24H
(every 24 hours) for 3 days: Stop on [**8-27**].
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] of [**Location (un) 583**]
Discharge Diagnosis:
Hyperkalemia
Ischemic Colitis
Chronic Renal Insufficiency
Malnutrition
Bradycardia
Discharge Condition:
Fair
Weak, deconditioned
Needs assistance with eating and drinking
Incision C,D,I with eccymosis
Discharge Instructions:
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 not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to amubulate several times per day.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 519**] in [**3-13**] weeks. Call ([**Telephone/Fax (1) 5323**]
to schedule an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2117-8-24**]
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icd9cm
|
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|
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|
333, 491
|
11831, 11930
|
3097, 5432
|
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|
2607, 2611
|
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11725, 11810
|
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|
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|
222, 295
|
519, 2151
|
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|
2520, 2591
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,901
| 167,417
|
13499+56462
|
Discharge summary
|
report+addendum
|
Admission Date: [**2147-4-14**] Discharge Date: [**2147-5-5**]
Date of Birth: [**2071-8-1**] Sex: M
Service: [**Hospital Unit Name 38208**] COMPLAINT: Weakness
HISTORY OF PRESENT ILLNESS: 76-year-old white male with a
history of symptomatic bradycardia status post pacemaker,
hypertension, hyperlipidemia, coronary artery disease,
weakness over the last three to four weeks. The patient has
a complicated cardiac history. He was hospitalized in
[**2144-10-28**] for an acute thrombosis of the left anterior
descending. The patient was seen earlier that week for an
episode of near-syncope, was seen the following week in
clinic by his primary care physician. [**Name10 (NameIs) **] in the clinic,
he stated that since his pre-syncopal episode, he had felt
fibrillation arrest and was resuscitated and brought to the
Coronary Care Unit. While in the Coronary Care Unit, his
enzymes were positive and, shortly afterwards, he was taken
to the cardiac catheterization laboratory. The
catheterization revealed near-total occlusion of his proximal
left anterior descending and thrombus at the site of
occlusion. The lesion was successfully stented with 0%
residual stenosis. There were no other identifiable lesions
in the left anterior descending. There was 50 to 60%
stenosis of the obtuse marginal I. The right coronary artery
showed minor irregularities in the proximal third.
Shortly after catheterization, the patient suffered from
another episode of ventricular fibrillation, and then was
successfully cardioverted, but then developed respiratory
distress and was intubated for cardiogenic shock.
Echocardiogram at that time revealed an ejection fraction of
25% with anteroseptal and apical hypokinesis. He was
intubated for over a month and required a tracheostomy.
While intubated, his pacemaker was replaced with an ICD
[**Company 1543**] Model #7273. Eventually, after a prolonged
hospital Coronary Care Unit stay, he was extubated and
underwent intensive cardiac rehabilitation.
Since his Coronary Care Unit admission, he has suffered from
the following events: In [**2146-9-29**], while in [**Location (un) 86**],
he had an episode of ventricular fibrillation for which he
was shocked. His defibrillator detection rate was
reprogrammed from 188 to 167 beats per minute. He has lost
70 or 80 pounds, and continues to lose weight. He went from
247 to 170 pounds. His ACE inhibitor was discontinued for
suspected cough, and his beta blocker discontinued for
asymptomatic hypotension. Over the last three to four weeks,
he has noted increased weakness. He has been playing golf
fairly recently, but is no longer able to play. He becomes
short of breath after walking a quarter of a mile, according
to him. He denies any chest pain. He also has been having
pain in his left shoulder, left upper chest, which was
attributed to him lying in bed on that side. He notes that
he has awakened in the middle of the night short of breath.
He has also required a variable height of pillows on which to
sleep. He denies any fevers or chills. He denies any nausea
or vomiting. He has had problems with constipation.
PAST MEDICAL HISTORY:
1. Insulin-dependent diabetes mellitus, possibly Type 2
diabetes. Since his myocardial infarction, he reports that
his glucose is on the low side, and he has not required any
insulin. His fasting glucose has been around 120 to 130.
Last hemoglobin A1c was 6.16.
2. Coronary artery disease as above
3. Symptomatic bradycardia; pacemaker was placed in [**2122**] and
was later replaced in [**2130**], which was then replaced with a
[**Company 1543**] ICD Model #7273.
4. Hypothyroidism, previously on Synthroid, reason for
discontinuing it is not known
5. Hyperlipidemia, last profile in [**2146-7-30**] with
LDL 93, HDL 53, triglycerides 135
6. Gout
7. Small bowel obstruction from previous hernia repairs
8. Peripheral neuropathy
9. Glaucoma
10. Chronic renal insufficiency, baseline creatinine 1.3
SOCIAL HISTORY: Denies smoking. Occasional ethanol. He
lives in [**State 108**] with his wife, visiting the [**Name (NI) 86**] area
because granddaughter is graduating. He has 2 sons and 1
daughter, and 10 grandchildren.
FAMILY HISTORY: Father died at 51 from a myocardial
infarction.
MEDICATIONS:
1. Coumadin, dose regularly adjusted for atrial
fibrillation, receives 2.5 mg for five days, then 1.5 mg for
two days, specifically on Monday and Wednesday
2. Prilosec 20 mg by mouth once daily.
He has been discontinued from many medications, including
Lanoxin, Vasotec, Atacand, Synthroid, lasix, Toprol XL,
Claritin and Singulair.
ALLERGIES: Questionable Tequin reaction. Additionally, he
was stopped also from amiodarone and Lipitor because of
elevated liver function tests but unclear which medication
caused the reaction.
PHYSICAL EXAMINATION: General: Elderly gentleman with cardiac
cachexia and obvious volume overload. Dyspneic with speaking but
able to
complete sentences. Heart rate 60, blood pressure 128/60,
respiratory rate 20. Head, eyes, ears, nose and throat:
Normocephalic, atraumatic, extraocular movements intact,
pupils equal, round and reactive to light and accommodation,
moist mucous membranes. Neck supple without thyromegaly, jugular
venous distention to angle of jaw. no lymphadenopathy.
Pulmonary: No wheezes or crackles appreciated. Cardiac
displace PMI
S1, split S2, S3 and systolic murmur. Abdomen: Normal bowel
sounds, soft, nontender, palpable liver edge. His abdomen was
distended in the
lower portions. He has a history of hernia. Extremities:
2+ lower extremity pitting edema up to thighs and presacral
edema. Neurological: Alert,
awake, oriented x 3.
LABORATORY DATA: White count 5.5, hematocrit 42.7,
platelets 146, MCV 89, neutrophils 65.3, lymphocytes 25.4,
monocytes .8, eosinophils .6, basophils .4. INR 1.4, PTT
31.2. Cholesterol 141, triglycerides 72, LDL 88, HDL 39, TSH
43.7, free T4 1.3. Sodium 140, potassium 4.5, chloride 101,
bicarbonate 29, BUN 20, creatinine 1.1, glucose 119. ALT 10,
AST 19, albumin 3.7, phosphate 3.8, alkaline phosphatase
________, total bilirubin 1.0, calcium 9.1. Helicobacter
pylori negative. Urinalysis with trace blood, greater than
300 protein, 1.025 specific gravity, pH 5. Troponin was less
than .3. Magnesium 1.9, phosphate 4.1, calcium 9.1.
Chest x-ray showed mild cardiomegaly with slight upper zone
redistribution of the pulmonary vasculature, without evidence
of interstitial or alveolar pulmonary edema. Mild blunting
of the left costophrenic angle and increased densities within
both major fissures on the lateral view, indicating pleural
thickening in these areas. Small pleural effusions present.
These findings were consistent with chronic congestive heart
failure. There was demineralization of the osseous
structures, but no evidence of compression fractures within
the thoracic spine. Dual lead defibrillator/cardiac pacer is
seen with the generator overlying the left hemithorax.
Electrocardiogram shows paced rhythm with a left bundle
branch block pattern. Echocardiogram showed an ejection
fraction of 15%.
Stress Thallium showed moderate defect involving the anterior and
septal walls. There was severe perfusion defect involving the
cardiac apex. However, the test was stopped because of Thallium
pickup in the lungs. No exercise stress test was done.
ASSESSMENT AND PLAN: 76-year-old white male with a history
of coronary artery disease, symptomatic bradycardia status
post pacemaker, ventricular fibrillation arrest, now comes
with progressive deterioration of exercise tolerance and
increase in dyspnea on exertion plus symptoms of paroxysmal
nocturnal dyspnea, orthopnea, peripheral edema and was found to
be in decompensated heart failure. He was admitted for
treatment of his congestive heart failure.
HOSPITAL COURSE BY SYSTEM:
1. Cardiac ischemia: The patient was felt to be in
decompensated heart failure secondary to a discontinuation in his
medications as well as possibly from an ischemic event. His
troponin was negative,
therefore he didn't have any event in the last week or so. He
was not started on a beta blocker because he was in congestive
heart failure. His cholesterol
was thought to be in the desired range, so he was not started
on any Lipitor. He had a cardiac catheterization done on the
fifth day of admission that showed right atrial pressure of
10, right ventricular pressure of 52/6, and the rest in the
pump section. LVgram showed an ejection fraction of 18%, with
left main being normal, the left anterior descending having
80% in-stent re-stenosis, 80% distal re-stenosis, 80%
diagonal lesion at the ostium. The left circumflex showed
mild disease. The right coronary artery showed mild disease.
Interventions were done, including the diagonal rotoblated
and dilated with angioplasty with 20% residual. His left
anterior descending had two interventions done. For the
distal stenosis, a stent was placed. For the in-stent
re-stenosis, angioplasty was done with subsequent
brachytherapy. After his cardiac catheterization, he was
continued on his aspirin and restarted on his Plavix and
Integrilin. The beta blocker was started once he was thought
to be in less overt congestive heart failure. The Plavix was
to be continued for 180 days, and the Integrilin was to be
continued for 18 hours.
On the seventh day of admission, he was started on carvedilol
3.125 mg by mouth twice a day as he was thought to be near
his dry weight. He was also started on an ACE inhibitor
early in the admission of Captopril. When
transferred to the Unit, he was continued on his aspirin, and
the Plavix was discontinued briefly. The Plavix was
restarted on the third day in the Coronary Care Unit. He was
transferred out of the Unit on [**2147-4-27**]. He was on
aspirin and Plavix, and he was continued on the beta
blockade. His beta blocker was held initially in the setting
of his hematoma, and has been continued. He will need follow
up for continuation on his Plavix for 180 days total.
2. Pump: The patient was in overt congestive heart failure
based on paroxysmal nocturnal dyspnea, chest x-ray, symptoms,
ejection fraction on echocardiogram. The initial
interventions were to give him furosemide 40 mg
intravenously. He had been on furosemide in the past, and
had been taking 20 mg by mouth once daily. It was thought
that giving him 40 mg intravenously would definitely cause a
response. He was also started on Digoxin .125 mg by mouth
once daily. He was also started on Captopril 6.25 mg by
mouth three times a day and it was uptitrated as tolerated. Beta
blocker would be started once he was compensated. His first
day, he diuresed a large amount. His input was 474 and his
output was 2605. Consequently, further lasix was held, as
more gentle diuresis was desired. The Captopril was
increased from 6.25 to 12.5 and then to 18.5.
On the second day, Captopril was increased to 25 mg by mouth
three times a day. Because he was going for cardiac
catheterization, further active diuresis with lasix was held.
He continued to diurese on the second day, with input of 600
and output of [**2094**]. On the third day, he was more even. His
Captopril was increased to 31.25 mg. He had his cardiac
catheterization, which showed a pressure of 10, RV 52/6, PA
53/21, wedge pressure 29. Left ventricular pressure of
135/13, area pressure of 136/75. He had constantly elevated
right-sided and left-sided pressures. He had elevated
left-sided pressure despite being on the diuresis. His
weight had decreased to 155 by the fourth day of admission.
He had come in at 172 pounds. The patient's blood pressure
was 104 to 132 by the fourth day of admission.
On the sixth day of admission, the patient had decreased
blood pressure. The patient had an increased wedge pressure
but decreased blood pressure. He initially received 250 ml
of normal saline. He responded to it and did not have any
respiratory complaints thereafter. His Captopril was held at
that time, as was his furosemide. However, because the
patient was considered to have increased wedge pressure and
he was not bleeding from his groin at that time, further
fluids were held. It was thought that if his blood pressure
were to further decrease, he may need inotropic support.
However, it did not come to that. He had improved on review.
He continued on lasix at the time of transition to by mouth.
He was started at 40 once a day. He was receiving lasix
after his cardiac catheterization. He was basically
receiving 20 to 40 mg by mouth once daily. He continued to
have mild diuresis. He had hypotension. The patient, on the
[**4-21**], had blood pressures basically between 90 and
110. His carvedilol and Lisinopril were continued. It was
decided to change his Captopril to Lisinopril and stagger the
doses between carvedilol and Lisinopril. They were to be
given in the morning and evening. His Digoxin was continued.
The patient was continued on some lasix. He is on 40 mg by
mouth once daily. His blood pressure was low, between 90 and
100. He had increased creatinine on the 25th. His lasix was
held at that time. Lisinopril was continued. He had much
weight loss, and it was thought that it was due to his
diuresis.
On the [**4-24**], the patient required a unit of blood.
His hematocrit had decreased to 28.3. He required a total
of two units before being transferred to the Unit. He was
still on lasix, but it was held because of increased
creatinine. His creatinine returned back to 1, however, he
had to be transferred to the Unit on the [**4-25**], on the
12th day of his admission. In the Unit, his lasix was held.
His blood pressure medications were held at that time. His
hematocrit was eventually stabilized and the medications were
restarted gradually and gently. The diuretic were held, but
his blood pressure medications were restarted on the 13th day
of admission.
On the 14th day of admission, he was still on his Zestril and
carvedilol, and he has been continued on this. He was
continued on his carvedilol and Lisinopril. At this point,
the patient is near euvolemic state, and he is not on his
lasix. He will need to be determined when to restart his
lasix, probably at a low dose at 20 mg by mouth once daily.
The patient responds fairly well to lasix.
The patient is supposed to be evaluated for biventricular
pacing, and was thought to be a good candidate for it. The
patient has a history of atrial fibrillation. He also had a
pacemaker placed previously, and a defibrillator. He, on the
same day of admission, had nonsustained ventricular
tachycardia. Consequently, the EP service was called and
consulted and pacemaker was interrogated. Their initial
recommendations were that the 20 beat run of nonsustained
ventricular tachycardia could be tolerated, and the fact that
his defibrillator did not go off was a good sign, and that it
had to be more prolonged before it should go off. It was
detected and charged appropriately and aborted shock
appropriately. They were concerned about his atrial
fibrillation, and they suggested cardioversion. They also
had plans for assessing for biventricular pacing. EP service
performed their EP study on the [**4-20**], the seventh day
of admission. They further weighed in on the 23rd. They
recommended anti-arrhythmics. They initially recommended
amiodarone, but the patient had a history of elevated liver
function tests. Consequently, they recommended putting the
patient on dofetilide. He was started on dofetilide. The
concern with dofetilide was that it may prolong QT intervals,
however, he did not suffer these effects. He had the EP
study on the [**4-22**]. The heparin was discontinued, he
was continued on the dofetilide. He had several things done.
The patient had an ablation done. He was also assessed for
biventricular pacing and was felt to be a good candidate. He
was also cardioverted. He had biventricular pacemaker
mapping. He had a hematoma on the left side, and pressure
was held, and it was considered stable. His blood pressure
was stable at that time.
Over the next couple of days, the patient was hypotensive,
with hematocrit decreased from 33 to 28.2. This was thought
to be due to the hematoma, but it was stable. He was given
two units of blood. He was considered to be in sinus rhythm.
He was continued on dofetilide. However, he did not have any
profound P waves. He was on heparin and Coumadin after the
procedure. His coumadin was given at 5 mg daily at bedtime.
His heparin was at a goal of 60. After his hematoma
expanded, he was stopped on the heparin and Coumadin.
Heparin and Coumadin were restarted on the 14th day of
admission. His heparin was started on the 14th day of
admission at a goal of around 60. The patient will have
further EP workup in the next month. They are awaiting the
biventricular pacer/defibrillator device to be approved by
the FDA. It is felt that the patient needs anticoagulation
primarily because of his risk of stroke from his cardiomyopathy
and his longstanding atrial fibrillation.
3. Vascular: After the patient had his EP study, he
developed a left-sided hematoma. He was essentially stable
for a few days. The patient had a controlled hematoma
initially. However, on the 12th day of admission, the
patient was walking around and then developed left flank
pain. On examination, he had an expanding hematoma of the
left groin. He had a hematocrit drop from the 30s to 28. He
received two units. He had a bedside ultrasound which showed
no pseudoaneurysm, but did show a large left hematoma. He
was transferred to the Unit for further observation.
Pressure was held initially for approximately two hours. The
hematoma stabilized, but was large in the left anterior
portion of his thigh. He was transferred to the Unit for
observation and had Vascular Surgery follow him.
On the second day in the Coronary Care Unit, the patient
continued to be seen by Vascular Surgery. It was felt that
he would benefit from surgical intervention. He went for
operation, and was found to have a pseudoaneurysm of the
profunda femoral artery. It was repaired, and the hematoma
was evacuated. The patient did not have further
interventions. The patient had anticoagulation initially
held, but it was restarted once the hematocrits were stable.
His hematocrit was stable in the Coronary Care Unit. He did
receive two units of blood prior to this large expanding
hematoma. Thereafter, he did require another two units. The
goal was to keep him above 30. His hematoma is still
present, but his hematocrit is stable, and the hematoma is
thought to be stable. He had another unit transfused in the
Unit. It was decided that, because of his stroke risk, that
he would need anticoagulation, and he was started on the 14th
day of admission, however, it had to be done gently.
4. Endocrine: The patient was on a regular insulin sliding
scale and did not really require much. He is mainly diet
controlled.
5. Hematology: The patient had decrease in his hematocrit
initially from 33 to 28.2 on the tenth day of admission.
This was thought to be due to his left femoral hematoma from
the initial EP study. He received one unit of blood, but his
hematocrit did not bump. Subsequently he received another
unit. He did respond to that, and increased to 29.6 and then
subsequently 31.3. However, when he suffered the expanding
hematoma while walking on the 12th day of admission, his INR
at that time was 1.4, and his PTT was 59. His
anticoagulation was stopped at that time, but it was
restarted on the 14th day of admission. He has continued on
Coumadin 5 mg by mouth daily at bedtime with a goal INR of 2
for the indication of atrial fibrillation and cardioversion.
He had stable hematocrits in the Coronary Care Unit, and at
the time of discharge summary, he had a hematocrit of 31.7.
6. Renal: The patient had a creatinine generally stable
despite diuresis, however, on the ninth day of admission, it
increased to 1.7. He had electrolytes done which showed a
FENA of less than 1% and a urea fairly low too. Consequently
he was thought to be dry, and his lasix was held at that
time. He did receive some units of blood in that setting,
and his creatinine did improve from 12.5 to 1.5. Then the
following day, it was 1.2. At the time of discharge summary,
it was .7.
The patient is still in the hospital awaiting his INR to be
above 2. This is just a discharge summary up to [**2147-4-28**]. His medications at this time are as such:
1. Heparin intravenous drip
2. Warfarin 5 mg by mouth once daily at bedtime
3. Aspirin 81 mg by mouth once daily
4. Plavix 75 mg by mouth once daily
5. [**Doctor First Name **] 60 mg by mouth twice a day
6. Carvedilol 3.125 mg by mouth twice a day
7. Lisinopril 10 mg by mouth daily at bedtime
8. Magnesium oxide 400 mg by mouth three times a day
9. Dofetilide 250 mcg by mouth twice a day
10. Digoxin .0125 mg by mouth once daily
11. Robitussin AC
12. Regular insulin sliding scale
13. Colace
14. Dulcolax
15. Protonix 40 mg by mouth once daily
The patient is waiting his INR to be greater than 2. He will
be discharged to home. He is to follow up with Dr. [**Last Name (STitle) **] and
with the electrophysiologist for ventricular
pacing/defibrillator placement next month. He should follow
up with Dr. [**Last Name (STitle) **] at that time, or in two weeks. The patient
lives in [**State 108**] and was visiting his granddaughter's
graduation prior to all of this happening. He will return to
[**State 108**] most likely, and then return in a month or so for the
placement, or he will have the procedure done in the South.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D.
Dictated By:[**Name8 (MD) 4523**]
MEDQUIST36
D: [**2147-4-28**] 20:18
T: [**2147-4-29**] 03:30
JOB#: [**Job Number 40848**]
Name: [**Known lastname **], [**Known firstname 63**] Unit No: [**Numeric Identifier 7363**]
Admission Date: [**2147-4-14**] Discharge Date: [**2147-5-5**]
Date of Birth: [**2071-8-1**] Sex: M
Service: [**Hospital Unit Name 6010**]: Addendum to discharge summary for dates of [**2147-4-29**] to [**2147-5-3**].
HOSPITAL COURSE: 1. Cardiac - A. Coronary, the patient was
continued on Aspirin, Carvedilol and Plavix. B. Pump, the
euvolemic after [**4-29**]. On [**5-2**] his Lasix was restarted at
40 mg p.o. q.d. and he tolerated this well. He was continued
on Lisinopril, Digoxin and Carvedilol. C. Rhythm, the
patient was status post VT ablation with implantable
cardioverter defibrillator placement. He was on dofetilide and
a beta blocker but
despite this had a few runs of ventricular tachycardia while
that which was ablated. His dofetilide was increased on [**5-1**],
however, despite this during the night between [**5-2**] and
[**5-3**], the patient had a 28 beat run of ventricular
tachycardia and was shocked by his implantable cardioverter
defibrillator out of it. Electrophysiology Service
followed the patient throughout his hospital course. His
implantable cardioverter defibrillator was interrogated on
[**5-4**] and supraventricular tachycardia zone was added by
ventricular fibrillation with one attempt at ATP prior to
shock treatment. His electrolytes were repleted as needed.
On [**5-3**], Mexiletine 150 mg p.o. t.i.d. was added to his
antiarrhythmic regimen and a CK was checked in case this was
reflective of any cardiac ischemia, which was negative.
2. Vascular - The patient's hematocrit remained around the
30 level. There were days between [**4-29**] and [**5-3**] where
there was question of his left thigh hematoma enlarging.
[**Location (un) 2021**]-[**Location (un) 2022**] drain was removed by Vascular Surgery on [**4-28**]. Vascular Surgery continued to follow the patient
throughout his hospital course. His hematocrit was checked
b.i.d. The patient was given 2 units of blood between [**4-29**]
and [**5-3**] for hematocrit less than 30 and it responded well
to these transfusions.
3. Heme - The patient was on heparin drip with Coumadin
until Coumadin became therapeutic, above 2 and then was
discontinued on [**2147-5-1**] because of concerns for
recurrent groin bleed, the Coumadin dose was decreased from 5
mg p.o. q.h.s. to 2 mg p.o. q.h.s. and held for one dose on
[**2147-5-1**].
DISPOSITION: The patient was seen and reconsulted by
physical therapy. His Foley catheter was discontinued. He
was able to ambulate and gain additional strength prior to
discharge.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Rehabilitation Center.
CURRENT MEDICATIONS: [**Month (only) 412**] be slightly different upon final
discharge - Protonix 40 mg p.o. q. 24 hours, Acetaminophen
650 mg p.o. q. 6 hours prn; Docusate sodium 100 mg p.o.
b.i.d., Bisacodyl 10 mg p.o. q.d., titrate 2.5 mg p.o.
q.h.s. prn, regular insulin sliding scale, Glucose 151-200 2
units, 201-250 4 units, 251-300 6 units, 301-350 8 units,
351-400 10 units, greater than 400 12 units, with
fingersticks four times a day, breakfast, lunch, dinner and
bedtime, Digoxin .125 mg p.o. q.d., Guaifenesin, Codeine
phosphate 5 to 10 mg p.o. q. 6 hours prn, Atropine Sulfate .5
mg intravenously times one prn, symptomatic bradycardia and
hypotension, magnesium oxide 400 mg p.o. t.i.d., Lisinopril
10 mg p.o. q.h.s., Carvedilol 3.125 mg p.o. b.i.d., 60
mg p.o. b.i.d., Morphine Sulfate 1 to 2 mg intravenously q. 4
to 6 hours prn pain, Lorazepam .5 mg p.o. q. 4-6 hours prn
nausea, Sulfate 75 mg p.o. q.d. for six months, Aspirin
81 mg p.o. q.d., 375 mcg p.o. b.i.d., check two
hours after each dose and reply to doctor. Coumadin 2.5 mg
p.o. q.d., Lasix 40 mg p.o. q.d., Mexiletine HCL 150 mg p.o.
q. 8 hours, Milk of magnesia 30 ml p.o. q. 6 hours prn.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease
2. Diabetes
3. Congestive heart failure
4. Ventricular tachycardia status post ablation and
implantable cardioverter defibrillator placement
5. History of hypothyroidism
6. Hyperlipidemia
7. Gout
8. repairs
9. Peripheral neuropathy
10. Glaucoma
11. Chronic renal insufficiency, baseline creatinine 1.3
12. Left groin pseudoaneurysm after catheterization
[**First Name8 (NamePattern2) 577**] [**Last Name (NamePattern1) 578**], M.D.
Dictated By:[**Last Name (NamePattern1) 1875**]
MEDQUIST36
D: [**2147-5-3**] 18:01
T: [**2147-5-3**] 20:00
JOB#: [**Job Number 7364**]
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23,028
| 117,744
|
19033
|
Discharge summary
|
report
|
Admission Date: [**2143-1-24**] Discharge Date: [**2143-1-28**]
Date of Birth: [**2101-11-13**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Doxycycline
Attending:[**First Name3 (LF) 603**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
41F HIV on HAART (compliant, CD4 350), HCV, DM2, chronic
neuropathic pain admitted [**1-24**] to MICU from [**Hospital **] clinic with
lethargy and AMS arousable only to sternal rub. Pt takes
fentanyl patch, dilaudid (pcp), gabapentin +/- oxycodone (has
scripts, denies taking) at home. Reports taking 4 tabs dilauded
before ID appoint + regular xanax and gabapentin. Explains that
woke up 5am day prior to admission in significant pain
(neuropathic) and took 3x her normal dose of dilaudid (usual
4mg, took 12mg) and 3x per normal dose of xanax (usual dose 2mg,
took 6mg). Then took her regular doses of both at noon before
going to her [**Hospital **] clinic at 1pm. At [**Hospital **] clinic she was noted to be
very lethargic and was sent to ED for further evaluation.
In the ED, initial vs were: T98.0 89 102/60 10 88% on RA. O2 sat
improved to mid 90s on 2L NC. Per ED report, she was very
lethargic and only responsive to sternal rub. Exam initially
felt notable for ?bilateral LE cellulitis. Multiple urine tox
screens positive (benzos, opiates, cocaine). UA with some WBCs
and nitrate. CXR with very poor inspiratory effort - limited
study but read as likely no infiltrate, though ED suspicious for
infiltrate. Patient was given ceftriaxone and vancomycin and
flagyl (though never appears to have received flagyl) and cipro
- coverage for UTI, pneumonia (aspiration), cellulitis. Came to
MICU because she was only responsive to sternal rub and
suspicion for hypoventilation from narcotic abuse. No ABG, no
narcan given. She brought with her a half-full bottle of xanax 2
mg tabs (#61 - 29 missing from bottle filled 2 weeks ago with
directions to take three times daily).
In the MICU, patient was arousable to loud voice but falls
asleep within seconds. Able to stay awake and answer some
direct questions, but unable to describe what happened today.
Denies IVDU, but does not answer when asked about other
ingestions. Says she takes a medication given to her by her PCP
for pain (?dilaudid) and wears a fentanyl patch. Endorses pain
but unable to specify where.
Review of systems on admission: unable to obtain.
Per discussion with PCP patient has long history of trying to
"stretch the system at both ends". Thinks legitimate pain but
likes her pain meds and tries to use her illness to get a lot
from the system. Of note, per PCP, [**Name10 (NameIs) **] was able to be placed on
hospice benefit within the last year which she outlived as she
was not actively dying of any illness (HIV+ but not with AIDS,
no OI, possibly placed due to liver disease which she is also
not dying of).
Past Medical History:
-HIV ([**2130**], compliant on HAART, last cd4 579 [**9-26**], nadir 43, OI
PCP [**2132**])
-multifactorial hypoxia w/ASD, OHS, OSA on bipap, baseline sat
~92ra%
-IDDM
-HCV (genotype 2B, bx [**5-23**] grade [**1-19**] inflammation, stage 3
fibrosis)
-chronic peripheral neuropathic pain [**2-19**] HIV, prior AZT,
exacerbated by DM
-Hypothyroidism
-HTN
-HepBcAb positive, sAb negative, sAg negative
-Diverticulitis w/hx of colovaginal fistula [**2136**]
-GERD
-Bipolar/anxiety
-genital HSV
-s/p TAH/BSO
Social History:
Has been living at home, has a PCA who visits her 30 hours per
week. Is currently smoking 6 cigs per day. No EtOH, no IVDU
since [**2133**]. She ambulates with the aid of either a walker or
cane depending on how she feels.
Family History:
The patient is adopted and is not aware of familial illnesses.
Physical Exam:
PHYSICAL EXAM ON ADMISSION TO MICU:
General: Somnolent, arouses to loud voice and tactile stimuli,
but falls back asleep within seconds. RR 10 when not
stimulated.
HEENT: PERRL 4->3, sclera anicteric, MMM, oropharynx clear
Neck: supple, JVD difficult to appreciate given obesity, no LAD,
excellent mobility.
Lungs: Clear bilaterally though with poor effort.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, soft, non-distended, multiple incisional scars,
bowel sounds present, appears to be diffusely tender to deep
palpation though no apprent rebound tenderness or guarding.
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or
pitting edema. Bilateral lower extremity erythematous
macular/micropapular rash from groin to shins, mostly medial
distribution. Slightly warm.
Neuro: Somnolent as above. Follows simple commands when asked
(moving all extrems, opens eyes and mouth to command), unable to
assess strength with formal testing.
PHYSICAL EXAM ON TRANSFER TO FLOOR:
VS: 96.3 109/58 79 16 99/2L FS 182 Wt 278.3
Gen: lethargic, somnolent
HEENT: dry MM, unable to assess JVP
Cardiac: RRR, unable to appreciate any murmurs
Lungs: clear anteriorly, unable to get pt to fully sit up
despite multiple attempts
Abdomen: obese, soft, very TTP LLQ with guarding but without
rebound, non-distended
Extremities: DP pulses 1+ bilaterally, unable to appreciate
other pulses
Neuro: CN II-XII grossly intact, moving all extremities,
sensation intact across upper and lower extremities, no
nystagmus appreciated, EOMI, pupils dilated ~6mm, equivocally
reactive to light
Skin: no rashes noted
Psych: denies SI
Pertinent Results:
Labs on Admission:
[**2143-1-24**] 04:40PM BLOOD WBC-6.7# RBC-4.88 Hgb-13.3 Hct-41.5
MCV-85 MCH-27.3 MCHC-32.1 RDW-14.7 Plt Ct-261
[**2143-1-24**] 04:40PM BLOOD Neuts-79.9* Lymphs-12.1* Monos-3.2
Eos-4.4* Baso-0.4
[**2143-1-24**] 04:40PM BLOOD Plt Ct-261
[**2143-1-24**] 04:40PM BLOOD WBC-6.7 Lymph-12* Abs [**Last Name (un) **]-804 CD3%-71
Abs CD3-571* CD4%-43 Abs CD4-349* CD8%-25 Abs CD8-200
CD4/CD8-1.8
[**2143-1-24**] 04:40PM BLOOD Glucose-216* UreaN-13 Creat-0.9 Na-140
K-3.8 Cl-96 HCO3-33* AnGap-15
[**2143-1-24**] 04:40PM BLOOD ALT-28 AST-22 CK(CPK)-59 AlkPhos-139*
TotBili-1.6*
[**2143-1-24**] 04:40PM BLOOD Lipase-22
[**2143-1-24**] 04:40PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2143-1-24**] 04:40PM BLOOD Albumin-4.4
[**2143-1-24**] 04:40PM BLOOD Osmolal-294
[**2143-1-24**] 04:40PM BLOOD TSH-1.9
[**2143-1-24**] 04:40PM BLOOD Free T4-1.2
[**2143-1-24**] 04:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2143-1-24**] 04:48PM BLOOD Lactate-1.6
Labs on Discharge:
[**2143-1-26**] 08:20AM BLOOD WBC-4.4 RBC-4.56 Hgb-12.8 Hct-39.4 MCV-87
MCH-28.1 MCHC-32.5 RDW-14.4 Plt Ct-223
[**2143-1-26**] 08:20AM BLOOD Plt Ct-223
[**2143-1-26**] 08:20AM BLOOD Glucose-309* UreaN-7 Creat-0.9 Na-137
K-3.5 Cl-95* HCO3-33* AnGap-13
[**2143-1-26**] 08:20AM BLOOD Calcium-9.0 Phos-3.4 Mg-1.8
Blood Gases:
[**2143-1-25**] 04:56AM BLOOD Type-[**Last Name (un) **] Temp-36.7 Rates-/10 pO2-65*
pCO2-69* pH-7.38 calTCO2-42* Base XS-11 Intubat-NOT INTUBA
Comment-AXILLARY=9
[**2143-1-24**] 08:38PM BLOOD Type-ART Temp-36.3 pO2-44* pCO2-77*
pH-7.33* calTCO2-42* Base XS-10 Intubat-NOT INTUBA
Micro:
Blood Cultures ([**2143-1-24**]): NGTD
Urine Cultures ([**2143-1-24**]): E COLI, >100,000.
Sensitive to: ceftriaxone, cipro, cefepime, cerazolin, ceftax,
nitrofurantoin, [**Doctor Last Name **]/tazo.
Resistent to: ampicillin, amp/sulbactam, TMX/SMP.
IMAGING:
CXR: There is marked crowding of the bronchovascular structures
due to
the profoundly low lung volumes. An element of mild edema simply
cannot be
excluded on the basis of this examination. Additionally, there
is slightly
more confluent opacity at the left perihilum and in the left
lower lung.
While this may again be due to technical and patient factors, an
early
developing pneumonia cannot be excluded.
Brief Hospital Course:
41F with HIV, HCV, obesity, chronic pain, admitted to MICU with
altered mental status and decreased responsiveness concerning
for narcotic overdose, and ED concern for multiple infections.
# ALTERED MENTAL STATUS: [**2-19**] medication overdose. Somnolent and
obtunded without focal neurologic deficit on admission.
Evaluated for broad differential including toxic, infectious,
metabolic, all of which were negative except for a toxicology
positive for cocaine and a positive U/A. Patient history felt
most consistent with narcotic and benzodiazepine overdose, which
was confirmed once patient was alert and explained that she had
taken 3 times her normal doses of dilaudid and xanax on the
morning of admission. She had no metabolic acidosis or anion gap
and no ketonuria. Of note, patient was not given Narcan due to
her history of neuropathy. All sedating medications including
her pain meds and benzos were initially held with the exception
of her fentanyl patch. She gradually became more lucid and her
pain medications were gradually reintroduced. Psych was
consulted and she was started on long-acting benzodiazepines. By
the third day of hospitalization was noted to be consistently
awake and relatively lucid although still with intermittently
slurred speech. At the time of discharge she was felt to be
close to baseline.
# MEDICATION OVERDOSE: Patient readily admitted to excessive
narcotic and benzodiazepine use on the morning of admission in
infectious disease clinic prior to being sent to the ED. On
interview she repeatedly denied any intentions to harm herself,
stating that she took these medications only due to excessive
pain upon wakening that morning. Continued on home SSRI.
Discharged with referral for psychiatric outpatient follow up.
# PAIN REGIMEN: Admitted on home regimen of gabapentin,
oxycodone (Rx by ID), dilauded (Rx by PCP) a fentanyl patch as
well as Xanax 4mg q6 hours. Medications held and gradually
restarted as detailed above. Per discussion with PCP patient
tries to receive pain meds at multiple places. Per discussion
with PCP and ID fellow (Dr. [**First Name (STitle) **] it was agreed it was best if
from now on patient only received pain and sedating medications
from her ID fellow. Patient informed would be required to sign
narcotics contract.
# HYPOXIA: Hypoxia and hypoventilation/respiratory acidosis.
Reported baseline low O2 sats (baseline ~low 90s based on past
gases and elevated bicarb, likely multifactorial including known
ASD, OHS, chronic hypoventilation). ED with concern for PNA but
CXR consistent only with poor inspiratory effort. Sats initially
87-89% RA and 95% on 2L. Initial concern for PNA but CXR showing
only poor inspiratory effort. Patient was maintained on oxygen
to sats of 89-92% to prevent further hypercarbia. BiPAP was held
given mental status. Repeat CXR showed no clear evidence of PNA.
Saturating ~94% on room air at time of discharge.
# HIV: CD4 count 349 on admission, from > 500 [**9-26**]. Per notes
excellent HAART compliance. Her HAART regimen was continued
during her hospitalization. Phenergan was continued with her
HAART medications to avoid nausea.
# UTI: U/A on admission showed few WBCs, nitrate positive, many
bacteria. Patient asymptomatic and afebrile but with borderline
WBC count at ~12. Started on ceftriaxone. Urine cultures grew
out pan-sensitive e coli, and she was subsequently narrowed to
complete a 3-day course of ciprofloxacin. Afebrile, WBC ~5 at
time of discharge.
# DM-II: On metformin and glargine insulin at home. Metformin
held on admission and replaced with ISS. Glargine continued.
Patient refused a diabetic diet and was noted to have poor sugar
control during her hospitalization with blood [**Month/Year (2) 6801**] mostly
ranging in the 200s to 300s. Her metformin was restarted on
discharge.
# PANNICULAR RASH: recurrent, [**2-19**] habitus. Treated with nystatin
powder.
# HYPERTHYROID: Per documentation patient has history of very
high TSH but is not currently on levothyroxine. TSH + fT4 both
WNL during admission.
Medications on Admission:
- ABACAVIR-LAMIVUDINE 600 mg-300 mg Tablet once a day
- ALPRAZOLAM 2 mg twice a day
- CHLORHEXIDINE 0.12 % Mouthwash - swish and spit 15 cc [**Hospital1 **] as
needed
- FENTANYL - 50 mcg/hour Patch apply to skin every 72 hours
- FLUOXETINE ?30 mg daily
- FUROSEMIDE 80 mg daily as needed for swelling
- GABAPENTIN 900 mg three times daily
- ANUSOL-HC - 2.5 % Cream - cream rectally twice daily
- INSULIN GLARGINE 45 units q am
- METFORMIN 1,000 twice a day
- NYSTATIN - 100,000 unit/gram Powder twice a day
- OXYCODONE - 5 mg Tablet - 1-2 tabs q6 prn pain
- PHENERGAN - 25MG Tablet EVERY 6 HOURS AS NEEDED FOR NAUSEA
- REYATAZ - 400 mg once a day
- ASPIRIN - 81 mg once a day
- INSULIN REGULAR per sliding scale
Discharge Medications:
1. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for swelling.
2. Promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for nausea.
3. Atazanavir 200 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
4. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
5. Fluoxetine 20 mg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
6. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO three times a
day for 2 weeks: Please see your infectious disease for refills.
Disp:*42 Tablet(s)* Refills:*0*
7. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain: please see your infectious disease
physician to have this continued past 2 weeks.
Disp:*56 Tablet(s)* Refills:*0*
8. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO Q8H
(every 8 hours) for 2 weeks.
Disp:*126 Capsule(s)* Refills:*0*
9. Epzicom 600-300 mg Tablet Sig: One (1) Tablet PO once a day.
10. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for skin irritation, rash.
12. Insulin Glargine 100 unit/mL Solution Sig: Forty Five (45)
units Subcutaneous every morning: as previously directed by your
physicians.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
1. Benzodiazepine overdose
2. neuropathic pain
3. IDDM
SECONDARY:
1. HIV
2. Obesity
3. Chronic hypoxia
Discharge Condition:
Mental Status:Confused - sometimes
Level of Consciousness:Lethargic but arousable
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were admitted with altered mental status and difficulty
staying awake after taking too many of your pain and anxiety
medications. While you were here we adjusted some of your
medications. We also treated you for a urinary tract infection.
Please take all of your medications exactly as prescribed.
STOP taking your oxycodone.
STOP taking Xanax.
START taking clonezepam 1mg three times daily. This is a more
appropriate drug for your anxiety, and will act longer than your
Xanax did.
DECREASE your dose of dilaudid to 2mg every 6 hours.
From now on you will get all your pain prescriptions from your
infectious disease physician at [**Hospital1 1170**]. You will have to sign a narcotics contract with Dr. [**Last Name (STitle) **].
This will require you to promise not to receive pain medications
from anyone else, including your primary care physician. [**Name10 (NameIs) **] have
discussed this with your primary care physician and he agrees
that this is the best plan.
Please follow up with your primary care physician and your
infectious disease physicians within the next 2 weeks.
Followup Instructions:
ID
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 22367**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2143-2-14**]
1:00
Schedule an appointment with your primary care doctor within 2
weeks of discharge.
GI
Provider: [**Name10 (NameIs) 1382**] [**Name11 (NameIs) 1383**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2143-4-8**] 12:10
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28,163
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3206
|
Discharge summary
|
report
|
Admission Date: [**2173-3-18**] Discharge Date: [**2173-3-30**]
Date of Birth: [**2101-11-14**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1580**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 71 year old woman with a history of chronic autoimmune
hepatitis, PBC, SLE who is transferred from an outside hospital
for worsening altered mental status.
.
She was admitted to [**Hospital3 **] Hospital on [**2173-3-13**] with N/V,
abdominal pain, and altered mental status/delerium x2 days. She
had diarrhea for 1 week prior to admission. Her sister went to
check on her and found her to be poorly responsive and had
labored breathing (but had been speaking normally on the phone a
few hours prior). In the ED at the OSH, she was noted to be
febrile as high as 104, tachycardic and had abdominal tenderness
on exam. BP was initially stable but then dropped to SBP 70s.
She was treated with IVF (unknown amount) and improved. CBC/diff
had 31% bands. UA was positive for UTI and lactate was 5.4. ABG
was 7.42/36/80. Head CT on admission was negative. She was
started on vancomycin, zosyn, and flagyl empirically and was
admitted to the ICU.
.
CT abdomen/pelvis showed acute colitis (concern for ischemia vs.
infectious). Surgery was consulted, and nonsurgical management
was pursued given her benign abdomen and improving clinical
status at that time.
.
She was transfused 1U PRBC for worsening anemia (hct 32 -> 26,
then 29 after transfusion). Hct remained stable after that time.
Hematology was consulted and recommended supportive care.
.
Urine culture grew E. coli sensitive to ceftriaxone. Blood
cultures grew group B strep 4/4 bottles ([**Last Name (un) 36**] to amp, levoflox,
pcn, vanco; resistant to clinda, erythromycin, tetracycline).
TTE reportedly showed no vegetation. No paracentesis was
performed. ID was consulted, and recommended 2 week course of
ceftriaxone. Other antibiotics were d/c'd.
.
She was also seen by rheumatology consult (by her own
rheumatologist) and was started on solumedrol empirically for
SLE flare (and for risk of adrenal insufficiency). GI was also
consulted and recommended stopping the Imuran and substituting
the steroids, and to titrate lactulose for hepatic
encephalopathy.
.
Over the last 2-3 days, the patient's mental status worsened.
This was felt to be multifactorial, possibly due to hepatic
encephalopathy, sepsis. Repeat head CT showed a small
subarachnoid and a small subdural hemorrhage in the R frontal
region. Neurosurgery was consulted and recommended correcting
coagulopathy (she received 6U FFP and 8U platelets on [**3-17**]
more FFP and 8 more platelets on [**3-18**] for INR 1.7) and repeating
CT scan tomorrow (no emergent need for decompression).
.
Prior to transfer, the patient was hemodynamically stable, not
intubated, and not on any pressors. On arrival, she remains
stable, but is not able to give any details of her history.
Past Medical History:
autoimmune hepatitis dx [**2152**]
primary biliary cirrhosis
SLE
ESLD
septic ankle (MSSA)
HTN
hyponatremia
osteoporosis
s/p ccy
Social History:
Lives alone. Husband is deceased, no children.
Family History:
No family history of liver disease.
Physical Exam:
VS: 97.5, 77, 151/67, 17, 92% on 2L nc.
GENERAL: Sleepy but arousable to voice.
HEENT: PERRL, anicteric, MM dry, OP clear.
LUNGS: CTAB.
HEART: RRR, no m/r/g
ABD: +BS, soft, NT/ND.
EXTREM: Warm, dry, no edema
NEURO: Awake, but not answering questions verbally. Follows
simple commands. Moving all 4 extremities.
.
Pertinent Results:
[**2173-3-18**] 08:56PM GLUCOSE-90 UREA N-15 CREAT-0.4 SODIUM-148*
POTASSIUM-3.2* CHLORIDE-112* TOTAL CO2-31 ANION GAP-8
[**2173-3-18**] 08:56PM estGFR-Using this
[**2173-3-18**] 08:56PM ALT(SGPT)-27 AST(SGOT)-37 ALK PHOS-73 TOT
BILI-2.7*
[**2173-3-18**] 08:56PM ALBUMIN-3.0* CALCIUM-9.7 PHOSPHATE-1.8*
MAGNESIUM-1.8
[**2173-3-18**] 08:56PM WBC-3.0* RBC-2.94* HGB-9.6* HCT-28.3* MCV-96#
MCH-32.8* MCHC-34.0 RDW-16.5*
[**2173-3-18**] 08:56PM NEUTS-79.4* LYMPHS-15.8* MONOS-4.6 EOS-0.1
BASOS-0.1
[**2173-3-18**] 08:56PM PLT COUNT-42*
[**2173-3-18**] 08:56PM PT-18.6* PTT-36.4* INR(PT)-1.7*
RADIOLOGY Final Report
CTA HEAD W&W/O C & RECONS [**2173-3-20**] 4:11 PM
CTA HEAD W&W/O C & RECONS
Reason: please eval for sinus thrombosis
[**Hospital 93**] MEDICAL CONDITION:
71 yo F with chronic autoimmune hepatitis, PBC, SLE, AMS and
respiratory failure with SAH/SDH seen on CT head
REASON FOR THIS EXAMINATION:
please eval for sinus thrombosis
CONTRAINDICATIONS for IV CONTRAST: None.
CTA HEAD WITHOUT AND WITH CONTRAST, [**2173-3-20**].
HISTORY: Autoimmune hepatitis with altered mental status.
Subarachnoid hemorrhage seen on CT. Is there evidence of dural
sinus thrombosis?
A non-contrast head CT was performed with contiguous axial
images through the brain. Subsequently, rapid axial imaging was
performed during infusion of 70 mL of Optiray intravenous
contrast. Comparison to a head CT of [**2173-3-19**].
FINDINGS: The non-contrast CT demonstrates slightly lower
density of the right frontal subarachnoid blood than on the
previous examination. Otherwise, there have been no significant
changes. There is no evidence of new hemorrhage. The CT
angiogram demonstrates no significant abnormalities. The
vertebral arteries, basilar artery, and internal carotid
arteries and their major intracranial branches appear normal.
Images of the dural venous sinuses reveal no evidence of sinus
thrombosis.
CONCLUSION: No evidence of dural sinus thrombosis. No arterial
abnormalities are detected. No evidence of new hemorrhage.
Residual right frontal subarachnoid hemorrhage again identified.
=
=
=
=
=
=
=
=
=
=
=
================================================================
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 15029**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 15030**]Portable TTE
(Complete) Done [**2173-3-20**] at 10:15:47 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) **], Critical Care & [**Last Name (un) 9368**]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Location (un) 830**], E/KS-B23
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2101-11-14**]
Age (years): 71 F Hgt (in): 67
BP (mm Hg): 160/78 Wgt (lb): 224
HR (bpm): 69 BSA (m2): 2.12 m2
Indication: Endocarditis. ?
ICD-9 Codes: 424.90, 428.0, 424.1, 424.0, 424.2
Test Information
Date/Time: [**2173-3-20**] at 10:15 Interpret MD: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) **], MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**Name2 (NI) 8154**] Bzymek,
RDCS
Doppler: Full Doppler and color Doppler Test Location: West MICU
Contrast: None Tech Quality: Adequate
Tape #: 2008W002-0:00 Machine: Vivid [**7-19**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.7 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *7.0 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.2 m/s
Left Atrium - Peak Pulm Vein D: 0.5 m/s
Left Atrium - Peak Pulm Vein A: 0.2 m/s < 0.4 m/s
Right Atrium - Four Chamber Length: *5.3 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.6 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *6.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 40% to 45% >= 55%
Left Ventricle - Lateral Peak E': *0.08 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.06 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': *16 < 15
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Ascending: *3.5 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.4 m/sec <= 2.0 m/sec
Mitral Valve - E Wave: 1.1 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A ratio: 1.57
Mitral Valve - E Wave deceleration time: 187 ms 140-250 ms
TR Gradient (+ RA = PASP): *26 to 44 mm Hg <= 25 mm Hg
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV
cavity. Mild-moderate regional LV systolic dysfunction. TDI E/e'
>15, suggesting PCWP>18mmHg. No resting LVOT gradient. No VSD.
RIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free
wall hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Mildly dilated ascending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No masses or vegetations on aortic valve. Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Myxomatous
mitral valve leaflets. No mass or vegetation on mitral valve.
Moderate mitral annular calcification. Mild thickening of mitral
valve chordae. Calcified tips of papillary muscles. Moderate
(2+) MR. [Due to acoustic shadowing, the severity of MR may be
significantly UNDERestimated.]
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Moderate tricuspid annular calcification. Moderate [2+] TR.
Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
PERICARDIUM: No pericardial effusion.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. There is mild to
moderate regional left ventricular systolic dysfunction with
hypokinesis of the basal to mid inferior and inferolateral
walls. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). There is no
ventricular septal defect. The right ventricular cavity is
mildly dilated with mild global free wall hypokinesis. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
masses or vegetations are seen on the aortic valve. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. The mitral valve leaflets are myxomatous. No
mass or vegetation is seen on the mitral valve. Moderate (2+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: No vegetations seen. Focal LV systolic dysfunction.
Diastolic dysfunction. Moderate mitral regurgitation. Mild
aortic regurgitation. Moderate pulmonary artery systolic
hypertension.
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) **] [**2173-3-20**] 12:51
Brief Hospital Course:
This is a 71 year old woman with autoimmune hepatitis and PBC
who presented with altered mental status, respiratory distress
and colitis which cleared during MICU course and was transferred
to medical floor with resolution of her acute presentation.
.
# Hypoxia: During her MICU course she had developed respiratory
distress which was thought to be due to aspiration PNA in the
setting of altered mental status. She was intubated for airway
precaution an treated empirically with clindamycin. Her
respiratory status improved over the course of hospital stay
with O2Sat of 94% RA.
.
# GBS Sepsis: Unclear source - likely abdominal vs line. Was
initially treated with empiric vancomycin, Zosyn, and Flagyl
which was switched to Ceftriaxone to finish a 14 day course.
Surveillance and line blood cultures remained negative.
Ceftriaxone stopped on [**2173-3-28**].
.
# Diarrhea: Given report of colitis and broad spectrum
antibiotic treatment we discontinued lactulose and started
Flagyl po for C-Diff prophylaxis (to finish a 10 day course on
[**4-7**]). Stool studies remained negative for c-Diff. Her symptoms
improved subsequently. We stopped lactulose/rifaximin given she
never was on this meds before and never was encephalopathic,
this episode of mental status change most likely due to sepsis.
.
# UTI: enterococcus UTI, treated empirically with Cipro.
Sensitivities not back at discharge and need to be followed up
by Rehabilitation center, to ensure proper coverage. Cipro to
continue until [**3-31**] to finish a 5 day course, given recent
complicated UTI.
.
# Liver disease: Due to autoimmune hepatitis, PBC. Impaired
synthetic function, without signs of decompensation, d/c'ed
lactulose/Rifaximin as above.
.
# SAH/SDH: followed by neurology and neurosurgery, essentially
signed off now that patient improved and no further advancement
od bleed on imaging.
.
# Altered Mental Status: Resolved. Likely multifactorial with
hepatic encephalopathy, SAH, sepsis, hypernatremia, etc.
[**Name (NI) **] sister also believes mental status worsened with
high-dose steroids. Repeat head CT showed SAH, intraparenchymal
hemorrhage, CTA [**3-20**] no mycotic aneurysm or sinus venous
thrombosis.
.
# SLE: Unclear whether SLE flare is contributing to current
picture. No current issues.
.
# Anemia: Likely related to liver disease, but patient also had
"hemorrhagic colitis" per OSH records. CTA negative. HCT
remained stable.
.
# Hypernatremia: Initially appeared dehydrated. Resolved with
correction of free water deficit.
.
# FEN: regular diet
.
# Access: LIJ placed [**3-19**], peripheral access, and d/c on [**3-29**].
.
# PPx: pneumoboots (no SC heparin given coagulopathy), PPI
.
# Communication: Sister [**Name (NI) **] [**Name (NI) 15031**] (?HCP) c:
[**Telephone/Fax (1) 15032**]; h: [**Telephone/Fax (1) 15033**]. Brother: [**Telephone/Fax (1) 15034**].
Medications on Admission:
Fosamax 70mg qSat
MVI
nadolol 20 mg daily
[**Last Name (un) **] Forte 500mg [**Hospital1 **]
Imuran (restarted 2-3 weeks prior to admission)
Discharge Medications:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q24H (every 24 hours).
3. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) treatment Inhalation Q4H (every 4 hours) as needed for
wheezing/dyspnea.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatment
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
5. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days: last day [**3-31**] .
7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed: maximal daily dose 2 gram.
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): last day of treatment [**4-7**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
1. Broup B streptococcal sepsis
2. pneumonia
3. UTI
4. Colitis
5. Subarachnoid hemorrhage
6. autoimmune hepatitis dx [**2152**]
7. primary biliary cirrhosis /ESLD
8. SLE
9. HTN
10. hypernatremia
11. osteoporosis
Discharge Condition:
Good, afebrile, stable O2 sat
Discharge Instructions:
You were treated for infection, colitis, and mental status
change. You had Urinary tract infection, bacteremia, pneumonia,
and subarachnoid hemorrhage.
You are being discharged to rehab, as all your active medical
issues resolved. However you need to continue taking some
antibiotics to finish their course.
Please follow uup with your appointments as instructed.
Please call your doctor or 911 if you develop any fevers,
chills, shortness of breath or any signs of infection, or if you
have any other health concern.
Followup Instructions:
Please follow up with your primary care doctor in 2 weeks!
Please follow up with our liver center : Provider: [**Name10 (NameIs) **] [**Name8 (MD) 15035**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2173-5-20**] 11:45
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1583**] MD, MSC, MPH[**MD Number(3) 1584**]
|
[
"995.92",
"571.49",
"038.0",
"599.0",
"518.81",
"285.29",
"430",
"733.00",
"276.0",
"558.9",
"571.6",
"572.2",
"401.9",
"710.0",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
15209, 15288
|
11233, 13113
|
338, 344
|
15545, 15577
|
3696, 4449
|
16143, 16511
|
3311, 3348
|
14289, 15186
|
4486, 4596
|
15309, 15524
|
14123, 14266
|
15601, 16120
|
9472, 11210
|
3363, 3677
|
277, 300
|
4625, 9423
|
372, 3080
|
13128, 14097
|
3102, 3231
|
3247, 3295
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,544
| 139,648
|
16982
|
Discharge summary
|
report
|
Admission Date: [**2161-5-23**] Discharge Date: [**2161-5-29**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
transferred to the medical service for shortness of breath
Major Surgical or Invasive Procedure:
none (tracheostomy removed)
History of Present Illness:
Patient is a [**Age over 90 **] year old female with multiple medical problems
who presents from the SICU for shortness of breath. Patient was
in her usual state of health until she developed gallstone
pancreatitis. She was sent to [**Last Name (un) 1724**] where an ERCP was performed.
The course was complicated by tracheostomy, percutaneous
gastrostomy, and percut cholecystectomy tube. She was treated
with a course of imipenem for her pancreatitis. She had a
positive abd tap with VRE that was treated with linezolid (d/c'd
[**4-19**]) and flagyl until [**2161-4-21**].
During this hospitalization she was found to have ischemia and
atrial arrythmias. She had EKG changes and increased troponin.
Next she was found to have UTI with klebsiella and tracheal
aspirate with MRSA. She became septic with probably urosepsis
and was taken to [**Last Name (un) 1724**] icu. She was treated with vanc, zosyn, and
flagyl. Bile cultures were positive for VRE on [**2161-4-28**]. She
improved markedly and was sent back to [**Hospital1 **].
She presented to [**Hospital1 18**] on [**5-23**] with concern of cellulitis and
foot ischemia. She was on the vascular service for possible
surgical intervention for her foot. She was transferred to the
SICU when her O2 sat dropped to 70-80s on the floor. She was
aggressively diuresed and has improved.
Currently she has no complaints. She says her breathing is much
better and that she would like to eat. She denies
n/v/d/cp/sob/urinary/bowel sx.
Past Medical History:
gallstone pancreatitis
cholecystitis
s/p percutaneous cholecystostomy tube
h/so CVA
anemia
CRI
hemorrhoids
AF
junctional arrhythymias
htn
h/o pna
s/p PEG tube placement
cholecystostomy tube placement
tracheostomy
s/p bilateral thoracentesis
Social History:
lives with son in [**Name2 (NI) **], but old records indiates that she
lives in SNIFF
Physical Exam:
Temp: 97.8 BP: 178/60 HR: 58 Resp: 23 Sats 93% on 1 liter, FS
122, 133, 153 overnight urine not recorded due to incontinence,
x2 overnight
GEN: NAD, lying on bed , Aox3
HEENT: PERRLA,EOMI, JVP elevated to level of chin
CV: nl s1,s2, RRR, no m/r/g
Pulm: bibasilar crackles, no wheezes or rhonchi
Abd: soft, nt, nd, nabs G-tube and cholecytsostomy tube in place
Ext: right foot, with mutiple necrotic toes, no ulcers
Pertinent Results:
[**2161-5-23**] 07:18PM TYPE-ART PO2-106* PCO2-42 PH-7.49* TOTAL
CO2-33* BASE XS-7
[**2161-5-23**] 07:18PM LACTATE-1.7
[**2161-5-23**] 06:59PM GLUCOSE-123* UREA N-36* CREAT-1.0 SODIUM-133
POTASSIUM-5.0 CHLORIDE-89* TOTAL CO2-34* ANION GAP-15
[**2161-5-23**] 06:59PM ALT(SGPT)-14 AST(SGOT)-18 LD(LDH)-215 ALK
PHOS-100 AMYLASE-54 TOT BILI-0.7
urine cx from [**5-27**] with foley growing garnerella
cxray with pleural effusions
Brief Hospital Course:
A/P [**Age over 90 **] year old female with multiple medical problems, h/o gall
stone pancreatitis, VRE in bile, MRSA in trach asperate, and
klebsiella uti, presenting originally for vascular evaluation of
necrotic toes, subsequently transfered to medicine with
shortness of breath.
.
1) necrotic toes: patient does not have pain. Source may be
embolic from afib. She does have a hx of stroke. Patient does
not want any intervention at this time and she states that she
makes her medical decision, [**Name (NI) 653**] son [**Name (NI) **] [**Telephone/Fax (1) 47781**],
no angio done to date
.
2) shortness of breath- several potential etiologies, most
likely etiology is chf-elevated jvp, uncomfortable when lying
flat. Patient improved with aggressive diuresis
-blt pleural effusions seen on chest xray
-echo with restrictive filling pattern, could be restrictive
cardiomyopathy
-cont 100 IV lasix once a day for a few more days. Patient at
the end of hospitalization was close to euvolemic so lasix
should be d/c'd as soon as patient looks clinically euvolemic
.
3) CV:
Atrial arrythmias- at outside hosipital, she was treated with IV
esmolol or IV dilt for tachyarrhytmias, hesistant to use long
acting beta blocker or CCB as patient has intermittent
junctional rhyhtm. Consider pacemaker, when the patient does
develop a junctional rhytym, she has a fall in bp which is
consistent with DD and loss of atrial kick
-admission EKG shows evidence of AV dissociation
- h/o of afib - unclear why not on coumadin. Will hold off for
now, since patient is treated with ASA
- we held digoxin during this hospitalization as this can be
associated with AV disassiocation, and supratherapeutic digoxin
level, if patient goes back into rapid atrial fibrillation
restart of digoxin or start of betablocker therapy should be
considered
- echo with restrictive pattern with low normal ef (50 - 55 %)
- started on aspirin,
-captopril 37.5 TID , should continue to titrate up as needed
- cardiac enzymes trending down with no chest pain or ekg
changes
.
4) ID: leukocytosis- decreasing over this hospitalization
although all cultures negative. Stress reaction necrotic leg is
most likely
-d/c'd levo and d/c linezolid as [**11-13**] day treatment completed
-chest xray with b/l pleural eff
-there was no indication for abdominal tap during this
hospitilization
-she was found to have garnerella from urine cx but was thought
to be related to colonization with foley since patient did not
have any symptoms
.
5) GI: Biliary drain is draining well; we think she was
adequately treated for recent VRE in bile
-increased amylase and lipase were likely due to her old
pancreatitis, not likely clinically relevant;
-would recheck amylase/lipase in a few days to make sure that
the enzymes are not trending upwards- lipase was ~200 at d/c
with no clincial sequelae of pancreatitis
.
6) FEN: contraction alk with rep. compensation
**needs speech and swallow consult**, npo for now
continue tube feeds for now,
.
7) Gout: patient has hx of gout, elevated uric acid, was treated
with colchicine. Patient got better over the next two days.
Colchicine should be d/c'd when the patient's left second finger
is no longer painful and a allopurinol should be considered.
.
8) small lesions on tips of 2 fingers- no pain, seems chronic,
please contact Dr. [**Last Name (STitle) 47782**] of vascular surgery for follow up
within 3-4 weeks
.
9) PPX: continue heparin SQ TID while inactive, protonix, bowel
regimen
.
10) code: full, have [**Last Name (STitle) 653**] son for a full discussion
Discharge Medications:
1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
units Injection [**Hospital1 **] (2 times a day).
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
4. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Furosemide 10 mg/mL Solution Sig: One Hundred (100) mg
Injection DAILY (Daily): IV.
6. Albuterol Sulfate 0.083 % Solution Sig: qs qs Inhalation Q6H
(every 6 hours) as needed.
7. Captopril 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a
day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
s/p gallstone pancreatitis
anemia
s/p cva
cri
hypertension
atrial fibrillation
tracheostomy
Discharge Condition:
stable
Discharge Instructions:
Please call Dr. [**Last Name (STitle) **] if you have any concerning symptoms
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 47783**] within 2 weeks
please contact Dr. [**Last Name (STitle) 47782**] of vascular surgery for follow up
within 3-4 weeks
Completed by:[**2161-6-8**]
|
[
"789.5",
"274.9",
"401.9",
"440.24",
"427.31",
"682.7",
"428.0",
"V44.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7388, 7467
|
3142, 6706
|
320, 349
|
7603, 7611
|
2683, 3119
|
7737, 7966
|
6729, 7365
|
7488, 7582
|
7635, 7714
|
2246, 2664
|
222, 282
|
377, 1863
|
1885, 2128
|
2144, 2231
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,260
| 171,746
|
24139
|
Discharge summary
|
report
|
Admission Date: [**2152-5-3**] Discharge Date: [**2152-5-4**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Unresponsive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is an 86 yo female w/ PMhx sig for COPD, CHF, schizophrenia,
dementia, discharged from [**Hospital1 18**] yesterday who presents from
rehab unresponsive. The patient was hospitalized from [**Date range (1) 14195**]
for COPD exacerbation c/b sepsis secondary to diarrhea and
hypovolemia. She was treated in the ICU and was on
pressors for a period of time. Her course was also complicated
by hypernatremia requiring free water boluses. She eventually
stabilized and was d/c back to rehab on levofloxacin and a
steroid taper.
This afternoon in rehab she was found to be unresponsive. She
was brought into [**Hospital1 18**] ED.
Previously her code status was DNR/DNI. At the time her
healthcare proxy (son Mr. [**First Name8 (NamePattern2) **] [**Known lastname **]) was contact[**Name (NI) **] from [**Name (NI) **],
he changed code status and wished to intubate patient and pursue
full treatment. The patient had a GCS of 3 on arrival to the ED
and was intubated. CT scan of the head showed a large R
hemisphere ICH.
Patient was stabilized at ED and admitted to Neurology ICU
service for further care.
Past Medical History:
Past Medical History:
-[**Hospital1 5595**] has a [**Location (un) 27292**] epidemic-symptom free for 10 days
-Influenza vaccine [**2151-12-7**]
-COPD/emphysema with CO2 retention: admitted in [**2152-2-14**] to
NEBH with fever, hypoxia and respiratory distress with
improvement with bipap, nebulizers, Levaquin and steroids. ABG
on admission in [**2-20**] was 7.38/64/70-per d/c summary report. In
[**2152-2-14**], found to have bilateral lower lobe PNA and
presented with hypotension with BP 83/50 requiring ICU
admission.
-Schizophrenia
-Cataracts, status post iridectomy ROS
-Congestive heart failure: EF 55% and mild pulmonary
hypertension ([**2152-4-13**])
-Vitamin B12 deficiency, with macrocytic anemia
-Dementia
-Bladder spasm
-Urinary incontinence
-Partial lung collapse in [**2149**]
-Diabetes Type II, with creatinine in [**2152-2-14**] of 0.8
Social History:
At baseline, she is able to hold a superficial conversation. Her
memory is quite poor. Dependent for all ADL. She could feed
herself after the tray was set up. Spoke to [**First Name8 (NamePattern2) 47532**] [**Last Name (NamePattern1) 4894**] at
[**Hospital 100**] Rehab who notes that patient is dependent in all ADLS
except feeding. Total care. Been at [**Hospital1 5595**] for 2 weeks.
Family History:
Noncontributory.
Physical Exam:
Vitals: T 98.7; BP 151/44; P 66; RR 14; o2sat 100%
General: intubated, sedated
HEENT: NCAT
Neck: supple, no carotid bruit
Pulmonary: CTA b/l
Cardiac: regular rate and rhythm, with no m/r/g
Carotids: no blood flow murmur
Abdomen: obese soft, nontender, non distended, normal bowel
sounds
Extremities: no c/c/e.
Neurological Exam:
Mental status: intubated, non-resposive to verbal commands
Cranial Nerves: R surgical pupil, L cornea was opaque, + corneal
reflex, eyes deviated L, face symmetric.
Motor/[**Last Name (un) **]: reacts to painful stimuli on L side, minimally on
Right. These responses were stereotypical triple flexion or
extensor.
Reflexes: 2+ oin UEs. 1+ patella, absent ankle jerks. Planter
reflexes showed upgoing toes bilaterally.
Pertinent Results:
ABG: pH 7.50 pCO2 44 pO2 459 HCO3 36 BaseXS 10
148 108 20 119 AGap=10
4.3 34 0.7
CK: 22 MB: Notdone Trop-T: <0.01
Comments: cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative
Valproate: Pnd
14.4 >9.4/30.0< 343
N:78 Band:1 L:14 M:3 E:0 Bas:0 Atyps: 1 Metas: 1 Myelos: 2
Hypochr: 1+ Macrocy: 3+ Polychr: 1+ Schisto: 1+ Stipple: 1+
U/A Straw Appear Clear SpecGr 1.013 pH 7.0 Urobil Neg Bili
Neg
Leuk Neg Bld Neg Nitr Neg Prot Neg Glu Neg Ket Neg
Head CT:
FINDINGS: There has been interval development of acute large
right intraparenchymal hemorrhage, extending from the basal
ganglia out to the cortex, measuring approximately 10 x 4 cm.
There is extensive surrounding
edema and mass effect on adjacent cortex and the ipsilateral
lateral ventricles, as well as uncal herniation, and
approximately 12 mm of leftward shift of normally midline
structures. Dilatation of the occipital [**Doctor Last Name 534**] of the ontralateral
left lateral ventricle suggests compression of the third
ventricle by the hemorrhage and associated edema. There is no
intraventricular blood. Surrounding osseous and soft tissue
structures are unremarkable.
IMPRESSION: Acute large 10 x 4 cm right intraparenchymal
hemorrhage and
associated edema causing mass effect on adjacent cortex and
ipsilateral
lateral ventricles, as well as uncal herniation and 12 mm of
leftward shift of normally midline structures.
CXR: 1. Interval placement of an ET and OG tube, with good
position.
2. Atelectasis at the left lung base, with likely small
associated pleural effusion.
Brief Hospital Course:
Pt is a 86 yo female w/ PMhx sig for COPD, dementia,
schizophrenia recently d/c yesterday from [**Hospital1 18**] for COPD flare
found to be unresponsive at rehabilitation hospital. Head CT
scan shows large R hemisphere ICH. Neurological exam was
significant for intact brainstem reflexes, L eye deviation,
withdrawal to nailbed pressure of L, minimal on R, b/l upgoing
toes. From the examination, the location of the hemorrhage
appears cortical/subcortical. Given her history of dementia,
amyloid angiopathy appears likely. Other possibilities include
metastatic disease, aneurysm, secondary transformation of an
ischemic stroke. Eye deviation may represent pressure on L
frontal eye field from midline shift or alternatively seizure.
Patient was admitted to Neurology ICU (SICU) and received
Prednisone taper, Valproic acid. We controlled blood pressure to
achieve SBP<180, MAP<130.
Considering her prognosis, due to location and the size of
hemorrhage, it was considered to be very poor functionally and
mortality wise.
We communicated and kept in touch with her son regarding to her
condition and possible poor outcome.
Her son wished to place her comfortable measures only
considering poor prognosis.
Patient was extubated at 11:45AM. Patient became bradycardic,
apneic and became asystolic. Patient's death was announced on
[**2152-5-4**] 2:45PM.
Death was announced to her health care proxy, son, Mr. [**First Name8 (NamePattern2) **] [**Known lastname **].
New Englan Organ Bank was contact[**Name (NI) **] prior to extubation,
declined the case.
Patient'd death was reported to Medical Examiner, declined the
case.
The family requested to perform autopsy to identify underline
pathology of hemorrhage.
Medications on Admission:
Heparin (Porcine) 5,000 unit/mL SC TID
Divalproex 500 mg Tablet PO QAM
Divalproex 250 mg Tablet PO QPM
Risperidone 1 mg PO BID
Donepezil 5 mg PO HS
Levofloxacin 500 mg PO Q24H for 4 days.
Albuterol Sulfate IH q6hr PRN
Ipratropium Bromide IH q6hr PRN
Multi-Vitamin
Ditropan 5 mg Tablet PO once a day.
Trazodone 50 mg PO at bedtime.
Lasix 40 mg PO once a day
Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day
for 2 days: Give 40 mg on [**5-3**] and [**5-4**].
Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days: Give 20mg on [**5-5**] and [**2152-5-6**].
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Intracranial hemorrhage (Intraparenchymal, likely due to amyloid
angiopathy)
Cerebral herniation
Discharge Condition:
Expired.
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2152-5-5**]
|
[
"491.21",
"348.5",
"348.4",
"295.90",
"294.8",
"277.30",
"431",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7554, 7563
|
5177, 6896
|
273, 279
|
7704, 7715
|
3530, 4052
|
7767, 7893
|
2726, 2745
|
7525, 7531
|
7584, 7683
|
6922, 7502
|
7739, 7744
|
2760, 3072
|
3091, 3091
|
221, 235
|
307, 1420
|
3166, 3511
|
4061, 5154
|
3106, 3150
|
1464, 2302
|
2318, 2710
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,824
| 184,882
|
46858
|
Discharge summary
|
report
|
Admission Date: [**2161-10-9**] Discharge Date: [**2161-10-27**]
Date of Birth: [**2090-4-8**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 71 year old female
with multiple medical problems, anxiety and depression, who
was initially admitted to medicine on the [**7-9**]
secondary to failure to thrive with decreasing p.o. intake,
diarrhea, increasing depression. All of these symptoms
escalated over approximately one week prior to admission.
PHYSICAL EXAMINATION: On admission, physical examination was
significant for temperature of 95.4; heart rate of 69; blood
pressure 151/68; respiratory rate of 20; 98% on room air. The
patient was lying in bed in no acute distress. HEAD, EYES,
EARS, NOSE AND THROAT: Significant for dry mucous membranes.
Neck was supple. Cardiovascular examination: Regular rate
and rhythm, 2/6 systolic ejection murmur. Chest was clear to
auscultation bilaterally. Abdomen soft, nontender,
nondistended with normoactive bowel sounds. There was no
clubbing, cyanosis or edema in the extremities. Skin
examination was notable for diffuse psoriatic rash.
LABORATORY DATA: QT's were performed and were without
evidence of ischemic changes. Echocardiogram was performed
initially on the [**6-12**] and revealed symmetric left
ventricular hypertrophy with preserved systolic function,
mild diastolic dysfunction and pulmonary artery systolic
hypertension. Pulmonary function tests were scheduled for
the day of discharge.
HOSPITAL COURSE: The patient was transferred to the medicine
service on the [**6-24**] following an 11 day
admission to the medical Intensive Care Unit, during which
time she was intubated from [**10-12**] to [**10-22**], secondary to
hypercarbic respiratory failure. At this time, she was
aggressively diuresed and her clinical condition continued to
improve. She was transferred to the medical service.
However, during her Intensive Care Unit stay, she was noted
to have a urinary tract infection which was treated with
Ciprofloxacin for seven days. Furthermore, the patient
received Vancomycin for seven days beginning on [**2161-10-17**],
secondary to what was thought to be a line induced
Staphylococcal bacteremia. Upon arriving on the floor, the
patient was tolerating p.o. and was breathing comfortably
without complaints of shortness of breath, cough or chest
pain. Her diabetes was maintained using an insulin sliding
scale. The patient was seen by physical therapy and
recommendations were made for rehabilitation facility.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSES:
Dehydration.
Depression.
Congestive heart failure.
DISCHARGE MEDICATIONS:
Aspirin 325 mg p.o. q. day.
Chlordiazepoxide 5 mg one tablet q. eight hours as needed.
Clotrimazole 1% cream apply topically twice a day as needed.
Glyburide 1.25 mg two tablets q. a.m.
Naproxen 375 mg one tablet q. 12 hours as needed for joint
pain.
Estrogen conjugated 1.25 mg one tablet q. day.
Triamcinolone 0.1% cream one application topically twice a
day to effected areas.
Amlodipine 5 mg two times p.o. twice a day.
Docusate sodium 100 mg one tablet p.o. twice a day.
Levothyroxine 50 mcg one tablet p.o. q. day.
Albuterol/ipratropium unit dose inhaler, one to two puffs
every four to six hours as needed.
Famotidine 20 mg one tablet p.o. twice a day.
Lisinopril 20 mg one tablet p.o. q. day.
Lasix 20 mg one tablet p.o. q. day.
Hydrocortisone 2.5% one application topically twice a day to
face scale.
FOLLOW-UP PLANS: Per Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**2161-11-4**], 12:20 [**Initials (NamePattern5) **]
[**Last Name (NamePattern5) **] [**Last Name (NamePattern1) **] with dermatology, [**2161-11-11**], 2:20 [**Initials (NamePattern4) **]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**2161-11-13**], 1:40 p.m.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1849**], M.D. [**MD Number(1) 5381**]
Dictated By:[**Name8 (MD) 28700**]
MEDQUIST36
D: [**2161-10-27**] 08:34
T: [**2161-10-27**] 07:42
JOB#: [**Job Number 99423**]
cc:[**Hospital3 99424**]
|
[
"996.62",
"599.0",
"038.10",
"496",
"401.9",
"276.5",
"518.84",
"250.00",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"38.91",
"38.93",
"96.71",
"96.6",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
2584, 2636
|
2659, 3470
|
1506, 2531
|
499, 1488
|
3488, 4147
|
160, 476
|
2556, 2563
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,283
| 161,540
|
20749
|
Discharge summary
|
report
|
Admission Date: [**2152-3-6**] Discharge Date: [**2152-3-20**]
Date of Birth: [**2132-10-23**] Sex: M
Service: PLAS [**Doctor First Name 147**]
HISTORY OF PRESENT ILLNESS: This is a 19 year old male from
[**Location (un) 3844**] with a history of motor vehicle accident three
years ago with residual right lower extremity common peroneal
nerve injury who had undergone triple joint fusion of the
foot on [**2152-1-1**]. His postoperative course was
complicated by wound infection and dehiscence with exposure
of tendons and bone on the dorsum of the right foot. The
patient was treated with Keflex postoperatively but then one
week later had increased swelling, hematoma and some drainage
with necrosis of the skin with exposing tendons and bone.
The patient was treated with p.o. Levofloxacin and followed
with intravenous Levofloxacin. The patient is unsure about
the duration of the antibiotics, but reports being on
antibiotics since [**2151-12-9**].
The patient denies fevers, chills and night sweats. Also the
patient with a foot ulceration on the right heel while in the
hospital.
PAST MEDICAL HISTORY:
1. Motor vehicle accident three years ago; has plate and
screws of the fusion and had undergone an arterial bypass
graft (femoral to popliteal on the right). Also, has a
history of Methicillin resistant Staphylococcus aureus during
hospitalization post Intensive Care Unit.
PAST SURGICAL HISTORY:
1. Triple joint fusion of the right foot [**2152-1-1**].
MEDICATIONS:
1. Levaquin.
ALLERGIES: Question of Ativan when given in Intensive Care
Unit with psychosis.
REVIEW OF SYSTEMS: Unremarkable.
PHYSICAL EXAMINATION: In general, a well appearing male.
Chest is clear to auscultation bilaterally. There is no
cervical lymphadenopathy. Heart sounds are regular with a
regular rate and rhythm. Abdomen is soft, nontender,
nondistended. Right leg shows a lateral fasciotomy scar,
medial fasciotomy skin graft, hammer toes, dry plantar skin;
no plantar sensation. There is an ulcer granulating the
right heel, 1 by 1 cm at the dorsum of the foot; there is a 4
by 5 cm ulcer with debridement [**Doctor Last Name 360**] in place and exposed
tendons. The wound looks deep centrally, granulating at the
margins.
LABORATORY: X-ray of the right foot shows calcaneus, talus
fusion screw and navicular staples times two. No signs of
osteomyelitis.
IMPRESSION: The wound was debrided in the [**Hospital **] Clinic,
dressings were applied.
PLAN: The patient was admitted to the Plastic Surgery
service for further debridement and wound care.
HOSPITAL COURSE: On [**2152-3-6**], the patient was taken to
the Operating Room where his right foot was debrided by Dr.
[**Last Name (STitle) 5385**]. The patient was started on Levofloxacin and received
Percocet for pain. The next day, the patient had an MRI /
MRA of the right lower extremity to evaluate the extent of
the infection and to evaluate the blood vessels (study has
not been read yet).
On postoperative day two, the wound looked satisfactory to
the team and a VAC was placed. Postoperatively, the patient
was also started on Vancomycin prophylactically. The patient
with a history of Methicillin resistant Staphylococcus aureus
from previous admission.
On [**3-9**], Infectious Disease Service was consulted who
evaluated the patient and recommended appropriate antibiotic
treatment. Nutritional consultation was also requested for
patient's nutritional support. On [**3-10**], the patient's
vac was changed; wound was granulating well with no signs of
infection or purulence. According to the Infectious Disease
Service recommendations, the patient's antibiotics were
changed to Ceftazidime, Flagyl, and Vancomycin was continued;
Levofloxacin was discontinued.
On [**2152-3-13**], the patient as taken back to the Operating
Room for a free gracilis muscle flap from the left thigh to
the dorsum of the right foot and split thickness skin graft
from the right thigh on the dorsum of the right foot by Dr.
[**Last Name (STitle) 5385**].
The patient was continued on Vancomycin, Ceftazidime and
Flagyl per Infectious Disease recommendations. He was also
started on aspirin 325 mg p.o. q. day. Flap checks were
performed q. 15 minutes for the first eight hours followed by
q. 30 minutes for the next eight hours followed by q. one
hour the last eight hours of the day, and the next day the
flap checks were progressed to q. two hours in the Intensive
Care Unit setting.
The patient's pain was controlled with intravenous morphine
and eventually p.o. percocet. On [**3-14**], the patient was
able to tolerate clears and on the 7th, his diet was switched
to a regular diet and he was transferred to the Floor in
stable condition. On [**2152-3-15**], again following
Infectious Disease recommendations, the patient's antibiotics
were switched to Vancomycin intravenously at 1250 mg p.o.
twice a day and Levofloxacin p.o. and Flagyl p.o.
On [**3-18**], the patient started foot dangling for
progressively longer periods of time. A PICC line was placed
on the [**3-16**] for home intravenous infusion of
Vancomycin. Of note, foot culture on the [****] had
only grown Staphylococcus coagulase negative. The patient
was discharged on the [**3-20**] home with visiting nurse
services for wound care. The patient is to continue taking
intravenous Vancomycin by his PICC line, Levofloxacin,
Flagyl, for a total of six weeks per Infectious Disease.
DISPOSITION: Home with [**Hospital6 407**] Services.
CONDITION AT DISCHARGE: Good.
DISCHARGE MEDICATIONS:
1. Percocet one to two tablets p.o. q. four to six hours.
2. Aspirin 325 mg p.o. q. day.
3. Flagyl 500 mg p.o. three times a day for 37 days.
4. Levofloxacin 500 mg p.o. q. day for 37 days.
5. Protonix 40 mg p.o. q. day.
6. Lactulose 30 ml p.o. q. eight p.r.n.
7. Vancomycin 1250 mg intravenously twice a day for 37 days.
DISCHARGE DIAGNOSES:
1. Right foot infection status post right foot debridement
with VAC placement.
2. Status post free gracilis flap from left leg and split
thickness skin graft from right thigh to the right foot and
ankle.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 7738**]
Dictated By:[**Name8 (MD) **]
MEDQUIST36
D: [**2152-3-22**] 15:16
T: [**2152-3-22**] 15:10
JOB#: [**Job Number 55368**]
|
[
"998.12",
"730.27",
"998.59",
"907.5",
"998.32",
"041.19",
"707.14",
"E878.8",
"355.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.56",
"96.59",
"88.48",
"86.01",
"86.69",
"38.93",
"77.68",
"86.22",
"83.82"
] |
icd9pcs
|
[
[
[]
]
] |
5924, 6386
|
5573, 5903
|
2606, 5527
|
1437, 1607
|
1665, 2588
|
5543, 5550
|
1627, 1642
|
193, 1115
|
1137, 1414
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,739
| 167,944
|
42949
|
Discharge summary
|
report
|
Admission Date: [**2148-4-23**] Discharge Date: [**2148-4-30**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Hypoxia, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
87-year-old woman with a history of dementia (non-verbal at
baseline), [**First Name9 (NamePattern2) 15099**] [**Last Name (un) 2902**], diverticulosis, CRI (baseline cr.
of 1.6), long-term resident of [**Hospital3 41599**] Home who
presents with cough, hypoxia (sats in the high 80s at NH),
hypotension (SBPs in the 80s at NH), fever to 101.5, and XRAY
concerning for pneumonia.
According to notes from nursing home, patient was in her usual
state of health until about 3 days ago when she developed above
symptoms.
In the ED, patient's initial vital signs were T: 101.8, HR: 102,
BP: 103/44, RR 28, 89% on RA. She was found to have SBPs in the
80s and was given a total of 1500cc. An XRAY showed hazziness
in right lower lobe, concerning for aspiration pneumonia.
Patient was given vancomycin, levoquin, and flagyl for HAP and
aspiration pneumonia. Lactate was 2.3 prior to administration
of fluids. EKG showed sinus tachycardia without significant ST
changes. Troponin was negative and patient was guiac negative.
Vitals on transfer to [**Hospital Unit Name 153**] were: HR 89, RR 20, 95% on 5LNC,
92/32.
Past Medical History:
--Alzheimer's Dementia (non-verbal at baseline)
--Diverticulosis
--CRI
--Sleep Apnea
--Stroke in [**2137**]
--History of hypertension
Social History:
Long-term resident of [**Hospital3 41599**] facility. Married with
2 children. No smoking or ETOH history.
Family History:
no relevent family history relating to this
hospitalization/illness
Physical Exam:
T: 98.7, HR: 103, BP: 102/76, RR: 26
GENERAL: Chronically ill appearing woman, no acute distress,
lying in bed
CHEST: Crackles at bases bilaterally, R>>L
CARDIAC: RRR, no murmurs, rubs, or gallops
ABDOMEN: +BS, scar right of midline, non-tender
EXTREMITIES: No edema bilaterally
SKIN: Warm and dry
Pertinent Results:
Admission labs:
[**2148-4-23**] 10:30AM BLOOD WBC-9.4 RBC-3.24* Hgb-9.6* Hct-29.0*
MCV-89 MCH-29.6 MCHC-33.2 RDW-13.6 Plt Ct-235
[**2148-4-23**] 10:30AM BLOOD Neuts-92.1* Lymphs-5.0* Monos-2.4 Eos-0.1
Baso-0.3
[**2148-4-23**] 02:58PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL
[**2148-4-23**] 02:58PM BLOOD PT-12.6 PTT-26.5 INR(PT)-1.1
[**2148-4-23**] 10:30AM BLOOD Glucose-194* UreaN-42* Creat-1.9* Na-140
K-4.7 Cl-107 HCO3-20* AnGap-18
[**2148-4-23**] 10:30AM BLOOD CK(CPK)-264*
[**2148-4-23**] 02:58PM BLOOD ALT-33 AST-34 LD(LDH)-208 AlkPhos-67
TotBili-0.5
[**2148-4-23**] 10:30AM BLOOD CK-MB-2
[**2148-4-23**] 10:30AM BLOOD cTropnT-<0.01
[**2148-4-23**] 10:30AM BLOOD Calcium-7.9* Phos-3.3 Mg-2.1
[**2148-4-23**] 10:38AM BLOOD Lactate-2.3*
[**2148-4-24**] 04:28AM BLOOD Lactate-0.9
[**2148-4-23**] 10:50AM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.014
[**2148-4-23**] 10:50AM URINE Blood-LG Nitrite-NEG Protein-75
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2148-4-23**] 10:50AM URINE RBC-[**2-2**]* WBC-0-2 Bacteri-MANY Yeast-NONE
Epi-0-2
[**2148-4-23**] 10:50AM URINE CastGr-0-2
[**2148-4-23**] 10:50AM URINE AmorphX-MOD
MICRO:
[**4-23**] BCx: pending
[**4-23**] UCx: pending
[**4-23**] Urine legionella: negative
[**4-24**] SputumCx: Contaminated
STUDIES:
[**4-23**] CXR: Right lower lobe and retrocardiac opacities concerning
for
pneumonia, possibly from aspiration.
[**4-24**] CXR: As compared to the previous radiograph, there is no
relevant
change. The known areas of pneumonia, predominating at the right
lung base, are unchanged in density and extent.
Unchanged borderline size of the cardiac silhouette without
pulmonary edema. No evidence of reactive pleural effusions.
.
[**2148-4-23**] 10:50 am URINE Site: CATHETER
**FINAL REPORT [**2148-4-26**]**
URINE CULTURE (Final [**2148-4-26**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. 2ND
MORPHOLOGY.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMPICILLIN------------ <=2 S <=2 S
AMPICILLIN/SULBACTAM-- <=2 S <=2 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S <=16 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
Brief Hospital Course:
87-year-old woman with a pmhx. of dementia, diverticulosis, and
CRI who presents with hypoxia and hypotension with RLL
infiltrate on CXR concerning for aspiration pneumonia.
.
# ASPIRATION PNA: Patient with signs/symptoms concerning for
pneumonia including fever, hypoxia, and CXR with new infiltrate.
Given elderly state, dementia, and residency in nursing home
resident, likely healthcare associated aspiration pneumonia as
well as for aspiration event. WBC count is not significantly
elevated, though differential was left-shifted. Patient was
started on vanc/levo/flagyl in the ED. She improved over the
course of admission, with resolution of her oxygen requirement.
Given negative blood, sputum, and MRSA screen, her vancomycin
was d/cd. She was continued on Levo/Flagyl and completed an 8
day course of therapy.
.
# Sepsis due to PNA/HYPOTENSION: Ms. [**Known lastname 92691**] had SBPs in the
80s at her nursing home and now has SBPs in the low 90s upon
administration of 1500cc of fluid. Likely etiology of
hypotension is SIRS/sepsis picture from pneumonia or
dehydration/insensible losses from poor PO intake and fever.
This improved to normal.
.
# Presumed UTI: Urine culture with sensitive E. coli. Continued
Levofloxacin to complete a course (see above).
.
# Acute renal failure: Unknown baseline creatinine. Last
creatinine we have is 1.6 from [**2142**]. BUN/cr ratio suggestive of
pre-renal etiology. Creatinine improved with IV fluid
resuscitation.
.
# DEMENTIA: Continued zyprexa at home dosing.
.
# Nutrition: Given patient's severe delirium with dementia, she
failed her swallowing evaluation multiple times. She was
treated with IVF. Eventually she was given a trial of thin
liquids, pureed solids, 1:1 supervision, which she passed. At
the time of discharge, she was able to take adequate PO intake,
including all medicaitons, with 1:1 assistance.
.
# Hypernatremia: Improved with IVF.
.
# CODE STATUS: DNR/DNI
NOTE - while in the hospital her daughter raised the possiblity
that she may have had lyme disease exposure nearly 30 years ago,
and asked if her arthritides and or cognitive impairments could
be at least in part from late lyme disease. I have alerted her
primary care MDs to this concern and have defered further
evaluation and treatment to their discretion. I explained to
Mrs.[**Known lastname 92692**] daughter that I felt that this is extremely
unlikely as late lyme disease only very rarely leads to mild
cognitive impairment.
In discussion with Dr. [**Last Name (STitle) **], she requested that the
serologies be ordered - this was done prior to d/c from the
hospital. Dr. [**Last Name (STitle) **] indicated to me that she will follow
this result and discuss treatment if indicated.
Medications on Admission:
Lisinopril 5mg QD
Plavix 75mg tablet QD
Bisacodyl 5mg every other day
Milk of Magnesia 30ml every other evening
Multivitamin 1 tablet QD
Zyprexa
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for irritation.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every
eight (8) hours.
7. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid
Dissolve PO EVERY OTHER DAY (Every Other Day).
8. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation: hold for
loose stools.
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehabilitation & [**Hospital **] Care Center - [**Location 1268**]
Discharge Diagnosis:
Aspiration pneumonia
Delirium
Acute renal failure (resolved)
hypernatremia (resolved)
deconditioning
dysphagia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Patient was diagnosed with an aspiration pneumonia, and spent
time in the ICU. With antibiotics her pneumonia improved.
Followup Instructions:
Please have patient follow up with her PCP 2 weeks after
discharge
|
[
"585.9",
"438.12",
"403.90",
"995.92",
"293.0",
"038.9",
"294.10",
"276.0",
"358.00",
"787.20",
"584.9",
"288.60",
"599.0",
"276.2",
"799.02",
"327.23",
"507.0",
"331.0",
"041.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8936, 9045
|
5098, 7848
|
283, 290
|
9200, 9200
|
2141, 2141
|
9479, 9549
|
1734, 1803
|
8043, 8913
|
9066, 9179
|
7874, 8020
|
9334, 9456
|
1818, 2122
|
223, 245
|
318, 1435
|
2157, 5075
|
9215, 9310
|
1457, 1592
|
1608, 1718
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,293
| 191,539
|
21324
|
Discharge summary
|
report
|
Admission Date: [**2171-6-24**] Discharge Date: [**2171-6-26**]
Date of Birth: [**2101-10-21**] Sex: M
Service: CME
HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old
male with a past medical history of hyperlipidemia,
hypertension, tobacco use, peripheral arterial disease
(status post left SFA stent), CRI, who presented for exercise
tolerance test today following several-month history of left
arm pain. Of note, the patient had an abnormal stress test
in [**12-20**], which showed inferior ST-segment depressions on [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **] protocol. On the repeat exercise tolerance test, the
patient was noted to have marked ST-segment elevations in
segments II, III and aVF, as well as ST-segment depressions
in V2 to V6. The patient reports that at the time of these
changes, he did experience substernal chest pain with
radiation to his left arm. He, however, denies any nausea or
vomiting. The test was discontinued and the patient's EKG
changes initially largely resolved. The patient was given
aspirin, Toprol and 300 mg of Plavix and was referred to the
emergency department for further evaluation. On the ED
admission, the EKG shows ST-segment elevations of 1 mm that
were upsloping in leads II, III and aVF as well as T-wave
inversions in aVL as well as Q-waves in II, III and F. The
patient was started on heparin IV as well as Integrilin and
was taken to the cardiac catheterization lab for further
evaluation.
PAST MEDICAL HISTORY: Hyperlipidemia. Cholesterol panel in
[**11-19**] revealed a total of 250 with an HDL of 50.
Hyperhomocysteinemia.
Chronic renal insufficiency with a baseline creatinine of
approximately 1.6.
Hypertension.
Peripheral arterial disease status post left SFA stent in
[**2170**].
COPD. The patient has an approximately 80-pack-year history
of smoking.
Asbestosis. The patient was a billboard and home painter and
was exposed to asbestos occupationally.
GERD status post partial gastrectomy.
Anemia, on Folate as well as B-complex replacement.
Colitis.
An echocardiogram in [**2170**] revealed an EF of 60 percent with
no wall motion abnormalities, normal chamber size and the
exercise tolerance test in [**12-20**], as mentioned in the HPI,
demonstrated inferior ST-segment depressions on [**Doctor First Name **]
protocol with maximum heart rate of 112 where he reached SVT
at 180.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Toprol 100 mg p.o. q.d.
2. Zestril 20 mg q.d.
3. Protonix.
4. Lipitor 20 mg q.d.
5. Plavix 75 q.d.
6. Enteric-coated aspirin 325 q.d.
7. Bextra.
8. Folate.
9. Cyanocobalamin.
10. Pyridoxine.
SOCIAL HISTORY: The patient was recently widowed, lives with
his children, smokes currently one-half pack per day, but
used to smoke 2-3 packs per day. Denies any significant
alcohol intake (states he has an occasional drink). Works
currently, pushing carts at the Stop and Shop, though
formerly worked as a painter of both billboards and homes.
He denies any IVDA.
REVIEW OF SYSTEMS: The patient states that he has had
occasional chest pain, both at rest and with activity, that
the pain lasts up to 15 minutes and subsides spontaneously.
Some episodes have been associated with left arm discomfort.
Denies any PND, orthopnea or lower extremity edema.
PHYSICAL EXAMINATION ON ADMISSION: Temperature is 97
degrees, blood pressure is 147/74, pulse is 59, respiratory
rate is 18, O2 saturation is 100 percent on 2 liters. The
patient is found lying flat in bed in no acute distress.
Pupils equally round and reactive to light. Extraocular
muscles intact. Mucous membranes are moist. JVP is
approximately 6 cm of water. He has a regular rate and
rhythm, normal S1, S2, no murmurs, rubs or gallops. His
chest is clear to auscultation bilaterally. There is no
peripheral edema, no calf tenderness. The patient has no
femoral bruit. He has 2 plus pulses on the right PT, as well
as 1 plus on the right DP. He has 1 plus pulses on the left.
Neurological examination: Mental status exam is normal.
Cranial II-XII are intact. He has 5 plus strength with a
normal cerebellar examination.
EKG ON ADMISSION: As mentioned, normal sinus rhythm with ST-
segment to 1-mm elevations in II, III and F, Q-waves in II,
III and F, T-wave inversions in L.
LABORATORY DATA ON ADMISSION: White count is 11.8,
hematocrit 39.2, platelets 156, sodium 141, potassium 4.4,
chloride 107, bicarbonate 27, BUN 23, creatinine 1.7, glucose
115, INR is 1.1, CK is 510 with an MB of 41, MB Index of 8
and troponin T of 3.25.
Chest film shows a bilateral pleural thickening with pleural
calcifications suggestive of asbestos exposure. Also, there
is minimal right basilar opacification.
HOSPITAL COURSE: CAD/ST-elevation MI: The patient was taken
to cardiac catheterization. Catheterization revealed a total
occlusion of the right coronary artery. The LMCA, LAD and
LCX arteries are without significant obstructive disease.
The RCA has total 99 percent mid-vessel occlusion with
evidence of fresh thrombus. The patient underwent placement
of 2 TAXUS drug-eluting stents in the right coronary artery
following successful Rheolytic thrombectomy. The stents were
placed in the proximal/mid right coronary with overlapping
stents and there was no residual stenosis, no dissection and
there was TIMI-3 flow. Hemodynamics revealed elevated right
filling pressures with diminished right systolic pressures.
Left heart filling pressures were elevated with a wedge of
20. Cardiac output indices were 3.4 and 1.9 respectively.
The patient was maintained on aspirin, Plavix, as well as
Toprol 100 mg q.d. and lisinopril at his outpatient dose.
His Lipitor dose was subsequently increased to 80 mg q.d.
However, a lipid panel revealed a total cholesterol of 144
with an HDL of 40, and a LDL of 76. Echocardiogram was
obtained the day following admission and revealed an ejection
fraction of greater than 55 percent with mild symmetric LVH
and mild regional left ventricular systolic dysfunction
including mild inferior hypokinesis. There was also 1 plus
MR. The patient's CK peak was 510 on admission, with peak CK-
MB of 41 on admission and a peak troponin T of 3.28. The
patient was maintained on telemetry and did not have any
episodes of NSVT witnessed.
Chronic renal insufficiency: The patient's creatinine on
admission was 1.7, which is similar to his baseline
creatinine. His creatinine diminished to 1.5 at the time of
discharge.
Borderline diabetes mellitus: The patient was noted on
several occasions to have elevated blood sugars. His fasting
blood glucose ranged from 143 to 170. A hemoglobin A1c was
sent and is pending at the time of this dictation. The
patient will follow up with his primary care physician to
receive the result of the hemoglobin A1c test. The
importance of dietary modification has been discussed with
the patient and it is possible that he may require oral
hypoglycemics for tighter glucose control.
Anemia: The patient's hematocrit was stable and was 39 on
admission and 36.6 at the time of discharge.
COPD: The patient was maintained on standing Atrovent as
well as p.r.n. albuterol. The patient maintained adequate
room air oxygen saturations.
GERD: The patient was maintained on pantoprazole.
DISCHARGE CONDITION: The patient is discharged in stable
condition.
DISCHARGE DIAGNOSES: ST-segment elevation myocardial
infarction (inferior).
Coronary artery disease.
Gastroesophageal reflux disease.
Anemia.
Chronic renal insufficiency.
Borderline diabetes mellitus.
Hypertension.
Hyperlipidemia.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325, enteric-coated.
2. Plavix 75 mg q.d.
3. Toprol XL 100 mg q.d.
4. Pantoprazole 40 mg extended-release q.d.
5. Folic acid as well as the vitamins.
6. Lipitor 80 mg q.d.
7. Lisinopril 20 mg q.d.
FOLLOWUP: The patient will follow up with his cardiology
doctor, Dr. [**Last Name (STitle) **], as well as with his primary care physician
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 5456**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8158**], [**MD Number(1) 8159**]
Dictated By:[**Last Name (NamePattern1) 8188**]
MEDQUIST36
D: [**2171-6-26**] 12:53:46
T: [**2171-6-27**] 00:07:15
Job#: [**Job Number 56360**]
|
[
"496",
"501",
"530.81",
"272.4",
"593.9",
"285.9",
"401.9",
"410.41",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"36.07",
"36.01",
"88.53",
"88.55",
"99.20"
] |
icd9pcs
|
[
[
[]
]
] |
7343, 7391
|
7413, 7631
|
7657, 8343
|
2482, 2683
|
4777, 7321
|
3073, 3363
|
166, 1503
|
4370, 4759
|
1526, 2456
|
2700, 3053
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,397
| 118,027
|
15950
|
Discharge summary
|
report
|
Admission Date: [**2176-2-26**] Discharge Date: [**2176-2-26**]
Date of Birth: [**2132-9-11**] Sex: M
Service: MICU
HISTORY OF PRESENT ILLNESS: The patient was admitted to the
Medical Intensive Care Unit with complaint of shortness of
breath. The patient is a 43 year-old male with a history of
poorly differentiated lung adenocarcinoma diagnosed in
[**2175-10-17**] status post radiation therapy and
chemotherapy and tracheal stent for malignant obstruction,
now here status post intubation for respiratory failure. The
patient was most recently admitted to [**Hospital1 190**] on [**2-5**] to the 30th with obstruction of
trachea and main bronchus for bronchoscopy and stent
placement. The patient was found also to have post
obstructive pneumonia and started on Ceftriaxone and
Metronidazole. The patient was discharged to [**Location (un) 511**]
[**Hospital 13247**] rehab. CT scan at [**Hospital1 1474**] on [**2-21**] showed
bilateral pneumonia, bilateral pulmonary metastases,
subcutaneous right chest wall mass and moderate pericardial
effusion. Radiation therapy on [**2-22**] to the right chest
wall mass, Gemzar planned for [**2176-2-27**] at [**Hospital3 7778**]. The patient experienced increased shortness of
breath since [**2-25**] with poor air movement. No response
to nebulizers and morphine and the patient reversed his do
not intubate status, but remained do not resuscitate.
On arrival to the Emergency Room the patient was sinus
tachycardic 140s to 150s. Blood pressure 157/97.
Respiratory rate 30 to 36, sating 86 to 88% on room air.
Arterial blood gas with CO2 of 70. At that time the patient
was admitted to the Medical Intensive Care Unit.
PAST MEDICAL HISTORY:
1. Lung cancer as mentioned above.
2. Cholelithiasis.
MEDICATIONS: Cefpodoxime 400 mg po q 12 hours, Flagyl 500 mg
q 8 hours, Morphine sustained release 30 mg q 12 hours, Paxil
20 mg q.d., multivitamin, Colace, Senna, Duragesic patch,
Ativan, Guaifenesin, Bisacodyl, Serax and Fleet.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Forty pack year history. He is also engaged
to be married. Fiance was his health care proxy.
PHYSICAL EXAMINATION: Temperature 96.0. Blood pressure
90/58. Heart rate 120s. Respiratory rate 20s. O2 sat 99%
on the vent of pressure support, 100% FIO2, pressure support
of 20, PEEP of 15, arterial blood gas was 7.25, 70, 325, and
32. He was uncomfortable, intubated, dyspneic. Mucous
membranes are moist. No JVD. Decreased breath sounds
globally, 3 cm mass on the right chest wall. He was
tachycardic. Abdomen was soft, nontender. There was no
edema in his extremities. He was awake and answering
questions.
White blood cell was 91.9000, hematocrit 38.3, platelets 585,
INR 1.2, BUN and creatinine 22 and .8, fibrinogen 978.
Lactate was 1.9, sodium 135, potassium 5.1, amylase 22, serum
tox was negative. Chest x-ray had right middle lobe opacity,
bilateral worsening densities. Bronchoscopy revealed a mass
obstructing the airway in the trachea unable to press scope
beyond the endotracheal tube.
The patient was taken to rigid bronchoscopy. During the
rigid bronchoscopy the tracheal tumor tissue was removed with
rigid forceps. No discernible airways were seen in the left
lung. The right middle lobe stent was seen and filled with
mucus and tumor tissues, which were removed with suction.
Distal lumen of the right lower lobe were seen. The patient
became hypoxic and had a pulseless electrical activity arrest
and expired on [**2176-2-26**] during the rigid
bronchoscopy.
DISCHARGE DIAGNOSIS:
Lung cancer with pulseless electrical activity arrest.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D.
[**MD Number(1) 3091**]
Dictated By:[**Doctor Last Name 229**]
MEDQUIST36
D: [**2176-3-19**] 10:45
T: [**2176-3-19**] 10:55
JOB#: [**Job Number 45712**]
|
[
"197.3",
"162.8",
"518.81",
"485"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"31.5",
"96.71",
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
3582, 3908
|
2181, 3561
|
162, 1696
|
1718, 2045
|
2062, 2158
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,920
| 181,470
|
21603
|
Discharge summary
|
report
|
Admission Date: [**2118-7-27**] Discharge Date: [**2118-8-3**]
Date of Birth: [**2040-9-22**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Transfer for management of MI
Major Surgical or Invasive Procedure:
Cardiac catheterization
Bedside I&D of left forearm
Venectomy
History of Present Illness:
77 yo female with PMH CAD, DM, HTN presented to OSH on [**7-23**] with
hematemsis. Pt was taking Aleve for HA x 2 weeks. Found to be
hypotensive at 80/50 with Hct of 25.6. Pt was transferred to ICU
and resuscitated with IVF and PRBCs, with increased in Hct to
34.5. In setting of GIB, developed acute MI (likely NSTEMI from
demand ischemia, however, has STE on EKG in antero-lateral
leads). Pt only sx were fatigue; denied any CP, arm, jaw pain.
Tn I peaked at 18 on [**7-24**]. Echo on [**7-24**] revealed EF 35-40%;
akinetic mid anterior, apical septal, apical anterior, apical
lateral, apical inferior and apical wall segments. Tn decreased
then bumped up to 14 on [**7-26**]. Tn has been decreasing since then,
last value of 6. Pt was medically managed with Lopressor, no
aspirin. Given nitro and IV lopressor for HR/BP control given
NPO status. On [**7-26**], pt had more hematemesis and decrease in hct
to 28.5. EGD was performed which showed retained blood and blood
clots in stomach with an ulcer which was cauterized. Pt was
intermittently on Nexium drip, transferred on this. Hct has
remained stable at 31 since 2pm [**7-26**]. Pt has not had any further
episodes of hematesis. Continues to pass liquid maroon stool. Pt
received a total of 6 U of PRBC; last given on [**7-27**] AM. Pt
remains asymptomatic from cardiac standpoint. Of note, pt was
noted to have ARF with creatinine up to 1.8, now decreased to
1.2.
Past Medical History:
CAD
DM2
HTN
Chronic anemia
s/p bilateral CEA
Social History:
Lives at home with 3 sons. Does not smoke or drink
Family History:
No hx of CAD
Physical Exam:
VS: t96.5, p77-120, 138/73, rr24, 100% 2L
Gen: NAD
HEENT: dry MM
CVS: tachycardic, no m/g/r
Lungs: bibasilar crackles
Abd: midline vertical scar, NT, ND, decreased BS
Ext: no edema, 2+ DP
Rectal: liquid maroon stool
Pertinent Results:
[**2118-7-27**] 01:42PM WBC-12.6 Hct-32.8 Plt Ct-153
[**2118-7-28**] 02:08AM
Hct-28.9-->31.4-->29.5-->32.0-->29.3-->29.3-->27.9-->28.1-->1 U
PRBCs-->30.1-->-->30.3-->27.2-->1 U PRBCs
.
[**2118-7-27**] 01:42PM Glucose-231 UreaN-53 Creat-1.2 Na-149 K-3.4
Cl-107 HCO3-32
[**2118-7-30**] 05:36AM Glucose-162 UreaN-32 Creat-1.4 Na-136 K-4.1
Cl-100 HCO3-26
[**2118-7-27**] 01:42PM CK(CPK)-222-->156-->119-->95-->81-->72
.
[**2118-7-27**] 01:42PM cTropnT-1.59-->1.85-->1.72-->1.34
.
Cardiac catheterization ([**2118-7-27**]): Selective coronary
angiography of this right dominant system reveals severe two
vessel disease. The left main coronary artery is widely patent.
The LAD has 80% proximal calcific disease- the mid LAD is
totally occluded after D1 takeoff. The left circumflex artery
has only mild luminal irregularities. The RCA has ostial 99.9%
stenosis with collaterals filling relatively undiseased PDA and
[**Name (NI) **]. Resting hemodyanmic measurment (see above) demonstrates
elevated
right and left side filling pressures with a normal cardiac
output.
.
Echocardiogram ([**2118-7-28**]): The LA is normal in size. There is
mild symmetric LVH. The LV cavity size is normal. Overall LV
systolic function is moderately-to-severely depressed (EF 30%)
secondary to severe hypokinesis of the anterior septum and
anterior free wall, with apical dyskinesis. Tissue velocity
imaging E/e' is elevated (>15) suggesting increased LV filling
pressure (PCWP>18mmHg). Tissue velocity imaging demonstrates an
e' of <0.08m/s c/w an elevated LV filling pressure (>12mmHg). RV
chamber size is normal. There is focal hypokinesis of the apical
free wall of the RV. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Trivial mitral regurgitation
is seen. There is no pericardial effusion.
Brief Hospital Course:
.
Myocardial infarction: The patient was transferred from an
outside hospital for management of a presumed anterolateral MI,
evidenced by persistent ST elevations in the precordial leads.
Her creatinine kinase (CK) peaked at 222 and decreased steadily
of the course of hospitalization. She undewent coronary
catheterization on [**7-28**], which revealed an 80% proximal calcific
disease in the LAD and total occlusion of the mid-LAD. The
right coronary artery had ostial 99.9% stenosis with collaterals
filling her coronary domains distal to that. Her calcific
lesions in both the LAD and RCA could not be passed during the
catheterization, and no stents could be placed. Her MI was then
medically treated with increases in her beta-blocker (toprol 150
PO QD), statin (atorvastatin 80 mg PO qd), and ACE (lisinopril
10 mg). She was placed on aspirin at a dose of 162 mg PO qd due
to concern for her past medical history of GI bleeding. She had
an echo to assess heart function, and her EF was found to be
35-40%. She was started on furosemide 40 mg qd, and her
outpatient diuretic, hydrochlorothiazide, was discontinued. Her
antihypertensive clonidine was also discontinued to allow for
the increase in her beta-blocker dose. Her discharge medications
provided adequate BP control while in the hospital. As
follow-up, the patient will need a viability assessment of
myocardium with MR, which has been scheduled 5 days from
discharge. She was also scheduled for follow-up with a
cardiologist, Dr. [**Last Name (STitle) **].
.
Gastrointestinal bleeding: The patient's GI bleed was caused by
a gastric ulcer, as determined on endoscopy at the outside
hospital she was transferred from. The ulcer probably formed in
the setting of NSAID use and H.pylori infection. The patient's
H.pylori antibody test performed here was positive. She was
started on 14-day triple therapy with clarithromycin 250 mg PO
bid, amoxicillin 1 gm PO bid and pantoprazole 40 mg PO bid. On
discharge she the amoxicillin was substituted with
dicloxacillin, which was being taken for an unrelated infection.
*
Cellulitis: On admission, the patient had cellulitic appearing
left forearm lesions apparently from attemtped phlebotomy at
OSH. She developed two small abscesses that were drained by
surgery at the bedside, and subsequently a venectomy was also
performed by the surgery team on her left arm. Her arm was then
elevated with twice a day dressing changes. Her cellulitis
cultured positive for Staph aureus bacteria, which was sensitive
to nafcillin. She was discharged on a ten day course of oral
dicloxacillin and has a follow-up appointment scheduled Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6633**], a surgeon who supervised her in-house care.
.
Diabetes: The patient's blood glucose control was managed with
her outpatient doses of oral hypoglycemics and sliding scale
insulin.
Medications on Admission:
Procrit
Lopressor 15mg [**Hospital1 **]
Lipitor 40mg qd
Lasix 40mg qd
Iron
Clonidine 0.2mg qhs
Lisinopril
HCTZ 12.5mg qd
Avandia 4mg [**Hospital1 **]
Prandin 2mg tid
Insulin
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
Three (3) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2*
4. Rosiglitazone 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
5. Repaglinide 2 mg Tablet Sig: One (1) Tablet PO TIDAC (3 times
a day (before meals)).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for
10 days.
Disp:*22 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. Clarithromycin 250 mg Tablet Sig: One (1) Tablet PO twice a
day for 10 days.
Disp:*22 Tablet(s)* Refills:*0*
8. Dicloxacillin 500 mg Capsule Sig: One (1) Capsule PO every
six (6) hours for 10 days.
Disp:*28 Capsule(s)* Refills:*0*
9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Procrit Injection
11. Aspirin 162 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
12. Iron Oral
13. Insulin NPH Human Recomb Subcutaneous
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 701**] VNA
Discharge Diagnosis:
Multivessel CAD (not intervened)
Cellulitis sp excision of phlebitic vein/I&D
Discharge Condition:
Stable, ambulatory, afebrile
Discharge Instructions:
You should have your wound dressing changed twice a day,
"wet-to-dry" dressings until the wound is well healed. Keep the
dressing dry while showering. You should elevate the wound above
the level of your heart while sitting down.
*
Please return to the emergency department if you have chest
pain, shortness of breath, fever, or worsening of your arm
infection.
*
There have been several changes to your medication regimen:
*
1) You have been prescribed an antibiotic named clarithromycin
to treat H.pylori, a bacteria in your stomach that can cause
ulcers. You should continue taking Clarithromycin for 10 days.
It is also necessary that you take Pantoprazole for 10 days to
treat this condition.
*
2) Your lopressor medication has been discontinued and you have
been placed on Toprol 150 mg every day.
*
3) You must take an antibiotic named Dicloxacillin for 10 days.
This is to treat the infection in your arm. It is important that
you complete the course of this medication. If your arm redness
or pain gets worse while on this medication or if it has not
resolved after seven days, you should contact your primary care
physician.
*
4) Your lipitor dose has been increased from 40 mg to 80 mg
every day.
*
5) Your clonidine medication has been discontinued.
*
6) Your hydrochlorothiazide medication has been discontinued.
*
7) Your Lasix, avandia, prandin, insulin, iron, and procrit
doses have remained the same.
*
8) You should take aspirin, two baby tablets daily. This is very
important to protect the health of your coronary arteries.
*
You should weigh yourself every day. If you gain more than 3
pounds, you should inform your primary care physician. [**Name10 (NameIs) **] may
want to adjust your medications.
*
You should continue to measure your blood sugar levels several
times a day and keep the results in a log to show your primary
care physician.
Followup Instructions:
You will be called by the office of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6633**] regarding
scheduling an appointment to make sure your arm is healing
properly. If you have not heard from them in the next 24 hours,
call their office at [**Telephone/Fax (1) 2998**] and ask to speak with Dr.
[**Last Name (STitle) 17477**] assistant, [**Doctor First Name **].
*
Please make an appointment with your primary care physician
[**Name Initial (PRE) 176**] 4 weeks.
*
You have an appointment for a cardiac MRI viability study on
[**2118-8-8**] at 10:30 AM. Tel: ([**Telephone/Fax (1) 56888**]
*
You have an appointment with Dr. [**Last Name (STitle) **], a cardiologist,
about your rapid heart rate: Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D.
Phone: [**Telephone/Fax (1) 2934**] Date/Time: [**2118-9-2**] 1:20 pm
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2118-8-3**]
|
[
"428.0",
"999.2",
"E935.9",
"041.86",
"410.71",
"682.3",
"401.9",
"531.40",
"584.9",
"414.01",
"250.00",
"451.82",
"999.3",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.22",
"37.23",
"88.56",
"99.04",
"38.63",
"86.04",
"88.52"
] |
icd9pcs
|
[
[
[]
]
] |
8631, 8689
|
4193, 7081
|
310, 373
|
8811, 8842
|
2243, 4170
|
10756, 11785
|
1978, 1992
|
7306, 8608
|
8710, 8790
|
7107, 7283
|
8866, 10733
|
2007, 2224
|
241, 272
|
401, 1826
|
1848, 1894
|
1910, 1962
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,128
| 135,819
|
26412
|
Discharge summary
|
report
|
Admission Date: [**2162-7-3**] Discharge Date: [**2162-7-14**]
Date of Birth: [**2106-12-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
Upper GI Bleed
Major Surgical or Invasive Procedure:
Endoscopy [**2162-7-4**].
History of Present Illness:
HPI: 55 y/o male with h/o EtOH cirrhosis, continuing EtOH use,
multiple prior upper GI bleeds secondary to grade III
esophagitis, esophageal ulcer, portal gastropathy, and h/o grade
I esophageal varices, transferred from OSH with UGIB. Patient
presented to OSH with hematemesis x2 and syncope, and found to
have Hct 14, pltl 13. He reports vomiting red and coffee ground
hematemesis, passing out without head trauma, and wife called
EMS. At OSH he was treated with 4units PRBC, 1unit FFP, started
on an octreotide gtt, and was transferred to [**Hospital1 18**] ED. On
arrival to [**Hospital1 18**] vitals T 97.5 HR 105 BP 100/80. He received
PRBC and platelet transfusion prior to transfer to the MICU.
.
Patient's last drink was today at 4pm. He continues to drink a
12pack beer daily. +history of withdrawals, but denies history
of DTs or seizures. Recent h/o nausea, dizziness, and dark
formed stools. He denies having chest pain, abdominal pain,
headache, or SOB. He is alert and oriented x3.
Past Medical History:
EtOH cirrhosis (Prior variceal bleed in [**2161-5-10**]. In [**1-15**] had
upper GIB from ? portal hypertensive gastropathy and not
variceal bleed.)
EtOH abuse
Barrett's esophagus
Upper GI bleed x 3 - Esophagitis, Portal gastropathy, grade I
varices
Psoriasis
Hypertension
Pancytopenia - suspected EtoH marrow suppression, cirrhosis
Inguinal hernia repair '[**59**]
HTN
Social History:
EtOh: 12 beers/day
No tobacco
Lives with wife in [**Name (NI) **], worked as a meat cutter 32yrs.
states sober for 6 wks after his last variceal bleed but started
drinking after this because of the stress of his job and caring
for his mother and father-in-law
Family History:
n/c
Physical Exam:
Exam: T 98.5 HR 100 BP 152/78 RR 17 99%RA
Gen: alert, cooperative, tremoring
HEENT: PERRL, mildly icteric, conjunctiva pale, dry MM
Neck: supple, no LAD, JVP nondistended
CV: RRR, no mrg
Resp: CTAB
Abd: +BS, soft, ttp RLQ, no rebounding/guarding, no masses, ND,
no fluid wave
Ext: no edema, 2+ DPs, 2+ radials
Neuro: A&Ox3, CN II-XII intact, strength 4+/5 throughout,
+pronator drift bilaterally, no asterixis
Skin: urticaria on face, neck, abdomen, and back
Pertinent Results:
[**2162-7-3**] 10:50PM HGB-11.4* calcHCT-34
[**2162-7-3**] 10:30PM GLUCOSE-130* UREA N-13 CREAT-0.7 SODIUM-146*
POTASSIUM-3.7 CHLORIDE-115* TOTAL CO2-16* ANION GAP-19
[**2162-7-3**] 10:30PM ALT(SGPT)-103* AST(SGOT)-154* LD(LDH)-345*
ALK PHOS-134* AMYLASE-83 TOT BILI-2.4* DIR BILI-1.0* INDIR
BIL-1.4
[**2162-7-3**] 10:30PM LIPASE-44
[**2162-7-3**] 10:30PM ALBUMIN-2.6*
[**2162-7-3**] 10:30PM HAPTOGLOB-<20*
[**2162-7-3**] 10:30PM ASA-NEG ETHANOL-92* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2162-7-3**] 10:30PM WBC-3.5* RBC-3.47* HGB-11.1* HCT-31.5* MCV-91
MCH-32.0 MCHC-35.3* RDW-17.8*
[**2162-7-3**] 10:30PM BLOOD WBC-3.5* RBC-3.47* Hgb-11.1* Hct-31.5*
MCV-91 MCH-32.0 MCHC-35.3* RDW-17.8* Plt Ct-16*#
[**2162-7-3**] 10:30PM BLOOD PT-20.2* PTT-31.8 INR(PT)-1.9*
[**2162-7-3**] 10:30PM BLOOD Fibrino-81*
.
Liver Ultrasound to rule out hepatic vein thrombosis, [**2162-7-4**]:
IMPRESSION: Patent hepatic vessels as described above.
Cirrhotic liver with moderate amount of ascites.
.
CT Scan, Abdomen [**2162-7-9**]:
1. Mild wall thickening of the ascending, transverse and
sigmoid colon
without significant inflammatory stranding and no mural gas.
Findings are consistent with nonspecific colitis with infectious
cause such as C. difficile colitis more likely.
2. Two small hepatic hypodense foci, which are too small to
definitively
characterize but probably cysts.
3. Air within the bladder, which may be due to prior Foley
catheterization and clinical correlation is advised.
4. Mottled appearance of the pelvic bones and proximal femurs
without
expansion or periosteal reaction. Overall has a nonaggressive
appearance and may represent the lytic phase of Paget Disease or
less likely an infiltrative process.
.
EGD [**2162-7-4**]
Grade 3 esophagitis in the gastroesophageal junction
Erosion in the stomach body
Normal mucosa in the duodenum
Otherwise normal EGD to second part of the duodenum
Brief Hospital Course:
Mr. [**Known lastname 65312**] is a 55 year old male with h/o EtOH cirrhosis,
esophagitis, esophageal ulcer, varices, and gastropathy with
multiple previous UGIB's presenting with UGIB
.
# UGIB: Mr. [**Known lastname 65312**] has a known history of esophageal varices
from alcoholic cirrhosis and thrombocytopenia likely from
chronic EtOH use and splenic sequestration. He presented from
an outside hospital with an UGIB with hemodynamic instability
with an INR 1.9, and platelets 16K and was admitted to the MICU.
He was transfused with 2 units PRBCs to maintain a Hct > 30.
He received platelet transfusions (4 total units) to maintain
platelets between 50-75K. He was started on a Protonix drip and
an Octreotide drip was given Vitamin K. He was given one unit
of cryoprecipitate as well as 2 units of fresh frozen plasma
during his initial hospitalization. He was examined by endoscopy
and found to have grade 3 esophagitits in the GE junction with
erosion in the stomach body. Varices were not noted on this EGD.
These interventions were successful in correcting his
coagulopathy. When he became hemodynamically stable, he was
transferred out of the MICU for further care.
.
# Thrombocytopenia: Mr. [**Known lastname 65313**] thrombocytopenia is likely due
to cirrhosis and chronic EtOH use. He was transfused with
platelets (4 units total) to correct his platelet count upon
admission (16K). His baseline platelet count is 40-60 K.
.
# Coagulopathy: Mr. [**Known lastname 65313**] coagulopathy is likely due to
hepatic synthetic dysfunction. He was given cryoprecipitate and
Vitamin K to attempt to correct his coagulopathy. His INR upon
admission was 1.9 but corrected to 1.2-1.4 for the remainder of
the admission.
.
# EtOH use: The patient continues to drink alcohol and his last
drink was the day of admission. He has no known history of
withdrawals. He was placed on a CIWA scale with Ativan PRN, as
well as MVI, thiamine and folate. He was seen by social work
and he has expressed a desire to stop drinking.
.
# Elevated LFTs: His transaminases and bilirubin are elevated
from baseline. His AST > ALT is suggestive of acute alcoholic
hepatitis, but his AST:ALT <2. His LFTs are Also with
obstructive picture as his bilirubin elevated. A RUQ ultrasound
was perfomed while the patient was in the MICU to rule out a
hepatic vein thrombosis. The RUQ ultrasound was negative for
hepatic vein thrombosis. His LFTs improved during this
admission.
.
# Abdominal Pain, Diarrhea: Shortly after Mr. [**Known lastname 65312**] was
transferred out of the MICU, he began to experience fever spikes
(100-103), abdominal pain and diarrhea. A CT scan was obtained
for concern of an acute process but the CT scan was negative for
obstruction or an acute process. Some thickening of the colonic
wall was seen on CT scan, throught to be consistent with a
colitis such as C dif colitis. Stool cultures for C dif toxin A
were negative but the patient improved symptomatically on
empiric treatment with flagyl 500mg tid so will be discharged on
this to complete a 10 day course.
.
# CT Findings, Mottled appearance of the pelvic bones and
proximal femurs without
expansion or periosteal reaction. Overall has a nonaggressive
appearance and may represent the lytic phase of Paget Disease or
less likely an infiltrative process. This should be followed up
as an outpatient for further workup.
Medications on Admission:
1. Multivitamin Daily
2. Sucralfate 1g po QID
3. Nadolol 20 mg Daily
4. Folic Acid 1 mg Daily
5. Thiamine HCl 100 mg Daily
6. Pantoprazole 40 mg Daily
7. Effexor 75 mg Daily
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 * Refills:*2*
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 9 days.
Disp:*18 Tablet(s)* Refills:*0*
8. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
nashuba nursing service
Discharge Diagnosis:
Upper GI Bleed
Discharge Condition:
Good
Discharge Instructions:
Please follow up with the liver center in 4 weeks with either
Dr. [**Last Name (STitle) **] or Dr. [**Last Name (STitle) 497**] ([**Telephone/Fax (1) 3618**] after your discharge.
Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**1-11**] weeks. ([**Telephone/Fax (1) 3995**]
Followup Instructions:
Please follow up with the liver center in 4 weeks with either
Dr. [**Last Name (STitle) **] or Dr. [**Last Name (STitle) 497**] after your discharge.
.
Additionally, the patient requested the following information
for support groups near his home town (from [**First Name8 (NamePattern2) 3403**] [**Last Name (NamePattern1) 805**]
social work note [**2162-1-13**]): [**Hospital3 3765**] outpt addictions
[**Telephone/Fax (1) 65314**] or Assabett Counseling [**Telephone/Fax (1) 65315**] to set up outpt
counseling.
.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
Completed by:[**2162-7-14**]
|
[
"731.0",
"372.30",
"401.9",
"599.7",
"530.82",
"276.2",
"008.45",
"284.8",
"571.1",
"696.1",
"530.12",
"303.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.07",
"45.13",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
9047, 9101
|
4536, 7937
|
329, 356
|
9159, 9165
|
2571, 4513
|
9537, 10205
|
2071, 2076
|
8162, 9024
|
9122, 9138
|
7963, 8139
|
9189, 9514
|
2091, 2552
|
275, 291
|
384, 1383
|
1405, 1777
|
1793, 2055
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,234
| 100,038
|
24771
|
Discharge summary
|
report
|
Admission Date: [**2127-7-11**] Discharge Date: [**2127-7-13**]
Date of Birth: [**2070-1-18**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
dizziness,nausea,vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: 57 y/o Spanish speaking female with h/o HTN, DM 2,
hyperlipidemia, CAD s/p 4V CABG [**4-12**], and asthma who presented
to her PCP for regularly scheduled visit, complained of
dizziness, nausea, vomiting for one week, and with chest pain,
and was found to be hypotensive. She was sent to the ED by her
PCP. [**Name10 (NameIs) **] the ED she got atropine x 3 for bradycardia, lasix, and
glucagon for blood sugar in the 30s, and was started on dopamine
drip for hypotension, which was weaned off once in the CCU
without futher hypotension. Ruled out for MI. AST/ALT and
amylase/lipase were normal. RUQ US done last month in [**State 108**]
was reportedly normal.
.
She decribes that she had been vomiting for one week before
going to her doctor's visit. She was vomiting almost daily for
one week. She was dizzy for most of that week, getting worse
when going from sitting to standing. Described as the room
spinning and lightheadedness. She did not have any syncope or
falls. Her chest pain lasted only one minute and occured after
vomiting. She had a mild cough for a week, no sputum and mild
fevers.
.
.
Past Medical History:
HTN
Hyperlipidemia
DM 2
CAD s/p 4V CABG ([**4-12**]) LIMA to LAD, SVGs to anterior
obtuse marginal, posterior obtuse marginal, and to RCA.
Obesity
Asthma
s/p CCY
s/p C-section
s/p Left foot surgery
Social History:
Married. Formerly from [**Male First Name (un) 1056**], Spanish-speaking only. No
history of tobacco use, EtOH, or IVDU.
Family History:
Mother had CAD, CVA, DM2. Father died of complications from
renal failure. Extensive DM in family.
Physical Exam:
Vitals: T 98.6 BP 120/70 HR 69 RR 18 SAT 96% RA
General: NAD
HEENT: NC, AT, amicteric, no injections, PERRLA, EOMI, OP clear.
Neck: no JVP elevation. wound over right neck tender to
palpation, no purulent drainage, no erythema.
CV: Normal S1, S2 with no m/r/g.
Pulm: Minimal bibasilar crackles. No wheezes.
Abd: Soft, NT, ND, + BS.
Ext: No c/c/e. DP 2+ B/L. Evidence of venous stasis changes.
Healing left thigh wound packed with dressing and covered with
gauze. No drainage or erythema.
Pertinent Results:
Labs on discharge: BUN 35 Cr 1.3 CK 69 trop <0.01 WBC 10.1 HCT
31.8
.
EKG: NSR at 60, normal axis, no acute ST changes
.
Last CXR lungs clear
.
[**2127-7-11**] 03:07PM BLOOD WBC-9.7 RBC-3.03* Hgb-8.8* Hct-25.7*
MCV-85 MCH-29.0 MCHC-34.1 RDW-15.3 Plt Ct-445*
[**2127-7-13**] 06:45AM BLOOD WBC-10.1 RBC-3.77* Hgb-10.9* Hct-31.8*
MCV-84 MCH-28.8 MCHC-34.2 RDW-15.4 Plt Ct-385
[**2127-7-11**] 03:07PM BLOOD Neuts-56.2 Lymphs-36.5 Monos-4.4 Eos-2.6
Baso-0.2
[**2127-7-11**] 06:19PM BLOOD Neuts-78.2* Lymphs-17.2* Monos-3.2
Eos-1.3 Baso-0.2
[**2127-7-11**] 03:07PM BLOOD Plt Ct-445*
[**2127-7-13**] 06:45AM BLOOD Glucose-119* UreaN-35* Creat-1.3* Na-140
K-5.1 Cl-104 HCO3-24 AnGap-17
[**2127-7-11**] 08:25PM BLOOD ALT-18 AST-16 CK(CPK)-49 AlkPhos-89
Amylase-79 TotBili-0.1
[**2127-7-11**] 08:25PM BLOOD Lipase-61*
[**2127-7-11**] 03:07PM BLOOD cTropnT-<0.01
[**2127-7-11**] 08:25PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2127-7-12**] 06:22AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2127-7-11**] 08:25PM BLOOD calTIBC-324 Ferritn-265* TRF-249
[**2127-7-11**] 06:29PM BLOOD Lactate-0.8
[**2127-7-11**] 03:07PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005
[**2127-7-11**] 03:07PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
.
bcx [**7-11**]: no growth
ucx [**7-11**]: genital contamination
Brief Hospital Course:
A/P: 57 y/o Spanish speaking female with h/o HTN, DM2, CAD s/p
4VCABG, hyperlipidemia, and asthma who presented to the ED with
hypotension, now resolved, a brief episode of chest pain, ruled
out, and abdominal pain, likely Gas/GERD.
.
1. Hypotension: the patient had nausea and vomiting prior to
admission and was found to be hypotensive at her PCP's office.
She was actually given lasix initially and started on dopamine
gtt. It is unclear from the note if she got fluid. The
hypotension was probably due to dehydration from vomiting the
week prior to admission. Dopamine gtt was weaned off and the
patient had no further issues with hypotension. She was
discharged on lisinopril and atenolol. Lasix dose was decreased
to 20 mg QD and her KCl was d/c'd because we halved her lasix
and her K on discharge was 5.1.
.
2. Renal Failure: Patient came in with a creatinine of 1.6 and
her baseline is unknown. Could be chronic renal failure from DM
that is giving her chronic renal insufficiency and perhaps she
was also prerenal from the vomiting prior to admission.
Creatinine steadily improved and is now 1.3 on discharge.
.
3. Anemia: Crit on admission was 25. Likely ACD from DM. s/p
transfusion of 2 units in the CCU. HCT improving. Crit now 31.8.
.
4. DM2:bedtime sugar was 152, fasting this am 73 and at noon
118. We continued actos and avandia as well as a RISS and
patient was advised to take her home doses of lantus and regular
insulin at home.
.
5. HTN: Blood pressure was stable after dopamine gtt was
titrated off in the CCU. No issues of hypertension or
hypotension. Discharged patient on atenolol and lisinopril.
.
6. CAD: Patient denies chest pain. Lipid profile showed LDL 84,
HDL 54. We continued ASA, atenolol, lisinopril. No acute issues.
.
7. Asthma: no wheezing, stable sats. We gave the patient
albuterol PRN.
.
Medications on Admission:
Lisinopril 20 mg PO daily
Lasix 40 mg PO daily
Trazodone
Avandia 2 mg PO daily
Lantus 100 QD
Regular insulin 20 in am, 30 in pm
Protonix 40 mg PO daily
Zoloft
Albuterol
KCl 10 meq PO daily
Atenolol 25 mg PO daily
ASA 81 mg PO daily
Lipitor 10 mg PO daily
Actos 45 mg PO daily
Discharge Medications:
1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atenolol 25 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. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Rosiglitazone 2 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Pioglitazone 45 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Trazodone 50 mg Tablet Sig: .5 Tablet PO at bedtime as needed
for insomnia.
Disp:*15 Tablet(s)* Refills:*0*
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Hypotension [**1-9**] volume depletion from vomiting
Discharge Condition:
Patient is afebrile, hemodynamically stable and tolerating her
BP meds.
Discharge Instructions:
Please take all of your medications as directed.
Please follow-up with all of your outpatient appointments.
Please return to the ED if you develop dizziness, loss of
consciousness, chest pain, trouble breathing, vomiting,
difficulty urinating or any other concerning symptoms.
Followup Instructions:
Please follow-up with your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 23903**]
this week. Her number is [**Telephone/Fax (1) 17826**]. At that time, they should
check right upper quadrant ultrasound. Patient also needs chem-7
checked as she is on lasix, lisinopril. We put patient on
reduced dose of lasix (20 mg QD) because of hypotension and took
her off KCl. Should see PCP this week to see if she really needs
to be on lasix 40 mg QD and KCl.
|
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icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
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] |
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340, 347
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,760
| 111,578
|
37274
|
Discharge summary
|
report
|
Admission Date: [**2187-1-1**] Discharge Date: [**2187-1-8**]
Date of Birth: [**2106-8-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5129**]
Chief Complaint:
Chief Complaint: s/p fall, subdural hematoma at OSH
Reason for MICU admission: management of hyperglycemia, rhabdo,
ARF
Major Surgical or Invasive Procedure:
None
History of Present Illness:
80M with DM on insulin, presenting after found down by EMS,
admitted to the medical ICU with hyperglycemia, rhabdomyolysis,
and acute renal failure. He was found in his driveway the
morning of admission, unknown down time. Had bags of diabetic
supplies with him and may have been trying to give himself
insulin per EMS report. Patient had been incontinent and found
to be hyperglycemic in the field. He was taken to an OSH where
he was found to have a FSG of >1200, elevated CKs with ARF. He
had a non contrast Head CT which showed small bilateral subdural
hematomas. He was then transferred to [**Hospital1 18**] for further
management.
.
In the [**Hospital1 18**] ED, initial vs were: T96.5, P79, BP 141/84, R16,
100% O2 sat. Labs notable for glucose 1010 with AG 20,
creatinine 5.4, CK [**Numeric Identifier 17451**], elevated transaminases, lactate 4.4.
No UA yet. He was oriented to self, but otherwise quite altered
and unable to provide further history. He got a RUQ ultrasound
given LFT abnormalities. Renal team was consulted. Patient
received >3L IVFs in the ED, including 1.5 amps bicarb.
.
On the floor, patient was lethargic but arousable. Able to
follow most commands, oriented to [**Hospital3 7569**]. Denied pain
anywhere.
.
Review of systems: patient unable to cooperate
Past Medical History:
- Diabetes mellitus
- BPH
- HTN
- Hyperlipidemia
Social History:
Lives at home alone (has brother and sister in [**Name (NI) 108**], no
friends), denies tobacco, denies EtOH (distant past), denies
drugs.
Family History:
Noncontributory
Physical Exam:
ON PRESENTATION TO Medical ICU:
General: Lethargic though arousable, C collar in place, no
distress.
HEENT: Sclera anicteric, PERRL, healing laceration/bruising over
R eye, MMM, oropharynx clear
Neck: supple, C collar in place, prominent thyroid cartilage
without gross abnormality.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, reports non-tender (though seems diffusely
uncomfortable with deep palpation), non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, no clubbing, cyanosis or edema
ON TRANSFER TO FLOOR:
Vitals: T:99 BP: 128/54-163/81 P: 61-72 R: 18 O2: 97-99% on RA
General: Lethargic but arousable
HEENT: Sclera anicteric, PERRL, EOMI, healing
laceration/bruising over R eye, MMM, oropharynx clear
Lungs: CTAB, 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, no clubbing or cyanosis, bilat hands
edematous, onychomycosis in bilat feet
Pertinent Results:
Admission labs ([**2187-1-1**]):
WBC-14.9* RBC-4.44* Hgb-11.6* Hct-35.9* MCV-81* MCH-26.1*
MCHC-32.3 RDW-14.8 Plt Ct-139*
Neuts-93.3* Lymphs-4.1* Monos-2.3 Eos-0.1 Baso-0.2
PT-11.3 PTT-27.7 INR(PT)-0.9
Glucose-1010* UreaN-79* Creat-5.4* Na-129* K-5.1 Cl-90* HCO3-19*
AnGap-25
ALT-136* AST-649* CK(CPK)-[**Numeric Identifier 83893**]* AlkPhos-154* TotBili-0.6
Albumin-4.7 Calcium-8.9 Phos-7.9* Mg-3.5*
.
[**1-1**] RUQ ultrasound:
Limited study. No acute GB process.
.
[**1-2**] CXR:
No evidence of pleural effusion. Moderate cardiomegaly but no
pulmonary signs of edema. No focal parenchymal opacities
suggesting
pneumonia. No pneumothorax or pleural effusions.
.
[**1-2**] CT head:
1. Stable bilateral frontoparietal subdural collections.
2. New intraventricular hemorrhage layering the left occipital
[**Doctor Last Name 534**] and new tentorium hemorrhage.
3. Questionable high attenuation at interpeduncular cistern,
which could be consistent with a new hemorrhage or artifact.
4. Unchanged calcifications seen, more prominent at the basal
ganglia and
cerebellum bilaterally. Differential diagnosis should include
Fahr's disease.
Followup is recommended to assess progression of subdural
hematoma and new
hemorrhage foci.
.
.
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2187-1-3**]
8:59 AM
IMPRESSION:
1. Frontoparietal subdural collections, unchanged over the
short-interval,
with no new foci of hemorrhage or acute vascular territorial
infarction.
2. Small intraventricular hemorrhage at the left lateral
ventricular
occipital [**Doctor Last Name 534**] and atrium, unchanged with the ventricles stable
in size.
3. Extensive dystrophic calcifications, as detailed above, with
pattern most suggestive of underlying Fahr disease.
.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2187-1-7**] 4:40
AM
Comparison with the previous study of [**2187-1-5**]. The lungs remain
clear except for minimal streaky density at the left base
consistent with
subsegmental atelectasis or scarring. The heart and mediastinal
structures
are unchanged. Nasogastric tube is in place, as before. It
terminates
approximately 7 cm beneath the level of the diaphragm. Its side
hole is not clearly identified.
.
.
Cardiology Report ECG Study Date of [**2187-1-4**] 7:48:54 AM
Sinus rhythm. Biphasic T wave in lead V2 is non-specific.
Otherwise, tracing is
within normal limits but clinical correlation is suggested.
Since the previous
tracing of [**2187-1-2**] atrial tachycardia is now absent.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
60 128 84 426/426 50 55 66
[**2187-1-1**] 12:40PM BLOOD WBC-14.9* RBC-4.44* Hgb-11.6* Hct-35.9*
MCV-81* MCH-26.1* MCHC-32.3 RDW-14.8 Plt Ct-139*
[**2187-1-2**] 03:36AM BLOOD WBC-19.6* RBC-4.38* Hgb-11.1* Hct-34.1*
MCV-78* MCH-25.5* MCHC-32.6 RDW-15.0 Plt Ct-148*
[**2187-1-3**] 03:44AM BLOOD WBC-9.5# RBC-3.89* Hgb-10.2* Hct-30.0*
MCV-77* MCH-26.1* MCHC-33.9 RDW-15.1 Plt Ct-113*
[**2187-1-3**] 03:32PM BLOOD WBC-7.6 RBC-3.67* Hgb-9.5* Hct-29.5*
MCV-80* MCH-25.8* MCHC-32.1 RDW-14.8 Plt Ct-91*
[**2187-1-6**] 05:55AM BLOOD WBC-7.3 RBC-3.80* Hgb-10.0* Hct-29.8*
MCV-78* MCH-26.4* MCHC-33.7 RDW-14.8 Plt Ct-94*
[**2187-1-7**] 05:50AM BLOOD WBC-9.0 RBC-4.15* Hgb-11.1* Hct-32.0*
MCV-77* MCH-26.7* MCHC-34.6 RDW-14.9 Plt Ct-134*
[**2187-1-8**] 06:35AM BLOOD WBC-8.0 RBC-3.71* Hgb-9.8* Hct-29.7*
MCV-80* MCH-26.4* MCHC-32.9 RDW-14.7 Plt Ct-118*
[**2187-1-1**] 12:40PM BLOOD Neuts-93.3* Lymphs-4.1* Monos-2.3 Eos-0.1
Baso-0.2
[**2187-1-3**] 03:44AM BLOOD Neuts-77.7* Lymphs-15.3* Monos-6.5
Eos-0.3 Baso-0.2
[**2187-1-1**] 12:40PM BLOOD PT-11.3 PTT-27.7 INR(PT)-0.9
[**2187-1-7**] 05:50AM BLOOD PT-12.2 PTT-29.0 INR(PT)-1.0
[**2187-1-1**] 12:40PM BLOOD Glucose-1010* UreaN-79* Creat-5.4*
Na-129* K-5.1 Cl-90* HCO3-19* AnGap-25
[**2187-1-1**] 06:06PM BLOOD Glucose-363* UreaN-73* Creat-4.8* Na-140
K-4.6 Cl-99 HCO3-23 AnGap-23
[**2187-1-1**] 10:13PM BLOOD Glucose-91 UreaN-60* Creat-3.6*# Na-143
K-3.2* Cl-97 HCO3-35* AnGap-14
[**2187-1-2**] 03:36AM BLOOD Glucose-306* UreaN-73* Creat-4.2* Na-140
K-4.5 Cl-100 HCO3-25 AnGap-20
[**2187-1-2**] 09:00PM BLOOD Glucose-175* UreaN-58* Creat-3.2* Na-143
K-4.4 Cl-105 HCO3-25 AnGap-17
[**2187-1-4**] 12:25PM BLOOD Glucose-119* UreaN-39* Creat-2.2* Na-142
K-4.8 Cl-110* HCO3-22 AnGap-15
[**2187-1-5**] 05:40AM BLOOD Glucose-125* UreaN-35* Creat-1.8* Na-142
K-4.4 Cl-110* HCO3-21* AnGap-15
[**2187-1-6**] 05:55AM BLOOD Glucose-207* UreaN-33* Creat-1.6* Na-142
K-4.4 Cl-109* HCO3-20* AnGap-17
[**2187-1-7**] 05:50AM BLOOD Glucose-216* UreaN-24* Creat-1.5* Na-141
K-4.0 Cl-108 HCO3-23 AnGap-14
[**2187-1-8**] 06:35AM BLOOD Glucose-318* UreaN-20 Creat-1.6* Na-142
K-3.8 Cl-109* HCO3-26 AnGap-11
[**2187-1-1**] 10:13PM BLOOD CK(CPK)-[**Numeric Identifier 83894**]*
[**2187-1-2**] 03:36AM BLOOD ALT-179* AST-921* LD(LDH)-1386*
CK(CPK)-[**Numeric Identifier 83895**]* AlkPhos-131* TotBili-0.7
[**2187-1-2**] 01:41PM BLOOD ALT-174* AST-820* CK(CPK)-[**Numeric Identifier **]*
AlkPhos-105 TotBili-0.6
[**2187-1-2**] 01:41PM BLOOD ALT-174* AST-820* CK(CPK)-[**Numeric Identifier **]*
AlkPhos-105 TotBili-0.6
[**2187-1-6**] 05:55AM BLOOD ALT-97* AST-181* LD(LDH)-419*
CK(CPK)-1046* AlkPhos-72 TotBili-0.6
[**2187-1-7**] 05:50AM BLOOD ALT-87* AST-114* LD(LDH)-422*
CK(CPK)-601* AlkPhos-82 TotBili-0.5
[**2187-1-1**] 12:40PM BLOOD cTropnT-0.15*
[**2187-1-1**] 06:06PM BLOOD CK-MB-151* MB Indx-0.3 cTropnT-0.13*
[**2187-1-2**] 03:36AM BLOOD CK-MB-116* MB Indx-0.2 cTropnT-0.11*
[**2187-1-3**] 03:44AM BLOOD cTropnT-0.05*
[**2187-1-7**] 05:50AM BLOOD Albumin-3.2* Calcium-8.7 Phos-3.5 Mg-1.7
[**2187-1-1**] 10:13PM BLOOD VitB12-656 Folate-8.5
[**2187-1-4**] 06:25AM BLOOD Ferritn-126
[**2187-1-2**] 03:36AM BLOOD %HbA1c-12.0*
[**2187-1-1**] 10:13PM BLOOD TSH-0.68
[**2187-1-1**] 10:13PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2187-1-1**] 06:40PM BLOOD Type-[**Last Name (un) **] Temp-36.9 pO2-47* pCO2-40
pH-7.42 calTCO2-27 Base XS-0 Intubat-NOT INTUBA
[**2187-1-2**] 04:36AM BLOOD Type-[**Last Name (un) **] pH-7.40 Comment-GREEN TOP
[**2187-1-1**] 12:52PM BLOOD Glucose-GREATER TH Lactate-4.4* Na-132*
K-5.1 Cl-93* calHCO3-40*
[**2187-1-2**] 04:36AM BLOOD Lactate-2.9*
[**2187-1-4**] 07:16AM BLOOD Lactate-1.3
Brief Hospital Course:
Patient is an 80M with history of DM on insulin, presenting
after found down with hyperglycemia, rhabdomyolysis, acute renal
failure, and acute on chronic subdural hematoma.
.
# Hyperglycemia/Diabetes:
Patient may have experienced Hyperosmolar Hyperglycaemic
Non-Ketotic Coma on presentation. His serum glucose level was
>12,000 on presentation to the outside hospital. He did present
with an anion gap, though it was also in the setting of lactic
acidosis and renal failure. The patient did not show evidence
of ketosis at the outside hospital or on presentation to [**Hospital1 18**].
In the MICU, the patient was given a total of 8.5L of fluids
including 1/2 NS plus 1.5 amps bicarb which was then
transitioned to LR. Patient was initially on an insulin drip,
then transitioned to 7 units glargine on [**1-2**] PM with a Humalog
sliding scale. Patient initially had an anion gap metabolic
acidosis, which was closed by the time of transfer to the floor.
The glargine dose was later increased to 15 units at bedtime,
then further increased to 20 units at bedtime on [**2187-1-7**] in
addition to the Humalog sliding scale.
The patient has an HbA1c of 12%. His pioglitazone was held
during hospitalization. He should be continued on the fixed
glargine dose and Humalog sliding scale at the rehabilitation
center for now; the glargine may need to be further uptitrated.
The patient's home insulin regimen consisted of levemir 18units
each morning, lispro/lispro protamine (humalog 50/50)
18U/18U/10U with meals, which he may be able to transition back
to once he is able to tolerate meals.
#. Rhabdomyolysis
Patient had been found down after an unknown period of time and
had rhabdomyolysis with CK peak at 54,000 and corresponding
elevation of LFTs and troponin, all of which trended down by the
time of discharge after significant amount of IV fluids
including bicarbonate drip. CK was 601 the day prior to
discharge. Patient's atorvastatin was held on presentation, but
it was restarted upon discharge.
#. Acute on Chronic Renal Failure
The patient presented with creatinine elevated to 5.4 from
baseline of 1.7, per PCP records from [**2186-12-15**]. Patient had
severe volume depletion and rhabdomyolysis, as above. He was
followed by the Renal team initially as well. On transfer to
floor from the medical ICU, patient was on 300ml/hr of LR, and
urine output was >150cc/hr. His creatinine had returned to 1.6
by the time of discharge after significant fluid resuscitation.
.
# Altered mental status
The patient had presented with altered mental status, likely
multifactorial with subdural hematomas status post fall in
addition to metabolic disturbances and electroylte imbalances in
the setting of hyperosmolar hyperglycemia. Patient had a normal
TSH, B12 and folate. A repeat CT scan of his head showed that
the subdural hematomas and small intraventricular hemorrhage
were stable in size. Extensive dystrophic calcifications were
also noted on CT.
# Subdural hematoma
Subdural hematomas were thought to be acute on chronic; the
acute component was small and may have resulted from the fall.
Neurosurgery was consulted. Repeat Head CT showed that the
frontoparietal subdural hematomas were stable with no new foci
of hemorrhage or acute vascular territorial infarction. There
was also a small intraventricular hemorrhage at the left lateral
ventricular occipital [**Doctor Last Name 534**] and atrium, unchanged from previous
imaging with the ventricles stable in size.
Patient has no focal signs on neuro exam, but his neuro exam
should continue to be monitored. The aspirin was stopped on
admission in the setting of subdural bleed and low platelets and
may be restarted on [**2187-1-11**]. His platelet count on [**2186-12-15**] at
his PCP's office was 100k, which is stable. The patient should
follow up in [**Hospital 4695**] clinic, either locally near the
rehabilitation center or return to [**Hospital1 18**] neurosurgery clinic.
# Anemia
Patient has anemia with Hct stable around 30 during this
hospitalization and no signs of active bleeding. Hct at PCP's
office on [**2186-12-15**] was 31.6. His hematrocrit should be rechecked
at his next PCP [**Name Initial (PRE) **].
# BPH.
Patient was continued on an alpha-blocker for his prostatic
hypertrophy.
.
# Nutrition:
Patient was given tube feeds through NG tube: Fibersource HN
Full strength, advanced to goal rate of 70 ml/hr. He
accidentally pulled his NG tube out [**2187-1-8**]. He failed a
speech and swallow study initially but was somewhat improved on
[**2187-1-8**]. He will need a video swallow study. Until he gets
his video swallow study, he may eat small volume pureed foods
with 1:1 supervision.
Prophylaxis: Subcutaneous heparin
Code: FULL
Communication: Patient, no known contacts/relatives in the area
Medications on Admission:
- Alfuzosin 10mg daily
- ASA 81mg daily
- Atorvastatin 10mg daily
- Levemir 18U Qam
- Lispro/lispro protamine (humalog 50/50) 18U/18U/10U with meals
- Metoprolol 25mg daily
- Pioglitazone 30mg daily
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day).
2. Alfuzosin 10 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
3. Insulin Glargine 100 unit/mL Cartridge Sig: Twenty (20) units
Subcutaneous at bedtime.
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
7. Insulin Lispro Subcutaneous -- sliding scale QACHS
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
9. Aspirin 81mg - to restart on [**2187-1-11**]
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 32674**] - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
Hyperosmolar Hyperglycemic Non-Ketotic Coma
Rhabdomyolysis
Secondary Diagnoses:
Dehydration
Diabetes Mellitus
Discharge Condition:
Stable
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to the hospital because you were found after
having fallen down in the driveway. You were found to be very
dehydrated with a very high blood glucose level. After your
fall, you also had some increased muscle breakdown which led to
some worsening of your kidney function temporarily. By the time
of your discharge, your kidney function had returned to the
level it was at your last doctor's visit. You were also found
to have some bleeding inside your head which was stable; the
neurosurgeons were following the head bleed and would like you
to follow up with them as an outpatient.
The following changes have been made to your medications:
- We have STOPPED the pioglitazone for now
- We STOPPED your levemir and lispro insulin regimen for now
- We have STARTED 20 units subcutaneous glargine insulin at
bedtime
- We have STARTED a Humalog insulin sliding scale
- We have INCREASED your metoprolol to 37.5mg and CHANGED it to
a short-acting dose to be taken TWICE DAILY
- We have STOPPED your aspirin for 10 days total, and it can be
restarted on [**2187-1-11**]
Please be sure to keep all of your followup appointments.
Please seek medical attention if you experience any symptoms
that are concerning to you.
Followup Instructions:
Please keep the following appointment with your Primary Care
Physician:
Thursday [**1-25**] 3:15pm
Name: [**Last Name (LF) **],[**First Name3 (LF) **] A.
Location: [**Hospital **] MEDICAL ASSOCIATES
Address: [**Location (un) 77760**], [**Location (un) **],[**Numeric Identifier 29816**]
Phone: [**Telephone/Fax (1) 62842**]
Fax: [**Telephone/Fax (1) 15181**]
Please schedule a Neurosurgery followup appointment in the next
2 weeks either at a clinic close to your Rehab facility or at
[**Hospital1 18**].
- [**Hospital 18**] [**Hospital 4695**] Clinic ([**Telephone/Fax (1) 88**]
|
[
"728.88",
"E888.9",
"V58.67",
"287.5",
"427.89",
"600.00",
"285.9",
"585.9",
"852.26",
"403.90",
"272.4",
"584.9",
"276.51",
"250.22",
"288.60",
"276.2",
"787.22",
"263.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
15300, 15375
|
9503, 14320
|
434, 440
|
15549, 15558
|
3262, 3935
|
16874, 17460
|
2002, 2019
|
14571, 15277
|
15396, 15396
|
14346, 14548
|
15582, 16851
|
2034, 3243
|
15496, 15528
|
1728, 1757
|
291, 396
|
468, 1709
|
3944, 9480
|
15415, 15475
|
1779, 1830
|
1846, 1986
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,102
| 165,732
|
35964
|
Discharge summary
|
report
|
Admission Date: [**2104-1-4**] Discharge Date: [**2104-1-12**]
Date of Birth: [**2028-2-24**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Lipitor / Zocor
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2104-1-8**] - Coronary Artery Bypass Grafting to three vessels.
(Left internal mammary artery->Left anterior descending artery,
Saphenous vein graft->Obtuse marginal artery, Saphenous vein
graft->Right coronary artery.
History of Present Illness:
75 year old women who presented to [**Hospital1 **] emergency room with
2 days of chest pain and shortness of breath. A cardiac
catheterization was performed which revealed severe three vessel
disease. She was thus transferred to the [**Hospital1 18**] for surgical
management.
Past Medical History:
Coronary artery disease, hyperlipidemia, GERD, degenerative
arthritis, syncope, s/p hysterectomy
Social History:
Denies smoking. Drinks one alcoholic beverage per week. Retired
and lives alone.
Family History:
None
Physical Exam:
98.7 108/48 74 sinus 20 94% RA
General: pleasant, answers questions appropriately
Neuro: alert and oriented x 3
Chest: lungs clear bilaterally. Sternum stable
COR: irregular
Sternal Incision: dry and intact. Slight erythema improved from
previous day
Abdomen: soft, nontender without rebound or guarding
extremities: 1+ pitting edema 3 inches above ankles bilaterally
Pertinent Results:
[**2104-1-4**] Carotid Ultrasound
Bilateral 1-39% ICA stenosis with mild plaque seen bilaterally.
[**2104-1-8**] ECHO
The left atrium is moderately dilated. No spontaneous echo
contrast is seen in the body of the left atrium. No
mass/thrombus is seen in the left atrium or left atrial
appendage. No spontaneous echo contrast is seen in the body of
the right atrium. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. Trace aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen.
There is no pericardial effusion.
Post Bypass
Patient is on a Neo infusion @1.5 mcg/kg/min
LV function is preserved
The MR is now trace
Trivial AI
[**2104-1-10**] 06:10AM BLOOD WBC-6.1 RBC-3.13* Hgb-9.3* Hct-26.6*
MCV-85 MCH-29.9 MCHC-35.1* RDW-15.4 Plt Ct-115*
[**2104-1-4**] 12:40PM BLOOD WBC-8.0 RBC-3.80* Hgb-11.1* Hct-31.7*
MCV-84 MCH-29.3 MCHC-35.1* RDW-14.6 Plt Ct-249
[**2104-1-12**] 07:00AM BLOOD UreaN-18 Creat-1.1 Na-139 K-5.0
[**2104-1-10**] 06:10AM BLOOD Glucose-121* UreaN-12 Creat-1.0 Na-136
K-4.3 Cl-101 HCO3-28 AnGap-11
[**2104-1-4**] 12:40PM BLOOD Glucose-97 UreaN-19 Creat-1.0 Na-136
K-4.4 Cl-101 HCO3-27 AnGap-12
[**2104-1-4**] 12:40PM BLOOD %HbA1c-5.9
Brief Hospital Course:
Patient was transferred from an outside hospital for surgical
management of CAD after catheterization showed severe
three-vessel disease. She was worked up in the usual manner. She
was brought to the OR on [**2104-1-8**] with Dr [**Last Name (STitle) **] for coronary
artery bypass surgery. Please see operative note for full
details. Post-operatively she was admitted to the CVICU for
invasive hemodynamic monitoring. Her drips were weaned and she
was extubated on POD 1.
She was transferred to the step down unit on POD 2. Physical
therapy was consulted to work on strength and balance. She was
gently diuresed towards her pre-operative weight. She had
experienced several days of rate controlled paroxysmal atrial
fibrillation and she was started on coumadin on POD 4 before
discharge.
Medications on Admission:
norvasc 5, atenolol 50, HCTZ 25, zantac 150", sertraline 100,
MVI, ASA 81
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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*0*
10. Cephalexin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every
6 hours) for 5 days.
Disp:*40 Capsule(s)* Refills:*0*
11. Warfarin 1 mg Tablet Sig: as directed Tablet PO once a day:
Please take 5mg [**1-12**] and [**1-13**]. Dr[**Name (NI) 71276**] office will adjust
dose monday after VNA drawns INR.
Disp:*75 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
CAD s/p CABGx3 [**2104-1-8**]
HTN
Hyperlipidemia
Syncope
GERD
Arthritis
Paroxysmal atrial fibrillation
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks at [**Hospital1 **] Heart
Center.
Please follow-up with Dr. [**Last Name (STitle) 3659**] in 2 weeks at Heart Center .
Please follow-up with Dr. [**Last Name (STitle) 68568**] in [**2-25**] weeks. [**Telephone/Fax (1) 5835**]
Please call all providers for appointments.
Heart Center of [**Hospital1 **] to follow your INR. ([**Telephone/Fax (1) 20259**].
Please have VNA fax results monday AM, and adjust your coumadin
as directed by them.
Completed by:[**2104-1-12**]
|
[
"599.0",
"410.71",
"715.90",
"427.31",
"E878.2",
"414.01",
"401.9",
"272.4",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"39.61",
"36.12",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
5116, 5178
|
2811, 3602
|
292, 516
|
5324, 5333
|
1470, 2788
|
6110, 6645
|
1057, 1063
|
3726, 5093
|
5199, 5303
|
3628, 3703
|
5357, 6087
|
1078, 1451
|
242, 254
|
544, 823
|
845, 943
|
959, 1041
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,881
| 121,933
|
35755
|
Discharge summary
|
report
|
Admission Date: [**2161-2-23**] Discharge Date: [**2161-3-4**]
Date of Birth: [**2078-8-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Morphine / Vancomycin / Ciprofloxacin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Acute myocardial infarction, left main coronary artery disease
Major Surgical or Invasive Procedure:
coronary artery bypass grafts x 2 (LIMA to LAD, SVG to PDA),
reapir of right ventricle tear [**2161-2-27**]
History of Present Illness:
This 82 year old white female was awakened from sleep on [**2-21**],
with chest pain radiating to her left arm. She ruled in for MI
with a troponin I of 0.35 at [**Hospital1 **]. Catheterization there
revealed severe left main and subsequent double vessel disease.
Sheaths were left in place, Heparin was begun and she was
transferred to [**Hospital1 18**] for surgical evaluation.
Past Medical History:
hypertension
hypercholesterolemia
seizure disorder
dementia
s/p left hip replacement
Social History:
retired
[**2-24**] glasses of wine per week
quit smoking 15 years ago
lives with daughter and son-in-law
Family History:
father suffered MI
Physical Exam:
Admission:
HR 68 RR 16 right 178/76 left 178/74
4'[**63**]" 48.5 kg
WDWN in NAD
skin and HEENT unremarkable
neck with full ROM, no carotid bruits appreciated
CTAB
RRR ? soft ejection murmur
abd + BS
extrems warm, well-perfused, no edema or varicosities noted
healed scar left hip
neuro grossly intact
2+ bil. fems/radials
1+ bil. DP/PTs
Pertinent Results:
Conclusions
PRE-BYPASS: The left atrium is moderately dilated. No atrial
septal defect is seen by 2D or color Doppler. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the ascending aorta. There are simple
atheroma in the aortic arch. There are complex (>4mm) atheroma
in the descending thoracic aorta. There are three aortic valve
leaflets. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis (area 1.2-1.9cm2). No aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. Trivial mitral regurgitation is seen. There is no
pericardial effusion.
POST-BYPASS: Left and right ventricular function is preserved.
The aorta is intact. The remainder of the examination is
unchanged.
Dr. [**Last Name (STitle) **] was notified in person of the results in the
operating room.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting
physician
?????? [**2155**] CareGroup IS. All rights reserved.
[**2161-3-2**] 01:05PM BLOOD WBC-10.7 RBC-2.96* Hgb-9.6* Hct-26.8*
MCV-91 MCH-32.4* MCHC-35.8* RDW-14.2 Plt Ct-81*
[**2161-3-2**] 01:05PM BLOOD Glucose-118* UreaN-19 Creat-0.6 Na-136
K-3.9 Cl-97 HCO3-31 AnGap-12
Brief Hospital Course:
She was admitted from [**Hospital1 **] on [**2-23**] to the CVICU for pre-op
workup and Plavix washout. Sheaths were removed uneventfully and
she was transferred to the floor prior to surgery. She remained
pain free.
Thoracic surgical consultation was obtained due to some pleural
calcification and CXR abnormality. There was not felt to be
anything done for these after a CT scan was performed to
demonstrate some bronchiectasis. A repeat CT scan in a month was
recommended.
On [**2-27**] she underwent CABG with Dr. [**Last Name (STitle) **]. See operative note
for details. Of note the patient developed maculopapular rash w/
mild hives after rec'ing Vanco just after induction. vancomycin
was stopped - pt was given benadryl, hydrocort, and pepcid.
Subsequently cefazolin was given peri-op. The case began as on
off pump operation, however, bypass was necessary to repair an
RV tear. She transferred to the CVICU in stable condition on
phenylephrine and propofol drips.
She was weaned from pressors easily, extubated on POD #1 and
transferred to the floor on POD #2 to begin increasing her
activity level. Chest tubes and pacing wires removed per
protocol. She is known to have a slight facial droop but was
thought to be slightly increased briefly after surgery but
returned to baseline. A new dime sized stage II developed on her
coccyx-Allevyn was placed.
Diuresis towards her preoperative weight was begun, as were beta
blockers. Physical therapy worked with the patient for strength
and mobility as well. She progressed slowly, and a
rehabilitation evaluation was obtained for further recovery
prior to her eventual discharge to home.
Medications on Admission:
at transfer:
plavix 75 mg daily
somvastatin 80 mg daily
lisinopril 40 mg daily
ASA 325 mg daily
protonix 40 mg daily
aricept 10 mg daily
norvasc 5 mg daily
keppra 500 mg [**Hospital1 **]
lopressor 25 mg [**Hospital1 **]
heparin IV gtt
nitroglycerin IV drip
MVI daily
calcium 500 mg daily
lovenox 45 mg [**Hospital1 **]
ambien prn
SL NTG prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
4. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
6. Donepezil 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed.
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours):
hold K+>4.5.
10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
12. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for 4 weeks.
13. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days: or until at pre-op wt of 48.5 kg.
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 931**] House Nursing & Rehabilitation Center - [**Location (un) 932**]
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass grafts x 2, repair of RV tear
s/p myocardial infarction
hypercholesterolemia
hypertension
seizure disorder
dementia
s/p left hip replacement
Discharge Condition:
deconditioned
Discharge Instructions:
no lotions, creams or powders on any incision
shower daily and pat incisions dry
call for fever greater than 100.5
call for redness of , or drainage from incisions
call for weight gain of more than 2 pounds in a day or 5 pounds
a week
if you drive, no driving for one month and off all narcotics
no lifting greater than 10 pounds for 10 weeks
take all medications as directed
Followup Instructions:
.
see Dr.[**Last Name (STitle) 81314**] [**Name (STitle) **] in [**1-23**] weeks
see Dr. [**Last Name (STitle) 32255**] in [**2-24**] weeks
see Dr. [**Last Name (STitle) **] at [**Hospital1 **] in [**2-24**] weeks [**Telephone/Fax (1) 6256**]
please call for appointments.
Completed by:[**2161-3-4**]
|
[
"V43.64",
"E930.8",
"272.0",
"285.9",
"433.30",
"707.22",
"708.0",
"440.0",
"287.5",
"410.71",
"433.10",
"494.0",
"707.03",
"294.8",
"E870.0",
"458.29",
"401.9",
"518.89",
"693.0",
"345.90",
"998.2",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"99.04",
"39.31",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
6343, 6457
|
2972, 4625
|
366, 476
|
6693, 6708
|
1531, 2949
|
7132, 7437
|
1134, 1155
|
5017, 6320
|
6478, 6672
|
4651, 4994
|
6732, 7109
|
1170, 1512
|
264, 328
|
504, 887
|
909, 996
|
1012, 1118
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,834
| 151,679
|
10079
|
Discharge summary
|
report
|
Admission Date: [**2193-5-10**] Discharge Date: [**2193-5-14**]
Date of Birth: [**2171-7-14**] Sex: F
Service: GYN
HISTORY OF PRESENT ILLNESS: The patient is a 21-year-old
gravida 0, last menstrual period [**2193-4-9**] who complains of
pain since 9:15 p.m., on the day prior to admission, during
intercourse. She reports that since then, the pain has been
continuous, accompanied by leg numbness and left lower
quadrant pain, now worsening. She reports that it has spread
to her upper abdomen. She denies vaginal bleeding. She has
never had pain like this before. She also reports some
dysuria since the night prior to admission. She reports
nausea but denies vomiting. She reports constipation over
the last few weeks, with occasional bloody stool. Her last
bowel movement was on the morning of admission. She reports
dizziness and lightheadedness. In the emergency room, she
received morphine sulfate and Percocet for pain control.
PAST OBSTETRICAL HISTORY: Gravida 0.
PAST GYNECOLOGIC HISTORY: Last menstrual period [**2193-4-9**],
regular menses, morning after pill on [**1-23**] and [**3-24**]. She
is using condoms for birth control, denies STDs, no abnormal
Pap smears, no gynecologic surgeries, no ovarian cyst, no
fibroids.
PAST MEDICAL HISTORY: Negative.
PAST SURGICAL HISTORY: Negative.
MEDICATIONS: None.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: denies ethanol, drugs, and tobacco use.
PHYSICAL EXAMINATION: Blood pressure 85/36, pulse 107. In
general, the patient appears uncomfortable. Abdomen:
Distended with diffuse tenderness. Mild rebound and no
guarding. Pelvic examination: Positive cervical motion
tenderness, uterus and adnexa difficult to assess secondary
to discomfort. Extremities: Warm and well perfused. No
clubbing, cyanosis or edema.
LABORATORY DATA: Hematocrit 41.5 down to 26.9, HCG less than
5, PT 13.5, PTT 25.3, INR 1.2. Urinalysis negative, cultures
negative. GC and Chlamydia cultures pending.
Pelvic ultrasound: Normal uterus and endometrium. Right
ovary 2.8 x 3.0 x 2.5 cm, left ovary 3.6 x 5.1 x 4.8 cm with
a 3.8 cm hemorrhagic corpus luteum. Normal flow bilaterally
to the ovaries.
CT scan: Large amount of hemoperitoneum with likely
continued active bleeding from the left ovary, foci of
hyperattenuation in the left adnexa probably representing
calcification.
HOSPITAL COURSE: The patient was seen by General Surgery,
who placed a central line and an NG tube. The gynecology service
was then consulted. Due to her hemodynamic instability and
likely continued bleeding, she was taken to
the operating room for laparotomy and left ovarian
cystectomy. Please see operative reports for full details of
procedure. In total, the patient received 4 units of packed
red blood cells and 2 units of fresh frozen plasma.
Following the surgery, she initially was stable. On
postoperative day 1, she experienced an episode of decreased
oxygen saturation to 70% while ambulating. A chest x-ray was
notable for consolidations consistent with aspiration. Of
note, the anesthesiologist had noted aspiration of CT contrast
dye while in the operating room. On postoperative day 2, the
patient experienced another episode of decreased oxygen
saturation. At this point, a CT angiogram was performed,
that was initially read as multiple pulmonary emboli. A
heparin drip was started at this time. Approximately 12
hours following the initial [**Location (un) 1131**], the [**Location (un) 1131**] was changed
to no pulmonary emboli. This was the official read done by
the attending. At this point, the heparin was discontinued, and
the presumptive diagnosis leading to the desaturation was a
chemical pneumonitis.
The patient was continued on levofloxacin and Flagyl for
treatment of pneumonia versus chemical pneumonitis. Her
vital signs continued to be stable, as well as her
hematocrit. On postoperative day 3, the patient was seen by
a Pulmonary consult, who felt that her CT angiogram finding
of bilateral consolidations, as well as her clinical
presentation, were most consistent with a chemical
pneumonitis. A recommendation was made to discontinue the
patient's Flagyl but to continue levofloxacin for 10 days.
The Flagyl was discontinued at this time. Recommendation was
also made for a repeat CT scan in 4 weeks, as well as
Pulmonary followup at that time. On postoperative day 3, the
patient still felt somewhat short of breath with ambulation,
however, her oxygen saturation was within normal limits. A
decision
was made to observe her for one more night prior to
discharge. On postoperative day 4, the patient's oxygen
saturations remained stable in the upper 90s with ambulation. She
was considered stable for discharge home. Her central line
was discontinued.
DISCHARGE STATUS: Home.
DISCHARGE CONDITION: Good.
DISCHARGE DIAGNOSES:
1. Ruptured left hemorrhagic ovarian cyst.
2. Blood loss, anemia.
3. Chemical pneumonitis.
DISCHARGE MEDICATIONS:
1. Levofloxacin 500 mg p.o., q.d., times 10 days.
2. Ibuprofen 600 mg p.o., 6 hours p.r.n.
3. Percocet one to two tablets p.o., 4 to 6 hours p.r.n.
DISCHARGE INSTRUCTIONS: The patient was instructed to take
the entire bottle of levofloxacin as prescribed. She was
instructed to take Percocet and ibuprofen as needed for pain.
She was also instructed to call with a temperature greater
than 101 degrees, worsening pain, nausea or vomiting, or with
other concerns or questions. She was scheduled with Dr. [**First Name (STitle) **]
for a follow-up on [**2193-5-27**] at 3:00 p.m. She was also
instructed to call to schedule her repeat CT scan in 4 weeks,
and to call Pulmonary for a follow-up visit. She was given
all necessary phone numbers.
[**Name6 (MD) **] [**Name8 (MD) 33675**], [**MD Number(1) 33676**]
Dictated By:[**Last Name (NamePattern1) 31362**]
MEDQUIST36
D: [**2193-5-15**] 06:30:43
T: [**2193-5-15**] 10:23:44
Job#: [**Job Number 33677**]
|
[
"285.1",
"V64.41",
"620.1",
"568.81",
"506.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.07",
"65.29"
] |
icd9pcs
|
[
[
[]
]
] |
4848, 4855
|
4876, 4969
|
4992, 5142
|
2402, 4826
|
5167, 5988
|
1330, 1400
|
1482, 2384
|
165, 1272
|
1295, 1306
|
1417, 1459
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,427
| 156,419
|
51700
|
Discharge summary
|
report
|
Admission Date: [**2126-8-8**] Discharge Date: [**2126-8-20**]
Date of Birth: [**2077-3-31**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
E-Mycin / Penicillins / Chlorpromazine Hcl
Attending:[**First Name3 (LF) 6743**]
Chief Complaint:
Vaginal bleeding, endometrial cancer
Major Surgical or Invasive Procedure:
Insertion and removal of Mirena IUD, total abdominal
hysterectomy, bilateral salpingoophrectomy
History of Present Illness:
[**Known firstname **] [**Known lastname 107101**] is a 49-year-old gravida 0 woman who reports a long
history of worsening irregular menstrual cycles. She reports
that her cycles became quite
irregular with heavy bleeding at times. This led to a pelvic
ultrasound, which revealed an irregularity concerning for the
possibility of a polyp or irregularity within the endometrial
cavity. The irregular bleeding continued and she delayed care
it looks like for five or six months. An attempt had at an
endometrial biopsy in the past was associated with severe pain
and so she was somewhat concerned about doing this. A biopsy
was eventually obtained by Dr. [**Last Name (STitle) **] and a grade I
endometrioid adenocarcinoma was identified. The uterus measured
back in [**Month (only) 1096**] was 8.3 x 3.5 x 4.6 cm. The endometrial biopsy
was
obtained on [**2126-7-1**]. The decision was made to proceed with
TAH/BSO.
Past Medical History:
PAST MEDICAL HISTORY: [**Known firstname **] has a number of medical problems
including schizoaffective disorder, bipolar disorder, borderline
personality disorder, diabetes, hypertension, asthma, tobacco
abuse, sleep apnea, morbid obesity, and now the endometrial
cancer.
PAST SURGICAL HISTORY: She had eye surgery in [**2104**].
OB/GYN HISTORY: She reports her last Pap smear was normal. She
denies any history of abnormal Pap smears. She denies any
history of pelvic infections or ovarian cyst.
Social History:
SOCIAL HISTORY: She reports smoking two packs of cigarettes per
day. She denies tobacco or drug use. She works as a
receptionist.
Family History:
FAMILY HISTORY: She reports that her mother's aunt had a cancer
of unknown type.
Physical Exam:
GENERAL: She appears her stated age, in no apparent distress.
HEENT: Normocephalic, atraumatic. Oral mucosa without evidence
of thrush or mucositis. Eyes, sclerae are anicteric.
NECK: Supple, no masses. No thyromegaly.
LYMPHATICS: Lymph node survey, negative cervical,
supraclavicular, axillary, or inguinal adenopathy.
CHEST: Lungs with poor inspiratory effort, insp/exp wheezes,
and decreased BS @ bases.
HEART: Regular rate and rhythm, there are no appreciable
murmurs.
BACK: No spinal or CVA tenderness.
ABDOMEN: Soft, obese, nontender, and nondistended. No palpable
abdominal or pelvic mass. The exam is somewhat limited due to
obesity.
EXTREMITIES: There is no clubbing, cyanosis, or edema.
PELVIC: Normal external genitalia. The inner labia minora is
normal. The urethral meatus is normal. Speculum was placed.
The walls of the vagina are smooth. The cuff is normal. The
cervix is normal. Bimanual exam reveals a mobile uterus that is
normally sized without any parametrial nodularity. There is no
mass palpated at cervix. Rectal exam reveals good sphincter
tone
without mass or lesion.
Pertinent Results:
[**2126-8-14**] 05:40AM BLOOD WBC-15.1* RBC-4.29 Hgb-13.1 Hct-39.4
MCV-92 MCH-30.6 MCHC-33.3 RDW-14.3 Plt Ct-242
[**2126-8-16**] 09:54AM BLOOD WBC-10.7 RBC-4.17* Hgb-12.6 Hct-39.3
MCV-94 MCH-30.2 MCHC-32.1 RDW-14.3 Plt Ct-230
[**2126-8-14**] 05:40AM BLOOD Neuts-89.0* Lymphs-7.7* Monos-2.9 Eos-0.1
Baso-0.3
[**2126-8-16**] 09:54AM BLOOD Neuts-65.1 Lymphs-27.5 Monos-4.1 Eos-3.1
Baso-0.2
.
[**2126-8-15**] 04:30AM BLOOD PT-12.3 PTT-22.4 INR(PT)-1.0
.
[**2126-8-14**] 05:40AM BLOOD Glucose-255* UreaN-11 Creat-0.7 Na-143
K-3.9 Cl-104 HCO3-31 AnGap-12
[**2126-8-16**] 09:54AM BLOOD Glucose-187* UreaN-13 Creat-0.6 Na-142
K-3.9 Cl-104 HCO3-28 AnGap-14
[**2126-8-19**] 11:53AM BLOOD Glucose-75 UreaN-21* Creat-0.8 Na-140
K-3.7 Cl-99 HCO3-35* AnGap-10
.
[**2126-8-14**] 05:40AM BLOOD Calcium-8.7 Phos-4.4 Mg-1.3*
[**2126-8-16**] 09:54AM BLOOD Calcium-8.6 Phos-3.0 Mg-1.5*
[**2126-8-19**] 11:53AM BLOOD Calcium-8.9 Phos-3.1 Mg-1.2*
.
[**2126-8-16**] 09:54AM BLOOD CK-MB-2 cTropnT-<0.01
[**2126-8-16**] 05:00PM BLOOD CK-MB-2 cTropnT-<0.01
[**2126-8-16**] 09:30PM BLOOD CK-MB-2 cTropnT-<0.01
.
[**2126-8-19**] 11:53AM BLOOD TSH-0.97
.
[**2126-8-9**] 01:24PM BLOOD Type-ART pO2-73* pCO2-48* pH-7.38
calTCO2-29 Base XS-1
[**2126-8-14**] 06:00AM BLOOD Type-ART pO2-140* pCO2-47* pH-7.38
calTCO2-29 Base XS-2
[**2126-8-14**] 12:43PM BLOOD Type-ART Temp-37.0 Rates-/14 O2 Flow-3
pO2-104 pCO2-36 pH-7.54* calTCO2-32* Base XS-8 Intubat-NOT
INTUBA
.
CXR [**8-13**]
The ET tube tip is 3.3 cm above the carina. The low lung volumes
exaggerate
the size of the cardiomediastinal silhouette which appears to be
slightly
enlarged compared to the prior study. The patient is in mild
volume overload with bilateral pleural effusions demonstrated,
right most likely more than left. No pneumothorax is seen.
.
CXR [**8-15**]
There is increased lower lobe atelectasis and slightly worsened
right middle lobe atelectasis. The mediastinal contour is
obscured by the lung
abnormality. Left lower lobe atelectasis is persistent, if any,
there are
small bilateral pleural effusions.
.
CXR [**8-16**]
Since yesterday, aeration in both bases improved. Bilateral
pleural
effusion, if present, are tiny. There are no signs of pulmonary
edema or new focal area of consolidation. Heart size is still
enlarged, could be in part due to patient position and AP
technique. No other change.
.
ECG [**8-16**]
Sinus arrhythmia. Non-specific T wave change in leads III and
aVF.
Compared to the previous tracing of [**2126-8-5**] the P wave is less
peaked
Brief Hospital Course:
Ms. [**Known lastname 107101**] is a 49yo presented for planned TAH/BSO for
endometrial cancer. In the preop holding area, the anesthesia
team evaluated the pt and noted that her oxygen saturation at
baseline was 90%. She had audible wheezes throughout the room.
By her own admission, she has been smoking more than she has in
the past. She denies any fever. Incentive spirometry was given
to the patient, but despite this, her oxygen saturation remained
low. There was a concern for the possibility of an inability to
wean the ventilator upon completion of surgery and again the
possibility of pulmonary issues postoperatively. Because of this
concern, her planned surgery was cancelled. As it was not
initially clear when the procedure could be rescheduled, the
patient was consented for and underwent placement of a Mirena
IUD. The Mirena IUD has been shown to be somewhat effective in
treating some endometrial cancers, but in this case, it is more
of a temporizing [**Doctor Last Name 360**] given her significant vaginal bleeding.
.
The decision was then made to admit the patient for optimization
of her pulmonary status. One main goal of this hospitalization
was to prevent the patient from smoking as much as she had been.
She was given a nicotine patch and a pulmonology consultation
was obtained. Her medications were optimized, with the addition
of a course of steroids and 7 days of levoquin, which she
completed. On HD#2, her case was discussed with the attending
anesthesiologist who had initially assessed her. He agreed that
after 4-5 days of steroids, antibiotics, oxygen therapy, and not
smoking, she would likely be more stable to complete the
initially planned procedure. It was thus scheduled for HD#6.
.
As her glucose fingersticks were extremely high, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
consult was obtained for optimization of diabetes medications.
Actos was discontinued and lantus was added, along with a more
aggressive insulin sliding scale. Her FS were subsequently much
improved.
.
On HD#6, Ms. [**Known lastname 107101**] was taken to the operating room, where
TAH/BSO was performed. Please see the operative note for full
details on this uncomplicated procedure. Postoperatively,
extubation was not attempted secondary to her poor respiratory
status and she was transferred to the ICU. She was subsequently
extubated on POD#1 and transferred back to the med/[**Doctor First Name **] floor on
POD#2, after further optimization of her pulmonary status.
Her postoperative course was complicated by the following
issues:
*) Pulmonary status: Pt did have an oxygen requirement following
transfer to the floor. She was maintained on her bi-pap
overnight. Her levoquin was d/c'd following the surgery, but
prednisone was continued until tapering was started on the day
of discharge. Her oxygen saturation ranged from 94-98% on RA-2L
O2 by NC during the day and 90-95% on 2L Bi-Pap at night. She
also received scheduled albuterol and atrovent nebulizer
treatments. The pulmonary service continued to follow the
patient and by the time of discharge to rehab, she was felt to
be operating at a stable baseline.
*) Sedation: During most nights postoperatively, the patient was
noted to be difficult to arouse from sleep. Often, sternal rub
or the equivalent was required to wake Ms. [**Known lastname 107101**] and keeping
her awake proved even more difficult. Her vital signs were
always stable during these episodes, and while sitting up during
the day, no abnormalities or mental status changes from baseline
were noted. The medicine team was consulted and her history was
reviewed. The team felt that she was likely difficult to arouse
at baseline secondary to her lung disease and that the
combination of narcotics, psychiatric medications, and
benzodiazapenes were contributing. Holding parameters for these
medications (including no benzos/narcotics after 6pm) were
applied.
*) EKG changes: An EKG obtained during an episode of sedation
revealed T wave changes. Three sets of cardiac enzymes were
negative and the pt was without symptoms. She was maintained on
telemetry and had multiple episodes of sinus arrhythmia, but the
character of such was deemed overall benign by the medicine
consultants.
*) T2DM: The [**Last Name (un) **] service continued to follow this patient and
insulin regimen was adjusted prn. She will continue metformin,
lantus insulin, and sliding scale insulin on discharge, but
should not be restarted on actos.
*) HTN: Her blood pressures continued to be elevated with
vasotec, so HCTZ was added to the regimen. This resulted in much
better control of her hypertension.
*) Psych: She was maintained on her home medications. These
medications do likely contribute to her somnolence and prn
medications were held for sedation. She should follow up with
psychiatry as soon as possible after discharge from
rehabilitation.
The patient was discharged on HD#13/POD#7 for transfer to a
rehabilitation facility. She has a follow up appointment
scheduled with Dr. [**Last Name (STitle) 2028**].
Medications on Admission:
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs
inhalation q4-6 hours as needed for cough/wheeze
BENZTROPINE - (Prescribed by Other Provider: [**Name Initial (NameIs) 2447**]) - 1
mg Tablet - 1 Tablet(s) by mouth twice a day
CLONAZEPAM [KLONOPIN] - (Prescribed by Other Provider: [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]) - 0.5 mg Tablet - 1 Tablet(s) by mouth twice a day
CLOZAPINE [CLOZARIL] - (Prescribed by Other Provider) - 100 mg
Tablet - 1 Tablet(s) by mouth q AM, 4 qhs
ENALAPRIL MALEATE [VASOTEC] - 5 mg Tablet - 1 Tablet(s) by mouth
once a day
FLUTICASONE [FLOVENT HFA] - 44 mcg Aerosol - 2 twice a day
IBUPROFEN - 600 mg Tablet - 1 Tablet(s) by mouth q 6 hours
INSULIN DETEMIR [LEVEMIR FLEXPEN] - (Dose adjustment - no new
Rx) - 100 unit/mL Insulin Pen - inject 50 units SQ at bedtime 1
BOX (5 X 3 ML)
IPRATROPIUM-ALBUTEROL [COMBIVENT] - 103 mcg (90 mcg)-18
mcg/Actuation Aerosol - 1 po 2 puffs qid
LORAZEPAM [ATIVAN] - (Prescribed by Other Provider: [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]) - 0.5 mg Tablet - 1 Tablet(s) by mouth three times a
day as needed for anxiety
METFORMIN [GLUCOPHAGE] - 850 mg Tablet - 1 Tablet(s) by mouth
three times a day
MONTELUKAST [SINGULAIR] - 10 mg Tablet - 1 Tablet(s) by mouth
once a day
OLANZAPINE [ZYPREXA] - (Prescribed by Other Provider: [**Last Name (NamePattern4) **].
[**Last Name (STitle) 75205**] - 2.5 mg Tablet - 1 Tablet(s) by mouth twice a day
as needed for agitation
OXYBUTYNIN CHLORIDE [DITROPAN XL] - 10 mg Tab,Sust Rel Osmotic
Push 24hr - 1 Tab(s) by mouth once a day
PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) -
1 Tablet(s) by mouth once a day - No Substitution
SALMETEROL [SEREVENT DISKUS] - 50 mcg Disk with Device - one
puff
po twice a day
SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day
TRAMADOL [ULTRAM] - 50 mg Tablet - 1 Tablet(s) by mouth twice a
day as needed for pain
TRAZODONE - (Prescribed by Other Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) -
150 mg Tablet - 1 Tablet(s) by mouth at bedtime
ZOLOFT - 100MG Tablet - 2 BY MOUTH EVERY MORNING PER DR.
[**Last Name (STitle) **]
Medications - OTC
BLOOD SUGAR DIAGNOSTIC [ONE TOUCH ULTRA TEST] - Strip - Use
as directed to check blood sugars once a day
LANCETS - Misc - Use to check blood sugars once a day
MICONAZOLE NITRATE [LOTRIMIN AF] - 2 % Powder - apply to
affected
areas once a day
MULTIVITAMINS WITH IRON - Tablet - 1 Tablet(s) by mouth once a
day
Discharge Medications:
1. Metformin 850 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
2. Oxybutynin Chloride 5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
3. Clozapine 100 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
4. Sertraline 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Clozapine 100 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
6. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed.
8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed: Do not exceed 4g acetaminophen daily.
Tablet(s)
10. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime) as needed.
11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID PRN ().
12. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed. Capsule(s)
16. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed: Hold after 6pm.
17. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
18. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
[**11-28**] puff Inhalation [**Hospital1 **] (2 times a day).
19. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**11-28**]
Puffs Inhalation once a day as needed.
20. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days.
21. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
22. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) INH Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
23. Insulin Glargine 100 unit/mL Solution Sig: Thirty Five (35)
units Subcutaneous qAM: 20 units qPM.
24. Humalog 100 unit/mL Solution Sig: 5-19 units Subcutaneous
four times a day: Please see insulin sliding scale.
25. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) patch
Transdermal once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 25878**] Rehab
Discharge Diagnosis:
Endometrial cancer, COPD exacerbation
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or return to the hospital if you have:
-Increased pain
-Redness or unusual discharge from your incision
-Inability to eat or drink because of nausea and/or vomiting
-Fevers/chills
-Chest pain or shortness of breath
-Any other questions or concerns
Other instructions:
-You should not drive for 2 weeks and while taking narcotic pain
medications
-No intercourse, tampons, or douching for 6 weeks
-No heavy lifting or vigorous activity for 6 weeks
-You can shower and clean your wound, but do not use perfumed
soaps or lotions. Be sure to pat completely dry after washing.
-You may resume your regular diet
-Many of your medications have been changed during this
hospitalization. Please refer to the your discharge medication
list for appropriate medications.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 5777**]
Date/Time:[**2126-8-26**] 11:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 5777**]
Date/Time:[**2126-9-11**] 1:00
You should also follow up with your primary care physician and
[**Month/Day/Year 2447**] as soon as possible following discharge from rehab.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6753**]
|
[
"295.70",
"250.00",
"278.01",
"305.1",
"V64.41",
"518.0",
"327.23",
"182.0",
"620.1",
"466.0",
"276.4",
"493.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"69.7",
"65.61",
"93.90",
"54.25",
"68.49"
] |
icd9pcs
|
[
[
[]
]
] |
15889, 15942
|
5866, 10947
|
352, 450
|
16024, 16033
|
3334, 5843
|
16864, 17424
|
2115, 2181
|
13522, 15866
|
15963, 16003
|
10973, 13499
|
16057, 16841
|
1723, 1931
|
2196, 3315
|
276, 314
|
478, 1402
|
1447, 1699
|
1964, 2082
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,631
| 105,287
|
45620
|
Discharge summary
|
report
|
Admission Date: [**2193-9-29**] Discharge Date: [**2193-10-4**]
Date of Birth: [**2115-1-23**] Sex: F
Service: SURGERY
Allergies:
Opioid Analgesics
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
exploratory laparotomy
pneumococcal vaccine administration
History of Present Illness:
73F with known PVD who presented on [**9-29**] with 2-3 days of bright
red blood per rectum & crampy abdominal pain. The pain
localizes to her lower abdomen & has been worsening. She denied
f/c, n/v, but does report progressive anorexia over last 24
hours.
Past Medical History:
PMH: CAD s/p MI, GIB, HTN, ^chol, Hypothyroid, Carotid Dz
PSH: CABG, SAH, Open [**Last Name (un) **], Appy, TAH
Social History:
lives alone in 2 story house
no toxic habits
Family History:
noncontributory
Physical Exam:
T 100.8 P 110 BP 151/80 RR 16 98% RA
Alert, toxic
anicteric
tachy
CTA bilat
Soft +RLQ rebound tenderness
Rectal: guaiac +, hemorrhoid +
no CCE
Pertinent Results:
[**9-29**] CT abdomen: Portal venous and mesenteric venous gas
extending from the region of the cecum, with question of cecal
pneumatosis. The findings are suspicious for bowel ischemia.
Extensive calcific atherosclerotic disease. Marked stranding
surrounding the rectum and probable rectal thickening,
incompletely evaluated due to the lack of contrast in this area.
The findings are suggestive of proctitis of uncertain etiology.
Multiple hypodense liver lesions, many of which demonstrate
characteristics consistent with hepatic cysts although some of
which are too small to accurately characterize.
[**2193-9-28**] 05:00PM BLOOD WBC-16.1*# RBC-3.96* Hgb-12.6 Hct-36.5
MCV-92 MCH-31.7 MCHC-34.4 RDW-14.0 Plt Ct-189
[**2193-9-28**] 05:00PM BLOOD Neuts-91.8* Bands-0 Lymphs-5.2* Monos-2.8
Eos-0.1 Baso-0.1
[**2193-9-28**] 05:00PM BLOOD PT-15.1* PTT-25.8 INR(PT)-1.6
[**2193-9-28**] 05:00PM BLOOD Glucose-134* UreaN-36* Creat-2.0* Na-139
K-4.8 Cl-107 HCO3-16* AnGap-21*
[**2193-9-28**] 05:00PM BLOOD CK(CPK)-128 CK-MB-3 cTropnT-<0.01
[**2193-9-28**] 07:25PM BLOOD Lactate-3.7*
Brief Hospital Course:
[**9-28**]: Admitted to SICU for close HD monitoring, serial exams &
IV resuscitation.
[**9-29**]: Taken to OR because of concerning physical exam &
persistent acidosis. See op note for details, but briefly, a
normal cecum was found, sigmoidoscopy showed a normal rectum,
and aspiration of a hepatic cyst was performed.
[**9-30**]: NGT removed. Transferred to floor.
[**10-1**]: Abdominal pain improved. No positive stool cultures.
Started on PO diet, which she tolerated.
[**10-2**]: Diet advanced w/o complication. Rehab screen started.
[**10-4**]: Pneumococcal vaccine given prior to trasnfer to [**Hospital 100**]
Rehab.
Medications on Admission:
plavix 75', toprol 50', asa, synthroid 75', lipitor 20', ativan
Discharge Medications:
1. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
2. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
6. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**3-27**]
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): while using narcotics.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
CAD s/p MI s/p CABG
HTN
^chol
hypothyroid
Discharge Condition:
good
Discharge Instructions:
Diet as tolerated. No bathing (showers okay, pat wound dry), no
lifting objects heavier than a gallon of milk, and no driving
until your follow up appointment.
Contact your MD if you develop fevers > 101, increasing redness
or drainage about your incisions, or if you have any questions
or concerns.
Followup Instructions:
Contact Dr [**Last Name (STitle) 15645**] office at ([**Telephone/Fax (1) 9000**] to arrange a follow
up appointment in about 1 week.
Completed by:[**2193-10-4**]
|
[
"412",
"578.9",
"573.8",
"276.2",
"211.1",
"244.9",
"272.0",
"401.9",
"455.3",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"48.23",
"50.0",
"54.11",
"44.15"
] |
icd9pcs
|
[
[
[]
]
] |
4076, 4161
|
2161, 2796
|
291, 352
|
4246, 4253
|
1058, 2138
|
4603, 4768
|
853, 870
|
2910, 4053
|
4182, 4225
|
2822, 2887
|
4277, 4580
|
885, 1039
|
237, 253
|
380, 640
|
662, 775
|
791, 837
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,230
| 162,966
|
53343+59516
|
Discharge summary
|
report+addendum
|
Admission Date: [**2124-7-13**] Discharge Date: [**2124-8-7**]
Date of Birth: [**2069-2-16**] Sex: M
Service:
This is an interim discharge summary.
HISTORY OF PRESENT ILLNESS: The patient is a 55 year old
Indian male with a past medical history of hypertension who
presented to the Emergency Department on [**2124-7-13**] with
crushing substernal chest pain radiating to the back.
Approximately 15 minutes later the patient also noted
numbness of his lower extremities which lasted approximately
20 minutes. The patient received two tablets of sublingual
Nitroglycerin and Aspirin without any significant improvement
of symptoms. In the Emergency Department he continued to
have crushing pain and received a total of four sublingual
nitroglycerin tablets as well as 5 mg of intravenous
Lopressor times three. He also received Morphine Sulfate 6
mg intravenously and was started on Labetalol. Computerized
tomography scan of the abdomen was done and was notable for
descending thoracic aorta dissection, extending to the
bifurcation and into the left common iliac as well as
external iliac artery. The patient denied dyspnea on
exertion, paroxysmal nocturnal dyspnea, edema, shortness of
breath. He did complain of nausea and vomiting. He denied
palpitations.
PAST MEDICAL HISTORY: Hypertension and questionable
hypercholesterolemia.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Aspirin, Atenolol 100 mg once a
day.
FAMILY HISTORY: Non-contributory.
SOCIAL HISTORY: Denies using ethanol or smoking tobacco.
PHYSICAL EXAMINATION: Heartrate 76, blood pressure 156/80,
respirations 20. Oxygen saturation is 99% on room air.
Blood pressure on the right arm 144/81, left arm 144/83. In
general this is a mildly obese Indian male lying in bed in
pain, alert and oriented times three. Head, eyes, ears, nose
and throat, pupils equal, round and reactive to light and
accommodation. Bilateral extraocular movements intact.
Sclera anicteric. Mucosal membranes are moist. Oropharynx
is clear. No jugulovenous distension and no thyromegaly.
Cardiovascular, regular rate and rhythm, II/VI systolic
murmur to left upper sternal border. Lungs clear to
auscultation bilaterally. Abdomen is soft, nontender,
nondistended with positive bowel sounds. No organomegaly.
Extremities, 2+ dorsal pedis, posterior tibial pulses
bilaterally, 1+ left radial and 2+ right radial pulses.
Neurological examination, nonfocal. Cranial nerves II
through XII were intact.
LABORATORY DATA: White cell count 7.7, hematocrit 38.4,
platelets 182. Sodium 144, potassium 3.6, chloride 104,
bicarbonate 27, BUN 25. Creatinine 1.2, glucose 126,
creatinine kinase 183, troponin less than 0.3. Calcium 9.4,
phosphate 2.7, magnesium 2.0.
HOSPITAL COURSE: Cardiovascular - The patient was
transferred to the floor and started on Labetalol intravenous
drip to control his blood pressures. On [**7-14**], 9 PM he
became agitated and was given Haldol intravenously. Shortly
after he experienced an episode of hypotension with pulseless
electrical activity arrest. The code was called. The
patient was resuscitated. His mean arterial pressures
remained in the low 30s for five minutes. He was intubated
for hypoxia. After intubation his blood pressures soon
needed to be controlled with two agents, Labetalol and
Nipride to decrease sheer forces. Nipride drip was stopped a
few days after initiation secondary to renal toxicity. The
patient was initially scheduled for surgery, however, the
surgery was cancelled secondary to mental status changes and
later fevers. On [**2124-7-23**], Mr. [**Known lastname 109742**] developed
another episode of hypotension requiring brief use of
Dopamine drip. Echocardiogram was repeated and showed trace
aortic insufficiency, no vegetations and normal aortic root
without dissection and normal left ventricular function at
about 55%. This echocardiogram was considered to be
unchanged from the one done initially on admission. On
[**2124-7-28**], computerized tomography scan of the chest
and abdomen were done and showed no change in aortic
experience, no retroperitoneal collections. The patient was
started on p.o. antihypertensives on [**2124-7-31**]. On the
same day magnetic resonance imaging scan was done and showed
proximal arch wall thickness to be decreased from 13 mm to 6
mm with decreased hematoma. It also showed partial
thrombosis in the false lumen without occlusion of the full
and normal renal arteries. By [**8-5**], blood pressures
were controlled with p.o. medications, Lopressor 150 t.i.d.,
Diltiazem 90 q.i.d. and Hydralazine 75 q.i.d. as well as
minimal Lopressor intravenous drip.
Neurological - The patient had mental status change shortly
after the administration of 6 mg of Morphine Sulfate in the
Emergency Department. He became disorientated and agitated
on the floor. He had emesis times three. An attempt was
made to reverse the action of narcotics with Naloxone which
resulted in agitation and required the use of benzodiazepines
and narcotics. Neurological consult was obtained on [**7-14**]
and felt that the patient's symptoms were consistent with
toxic metabolic encephalopathy. On [**7-15**], the patient
became agitated again, required Haldol and was intubated.
Computerized tomography scan of the head was done on [**7-16**]
and was negative for intracranial bleed or any other
abnormalities. By [**8-5**], at the time of this dictation,
the patient was fully sedated for 24 hours, still minimally
responsive with some eye tracking and no other responses. he
had no focal signs on neurological examination.
Infectious disease - Shortly after admission the patient
developed fever and was started on antibiotics for presumed
aspiration pneumonia. He was initially started on Cefepime,
Vancomycin and Levofloxacin, however, when his respiratory
cultures came back positive for guaiac positive
Staphylococcus and his gram stain was positive for gram
negative rods, his antibiotic regimen was changed to
Oxacillin. The patient continued to have fevers and
infectious disease consult was obtained. They recommended
getting an abdominal ultrasound and liver function tests.
Abdominal ultrasound showed positive sludge in the
gallbladder without any evidence of cholecystitis as well as
benign hemangioma of the liver. Liver function tests showed
increased LDH and alkaline phosphatase enzymes. Mr. [**Known lastname 109742**]
continued to have fevers on Oxacillin and his antibiotics
were changed once again to Unasyn. Unfortunately the patient
developed a rash to this medication in two days and Unasyn
was changed to Clindamycin and Levofloxacin and then to
Flagyl and Levofloxacin. At this time his cultures were only
positive for coagulase negative Staphylococcus from the
catheter tip and gram positive Staphylococcus in the sputum.
He finished the course of antibiotics on [**2124-7-31**] and
remained off of antibiotics since then until the time of this
dictation. His temperature and white blood cell count
remained stable. No new positive cultures were detected.
Pulmonary - The patient developed increased oxygen
requirements shortly after admission. The Swan catheter was
flooded and showed right atrial pressure of 17, right
ventricular pressure of 37/18, pulmonary artery pressure of
54/16 and capillary wedge at 23. Later he developed adult
respiratory distress syndrome-like picture with multiple
bilateral passing opacities and bilateral pleural effusions
on chest x-ray. His ventilation settings were changed to low
title volumes and increased positive end-expiratory pressure.
He also developed nonanion gap metabolic acidosis. On [**2124-7-30**], bronchoscopy was done which showed patchy thick
secretions throughout the upper and lower lobes bilaterally
without any masses. Bronchial alveolar lavage results showed
4+ PMNs on gram stain and no organisms. By [**2124-8-4**]
metabolic acidosis was corrected with bicarbonate infusion.
Chest x-ray and clinical examination as well as oxygen
requirements improved and the patient was extubated. At the
time of this discharge, Mr. [**Known lastname 109742**] remained off of the
ventilator for 24 hours, stable.
Renal - The patient's baseline creatinine was 1.1 on
admission. He received 350 cc of contrast with first
computerized tomography scan angiogram and 300 cc with the
second one. His creatinine rose up to 2.4 shortly after.
The patient continued to be in renal failure over the next
three weeks with urine electrolytes consistent with a good
renal picture and metabolic acidosis secondary to bicarbonate
loss. Renal consult was obtained on [**8-2**] and suggested
that acute renal failure was the most consistent with acute
tubular necrosis with diarrhea contributing to bicarbonate
loss. Bicarbonate was repleted over the next two days with
good results.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-222
Dictated By:[**Last Name (NamePattern4) **]
MEDQUIST36
D: [**2124-8-5**] 17:45
T: [**2124-8-5**] 19:43
JOB#: [**Job Number **]
Name: [**Known lastname 17994**], [**Known firstname **] Unit No: [**Numeric Identifier 17995**]
Admission Date: [**2124-7-13**] Discharge Date: [**2124-8-23**]
Date of Birth: [**2069-2-16**] Sex: M
Service: CCU
ADDENDUM:
This is an addendum to the previously described interim
discharge summary. Please see admission history, physical
and hospital course through [**2124-8-7**] accordingly.
HOSPITAL COURSE CONTINUED:
1. CARDIOVASCULAR: As of [**2124-8-7**] blood pressures
continued to remain labile. Metoprolol 150 mg t.i.d.,
Diltiazem 90 mg q.i.d., Hydralazine 100 mg q.i.d. and
Clonidine 0.2 mg t.i.d. and Labetalol drip. On [**2124-8-8**], the patient was weaned off the Labetalol drip and
Clonidine dosing was gradually increased to maximum dose of
0.8 mg t.i.d. The patient was also started on
Hydrochlorothiazide 50 mg q.d. with little improvement of
blood pressure control. With improvement of renal function,
an angiotensin converting enzyme inhibitor was also added to
the regimen on [**2124-8-11**].
At this time the patient's systolic blood pressure was
staying at approximately 140 mmHg and a heart rate between 75
to 85 and a CCU Team decided this patient was stable enough
to be transferred to the floor.
Within 48 hours of transfer, the patient began to experience
chest pain with radiation to the back. Sublingual
Nitroglycerin was given three times and 0.5 mg of IV Morphine
with mild relief. The patient was taken for emergent CT SCAN
angiogram of the chest that revealed further increase of
thoracic luminal diameter from 3.5 to 3.8 cm, increase in
size of the luminal thrombosis and increase in size of the
lumen at the left pulmonary artery to 4.5 cm. Cardiothoracic
surgery was consulted at this time and stated that there was
no indication for surgery at this time.
The patient was then transferred back to the CCU for more
aggressive control of his blood pressure and the patient was
restarted on Nitroglycerin drip for 48 hours. The patient
was then started on Norvasc 5 mg. The following evening, the
patient again experienced an episode of chest pain, but this
time without back pain and showed no clinical signs of
extension or dissection nor changes on EKG. Later on that
evening, the patient experienced a drop in blood pressure to
systolic blood pressure of 70, 30 minutes after receiving
night time dosages of Clonidine and Captopril. The patient
responded to 500 cc bolus of normal saline and maintained him
at greater than 60.
Within the next 24 hours, the patient had another episode of
substernal chest pain with stable vital signs and no EKG
changes. The patient had moderate relief with Nitroglycerin
times two. There are no EKG changes at this time. Repeat CT
Scan angiogram revealed no progression of dissection. Again,
blood pressure remained stable in both arms. There are no
clinical signs for evidence of progression of dissection.
Given the episode of substernal chest pain, the patient was
started on aspirin.
The patient's blood pressure remained well controlled in the
unit. The patient was, again, transferred to the floor on
[**2124-8-19**]. Between the time of transfer and
patient's date of discharge on [**8-23**], patient's
blood pressure was controlled on blood pressure medication.
Blood pressure medication regimen was adjusted as necessary.
Please see discharge medications for discharge
antihypertensive medications.
2. INFECTIOUS DISEASE: The patient completed a 14 out of 14
day course of Linezolid and aztreonam for MRSA and potential
gram negative pneumonia as per Infectious Disease. Patient
remained afebrile with a stable white blood cell count for
the remainder of the hospital stay.
3. NEUROLOGY: Given patient's somnolence, confusion, mental
status changes status post extubation, Neurology was
consulted given these findings on exam. On exam it was noted
that the patient also had a left gazed deviation, right
field, right hemiparesis.
A MRI on [**2124-8-17**] revealed:
1. Laminar necrosis with hemorrhage in media left occipital
lobe and left thalamus.
2. Sinus disease.
Neurology recommendations including maintaining systolic
blood pressure less than 140, keep head of bed elevated
greater than 30 degrees, and patient was followed by the
Neurology for the remainder of the hospital course.
The patient improved mental status throughout the remainder
of the hospital stay with increased speech and movement of
all extremities. The Stroke Service was also consulted to
evaluate the patient for possible cardiac catheterization
given patient's history of substernal chest pain and possible
future need of cardiothoracic surgery for aortic dissection.
A MRI showed a left PCA involving infarct and thus it was
concluded it was best to wait two to three weeks for
anticoagulation. Patient is to follow with [**Hospital 2996**] Clinic
as an outpatient.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To rehab facility.
DISCHARGE DIAGNOSES:
1. Aortic dissection, type B.
2. Cerebrovascular accident.
3. Hypertension.
4. Aspiration pneumonia.
5. ARDS.
6. Acute renal failure.
7. Methicillin-resistant Staphylococcus aureus bacteremia.
DISCHARGE MEDICATIONS:
1. Atenolol 100 mg p.o. q.d.
2. Lisinopril 40 mg p.o. q.d.
3. Norvasc 10 mg p.o. q.d.
4. Clonidine 0.2 mg p.o. t.i.d. times one week.
5. Nitroglycerin sublingual p.r.n. chest pain
6. Aspirin 325 mg p.o. q.d.
7. Vitamin C 250 mg p.o. b.i.d.
8. Zinc Sulfate 220 mg p.o. q.d.
FOLLOW UP PLANS:
1. Follow up with Cardiothoracic Surgery in one month.
2. Follow up with Dr. [**Last Name (STitle) **] in one to two weeks for blood
pressure management, this is the patient's primary care
physician.
3. Follow up with Cardiology in one month including
outpatient stress test.
4. Follow up in [**Hospital 2996**] Clinic in two to three weeks.
5. Occupational Therapy and Physical Therapy.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-462
Dictated By:[**Last Name (NamePattern1) 17996**]
MEDQUIST36
D: [**2124-9-18**] 14:08
T: [**2124-9-18**] 14:31
JOB#: [**Job Number 17997**]
|
[
"427.5",
"441.01",
"401.9",
"584.5",
"276.2",
"482.41",
"434.91",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"89.64",
"33.24",
"88.42",
"38.91",
"03.31",
"96.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
1484, 1503
|
14104, 14305
|
14328, 15254
|
1429, 1467
|
2784, 14012
|
1585, 2766
|
197, 1288
|
1311, 1402
|
1520, 1562
|
14037, 14083
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,682
| 180,937
|
51572
|
Discharge summary
|
report
|
Admission Date: [**2145-2-14**] Discharge Date: [**2145-2-26**]
Date of Birth: [**2064-3-7**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Sulfonamides / Erythromycin Base / Atorvastatin /
Phenergan / Colchicine / Nickel / Iodine; Iodine Containing /
Quinine / Ciprofloxacin Hcl / Neurontin
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
PEA Arrest
Major Surgical or Invasive Procedure:
Intubation
Extubation
PA catheter placement and removal
Cardiac catheterization x2 with stents to Left Anterior
Descending and Right Coronary Arteries
History of Present Illness:
This is a 80y.o F with a PMH of ESRD on HD, CVA, diastolic CHF
now admitted after PEA arrest. The patient presented to the ER
with complaints of nausea/emesis and diarrhea for three days.
Reported she was unable to tolerate po intake and felt weak and
lethargic. She denied abd pain. Reported fever intermittently.
Last HD on friday.
The patient denies any chest pain or pressure, new exertional
dyspnea, orthopnea, PND or leg edema, palpitations or syncope,
claudication-type symptoms, melena, rectal bleeding, or
transient neurologic deficits. No change in weight, bowel habit
or urinary symptoms. No cough, night sweats, arthralgias,
myalgias, headache or rash. All other review of systems
negative.
In the ED, initial vitals were T: 98.2 HR: 77 BP: 136/56 RR: 20
O2Sat: 100% RA. Vancomycin 1gm and zosyn given. The patient then
became unresponsive and was found to be pulseless. CPR was
begun. Pt was intubated. She received epi 1mg IV, atropine 1mg
IV, Bicarb 1 amp IV, Calcium chloride 1amp IV, followed by
second round of epi/atropine with return of spontaneous
circulation after approx 8 minutes. She was them given versed
2mg IV for sedation and a R femoral line and NGT were placed.
The artic sun was placed. She was plavix loaded with 300mg,
given ASA 600mg PR. 30g kayexelate given. Head CT showed no
acute process but evidence of chronic microvascular ischemic
disease. CT A/P with no acute intaabdominal process but
bilateral pulmonary infiltrates concerning for PNA or
aspiration. CE returned elevated with CK 452 MB 44 MBI 9.7 and
Troponin 3.74. ABG 7.21/54/203/23. She was taken urgently to the
cath lab.
Cardiac catheterization revealed LAD with 80% mid stenosis, RCA
with 70% proximal, 90% distal - both stented with 0% residual.
Severe bilateral iliac stenosis. She was given 200mg IV lasix
and NTG to reduce PCWP from 45mmg Hg to 40mg Hg and mean PA from
46 to 40mm Hg. CO 5.4, CI 3.1. The artic sun protocol was not
continued given duration of patient's arrest and her return of
spontaneous movement post cath.
The patient is now transferred to the CCU for further managment.
On arrival to the CCU, dialysis was instituted.
Past Medical History:
- ESRD: [**1-25**] renal artery stenosis, on hemodialysis Q MWF,
followed by Dr. [**First Name8 (NamePattern2) 3122**] [**Name (STitle) 1860**]
- CAD s/p PCI: midRCA [**2132**]
- Chronic Diastolic CHF: ECHO [**5-30**] w/ EF 70%
- Hypertension
- Moderate AS (AoVA 1.0-1.2cm2) Mild (1+) AR as of [**9-30**]
- CAD with EF 55% and mild regional left ventricular systolic
dysfunction with hypokinesis of the distal septum and inferior
walls and apex as of [**9-30**]
- H/o pancreatitis: [**2134**], [**1-25**] statins vs ERCP
- H/o ischemic bowel- s/p SMA and celiac artery stents
- Osteoarthritis
- Bilateral cataract surgery
- s/p Left carotid endarterectomy in [**2137**]
- Chronic microvascular disease, 4mm MCA aneurysm
- Removal and replace RIJ cath for CNS bactermia [**9-27**]
- Gout
- Hypothyroidism
- Spinal stenosis
- GIB thought to be diverticular, but no c-scope done by report
- Orthostatic hypotension? - takes midodrine after HD
Social History:
Patient currently lives in an [**Hospital3 **]. At baseline she
reports she is able to walk with a walker, meals are prepared
for her. She dresses and feeds herself.
Tobacco: Previous 50 years, quit
ETOH: None
Family History:
Mother, brother possible stroke or MI (83 yo); Father MI (51
[**Name2 (NI) **]); Sister skin cancer
Physical Exam:
VS - T 92.9, HR 90, BP 116/67, 100% FI02 70% PEEP 12 AC
Gen: WD elderly female intubated and sedated.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with elevated JVP to earlobe.
CV: RRR, normal S1, S2. Distant heart tones, No m/r/g
appreciated. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, Clear anteriorly, bibasilar crackles
Abd: Soft, NTND. No HSM or tenderness. No abdominial bruits.
Ext: No c/c/e. No femoral bruits. R femoral PA line in place
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ Femoral 1+ DP/PT +dopplerable
Left: Carotid 2+ Femoral 1+ DP/PT + dopplerable, L PT faint
doppler
Pertinent Results:
[**2145-2-14**] 01:10PM BLOOD WBC-14.5*# RBC-3.23* Hgb-11.0* Hct-33.7*
MCV-104* MCH-34.1* MCHC-32.7 RDW-15.0 Plt Ct-302
[**2145-2-14**] 01:10PM BLOOD Neuts-86.3* Lymphs-8.9* Monos-4.1 Eos-0.4
Baso-0.3
[**2145-2-14**] 01:10PM BLOOD Neuts-86.3* Lymphs-8.9* Monos-4.1 Eos-0.4
Baso-0.3
[**2145-2-14**] 01:10PM BLOOD PT-12.6 PTT-23.2 INR(PT)-1.1
[**2145-2-14**] 01:10PM BLOOD Glucose-129* UreaN-25* Creat-5.1* Na-134
K-7.6* Cl-89* HCO3-31 AnGap-22*
[**2145-2-14**] 01:10PM BLOOD CK(CPK)-452*
[**2145-2-14**] 09:00PM BLOOD ALT-47* AST-155* LD(LDH)-677*
CK(CPK)-606* AlkPhos-109 Amylase-43 TotBili-0.3
[**2145-2-14**] 09:00PM BLOOD Lipase-19
[**2145-2-14**] 01:10PM BLOOD CK-MB-44* MB Indx-9.7*
[**2145-2-14**] 01:10PM BLOOD Calcium-9.8 Phos-4.7* Mg-1.9
[**2145-2-17**] 06:30AM BLOOD calTIBC-143* Ferritn-1028* TRF-110*
[**2145-2-15**] 05:40AM BLOOD %HbA1c-5.3
[**2145-2-15**] 05:40AM BLOOD Triglyc-166* HDL-44 CHOL/HD-3.1
LDLcalc-58
[**2145-2-17**] 06:30AM BLOOD TSH-0.21*
[**2145-2-18**] 05:45AM BLOOD TSH-0.70
[**2145-2-18**] 05:45AM BLOOD Free T4-1.2
[**2145-2-15**] 05:40AM BLOOD CK-MB-159* MB Indx-18.9* cTropnT-4.00*
[**2145-2-18**] 05:45AM BLOOD CK-MB-12* MB Indx-6.5*
[**2145-2-14**] 01:10PM BLOOD cTropnT-3.74*
[**2145-2-15**] 05:20PM BLOOD CK-MB-104* MB Indx-16.0* cTropnT-4.07*
[**2145-2-16**] 11:47PM BLOOD CK-MB-31* MB Indx-7.3* cTropnT-3.84*
[**2145-2-24**] 05:05AM BLOOD WBC-10.6 RBC-4.30 Hgb-13.3 Hct-42.1
MCV-98 MCH-31.1 MCHC-31.7 RDW-17.0* Plt Ct-431
[**2145-2-26**] 05:21AM BLOOD WBC-12.0* RBC-3.74* Hgb-12.0 Hct-35.8*
MCV-96 MCH-32.1* MCHC-33.5 RDW-17.0* Plt Ct-349
[**2145-2-26**] 05:21AM BLOOD Glucose-101 UreaN-24* Creat-5.2*# Na-141
K-4.2 Cl-102 HCO3-28 AnGap-15
C diff neg x2
Sputum cx ([**2-15**], [**2-17**]): Yeast
Blood cx: Negative x6
Cath tip cx ([**2-18**]): Negative
Urine cx ([**2-19**]): ENTEROBACTER CLOACAE
CEFEPIME-------------- S
CEFTAZIDIME----------- 4 S
CEFTRIAXONE----------- <=4 S
CIPROFLOXACIN--------- <=0.5 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- S
NITROFURANTOIN-------- 64 I
PIPERACILLIN---------- <=8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=2 S
Cardiac catherization [**2145-2-14**]
COMMENTS: Successful PTCA and stenting of RCA with a 2.5x15mm
and a 3.0x15mm Vision stents. Final angiography revealed no
residual stenosis, no angiographically apparent dissection and
TIMI III flow (See PTCA comments).
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Normal ventricular function.
3. Successful stenting of the RCA.
EKG [**2145-2-14**]- Normal sinus rhythm, rate 102. Right
bundle-branch block. Significant ST segment depression in leads
V2-V6 is less prominent than was true during the tachycardia
noted in tracing #2.
[**2145-2-14**]
CT abdomen/pelvis - IMPRESSION:
1. New bilateral consolidative changes at the bases are
concerning for
multifocal pneumonia or aspiration.
2. Pneumobilia has decreased since the prior exam. Stable
dilated common bile duct and pancreatic atrophy.
[**2145-2-14**]- CT head - IMPRESSION: No acute intracranial pathology
including no hemorrhage or mass effect. Stable chronic
microvascular infarction.
Echo - The left atrium is normal in size. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is mild to moderate regional left ventricular systolic
dysfunction with severe hypokinesis of the distal 2/3rds of the
anterior septum and anterior walls, distal inferior and apical
walls. The remaining segments contract normally (LVEF = 40 %).
No left ventricular thrombus is seen, but apical images are
suboptimal. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets are moderately thickened.
There is moderate aortic valve stenosis (area 1.0cm2). Mild to
moderate ([**12-25**]+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild to moderate ([**12-25**]+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
high normal. There is an anterior space which most likely
represents a fat pad.
Compared with the prior study (images reviewed) of [**2144-10-12**],
regional left ventricular systolic dysfunction is more extensive
with lower global ejection fraction. Though the aortic valve
gradient is lower, the severity of aortic stenosis likely
similar.
[**2145-2-16**] - Repeat cardiac catherization:
COMMENTS:
1. Successful PTCA and stenting of the mid LAD stenosis with a
2.5x23mm
and a 2.25x12mm Mini Vision stents that was postdilated to 2.5
proximally. The diag was rescued and dilated with a 2.0x8mm
Voyager
balloon. Final angiography revealed no residual stenosis in the
stent,
no angiograpically apparent dissection and TIMI III flow (See
PTCA
comments).
2. Successful direct stenting of the proximal LAD stenosis with
a
3.0x8mm Vision stent. Final angiography revealed no resdiual
stenosis,
no angioraphically apparent dissection and TIMI III flow (See
PTCA
comments).
FINAL DIAGNOSIS:
1. Successful PTCA and stenting of the proximal and mid LAD
stenoses.
Brief Hospital Course:
80 yo F with a PMH of ESRD on HD, CVA, diastolic CHF admitted
after witnessed PEA arrest in the ED. Cath showed stenotic RCA.
PCWP was 45mmHg. RCA was stented and hemodynamics improved with
PCI. Transferred to the CCU on pressors initially on HD, then on
CVVH due to hypotension. Patient then underwent repeat cardiac
catherization with 2 stents to the LAD on [**2-16**]. Patient called
out to the floor when stable.
# PEA arrest: Likely [**1-25**] to CAD/Ischemia s/p revascularization.
Continued aspirin, statin, plavix, BB, [**Last Name (un) **]. She was monitored on
tele. Managed complicating factors and ESRD, respiratory failure
(resolved), cardiogenic shock (resolved), and altered mental
status (improving) as below.
# CAD: s/p stent to RCA and LAD on this admission. Continued
statin/asa/plavix.
# ESRD: on CVVH then transferred back to HD: On MWF HD schedule,
BP improved, continue dialysis as scheduled. Holding off on EPO
given recent coronary artery intervention but hct stable.
# Altered Mental Status: MS improving daily. According to son,
patient is at 70% of baseline. Per daughter has baseline mild
dementia. Likely element of anoxic brain injury from hypotension
peri and post PEA arrest. Continued frequent reorientation.
# Fever/UTI: Now afebrile>48hrs. Fever curve trended down s/p
femoral line D/C. Only positive cultures so far from urine
culture growing enterobacter cloacae. Patient completed Zosyn
for urine infection, previously on vanco now off. Encourage out
of bed to chair for likely component of atelectasis. Had
elevated WBC 13 from 10 on [**2145-2-25**] but no other s/s of infection.
# Hypoxic Respiratory Failure: Now resolved. Underwent CVVH and
then HD to improve pulmonary edema. Ultimately weaned off vent
and extubated. S and S recommended pureed and nectar diet
# Cardiogenic Shock: BP initially supported with dopamine, now
stably normotensive on beta blocker and [**Last Name (un) **]. [**Last Name (un) **] was decreased
to 25 daily (home dose 50) given hypotension in unit.
# Chronic diastolic CHF: Restarted lopressor at 25mg PO BID and
[**Last Name (un) **].
# Anemia: No obvious hematomas s/p cath. Hct stable.
# Hypothyroidism: continued home synthroid dose.
# Orthostatic hypotension: on midodrine as outpatient after HD,
will hold for now given blood pressure issues as above but
consider restart.
# Rash: Perineal erythema likely due to loose stools occurring
after HD. Wrote for miconazole powder and immodium with HD.
Medications on Admission:
NEPHROCAPS - 1 Capsule(s) daily
COZAAR - 50MG daily
FOLIC ACID - 1 mg daily
HYDROCODONE-ACETAMINOPHEN [VICODIN] - 5mg-500mg [**Hospital1 **]:PRN
LEVOXYL - 88MCG daily except Sundau
LIDOCAINE-PRILOCAINE [EMLA] - 2.5 %-2.5 % Cream QHD
MIDODRINE - 2.5 mg 45 min before end of dialysis
NIFEDIPINE - 30 mg Tab,Sust Rel daily
PLAVIX - 75MG daily
RANITIDINE HCL - 150 mg daily
RIVASTIGMINE - 4.6 mg/24 hour Patch 24 hr daily
SIMVASTATIN - 40 mg Tablet daily
TOPROL XL - 50MG daily
ASPIRIN - 81 mg daily
CALCIUM CARBONATE - 1000 mg TID with meals
VITAMIN E - Dosage uncertain
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
6. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
13. Loperamide 2 mg Capsule Sig: One (1) Capsule PO twice a day
as needed for diarrhea.
14. EMLA 2.5-2.5 % Cream Sig: One (1) application Topical to use
around fistula before dialysis.
15. Calcium 500 with Vitamin D 500 (1,250)-200 mg-unit Tablet
Sig: Two (2) Tablet PO twice a day: with meals.
16. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
17. Midodrine 2.5 mg Tablet Sig: One (1) Tablet PO after
dialysis.
18. Exelon 4.6 mg/24 hour Patch 24 hr Sig: One (1) patch
Transdermal once a day.
19. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Non ST Elevation Myocardial Infarction with PEA Arrest and
Cardiogenic shock
Acute on Chronic Systolic Congestive Heart Failure: EF 40%
Dementia
End Stage Renal Disease on Hemodialysis
Hypertension
Hypothyroidism
Urinary Tract Infection
Discharge Condition:
stable
Discharge Instructions:
Your heart stopped right after you were admitted here at [**Hospital 61**] requiring a resucitation effort. You had a heart attack
and a cardiac catheterization with multiple stents placed in
your coronary arteries. You also had a urinary tract infection
that was treated with antibiotics. A speech therapist evaluated
your swallowing and felt that you are at increased risk of
aspiration and need to drink thick liquids and soft foods for
now. You had hemodialysis in the CCU and then at the dialysis
clinic. You had some fluid in your lungs that was removed with
continuous hemodialysis.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1
day. the dialysis doctors [**Name5 (PTitle) **] follow your weights as well.
Adhere to 2 gm sodium diet
.
Please call Dr. [**Last Name (STitle) 665**] if you have any fevers, chest pain,
vomiting, trouble urinating, trouble breathing or any other
concerning symptoms.
.
Take Plavix and aspirin every day for at least one month, do not
stop taking Plavix or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr. [**Last Name (STitle) 665**] tells
you to.
Medication Changes:
1. Increase simvastatin to 80 mg daily
2. Decrease Losartan to 25 mg daily
Followup Instructions:
Primary Care:
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 665**] Phone: [**Telephone/Fax (1) 250**] Date/Time: Wednesday [**3-17**] at 10:20am AND [**9-1**] at 10:00 am.
.
Nephrology:
Dr. [**First Name4 (NamePattern1) 429**] [**Last Name (NamePattern1) 118**] Phone: [**Telephone/Fax (1) 60**] Sees pt at dialysis
Completed by:[**2145-2-26**]
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icd9cm
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[
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[
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3748, 3959
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,736
| 176,590
|
5438
|
Discharge summary
|
report
|
Admission Date: [**2117-6-9**] Discharge Date: [**2117-6-11**]
Date of Birth: [**2033-4-3**] Sex: F
Service: MEDICINE
Allergies:
Soma / Ciprofloxacin / Epinephrine / Oxycodone / Quinolones
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Ventricular tachycardia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
84 y.o woman with history of CAD s/p CABG, cardiomyopathy with
EF of 30%, left ventricular aneurysm, vtach and Vfib s/p ICD
placement in [**2104**] who presented initially to the ED with a
complaint of urinary retention but was then found to be in
ventricular tachycardia. The patient initially described
symptoms of 2 weeks of dysuria, suprapubic tenderness and
urinary retention consistent with a UTI. However during her
workup, she developed palpitations and was triggered for a heart
rate in 140s-150s.
.
The patient's EKG demonstrated a narrow complex ventricular
tachycardia with a left axis, at a rate of 132bpm. She
maintained her pressure initially, however at one point
developed mild hypotension with BP of 87/62 for which she was
given a 500cc NS bolus. She was initially treated with
metoprolol 10mg IV, and cardiology was consulted. On
interrogation of the ICD, the patient has had since her prior
admission multiple episodes of ventricular tachycardia that had
been terminated by anti-tachycardia pacing. Her native rhythm
currently is sequential A-V pacing. She was subsequently loaded
with 50mg of lidocaine and started on a drip of 1mg/min, and her
rhythm self terminated. She was noted to be mentating
throughout this episode. The patient does report that she has
had episodes in the past similar to this that generally
terminate within several minutes, however none as severe as this
one today. She also reported some nausea associated with the
episode, but no chest pain.
.
Other events in the ED included a workup for her UTI/suprapubic
tenderness. Her urinalysis was negative, however a CT of the
[**Last Name (un) 103**]/pelvis demonstrated an infra-renal aortic clot of
undetermined age for which vascular surgery was consulted.
Blood cultures were drawn and she was started on levofloxacin
and flagyl empirically. Prior to transfer, she was in her
native rhythm with vitals of HR 76 BP 117/69 RR 18 Saturation
98% on 2L, afebrile.
.
Review of systems was negative for fevers, chills, vomiting,
shortness of breath, chest pain, abdominal pain, dizziness or
lightheadedness.
.
Past Medical History:
CAD s/p CABG in [**2083**], MI in [**2079**], c/b left ventricular aneurysm
and severe infarct-related cardiomyopathy with EF 30%, Vtach and
VF s/p ICD in [**2104**], replacement with [**Company 1543**] Virtuoso
dual-chamber ICD in [**2116**]
- most recent settings per clinic note [**2117-6-4**]:
Her device is programmed to treat rates greater than 150 beats
per minute for 16 intervals in the VT zone. Rates greater than
188 beats per minute for 18/24 intervals are treated in the VF
zone. The brady portion of her device is in the DDD mode, lower
rate 75 beats per minute, maximum tracking 110 beats per minute.
The paced AV interval is 140 milliseconds, sensed AV interval
130
milliseconds. The mode switch function is ON for atrial rates
greater than 171 beats per minute.
.
afib
htn
Dyslipidemia
Recurrent TIAs
Gerd
Gout
DVT/PE s/p IVC filter
Low back pain and herniated disc s/p multiple back surgeries and
Right-sided sciatica
Basal cell CA on R shin and forehead
s/p CCY
Giant Cell Arteritis, s/p 6 yr therapy with prednisone
.
Social History:
Lives with husband in senior citizen complex. Has two children,
several grandchildren and great-grandchildren. Has hx of smoking
3-4ppd; quit in [**2075**]. Drinks 1 cocktail on most nights. No
illicit drug use.
Family History:
Father: bladder cancer
Physical Exam:
Admission physical exam:
Vitals: Temp 97.5 HR 81 BP 143/47 RR 20 Sat 98% on 2L.
General: NAD, aaox3
HEENT: Sclerae anicteric, EOMI. MMM. Mild conjunctival pallor
Neck: JVP not elevated, no hepatojugular reflex. Mild bruit
auscultated in left carotid.
CV: Regular rate and rhythm. 2/6 systolic ejection murmur at
left lower sternal border consistent with likely tricuspid
regurgitation.
Pulm: clear to auscultation bilaterally
Abdomen: Soft, non-tender, non-distended. No HSM.
Extremities: No edema.
Skin: Extensive ecchymoses, frail skin from prior corticosteroid
use.
Neurologic: Strength 5/5 in upper extremities biceps, triceps,
interossous. Strength 4+/5 right hip flexor, [**3-2**] anterior
tibialis. Otherwise [**4-1**] throughout.
.
Discharge physical exam:
Vitals: T 97, HR 75, BP 138/49, RR 17, 97% on RA
General: Patient irritated, frustrated, complaining
Skin: Multiple ecchymosis along right greater than left arm.
Cardiac: RRR, questionable S3 sound, 2/6 systolic murmur
Lungs: CTAB good air movement
Abdomen: Soft, mild tenderness, non-distended
Extremities: no edema, WWP
Pertinent Results:
Admission Labs:
[**2117-6-9**] 11:45AM BLOOD Glucose-154* UreaN-20 Creat-0.8 Na-130*
K-3.9 Cl-91* HCO3-25 AnGap-18
[**2117-6-9**] 11:45AM BLOOD ALT-26 AST-43* AlkPhos-51 TotBili-0.8
[**2117-6-9**] 11:45AM BLOOD Lipase-32
[**2117-6-10**] 04:33AM BLOOD CK-MB-4 cTropnT-0.09*
[**2117-6-9**] 11:45AM BLOOD Albumin-3.8 UricAcd-6.7*
[**2117-6-9**] 11:45AM BLOOD Digoxin-0.9
[**2117-6-9**] 11:56AM BLOOD Lactate-3.3*
.
Other pertinent labs:
[**2117-6-10**] 12:55PM BLOOD WBC-12.6* RBC-3.36* Hgb-11.0* Hct-32.5*
MCV-97 MCH-32.7* MCHC-33.7 RDW-17.1* Plt Ct-129*
[**2117-6-10**] 12:55PM BLOOD CK-MB-3 cTropnT-0.09*
[**2117-6-9**] 11:45AM URINE RBC-<1 WBC-0 Bacteri-NONE Yeast-NONE
Epi-<1 TransE-<1
[**2117-6-9**] 11:45AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2117-6-10**] 10:16PM BLOOD %HbA1c-5.7 eAG-117
.
Discharge labs:
[**2117-6-11**] 04:26AM BLOOD WBC-12.7* RBC-3.21* Hgb-10.4* Hct-30.5*
MCV-95 MCH-32.6* MCHC-34.2 RDW-17.6* Plt Ct-122*
[**2117-6-11**] 04:26AM BLOOD Glucose-186* UreaN-16 Creat-0.9 Na-130*
K-3.6 Cl-94* HCO3-22 AnGap-18
[**2117-6-11**] 04:26AM BLOOD CK(CPK)-36
[**2117-6-11**] 04:26AM BLOOD CK-MB-4 cTropnT-0.08*
[**2117-6-11**] 04:26AM BLOOD Calcium-9.6 Phos-1.8* Mg-2.4
.
MICROBIOLOGY:
- Urine Culture [**2117-6-9**]: Less than 10,000 organisms/mL
- Blood culture [**2117-6-9**] x2: PENDING AT THE TIME OF DISCHARGE
.
ECG [**2117-6-9**]: A-V paced rhythm. One ventricular premature beat.
Compared to the previous tracing of [**2117-5-23**] there is now more
consistent pacing and apparently less ventricular ectopy.
.
ECG [**2117-6-9**]: A-V paced rhythm. Compared to the previous tracing
ventricular ectopy is not now seen.
.
CT ABDOMEN/PELVIS WITH CONTRAST [**2117-6-9**]:
IMPRESSION: 1. 3-cm long segment of infraabdominal aortic
dissection with associated eccentric thrombus of indeterminate
age, but new since [**2106**]. 2. Appendix not identified, but no
secondary inflammatory findings in the right lower quadrant to
suggest appendicitis. No evidence of acute
diverticulitis.
.
CXR PA & LATERAL [**2117-6-9**]:
FINDINGS: PA and lateral chest radiographs were obtained. The
lungs are clear with no evidence of pneumonia or CHF. No pleural
effusion or pneumothorax is present. Median sternotomy wires are
intact. A left-sided generator is seen with leads implanted in
the right atrium and right ventricle. Heart size is top normal
and unchanged. Several calcified granulomas are seen at the
right base and right mid lung. IMPRESSION: No acute
cardiopulmonary process.
Brief Hospital Course:
84-year-old female admitted from rehab facility for complaints
regarding urination and found to have monomorphic ventricular
tachycardia in the emergency department.
ACTIVE ISSUES:
# Monomorphic ventricular tachycardia: This was possibly
precipitated by reduced home metoprolol dose. Initially treated
in the emergency department with metoprolol with limited
success, then treated with lidocaine drip with reversion to
sinus rhythm. Though there was a low suspicion for ischemia
having a role in etiology, cardiac enzymes were checked which
demonstrated mildly elevated troponin to 0.09 but flat CK and
CK-MB. Patient stable in CCU with lidocaine drip and
transitinoed to phenytoin PO after loading. (Phenytoin was
chosen as an antiarrhythmic [**Doctor Last Name 360**] given previous side effects
with amiodarone.) Patient stayed in atrial fibrillation with
atrial ventricular pacing, but had no further episodes of
ventricular tachycardia. Outpatient dose of metoprolol
succinate increased initially to 300 mg, then to 200mg. Patient
will need phenytoin level checked one week after discharge to
rehab, with results faxed to Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 3341**]
(expected level is less than the normal therapeutic range for
seizure prophylaxis). If she tolerates this medication poorly
due to nausea/vomiting, dose may be reduced to 200 mg PO daily.
She will need follow up with Dr. [**Last Name (STitle) **] for device
interrogation in approximately one month (appointment
scheduled).
#Urinary rentention/suprapubic tenderness on exam of unclear
etiology. Patient initially treated in the emergency department
with levofloxacin (she has documented allergy to
fluoroquinolones, but had no reaction) and metronidazole and had
an abdominal scan with an incidental finding of an infra-renal
aortic clot. Initial urine dipstick unremarkable and urine
cultures growing <10,000 organisms/ mL. Patient was also given
metolazone, which caused brisk diuresis and numerous electrolyte
abnormalities. Patient's electrolyte abnormalities were
corrected and her urinary retention resolved with continued
diuresis. This episode was felt most likely due to use of
tramadol for pain control; this medication was held while in
house. As she may require use of tramadol to control shoulder
pain in the future, we recommend lowest effective dose and
maximization of other pharmacologic agents and non-pharmacologic
interventions for pain control.
#Infra-renal aortic clot with associated dissection of
indeterminate age (at least since [**2106**]) incidentally found on
abdominal computed tomography scan. Vascular surgery consulted
and confirmed no acute process threatening legs or urine
production and recommended no further intervention. Metoprolol
succinate XL 200mg PO daily.
#Congestive heart failure secondary to known coronary artery
disease with an EF of 30% and ventricular aneurysm. Continued
digoxin 0.0625 mg po daily. Spironolactone 12.5mg po daily was
restarted, given current potassium low-normal (typically upper
3's prior to repletion); this medication was previously held for
hyperkelamia. Increased furosemide dose to 40mg po daily. Held
metolazone; will monitor for normalization of potassium on the
above medications.
#Shoulder pain. Chronic secondary to rotator cuff injury.
Tramadol held while inpatient as above. Acetaminophen and
lidocaine patch used for pain control.
#Hyponatremia. Likley secondary to a combination of heart
failure and diuretic use. Na ranged from 130-138 during this
admission. Recommend repeat chem-7 if any further changes in
diuretics.
INACTIVE ISSUES:
#Gout: Decreased allopurinol to 100 mg PO daily based on current
creatinine clearance. No active symptoms.
# Atrial fibrillation - CHADS 2 score is 4, however previously
not anticoagulated per clinic notes secondary to fall risk.
Increased dose of metoprolol as above and continued on full-dose
aspirin. Currently in A-V paced rhythm.
TRANSFER OF CARE:
1. Patient will need phenytoin level checked one week after
discharge to rehab, with results faxed to Dr. [**Last Name (STitle) **] at
[**Telephone/Fax (1) 3341**] (expected level is less than the normal therapeutic
range for seizure prophylaxis). If she tolerates this medication
poorly due to nausea/vomiting, dose may be reduced to 200 mg PO
daily. She will need follow up with Dr. [**Last Name (STitle) **] for device
interrogation in approximately one month (appointment
scheduled).
2. Blood cultures (2 sets) from [**2117-6-9**] no growth to date but
pending at the time of discharge.
3. Please trend potassium (with Chem-10) QOD while in rehab x 1
week and supplement to K > 4. If K consistently below 4, would
uptitrate spironolactone to 25 mg PO daily. If still below 4,
would resume potassium supplementation (stopped this admission).
Goal potassium is [**3-2**]. Goal magnesium > 2.
4. Please monitor weights and urine output on new doses of
diuretics.
5. Patient may require tramadol for shoulder pain control;
however, we would recommend using this medication sparingly as
it likely contributes to delirium and urinary retention. She may
benefit from continued warm or cool packs to shoulder, lidocaine
patch, standing acetaminophen, and steroid injections to help
manage her pain with minimal narcotic or narcotic-like agents.
Would closely monitor patient for recurrent urinary retention
with resumed use of this medication; she may require periodic
straight catheterization.
6. Patient will need PCP follow up scheduled at discharge from
rehab.
7. Full code
8. Contacts: Daughter [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 22038**] [**Telephone/Fax (1) 22039**]. Sister [**Name (NI) **]
cell [**Telephone/Fax (1) 22040**]
house [**Telephone/Fax (1) 22041**].
Medications on Admission:
.
On d/c [**5-24**]:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. digoxin 125 mcg Tablet Sig: .5 Tablet PO DAILY (Daily).
4. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
5. folic acid 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: Three (3) Tablet Extended Release 24 hr PO once a day.
7. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual qday prn as needed for chest pain.
.
At rehab:
Allopurinol 200mg daily
Aspirin 325mg daily
Digoxin 0.0625 daily
Folic acid 2mg daily
isosorbide mononitrate 60mg daily
Lasix 20mg daily
Lidoderm patch 5% daily
Metoprolol succinate 150mg daily
Potassium 20meq daily
Simvastatin 40mg daily
Metolazone alternating 5/2.5mg qod
ultram 50mg q6h prn
tylenol 650 q4h prn
.
Discharge Medications:
1. digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. folic acid 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
5. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical ONCE (Once): 12 hours
on, 12 hours off to affected shoulder.
7. phenytoin sodium extended 100 mg Capsule Sig: Three (3)
Capsule PO DAILY (Daily).
8. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily).
9. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
11. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
12. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11851**] Rehabilitation and Nursing Center
Discharge Diagnosis:
Primary: Monomorphic ventricular tachycardia with a pulse,
urinary retention. Secondary diagnosis: Infra-renal aortic
clot, atrial fibrillation: paced.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you in the hospital. You were
admitted to the hospital initially for urinary retention and
treated with a dose of antibiotics. During the initial
treatment, you were found to have an abnormaly fast heart rhythm
with a pulse, and we eventually controlled the rhythm with an
intravenous drug called lidocaine. We then transitioned you to
an oral drug, which works in a similar fashion to control your
heart rate called phenytoin. You began to make urine with some
help with diuretics, or water pills, and the discomfort that you
had resolved. Incidentally, we discovered an old clot in your
aorta, a giant artery in your abdomen, which you do not need to
be worried about.
Please start taking these medications:
Phenytoin 300 mg daily
Spironolactone 12.5 mg daily
Please change current medications to:
Allopurinol 100mg daily
furosemide 40 mg daily
Metoprolol succinate XL 200 mg daily
Please continue taking:
Aspirin 325mg daily
Digoxin 0.0625 daily
Folic acid 2mg daily
isosorbide mononitrate 60mg daily
Simvastatin 40mg daily
Please stop taking:
Potassium 20meq daily
Metolazone alternating 5/2.5mg qod
ultram 50mg q6h prn
Please keep the appoinments we have for you.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
1. CARDIOLOGY
Department: CARDIAC SERVICES
When: FRIDAY [**2117-6-18**] at 1:20 PM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
2. PRIMARY CARE
- Please schedule follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **]e from rehab
Completed by:[**2117-6-11**]
|
[
"414.00",
"719.41",
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"428.0",
"401.9",
"272.4",
"V45.02",
"V10.83",
"V58.65",
"V12.54",
"412",
"E935.2",
"V45.81",
"V15.82",
"428.22",
"427.1",
"530.81",
"442.89",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
15389, 15470
|
7538, 7705
|
342, 348
|
15667, 15667
|
4956, 4956
|
17176, 17666
|
3802, 3826
|
14320, 15366
|
15491, 15570
|
13347, 14297
|
15850, 17153
|
5837, 7515
|
3866, 4588
|
279, 304
|
7721, 11153
|
376, 2490
|
15591, 15646
|
11171, 13321
|
4972, 5368
|
5390, 5821
|
15682, 15826
|
2512, 3555
|
3571, 3786
|
4613, 4937
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,519
| 118,908
|
14072
|
Discharge summary
|
report
|
Admission Date: [**2135-10-25**] Discharge Date: [**2135-11-19**]
Date of Birth: [**2062-1-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
hypotension and dehydration
Major Surgical or Invasive Procedure:
Bronchoscopy c BAL
ET Intubation
History of Present Illness:
Patient is a 73 year old man w/ CAD s/p CABG [**2110**] and [**2125**],
chronic atrial fibrillation on coumadin, and PVD. Recently dc'd
from [**Hospital1 18**] ([**Date range (1) 41968**]) following new dx of R hallux
osteomyelitis, epidural abscess and MRSA bacteremia. BxCx + for
MRSA ([**3-21**]). Started on vancomycin.
.
Course c/b development of epidural abscess, discovered [**1-19**] back
pain and ongoing + bxcx's, extending from sacrum to T5. Req'd
T4-L5 laminectomy [**2135-9-20**]. The cervical portion of the abscess
could not be drained in the OR and plan was made for treatement
with vancomycin. Hospital course was complicated by persistant
fevers and elevated wbc. Patient was started on
flagyl/cefepime/vanc. Flagyl and cefepime were d/c'd as cultures
were all negative. Initial CT showed residual epidural abscess
at C1-C5. Patient continued on vancomycin. Repeat MRI showed
improvement in cervical abscess. Underwent R hallux amputation
[**2135-10-4**].
.
Also developed Tn leak (0.48 x3)-> consistent w/demand ischemia,
medically managed. Patient was diagnosed with parkinson's and
started on sinemet. He had dysphagia and failed a speech and
swallow evaluation and a peg tube was placed. He had persistant
Afib with difficult rate control. Patient was discharged to
[**Hospital1 **].
.
Patient was transfered to [**Hospital1 18**] on [**10-25**] with new onset ARF and
fever. By report, pt had been doing well until monday before
admission when his cr was noted to be 1.2 (by report, not
verified in documentation). On admission noted to be 3.3 (bun
60), random vancomycin lev 63. [**10-24**] u/s at [**Hospital1 **] w/o
hydronephrosis. tte showed lvef 40%mild to mod MR, AV
thickeened,. Grad peak 21, mean 10. RVSP 38, septal HK.
Transferred for further w/u of ARF.
.
While on the medical service he had an episode of acute
hypercarbic and hypoxic respiratory failure thought to be due
aspiration. He was intubated and was in the MICU for two days.
.
On [**11-6**] patient had another acute respiratory event. He
desaturated to 84% and was tachypnic to 30s and diaphoretic. His
sat was 94% on 50% FM. He was intubated for respiratory failure.
After intubation his blood pressure dropped to 50/P. He was
started on levophed and blood pressure improved.
Past Medical History:
1. Hyperlipidemia
2. CAD s/p MI s/p CABG in [**2110**] and [**2125**]. last stress was an
adenosine stress in [**8-22**] showing fixed mid-lateral wall defect
3. CHF with normal EF (last echo [**2135-8-30**])
4. Mild aortic stenosis
5. Mild mitral regurgitation
6. Hypertension
7. Chronic Atrial fibrillation/flutter since [**2128**] on Coumadin
8. Right foot cellulitis [**2133-9-24**]
9. Osteoarthritis
10. Does not have DMII (as all previous notes have said). This
was confirmed with the daughter
Past Surgical History:
1. CABG x2 in [**2110**] and [**2125**]
2. multiple toes right foot amputated from dry gangrene
following aneurysm rupture in right leg (unclear what caused
anyersum)
3. Right leg aneurysm repair
4. Tonsillectomy
5. Appy
Social History:
Social History: lives w/ wife. active @ [**Name2 (NI) 4222**]. Transitioning
to Rehab
Family History:
NC
Physical Exam:
VS: T 98.8 HR 76 BP 87/37 (54)-->107/49 on levophed 0.05 RR 20
O2 sat 100% on 100%
AC 500/560 x 18 PEEP 5 7.28/56/289
Gen: Intubated and sedated.
HEENT: PERRL, EOMI, sclera anicteric, MMM.
Neck: No LAD, or thyromegly.
CV: Irregularly irregular with no MRG
Lungs: Crackles at bases bilaterally.
Abd: soft, NT, ND active BS, no hepatosplenomegly.
ext: No clubbing, cyanosis or edema.
Pertinent Results:
Studies: CXR: Increased interstitial markings bilaterally.
.
ECG: Q in V1-V2. poor R wave progression. No acute changes..
.
ECHO:
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. EF 40%. There is
mild-to-moderate global left ventricular hypokinesis. Right
ventricular systolic function appears depressed. The tricuspid
valve leaflets are mildly thickened. There is no pericardial
effusion.
.
MICRO:
Sputum: [**10-31**] Acinetobacter ([**Doctor Last Name **] to tobra)
Brief Hospital Course:
AP:73yo M with CAD/MI/CABG, CHF, HTN, AFib recent h/o MRSA
bacteremia c/b spinal abscess requiring laminectomy, admitted
for ARF and dehydration, s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 153**] stay/intubation for
respiratory failure. Poor MS.
.
# Respiratory failure- [**1-19**] aspiration, CHF, for Acinetobacter
baumannii pna.
- Patient was extubated [**11-8**] AM .Sats 95% 2 lt of O2. Last ABG
c PCO2 of 45.O2 80.
- BAL results show WBC 0, RBC 0, PMN 27%, Lymphs 27%, Macro 46%,
and shows +Acinetobacter
- Given Imipenem, inhaled Tobramycin (since [**11-7**]) switched
later to Unasyn ([**11-10**]).Patient finished 2 week course .CxR
prior to discharge c no residual infiltrates.
- CT chest shows ground glass opacities indicative of CHF or
pulm edema, nodular opacities indicative of infectious process
#ID :Pt had epidural abscess after low extremity
osteomyelitis.S/P Laminectomy [**10-25**].
He finished a 60 day course of Vancomycin [**11-18**].Complete spine
MRI done [**2135-11-18**] c no evidence of osteo or residual disease.ID
recommends f/u on [**12-2**] c Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. He will need ESR, CBC,
UA.
.
# ARF- Pre-renal and ATN. Cr improved now 1.4 (from
3.5).Probably multifactorial.Captopril restarted [**11-14**] .There
was no worsening hyperkalemia or renal failure.
# # Afib/flutter - Currently in afib/flutter, BP tolerating well
- continue rate control with Metoprolol and digoxin
- restarted coumadin [**2135-11-3**] - goal INR [**1-20**], INR currently
therapeutic at 2.2
Needs to f/u INR.
.
# CHF - Probably ischemic in origin.EF 40% with 3+ MR and mild
LVH. On transfer had crackles bilaterally [**12-19**] way up. Likely
some volume overload and decompensation.
Pt currently on ASA, Metoprolol, Captopril and Digoxin.Has
remained euvolemic without use of LAsix.
#Neuro: Pt MS has been waxing and [**Doctor Last Name 688**]. Per family MS was
completely normal prior to laminectomy.
CT showed microvacular infarcts c/w microvascular dementia.
Neurology followed. Attributed MS changes to metabolic
derrangements and prolonged hopsital course in pt c damaged
brain.B12 levels, RPR, ammonia, TSH were nl.
No further MRI needed at this point.
-Continue coumadin and ASA.
.
# fen - Passes speech/swallow but aspirated. Continue TFs Nepro
with goal 55cc/hr, was changed to Procare-goal of 80cc/hr on
[**11-11**]. CaCO3 for phos binding. Continue aspiration precautions.
-video swallow when mental status improves
.
# code - full but no prolonged intubation
.
# Access - Left SC line was d/c'd [**11-11**] Tip sent for cultures.
PICC d/ced prior to d/c.
# Commmunication. Daughter [**First Name4 (NamePattern1) **] [**Known lastname 41969**] and wife [**Name (NI) 6303**] can be
reached at ([**Telephone/Fax (1) 41970**]-daughter's cell phone)
.
# Dispo - Pt going to [**Hospital 100**] Rehab facility.
Medications on Admission:
Medications at [**Hospital1 **]:
iv heparin
coumadin, held [**10-25**]
ASA 325
lipitor 40 qday
prevacid 30mg qday
lopresser 100mg [**Hospital1 **]
sinemet 25/100 [**Hospital1 **]
.
Medications on Transfer:
ASA 325
lipitor 40 qday
prevacid 30mg qday
lopresser 100mg [**Hospital1 **]
sinemet 25/100 [**Hospital1 **]
Levofloxacin 250 daily
Flagyl 500 tid
Protonix 40 daily
Heparin SC
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
Disp:*120 Tablet(s)* Refills:*2*
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-19**]
Inhalation three times a day.
Disp:*2 2* Refills:*2*
5. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO QHS (once a day
(at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
6. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
Disp:*100 ML(s)* Refills:*3*
7. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*3*
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
10. Therapeutic Multivitamin Liquid Sig: One (1) Cap PO
DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
11. Captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
12. Digoxin 0.2 mg Capsule Sig: half Capsule PO every other day.
Disp:*30 Capsule(s)* Refills:*2*
13. 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*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
Nosocomial Pneumonia
Acute Renal Failure
Parkinson's Disease
Respiratory Distress
Discharge Condition:
Pt is afebrile, mental status waxing and [**Doctor Last Name 688**] , oriented at
times.
Heart Rate controlled around 80 bpm. Pulse Ox 96% on 2 lt
Afebrile , c no evidence of infection
Discharge Instructions:
Pt to come back to ED in the presence of fever , progressively
worsened mental status or dehydration.
Followup Instructions:
-Follow up with(Infectious Disease) DR. [**First Name (STitle) **] [**First Name (STitle) **]
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2135-12-2**] 9:00
Get f/u labs CBC,Chem 7 ESR, UA before appointment.
-Follow back with PCP [**Last Name (NamePattern4) **].[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3649**]
-Follow up INR and anticoagulation parameters
-Follow up Digoxin levels periodically
Completed by:[**2135-11-19**]
|
[
"427.31",
"332.0",
"730.18",
"518.81",
"349.82",
"428.0",
"324.1",
"507.0",
"482.83",
"458.9",
"584.5",
"285.1",
"276.4",
"276.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"33.24",
"00.17",
"38.91",
"99.04",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
9441, 9514
|
4536, 7447
|
344, 379
|
9640, 9827
|
3995, 4513
|
9977, 10430
|
3573, 3577
|
7878, 9418
|
9535, 9619
|
7473, 7654
|
9851, 9954
|
3230, 3453
|
3592, 3976
|
277, 306
|
407, 2684
|
7679, 7855
|
2706, 3207
|
3485, 3557
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,793
| 150,655
|
5887
|
Discharge summary
|
report
|
Admission Date: [**2117-12-9**] Discharge Date: [**2117-12-15**]
Date of Birth: [**2070-2-19**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 5188**]
Chief Complaint:
admitted for adrenal adenoma removal; transferred to MICU due to
ischemia
Major Surgical or Invasive Procedure:
Laparoscopic right adrenalectomy
Diagnostic laparoscopy.
Evacuation of clot.
History of Present Illness:
The patient is a 47-year-old woman originally from El [**Country 19118**]
living in this country since approximately 15 years. She is
mainly [**Country 8003**]-speaking and history today was taken with the
help
of a [**Country 8003**]-speaking interpreter.
The patient has a previous medical and surgical history
significant for thyroidectomy for papillary cancer in [**2105**]. She
was also treated with postoperative radioiodine ablative
treatment.
The patient has been followed for a right adrenal nodule since
the year [**2109**]. She has been worked up and there is no evidence
of a hormonal activity of the tumor (normal catecholamines,
cortisol, and renin levels, etc.). Of some concern is that the
adrenal gland mass has increased progressively in size over the
last couple of years. It presently measures approximately 3.8
cm
in greatest diameter compared with a 3.4 cm in [**2116-12-24**] and
3.2 cm in [**2110-10-24**]. The patient was therefore now referred
for possible right adrenalectomy.
It should also be added that the right adrenal tumor was first
discovered when the patient was undergoing imaging tests for
back
pain. Her back pain persists and is described mainly as located
on the right side in the lumbar area radiating around the flank
towards the right groin area.
Past Medical History:
PMH
Papillary thyroid cancer
poor glucose tolerance
PSH
status-post
thyroidectomy and ablation in [**2105**].
Hypertension
tubal ligation
Social History:
Originally from El [**Country 19118**]. [**Country 8003**] Speaking, some English. She
lives with her husband in [**Name (NI) 8**]. She has two children and
four
grandchildren who all live in El [**Country 19118**]. She does not exercise
at this time. She denies any tobacco, alcohol or drug use.
Family History:
Significant for diabetes, hypertension, and a
question of elevated uric acid levels. The patient is unclear
of
significant thyroid disease in family.
Physical Exam:
At Discharge:
Vitals: 99.6, 82, 130/90, 18, 98%RA
GEN: NAD, A/Ox3
CV: RRR, no m/r/g
RESP: CTAB, no w/r/r
ABD: soft, ND, appropriately TTP, +BS, +flatus
Incision: small right upper abdomen OTA with steri strips, CDI
Extrem: no c/c/e
Pertinent Results:
[**2117-12-12**] Blood Cx pending
[**2117-12-12**] UCx negative
[**2117-12-12**] CXR ETT position - 1.3 cm above carina
[**2117-12-12**] UA negative
[**2117-12-11**] CXR moderate fluid overload and bibasilar atelectasis
[**2117-12-9**] R adrenal pathology report-logged only
.
[**2117-12-15**] 06:22AM BLOOD WBC-9.7 RBC-4.96 Hgb-14.6 Hct-43.2 MCV-87
MCH-29.5 MCHC-33.9 RDW-14.2 Plt Ct-301
[**2117-12-15**] 06:22AM BLOOD Glucose-126* UreaN-7 Creat-0.5 Na-138
K-4.1 Cl-100 HCO3-27 AnGap-15
[**2117-12-13**] 01:47AM BLOOD ALT-104* AST-86* LD(LDH)-299* AlkPhos-56
TotBili-1.3
[**2117-12-15**] 06:22AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.0
Brief Hospital Course:
47 yo female with history of papillary thyroid carcinoma,
hypertension, impaired glucose intolerance, transferred to ICU
POD 1 from right adrenalectomy for non-hormone secreting tumor
after Hct drop of 12 points. Pt was resuscitated with several
units PRBCs and stat CT abd showed hemoperitoneum and likely
liver laceration, but no active extravasation of blood. Pt's
hct again dropped and she was taken back to OR; clots were
evacuated and area of active bleeding was stopped
intraoperatively. The patient remained stable post-op from
re-exploration. She was transferred out of the ICU on post-op
day 2 from re-exploration, and was tolerating PO clears and
medications.
.
Hcts remained stable. Reported flatus and had a bowel movement.
Tolerated a regular diet, and oral pain medication. Blood
pressue slightly elevated a few days post-op, SBP's to 150's.
Home dose of HCTZ given. Advised to follow-up with PCP.
[**Name10 (NameIs) **] incision intact with steris. Voided without difficulty
after removal of Foley. Ambulated with minimal assist. Discharge
instruction reviewed with patient and husband with [**Name (NI) 8003**]
interpreter prior to discharge. Advised to follow-up with
Dr.[**Last Name (un) 14682**] in [**12-25**] weeks.
Medications on Admission:
Levoxyl 137 mcg qd,
hydrochlorothiazide 12.5 mg qd
two Multi-Vitamins qd,
1000 mg calcium qd
magnesium qd
zinc supplement qd
800 units Vitamin D qd
Discharge Medications:
1. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
3. Multivitamin Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation for 2 weeks.
Disp:*30 Capsule(s)* Refills:*0*
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**3-29**]
hours as needed for pain for 2 weeks: Do not exceed 4gm in
24hrs.
8. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas for 1 weeks.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation for 2 weeks.
Disp:*30 Tablet(s)* Refills:*0*
10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO QHS (once a day (at bedtime)) as needed for constipation
for 1 weeks.
Disp:*qs ML(s)* Refills:*0*
11. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: [**12-25**]
Nasal once a day.
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
14. Calcium-Magnesium 333-167 mg Tablet Sig: One (1) Tablet PO
twice a day.
15. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
16. Centrum Silver Tablet Sig: One (1) Tablet PO once a day.
17. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO once a day
as needed for vertigo.
Discharge Disposition:
Home
Discharge Diagnosis:
Right adrenal mass
Acute blood loss Anemia
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
-Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
Bowel regimen:
-Continue taking Colace, Senna, and Milk of Magnesium as
prescribed to help keep your bowel movements regular. You have
been provided with prescriptions for these medications, but they
are available without prescription at your local pharmacy.
Followup Instructions:
1. Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. SURGICAL SPECIALTIES CC-3
(NHB) Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2117-12-28**] 8:30
2. Provider: [**First Name11 (Name Pattern1) 312**] [**Last Name (NamePattern4) 3015**], M.D. Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2118-1-27**] 9:30
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**]
Completed by:[**2117-12-15**]
|
[
"E878.6",
"998.12",
"790.29",
"285.1",
"244.0",
"275.41",
"V10.87",
"227.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"07.22",
"54.21"
] |
icd9pcs
|
[
[
[]
]
] |
6518, 6524
|
3370, 4614
|
390, 471
|
6612, 6612
|
2715, 3347
|
8415, 8900
|
2296, 2448
|
4813, 6495
|
6546, 6591
|
4640, 4790
|
6756, 7793
|
7808, 8392
|
2463, 2463
|
2477, 2696
|
277, 352
|
499, 1802
|
6626, 6732
|
1824, 1965
|
1981, 2280
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,137
| 145,653
|
52348
|
Discharge summary
|
report
|
Admission Date: [**2114-7-2**] Discharge Date: [**2114-7-12**]
Date of Birth: [**2067-6-25**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Naproxen
Attending:[**First Name3 (LF) 562**]
Chief Complaint:
? seizure, delta MS
Major Surgical or Invasive Procedure:
Lumbar puncture [**7-11**] and [**7-3**]
History of Present Illness:
47 year old female with Hep C cirrhosis, HIV ([**5-27**] CD4 >1000,
VL>916,000), Type II DM, and recently diagnosed chronic renal
failure presents following possible seizure. Her boyfriend
reports that earlier today, he noted that, when she was giving
herself insulin her right hand began shaking for a few minutes.
She was also complaining of a mild frontal headache, relieved
with ibuprofen. Boyfriend left the pt at 6am this morning. Both
pt's mother and boyfriend attempted to call the pt at 10am then
at 11am, but pt did not respond to the phone. After returning
from work at 3:45 p.m., her boyfriend found her unconscious and
covered in stool/urine; she later opened her eyes, but did not
seem to recognize him. No known fevers, chills, URI symptoms,
abdominal or urinary symptoms. She was brought to the ED, where
T 99.8, HR 112, bp 178/101, resp 20 96% 2L NC. She was noted to
have eye deviation to the left with nystagmus, followed by
deviation to the right with nystagmus. She received Ativan 4 mg
IV X 1 with resolution of eye deviation. Given shallow breathing
and diminished gag, she was intubated for airway protection.
.
The patient was recently admitted [**Date range (1) 44757**] after she presented
with decreased UOP, increased LE edema, and increased abdominal
girth and was found to be in subacute renal failure (BUN
64/5.1). Exam/laboratory studies were c/w nephrotic syndrome,
and a renal U/S showed lg echogenic kidneys with nl perfusion.
Initially, her symptoms were fel to be c/w HIV-associated
nephropathy. Renal bx [**6-27**] was c/w diabetic nephropathy +/- IgA
nephropathy. She was aggressively diuresed with good response;
her Cr declined to 4.2 at time of discharge.
Past Medical History:
1) HIV diagnosed [**2099**]: off HAART since [**6-25**]; [**5-27**] CD4 1065
2) Hepatitis C: genotype 1; [**8-23**] liver bx c/w stage IV fibrosis;
s/p IFN and ribaviran [**Date range (1) 108215**], stopped secondary to
neutropenia
- [**3-27**] EGD grade I varices at GE jxn, portal HTN gastropathy
3) Type II DM: HgbA1C [**3-26**] 5.4
4) Asthma
5) Glaucoma
6) h/o pancreatitis
7) h/o EtOH abuse
Social History:
No current smoking, alcohol, no drug use.The patient has a prior
history of heavy alcohol use and has not
drank in over a year. 25-pack-year smoking history. [**3-27**]
cigarettes daily now. The patient admits to a prior history of
cocaine use/IVDU
but quit 10 years ago. The patient works at a fast food
restaurant. She lives with her boyfriend and son in [**Name (NI) 669**].
Family History:
Mother with type 2 diabetes.
Physical Exam:
Tc 99.8, HR 92, bp 175/87, resp 18, 100%
AC TV 500, RR 16, FiO2 0.6 PEEP 5; ABG 7.41/32/223
Gen: middle-aged African Amirican female, intubated, sedated,
not responsive to verbal or tactile stimulus.
HEENT: PERRL, anicteric, nl conjunctiva, OMMM, OGT in place, ETT
in place, neck supple, no LAD, no JVD
Cardiac: RRR, no M/R/G appreciated
Pulm: Scatterred ronchi throughout, minimal crackles at bases
bilaterally
Abd: NABS, soft, NT, mildly distended
Ext: 2+ LE edema to knees bilaterally, extremities warm with 1+
DP bilaterally
Skin: scatterred petechiae over lower extremities bilaterally
Neuro: Moves all 4 extremities in response to noxious stimuli,
brisk DTR throughout, toes downgoing bilaterally, normal tone.
Pertinent Results:
[**2114-7-2**] URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2114-7-2**] TYPE-ART 7.41/32/223
[**2114-7-2**] LACTATE-2.1
[**2114-7-2**] AMMONIA-84
[**2114-7-2**] GLUCOSE-108* UREA N-55* CREAT-4.4* SODIUM-136
POTASSIUM-5.7* CHLORIDE-109* TOTAL CO2-20* ANION GAP-13,
ALT(SGPT)-30 AST(SGOT)-111* ALK PHOS-123* AMYLASE-415* TOT
BILI-0.8, LIPASE-78*, ALBUMIN-2.0* CALCIUM-7.8* PHOSPHATE-6.0*
MAGNESIUM-1.3*
[**2114-7-2**] WBC-6.0 RBC-3.55* HGB-11.0* HCT-33.6* MCV-95 MCH-31.1
MCHC-32.8 RDW-17.4*, NEUTS-69 BANDS-1 LYMPHS-23 MONOS-6 EOS-0
BASOS-1 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1*
[**2114-7-2**] EKG
Sinus tachycardia, rate 109. Probable left atrial abnormality.
Compared to the previous tracing of [**2114-6-20**] sinus tachycardia
and left atrial abnormality are new.
[**2114-7-2**] CT HEAD W/O CONTRAST
No intracranial hemorrhage or mass effect.
[**2114-7-2**] SPINAL FLUID
NEGATIVE FOR MALIGNANT CELLS. Lymphocytes and monocytes.
[**2114-7-3**] MRI/MRA HEAD
1. Multiple lesions with high T2 signal in the periventricular
and subcortical white matter of the cerebral hemispheres
bilaterally, which appear nonspecific but may represent
infection, chronic microvascular ischemia, or demyelinating
disease.
2. Flow in all major tributaries of the circle of [**Location (un) 431**] on
otherwise limited MRA.
CXR [**2114-7-9**]
Improved consolidation with residual consolidation in the
posterior basilar segment of the right lower lobe.
[**2114-7-9**] CT HEAD
There is no acute intracranial hemorrhage, mass effect, or shift
of normally midline structures. The ventricles are stable in
size. There are new small bilateral low density fluid
collections over the frontal convexities.
[**2114-7-9**] ABD ULTRASOUND
1. No findings suggestive of acute cholecystitis on ultrasound.
2. Questionable subcentimeter area of focal thickening in
relation to the anterior gallbladder wall, which could be
followed up at interval with focused ultrasound.
3. No intra-abdominal ascites for paracentesis.
CSF [**2114-7-11**]
NEGATIVE FOR MALIGNANT CELLS. Lymphocytes, monocytes, and red
blood cells.
EEG [**2114-7-10**]
This is an abnormal routine EEG obtained in stage II sleep
progressing to stage III sleep with brief periods of wakefulness
due to
the presence of sharp and spikes bifrontally, left more than
right. In
addition, the patient is excessively drowsy and sleepy. This
finding
could either be due to a previous sleep deprivation or could be
a
medication overdose effect. This can be seen in context of high
blood
levels of antihistamines, Albuterol. No seizure activity
recorded.
Brief Hospital Course:
47 y/o AAF with PMH significant for HIV, Hepatitis C, cirrhosis,
Type II DM, HTN, and most recent hospitalization for subacute
renal failure (DM nephropathy +/- IgA Nephropathy), presents
with altered mental status.
1. Mental status changes
While her initial mental status changes were thought to be due
to hypoglycemia (glucose on admission was 36), the differential
regarding this remains broad. Acyclovir and levofloxacin, as
well as sedatives she was given in the ICU may have contributed
to her MS given her poor renal and hepatic clearance (propofol,
d/c on [**7-4**]; morphine, dosed 2mg on [**7-6**], and ?amt on [**7-4**]).
She was also found to have aspiration pneumonia, which also may
have aggrevated her mental status. Initially, following
transfer from the ICU, her mental status improved and was
thought to be secondary to medications over her stay . Hepatic
encephalopathy is still a possibility, with her elevated ammonia
(84 umol/L), but was not encephalopathic during previous
hospital stay and did not receive lactulose at that time; she
received lactulose throughout this admission. Similarly, uremic
encephalopathy was also considered although her BUN today was
70, and at prior admission, she was not encephalopathic though
in ARF with elevated BUN/Cr. Delirium tremens was also
considered, however her history and speaking with her family
speaks against this. Her family states that she did not drink
from the time she was discharged to her admission. The time
frame was off given her stay in the MICU for delerium tremens,
and her symptoms were not consistent with this. In addition, a
ppd was planted and read as negative on [**7-9**]. Finally, an
HTLV1/2 was found to be negative, suggesting her high CD4 count
of >1000 did represent true immunocompentency, as HTLV1/2
infection can give a false impression of a high CD4 count. Two
LPs failed to reveal a cause for her change in MS, such as
active meningitis, thus nondiagnostic. At discharge, crypto was
negative but JCV, CMV, and toxo were pending. At discharge, the
patient was afebrile, her renal biopsy site was resolving well,
her WBC on [**7-11**] was 11.2, and she was alert, oriented to person,
place and time, and appropriate.
.
2. Hypovolemic hypernatremia
Over the course of her admission, the patient had a gradually
rising sodium, which peaked at 151 on [**7-10**]. This was likely
iatrogenic and resolved when she was removed from restraints and
put on clears. Her sodium normalized at discharge to 137.
.
3. ?holosystolic/?outflow tract heart murmur
When the patient was hypovolemic, she was found to have a
systolic murmur, heard best in the L upper sternal border.
Prior echo ([**7-2**]) and repeat echo ([**7-9**]) revealed no valvular
abnormalities, no vegetations. The murmur was judged to be an
outflow tract murmur, given the patient's low volume status.
The murmur was no longer present on exam at discharge on [**7-12**].
.
4. Pneumonia:
On admission, the patient was intubated in ED for airway
protection. She was extubated after her MRI but then became
hypercarbic likely secondary to volume overload. The patient
was diuresed and placed on BiPAP for one day. Upon transfer
from the ICU, she continued to be stable on room air but was
running a low grade fever and did have a chest Xray consistent
with RLL aspiration pneumonia with possible LUL pneumonia. She
was placed on levofloxacin/flagyl. A repeat CXR on [**7-9**] showed
improvement in the RLL consolidation. Given her mental status
changes, she was switched from levofloxacin to clindamycin for
the final two days of her course. At discharge, she was
afebrile and her lung exam was clear to ascultation.
.
5. Possible seizure:
The patient's initial presentation on admission was consistent
with a seizure (lateral eye deviation, stool/urine
incontinence). The differential diagnosis considered in a
patient with HIV, HepC, Cirrhosis and DM2 was broad and included
hypoglycemia, hepatic encephalopathy, renal encephalopathy,
HIV-associated encephalopathy (20% of HIV encephalopathy is
first presentation of symptomatic disease), toxins, withdrawal
(given her polysubstance abuse), malignancy (lymphoma or primary
or secondary tumor) vasculitidites (mixed cryos, microscopic
polyarteritis, primary CNS vasculitis), hemmorhagic stroke, or
OI with HIV (including toxo, crypto, TB, listeria, PML).
Her MRI/MRA showed an increase in T2 signal in periventricular
and subcortical white matter of both cerebral hemispheres.
These findings were nonspecific but consistent with infection,
chronic microvascular disease, or demyelinating disease.
Hypoglycemia, given the boyfriend's history, was considered most
likely. Alcohol withdrawal may have also precipitated the
initial event or the hypoglycemia, but was considered less
likely given her recent [**Hospital 47424**] hospital stay. Hepatic or
uremic encephalopathy are still possibilities (given MRI
findings) but may be contributing to her ongoing mental status
changes more than precipitating her acute event. The MRI showed
no mass effect or bleed, ruling out tumor or hemmorhagic stroke.
Her CD4 count remains high at +1000 (despite her high viral
load of 916,000) making HIV encephalopathy still a possibility
but any OI unlikely. An EEG during admission was consistent
with no epileptiform activity. She was found to be HSV negative
on [**7-9**], ppd negative on [**7-9**], HTLV1/2 negative on [**7-12**], and
crypto negative on [**7-12**]. Two LPs, on [**7-3**] and [**7-11**], were
negative for polys and microorganisms on gram stain. TTE on
[**7-6**] and [**7-9**] showed no vegetiations, with the remainder of the
study normal. JCV, CMV and Toxo from [**7-11**] LP were pending at
the time of discharge.
.
6. hip/flank pain
Most likely secondary to hematoma following renal biopsy,
visualized on abdominal CT ([**7-6**]) as 2.7 by 4.8 cm lesion. Per
ID's recommendation, a unilateral hip x-ray was conducted on
[**7-10**] and showed no evidence of osteomyeolitis.
.
7. Leukocytosis
The patient was started on Levofloxacin/Flagyl on [**7-5**] for RLL
infiltrate seen on CXR and increasing WBC (see above). The
Levofloxacin was switched to clindamycin [**7-10**] for the 2
remaining days of the course.
.
8. Renal failure
Recent progression of Cr from 1 [**12-27**] to 5 [**5-27**] with evidence of
nephrotic syndrome. Creatinine on discharge was 3.2. Pathology
from renal biopsy consistent with diabetic nephropathy and
possibly IgA nephropathy.
.
9. Hypertension
The patient's hypertension was well-controlled over admission.
She maintained on metroprolol 37.5 mg PO TID, lisinopril 5mg PO
daily, and restarted on her furosemide 40mg [**Hospital1 **] on discharge.
.
10. Non-AG metabolic acidosis
Etiologies include diarrhea, type I or Type IV RTA (given
positive UAG), renal failure. The patient's acidosis was stable
over the course of this and last admission.
.
11. Diarrhea
C. diff negative, judged likely related to HIV
.
12. Anemia
During her last admission, the patient's anemia and iron studies
were consistent with anemia of chronic disease. Her hematocrit
was stable over this admission and discharged at 26.5%.
.
13. Thrombocytopenia
Over course of prior admission found to be TTP/HUS negative.
Most likely secondary to liver disease. Currently stable and
discharged with platelet count of 68.
.
14. Hep C cirrhosis
Her ammonia level was found to be 84 on [**7-2**] but fell to 40 on
[**7-11**]. She received lactulose over the course of her admission.
Hepatic encephalopathy may have been contributing to patient's
change in mental status, however she was not receiving lactulose
during her entire previous admission, and was NOT
encephalopathic therefore unlikely casue of her delta ms.
.
15. Code: Full Code
Medications on Admission:
1) Quinine 650 mg PO qhs prn
2) Reglan 10 mg PO BID
3) Albuterol 2 puffs q6h prn
4) Flovent 2 puffs [**Hospital1 **]
5) Pantoprazole 40 mg PO daily
6) Lisinopril 5 mg PO daily
7) Oxycodone 10 mg PO BID prn
8) Furosemide 40 mg PO BID
9) Insulin
Discharge Medications:
1. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*qs 1 MDI* Refills:*2*
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every 4-6 hours as needed for wheezing.
Disp:*qs 1 MDI* Refills:*2*
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*2*
5. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1. Change in mental status
2. Seizure, likely secondary to hypoglycemia
3. Aspiration pneumonia
4. Chronic renal insufficiency with Diabetic Nephropathy and
IgA Nephropathy
5. HIV
6. Hepatitis C
7. cirrhosis
8. Type II Diabetes Mellitus
9. Asthma
10. anemia of chronic disease
11. hypertension
12. thrombocytopenia
Discharge Condition:
Good
Discharge Instructions:
Please go to the ED if you feel confused, disoriented, have
palpitations, chest pain, nausea or vomiting.
Please follow up with PCP as soon as possible (see below for
instructions.)
Followup Instructions:
1. Please follow up with PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 333**] [**Last Name (NamePattern1) 5543**] at
[**Telephone/Fax (1) 2393**]. Please call this number as soon as possible to
schedule an appointment.
2. Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Where: LM [**Hospital Unit Name 7129**]
CENTER Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2114-8-2**] 9:30
Completed by:[**2114-8-5**]
|
[
"285.9",
"250.60",
"E932.3",
"250.80",
"998.12",
"287.5",
"799.4",
"780.39",
"070.70",
"276.0",
"V08",
"401.9",
"583.81",
"572.2",
"276.5",
"493.90",
"518.81",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.71",
"03.31",
"96.6",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
15164, 15222
|
6337, 14119
|
301, 344
|
15590, 15596
|
3691, 6314
|
15827, 16288
|
2907, 2938
|
14413, 15141
|
15243, 15569
|
14145, 14390
|
15620, 15804
|
2953, 3672
|
242, 263
|
372, 2073
|
2095, 2493
|
2509, 2891
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,597
| 118,667
|
7909
|
Discharge summary
|
report
|
Admission Date: [**2139-10-21**] Discharge Date: [**2139-10-29**]
Date of Birth: [**2069-9-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6180**]
Chief Complaint:
shortness of breath and fever
Major Surgical or Invasive Procedure:
ERCP with biliary stent placement
Subclavian central line
PICC
History of Present Illness:
70 yo M with inoperable pancreatic cancer s/p ERCP with stent
placement, laparotomy with attempted Whipple, h/o cholangitis,
on gemcitabine (received 1st dose of his 2nd round yesterday)
who presents with fever to 105 and shortness of breath. Pt was
in his USOH until last evening when he developed SOB. He denies
CP, palpitations, belly pain, N/V/D, hematochezia, dysuria.
Denies sick contacts or recent travel.
.
In the ED his O2 sat was found to be 78% on RA, CTA negative for
PE, CXR revealed Bilateral basilar opacities and right pleural
effusion. He was noted to be in Aflutter with Lateral ST
depressions and inverted T waves on ECG. Trop was found to be
0.11 with a CK of 59. He was given an ASA and started on a
Heparin gtt. He received Lopresser 5 mg IV x3 and lopressor 25
mg po x1 for rate control. He also received Vanco, Levo, flagyl
and 2 liters of Normal Saline.
.
Past Medical History:
- inoperable pancreatic cancer diagnosed [**6-16**] s/p ERCP with
stent placement, laporatomy with attempted Whipple, on
gemcitabine (received 3 weekly treatments starting [**2139-9-22**],
followed by a week off, then a fourth dose yesterday [**2143-10-20**])
- h/o SBO
- h/o cholangitis ([**6-16**]) with Enterococcus, Pseudomonas, and
Strep Viridans
- h/o bacteremia with Enterococcus fecalis (Vanc sensitive) and
Pseudomonas (sensitive to Zosyn)
- s/p choecystectomy tube (fell out [**7-17**])
- Hypertension
- ankylosing spondylitis
- right kidney cystic lesion
- Moderate Aortic stenosis
- intermittent SVT
- anemia
- tinea corporis
.
Home Meds:
- Lopressor 25 mg tid
- Colace [**Hospital1 **]
- multivitamin
- compazine prn
.
All: NKDA
.
SH: He previously lived in [**State 531**] City. He was an accountant
from [**2096**] to [**2123**]. He then worked as a volunteer at the [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] Center. Currently, he is living at [**Location (un) 5481**] [**Hospital 4382**] facility. He has not been married and has no children.
He denies past or present tobacco, alcohol, or other drug use.
.
FH: His sister had pancreatic cancer and is status post a
Whipple procedure.
.
Physical Exam:
Tm >104.8 Tc 97.4 BP 166/85 HR 100-120 RR 20-35 Sat 100%
15L NRB
Gen: mild respiratory distress, speaking in full sentences,
appears comfortable
HENNT: MMM, scleral icteris
Neck: no LAD, JVD flat
CV: irregularly irregular, tachy, No M/R/G
Lungs: decreased at bases, crackles [**12-15**] way up lung fields, no
wheezes
Abd: soft, minimal RUQ tenderness to deep palpation, +BS, well
healed scar
Ext: 1+ pitting edema, strong DP/PT pulses bilaterally
Neuro: A&Ox3, moving all extremeties
.
Labs:
.
.
.
.
.
.
.
.
.
Studies:
CT chest [**2139-10-21**]:
1. No evidence of pulmonary embolism.
2. New bilateral pleural effusions.
3. New low-density low attenuating fluid seen surrounding the
ascending aorta with no evidence of aortic contour abnormality,
dissection, or aneurysm.
4. Interval resolution of intrahepatic biliary ductal
dilatation.
5. Presence of intraductal air is most consistent with
patient's interval stent replacement.
6. Stable biapical pleural-based nodules.
7. Stable calcified pulmonary nodules.
8. Large right renal cyst, with rim calcifications.
.
CXR [**2139-10-21**]:
1. Bilateral basilar opacities, worrisome for aspiration.
2. Right pleural effusion.
3. Mild congestive heart failure.
.
ECHO [**2139-7-27**]:
1. Left ventricular systolic function is normal (LVEF>55%).
2. Moderate aortic valve stenosis.
3. Mild (1+) aortic regurgitation is seen.
4. Mild to moderate ([**12-14**]+) mitral regurgitation is seen.
5. Borderline pulmonary artery systolic hypertension.
6. No pericardial effusion.
.
A/P: 70 yo M with inoperable pancreatic cancer s/p ERCP with
stent placement, laparotomy with attempted Whipple, h/o
cholangitis, on gemcitabine (received first dose of 2nd round
yesterday) who presents with fever to 105 and shortness of
breath.
.
# Fever/leukocytosis. Likely secondary to PNA seen on CXR
however need to consider biliary source given pancreatic cancer
with previous biliary obstruction requiring stent placement.
TBili increased to 6.5 from 1.0, AP increased from 590 to 790
from yesterday. Need to monitor closely for sepsis given
tachycardia, tachypnea, and fever.
.
- s/p 3 liters NS with good BP, will hold off on additional
fluid hydration given mild CHF and pleural effusions seen on CXR
- will obtain CT abd with oral contrast to evaluate for evidence
of infection; may need ERCP to evaluate biliary stent placement
- will start Vanco and Zosyn (previous culture data from
cholangitis revealed Enterococcus and Pseudomonas sensitive to
vanco and zosyn)
- control fever with tylenol
- monitor blood and urine culture
.
# Hypoxia. ABG with PO2 of 168 on NRB. CT negative for PE.
Etiology likely PNA and pleural effusions. Need to control HR
to prevent worsening pulmonary congestion.
- dilt gtt for rate control
- wean O2 as tolerated
.
# Aflutter with rapid rate. ? h/o intermittent SVT. [**Month (only) 116**] be
secondary to current pulmonary process.
- control rate with dilt gtt
.
# Elevated Trop of 0.[**Street Address(2) 28437**] depressions and TWI's
likely secondary to demand ischemia in setting of rapid aflutter
and hypoxia. CK's flat.
- continue to cycle cardiac enzymes
- monitor on tele
- will d/c heparin gtt as likely demand ischemia
- continue ASA
.
# Pancreatic cancer. Pt is not a surgical candidate. Last
dose of gemcitabine [**2143-10-20**].
- will consult Onc in am
.
# HNT.
- dilt gtt as above
- once off dilt gtt will restart metop 25 tid
.
# FEN. NPO for now, replete lytes prn
.
# PPX. SC heparin, bowel regimen
.
# Code: Full
Past Medical History:
- inoperable pancreatic cancer diagnosed [**6-16**] s/p ERCP with
stent placement, laporatomy with attempted Whipple, on
gemcitabine (received 3 weekly treatments starting [**2139-9-22**],
followed by a week off, then a fourth dose yesterday [**2143-10-20**])
- h/o SBO
- h/o cholangitis ([**6-16**]) with Enterococcus, Pseudomonas, and
Strep Viridans
- h/o bacteremia with Enterococcus fecalis (Vanc sensitive) and
Pseudomonas (sensitive to Zosyn)
- s/p choecystectomy tube (fell out [**7-17**])
- Hypertension
- ankylosing spondylitis
- right kidney cystic lesion
- Moderate Aortic stenosis
- intermittent SVT
- anemia
- tinea corporis
Social History:
No tobacco, alcohol, or other drug use. Currently living at
skilled nursing facility where his sister is also a resident.
Never married. No children.
Family History:
Sister with pancreatic cancer
Physical Exam:
VITALS 98.3/96.5 141-170/65-82 83-107 16-20 94-100% on 3LNC
GEN:Elderly man seated in chair
HEENT: PERRL EOMI sclera yellow mmm OP clear
NECK: Supple No LAD
SKIN: warm dry no rash, L subclavian triple lumen c/d/i
LUNGS: b/l crackles at the bases, otherwise CTAB
CV: RRR nl S1-S2 loud III/VI early systolic murmur heard best at
RUSB
ABD: Soft NT/ND BS+
EXT: ppp no edema
NEURO: AOX3 non-focal
Pertinent Results:
[**2139-10-21**] 09:39PM TYPE-ART PO2-184* PCO2-35 PH-7.39 TOTAL
CO2-22 BASE XS--2 INTUBATED-NOT INTUBA
[**2139-10-21**] 09:09PM TYPE-ART TEMP-37.2 O2-100 O2 FLOW-15 PO2-33*
PCO2-46* PH-7.35 TOTAL CO2-26 BASE XS-0 AADO2-633 REQ O2-100
INTUBATED-NOT INTUBA
[**2139-10-21**] 09:09PM LACTATE-1.5
[**2139-10-21**] 07:45PM CK(CPK)-59
[**2139-10-21**] 07:45PM CK-MB-NotDone cTropnT-0.14*
[**2139-10-21**] 02:00PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.024
[**2139-10-21**] 02:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-4* PH-6.5
LEUK-NEG
[**2139-10-21**] 02:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2139-10-21**] 02:00PM URINE HYALINE-0-2
[**2139-10-21**] 01:40PM LACTATE-1.5
[**2139-10-21**] 01:37PM GLUCOSE-132* UREA N-19 CREAT-0.9 SODIUM-137
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-22 ANION GAP-18
[**2139-10-21**] 01:37PM ALT(SGPT)-136* AST(SGOT)-112* CK(CPK)-59 ALK
PHOS-791* AMYLASE-35 TOT BILI-6.5*
[**2139-10-21**] 01:37PM LIPASE-23
[**2139-10-21**] 01:37PM cTropnT-0.11*
[**2139-10-21**] 01:37PM CK-MB-NotDone
[**2139-10-21**] 01:37PM CALCIUM-9.2 PHOSPHATE-2.9 MAGNESIUM-2.1
[**2139-10-21**] 01:37PM WBC-18.3*# RBC-4.50* HGB-11.4* HCT-34.5*
MCV-77* MCH-25.3* MCHC-33.0 RDW-17.7*
[**2139-10-21**] 01:37PM PLT COUNT-418
[**2139-10-21**] 01:37PM PT-13.9* PTT-26.3 INR(PT)-1.3
[**2139-10-20**] 10:55AM GLUCOSE-75 UREA N-15 CREAT-0.9 SODIUM-142
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-25 ANION GAP-15
[**2139-10-20**] 10:55AM ALT(SGPT)-83* AST(SGOT)-52* ALK PHOS-591* TOT
BILI-1.0 DIR BILI-0.3 INDIR BIL-0.7
[**2139-10-20**] 10:55AM GGT-593*
[**2139-10-20**] 10:55AM ALBUMIN-3.5 CALCIUM-8.6 PHOSPHATE-3.8
MAGNESIUM-2.1
[**2139-10-20**] 10:55AM CEA-2.7
[**2139-10-20**] 10:55AM WBC-9.4 RBC-4.23* HGB-10.8* HCT-32.5* MCV-77*
MCH-25.6* MCHC-33.3 RDW-19.2*
[**2139-10-20**] 10:55AM PLT COUNT-401
[**2139-10-20**] 10:55AM GRAN 6480
_
_
_
_
_
_
________________________________________________________________
RADIOLOGY Final Report
CTA CHEST W&W/O C &RECONS [**2139-10-21**] 3:21 PM
CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST
Reason: r/o PE
Field of view: 38 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
70 year old man with pancreatic CA & sudden onset of SOB,
hypoxia, & large R pleural effusion
REASON FOR THIS EXAMINATION:
r/o PE
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 70-year-old man with pancreatic cancer, with sudden
onset of shortness of breath and hypoxia. Evaluate for pulmonary
embolism.
COMPARISON: CT angiogram chest dated [**2139-7-24**]. AP upright
portable chest x-ray dated [**2139-10-21**].
TECHNIQUE: MDCT imaging of the chest was performed before and
after the administration of 100 cc of intravenous Optiray.
Nonionic contrast was administered per protocol. Coronal and
sagittal reformatted images were obtained.
CT ANGIOGRAM CHEST: There are no filling defects within the
pulmonary arteries to suggest the presence of a pulmonary
embolism. Prominent mediastinal lymph nodes are seen, without
meeting CT criteria for pathologic enlargement. The largest
lymph node is pretracheal, and measures 9 mm. There is no
axillary or hilar lymphadenopathy. Low-density fluid surrounds
the ascending aorta, and appears new since prior exam. The
aortic contour is normal, and there is no evidence of wall
abnormality, intimal flap ulceration or contrast extravasation.
There are dense coronary artery calcifications. The remaining
great vessels are unremarkable. There is no pericardial
effusion.
There are new bilateral pleural effusions, right greater than
left, with compressive atelectasis. There are stable pleural
plaques within the right lung posteriorly. On lung windows,
pleural-based nodules are seen within bilateral lung apices
posteriorly, which are stable in size and appearance since prior
exam. Scattered calcified granulomas within the lungs are again
seen. No new nodules or masses are detected.
Limited imaging of the abdomen reveals new air within the
biliary ductal system, presumably related to patient's interval
biliary stent exchange. A large right renal cyst, with rim
calcifications is again seen.
BONE WINDOWS: There are no suspicious lytic or sclerotic osseous
abnormalities. A nonaggressive-appearing sclerotic focus is
again seen within the right humeral head and is stable since
prior exam. Degenerative changes are seen along the thoracic
spine.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. New bilateral pleural effusions.
3. New low attenuating fluid seen surrounding the ascending
aorta , of uncertain cause in the absence of evidence of aortic
contour abnormality, dissection, or aneurysm. Correlate
clinically to determine if further evaluation by MR exam (or
intra-esophageal ultrasound) should be considered.
4. Interval resolution of intrahepatic biliary ductal
dilatation.
5. Presence of intraductal air is most consistent with patient's
interval stent replacement.
6. Stable biapical pleural-based nodules.
7. Stable calcified pulmonary nodules.
8. Large right renal cyst, with rim calcifications.
These findings were enterred into the Emergency department
dashboard, and discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 28438**] at 4:15 pm
[**2139-10-21**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DR. [**First Name8 (NamePattern2) 4075**] [**Last Name (NamePattern1) 5999**]
Approved: [**Doctor First Name **] [**2139-10-22**] 3:29 PM
_
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
Cardiology Report ECG Study Date of [**2139-10-21**] 4:01:30 PM
Compared to the previous tracing of [**2139-10-21**] the rhythm is now
probbaly atrial
flutter with 2:1 A-V block, atrial rate, 260, ventricular rate
130.
Non-specific repolarization changes consistent with ischemia
and/or tachycardia
persist.
TRACING #3
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] S.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
132 0 96 326/404 0 -6 168
([**-4/5350**])
_
_
_
_
_
_
_
_
_
________________________________________________________________
RADIOLOGY Final Report
CT ABDOMEN W/O CONTRAST [**2139-10-22**] 1:03 AM
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST
Reason: please eval for evidence of cholangitis, obstruction
[**Hospital 93**] MEDICAL CONDITION:
70 year old man with pancreatic cancer, T to 105, tachycardia,
hx of cholangitis and bacteremia, indwelling stent
REASON FOR THIS EXAMINATION:
please eval for evidence of cholangitis, obstruction
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Pancreatic cancer with febrile to 105.
TECHNIQUE: Multidetector CT images were obtained from the lung
bases to the pubic symphysis without intravenous contrast.
Coronal and sagittal reformatted images were obtained.
The lung bases show large bilateral pleural effusions with
associated compressive atelectasis. The heart shows coronary
artery calcifications. Otherwise, the heart and pericardium are
unremarkable. The non-contrast-enhanced liver demonstrates
diffuse intrahepatic biliary ductal dilatation extending into
the extrahepatic biliary ductal system. A plastic stent is seen
coursing from the common hepatic duct to the ampulla of Vater.
The gallbladder is nondistended. There is no gallbladder wall
thickening or gallstones identified. The non-contrast-enhanced
pancreas is unremarkable. The spleen is normal. The left kidney
is unremarkable. The right kidney contains a large unchanged
simple renal cyst at the upper pole. Both kidneys excrete
contrast symmetrically from a prior contrast-enhanced
examination. The adrenal glands are normal. The opacified
stomach and intra-abdominal loops of small bowel are
unremarkable. Diverticulosis without evidence for diverticulitis
is seen throughout the large bowel, most predominantly within
the sigmoid colon. There are no focal fluid collections. There
is a small amount of ascites. There is no pathologically
enlarged mesenteric or retroperitoneal lymphadenopathy. There is
no free air.
CT OF THE PELVIS WITHOUT CONTRAST: The rectum is unremarkable.
The sigmoid colon contains extensive diverticula without
evidence for diverticulitis. The distal ureters are
unremarkable. The bladder contains a Foley catheter. There is no
free air. There is a small amount of free fluid. The seminal
vesicles and prostate are unremarkable. There is no
pathologically enlarged inguinal, pelvic, retroperitoneal, or
mesenteric lymphadenopathy. The aorta contains calcifications.
BONE WINDOWS: There are no suspicious lytic or sclerotic osseous
lesions.
CT REFORMATS: Coronal and sagittal reformatted images confirm
the axial findings. Value grade 1.
IMPRESSION:
1. Diffusely dilated intrahepatic biliary ducts extending into
the extrahepatic biliary ductal system. Plastic stent extending
from the common hepatic duct to the ampulla of Vater. No focal
fluid collections or abscesses are identified. There is no free
air.
2. Large bilateral pleural effusions with associated compressive
atelectasis at the bilateral lung bases.
3. Diverticulosis without evidence for diverticulitis.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 5998**]
DR. [**First Name (STitle) 8085**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8086**]
Approved: [**Doctor First Name **] [**2139-10-22**] 1:29 PM
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
ERCP Report [**Hospital1 **]
[**Hospital Ward Name 516**]
Date: Thursday, [**2139-10-22**] Endoscopist(s): [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], MD
[**First Name4 (NamePattern1) 333**] [**Last Name (NamePattern1) 28439**], MD (fellow)
Patient: [**Known firstname **] [**Known lastname 16268**]
Ref.Phys.: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD; [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Birth Date: [**2069-9-11**] (70 years) Instrument: TJF [**Numeric Identifier 28440**] Indications: 70 year old with inoperable pancreatic
cancer. Presents with stent in situ and cholangitis.
Medications: Midazolam 8 mg
Fentanyl 100 micrograms
ASA Class: P3
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated his
understanding and signed the corresponding consent forms. The
patient was placed in the prone position and an endoscope was
introduced through the mouth and advanced under direct
visualization until the second part of the duodenum was reached.
Careful visualization was performed. The procedure was not
difficult. The quality of the preparation was good. The patient
tolerated the procedure well. There were no complications.
Findings: Esophagus: Limited exam of the esophagus was normal
Stomach: Limited exam of the stomach was normal
Other Multiple elevated erosions suspicious for malignant
involvement of the duodenum.
Major Papilla: A plastic stent placed in the biliary duct was
found in the major papilla. Evidence of a previous
sphincterotomy was noted in the major papilla.
Cannulation: Cannulation of the biliary duct was successful and
deep with a cannula using a free-hand technique. Contrast medium
was injected resulting in partial opacification. The procedure
was not difficult.
Biliary Tree: Dilated CBD with filling defects and distal
stricture. Note C arm used in ICU.
Procedures: A plastic stent was removed from the lower third of
the common bile duct.
A 6 cm by 10 mm covered wall stent biliary stent was placed
successfully in the common bile duct. 3 'diamond' spaces of the
stent extended into the duodenum.
Impression: Multiple elevated erosions suspicious for malignant
involvement of the duodenum.
Plastic stent removal - evidence of prior sphincterotomy
Biliary dilation with distal CBD stricture
6 cm Wallflex stent placed - pus, bile and sludge evident
following stent placment.
Recommendations: Continue IV anti-biotics
Remain in ICU
_________________________________
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
_________________________________
[**First Name4 (NamePattern1) 333**] [**Last Name (NamePattern1) 28439**], MD (fellow) Case documented on [**2139-10-22**]
9:15:08 PM
Patient: [**Known firstname **] [**Known lastname 16268**] ([**Numeric Identifier **])
Brief Hospital Course:
This is a 70 yOM with known pancreatic CA with biliary stent
placement who presented to the ED with fever and SOB.
# Cholangitis - Found by CT scan, blood cultures negative. s/p
ERCP and stent placement. Puss seen on ERCP but no culture data.
Hx of cholangitis with Enterococcus fecalis (Vanc sensitive) and
Pseudomonas (sensitive to Zosyn).Treated initally with
vancomycin and zosyn. Remained afebrile. Switched to augmentin.
Pt remained afebrile and was discharged on 2 weeks of po
augmentin.
#Elevated LFTs - elevated during acute illness after ERCP.
Trending of enzymes showed graduall decrease back to baseline.
Likely secondary to acute infection.
# Hypoxia -Related to small b/l effusions, atelectasis and RLL
PNA. Initial require intubated due to increased work of
breathing. Extubated after one day in the ICU. Maintianied on
supplemental oxygen for a few days post -extubation. Given
insentive spirometer. Now stable on room air.
# Aflutter with rapid rate. ? h/o intermittent SVT. Seen on
telemetry in ICY. Treated with metoprolol. DOse titrated up to
100 mg po tid. Now in normal sinus rhythm.
.
# Pancreatic cancer. Pt is not a surgical candidate. Last dose
of gemcitabine [**2143-10-20**]. Holding further treatment until
resolution of this acute illness.
.
#Aortic stenosis - heard on exam and seen on echo in [**7-17**]. No
symptoms at this point. must be careful with BB.
.
.
# Elevated Trop of 0.[**Street Address(2) 28437**] depressions and TWI's
likely secondary to demand ischemia in setting of rapid aflutter
and hypoxia. CK's flat. Has now resolved.
.
Medications on Admission:
- Lopressor 25 mg tid
- Colace [**Hospital1 **]
- multivitamin
- compazine prn
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
8. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 2 weeks.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 5481**] Home Health, [**Location (un) 2624**]
Discharge Diagnosis:
pancreatic cancer
cholangitis
pneumonia
Discharge Condition:
Good
Discharge Instructions:
Please call Dr.[**First Name (STitle) **] at([**Telephone/Fax (1) 16336**] or return to the
emergency department if you have fever, chills, nausea,
vomitting, shortness of breath, or chest pain.
Followup Instructions:
Please call Dr.[**First Name (STitle) **] at([**Telephone/Fax (1) 16336**] to arrange a follow up
appointment for next week.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4425**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2139-11-3**]
11:30
Provider: [**Name Initial (NameIs) 4426**] 17 Date/Time:[**2139-11-3**] 11:30
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2139-11-10**] 11:00
Completed by:[**2139-10-29**]
|
[
"427.32",
"455.3",
"401.9",
"424.1",
"428.0",
"518.81",
"285.9",
"576.1",
"157.8",
"197.4",
"486",
"V16.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.93",
"96.04",
"51.87",
"97.55",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
22502, 22590
|
20083, 21663
|
347, 412
|
22674, 22681
|
7447, 9674
|
22924, 23415
|
6988, 7019
|
21793, 22479
|
13953, 14067
|
22611, 22653
|
21689, 21770
|
22705, 22901
|
7034, 7428
|
278, 309
|
14096, 20059
|
440, 1328
|
6164, 6804
|
6820, 6972
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,049
| 134,539
|
10613
|
Discharge summary
|
report
|
Admission Date: [**2142-5-28**] Discharge Date: [**2142-6-4**]
Date of Birth: [**2078-1-6**] Sex: M
Service: MEDICINE
Allergies:
Vicodin / Ms Contin
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a 64 year old man with a history of CAD, COPD, CHF,
diabetes, and hypertension who presented to the ED from
[**Hospital1 **] with ectopy during a sleep apnea test. On the night
prior to admission the patient had a sleep study done at
[**Hospital1 **] which showed frequent SVT. He also complained of
itching during the study. He was transfered to the ED there
where an ECG showed NSR at a rate of 61 with Q in III, aVF but
no other abnormalities. BP was 124/79. Patient had a bladder
scan that showed 550 cc of urine but he refused a urinary
catheter. Patient requested transfer to [**Hospital1 18**].
.
At the [**Hospital1 18**] ED BP was 106/50, HR 65, RR 16, O2 94% RA, T 97.3.
He was given his am meds which included isosorbide mononitrate
60 mg, finasteride 5 mg, lisinopril 5 mg, metoprolol XL 25 mg,
and aspirin 325 mg. At 3 pm his BP was noted to be 73/58. He
denied dizziness, shortness of breath, chest pain. He received
500 ml of NS with no change in BP. At 4:30 BP was 101/49, but
at 7:30 BP was 90/69 and patient was somnolent. He received
another 700 cc of NS and BP was 80/58.
.
ROS: positive for vision changes, headaches. negative for
fevers, chills, sweats, nausea, vomiting, shortness of breath,
chest pain, dysuria, abdominal pain, diarrhea, black or bloody
stools.
Past Medical History:
1) CHF, EF 45% from most recent echo [**6-5**], mixed LV systolic and
diastolic dysfunction, cardiomyopathy
2) CAD, NSTEMI in [**3-6**] during admission for urosepsis with
hypotension and coma.
3) Type II DM c/b neuropathy, nephropathy, per pt no retinopathy
4) HTN
5) CRI, baseline creatinine of 1.7
6) Anemia of chronic disease.
7) Sleep apnea on BiPAP, currently [**10-10**]
8) Chronic restrictive ventilatory disease secondary to a bile
duct leak with pulmonary fibrosis requiring decortication
9) Neuropathy - hands and feet
10) Lower extremity claudication
11) BPH.
12) Glaucoma; on carbonic anhydrase inhibitor
13) Bilateral cataracts s/p surgical removal
14) Depression
15) Osteoarthritis
16) Erectile dyscunction s/p Penile implant [**11-6**]
..
Past surgical history:
1) [**2138**] Roux-en-y reconstruction after laparoscopic
cholecystectomy c/b damage to CBD
2) [**2139**] Decortication for fibrothorax complicated by
respiratory failure requiring tracheostomy.
3) Appendectomy.
4) Left knee/hip replacement
Social History:
The patient lives with his wife. [**Name (NI) **] does not smoke. Only minimal
ethanol. Otherwise, he is extremely sedentary.
Family History:
CVA - brother
Breast [**Name (NI) 3730**] - mother
emphysema - father
Physical Exam:
VS: T 96.8 HR 63 BP 103/50 RR 15 O2 sat 87-96% 2L
Gen: Well appearing, comfortable, lying in bed in NAD. Slightly
somnolent but arousable and oriented x 3.
HEENT: PERRL, EOMI, sclera anicteric, MMM.
Neck: No LAD, or thyromegly. JVP at 10 cm.
CV: RRR with no m/r/g
Lungs: Decreased BS bilaterally with expiratory wheezes.
Abd: soft, NT, ND active BS, no hepatosplenomegly.
ext: cool with 1+ DP pulses. No clubbing, cyanosis or edema
Pertinent Results:
[**2142-5-28**] 08:00AM PLT COUNT-133*
[**2142-5-28**] 08:00AM NEUTS-70.4* LYMPHS-20.0 MONOS-4.1 EOS-4.6*
BASOS-0.8
[**2142-5-28**] 08:00AM CALCIUM-8.4 PHOSPHATE-6.4*# MAGNESIUM-2.6
[**2142-5-28**] 08:00AM WBC-6.7 RBC-3.89* HGB-12.2* HCT-34.8* MCV-90
MCH-31.4 MCHC-35.1* RDW-13.9
[**2142-5-28**] 08:00AM cTropnT-0.10*
[**2142-5-28**] 08:00AM CK(CPK)-257*
[**2142-5-28**] 08:00AM GLUCOSE-185* UREA N-63* CREAT-3.0* SODIUM-138
POTASSIUM-5.0 CHLORIDE-99 TOTAL CO2-27 ANION GAP-17
[**2142-5-28**] 04:20PM CK-MB-4
[**2142-5-28**] 04:20PM cTropnT-0.11*
[**2142-5-28**] 04:20PM CK(CPK)-275*
[**2142-5-28**] 10:45PM PLT COUNT-148*
[**2142-5-28**] 10:45PM WBC-12.2*# RBC-3.76* HGB-11.9* HCT-34.0*
MCV-91 MCH-31.6 MCHC-34.8 RDW-14.1
[**2142-5-28**] 10:45PM CALCIUM-7.7* PHOSPHATE-8.8*# MAGNESIUM-2.6
.
Blood cultures remained negative
.
CXR [**5-29**]: Unchanged appearance of the chest without evidence of
acute
cardiopulmonary disease.
.
ECG: NSR at 60 bpm with normal intervals. Normal axis. Q in III
and aVF. Biphasic TW in III. No change from prior.
.
[**5-29**] Renal US:
1. No hydronephrosis.
2. Renal size asymmetry is stable, but raises the possibility
of underlying renal artery stenosis and clinical correlation is
suggested.
2. Splenomegaly.
Brief Hospital Course:
64 year old man with CHF, CRF (baseline Cr 1.7), CAD and COPD
who presents from ED after developing asymptomatic hypotension
and acute on chronic renal failure after taking his blood
pressure medications.
.
Chronic pain: Mr. [**Known lastname **] suffers from chronic pain in his left
hip s/p hip replacement ([**2135**]) and pain in his left shoulder
secondary to bursitis. He had previously been treated at the
[**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**] Center ([**2137**]) for left hip pain. After four doses
of MS Contin, he developed lethargy and hypotension and was
referred to the [**Hospital1 **] Emergency Department. MS contin was believed
to cause the itching present on presentation in addition to
possibly contributing to his hypotension. It was also felt that
his blood pressure medications had been given all together and
this compounded his drop in blood pressure. Due to the
potential for MS Contin misuse in addition to the above
concerns, he was changed to percocet for pain control. The pain
service was consulted who recommended Topiramate which was
started on [**6-1**]. He will follow up with the [**Hospital1 **] pain center as
an outpatient and will continue with Mind Body Program.
.
ARF on CKD: On admission, the patient's creatinine had peaked at
4.0 before normalizing. He was noted to be in non-oliguric
acute renal failure. The patient was given IVF with resolution
of ARF; his creatinine returned to baseline 1.4. As his
creatinine responded to fluids, the renal team felt that the
etiology of his renal failure was pre-renal. Renal US showed
asymmetric sized kidneys. He will follow up with Dr. [**Last Name (STitle) 4090**] as
outpt. Pt voided well after foley d/c.
.
Hypotension: Mr. [**Known lastname **] presented with persistent hypotension
despite boluses of NS in the ED. After work-up in MICU, the
differential was narrowed to include hypotension from
dehydration vs. med related hypotension. He was able to regain
a normal blood pressure holding his BP meds for short period of
time. Fluids were also administered. A renal US was done on
admission to evaluate cause of ARF which showed that the patient
had asymmetric sized kidneys and raised the possibility of renal
artery stenosis in the setting of starting an ACE-I. The ACE-I
had been stopped on admission due to hypotension, but the renal
team felt that the patient could be restarted on a low dose [**Last Name (un) **].
Once his blood pressure stabilized, losartan and metoprol were
restarted. He was kept even fluid-wise.
.
OSA: Mr. [**Known lastname **] had a sleep study done which reaffirmed complex
sleep-disordered breathing with partially successful titration
study. They recommended home therapy at BiPAP 16/13 with 100 mL
of dead space and 4 liters of O2.
.
DM: While in the hospital he was kept on a RISS and was followed
by [**Last Name (un) **].
.
HTN: Once his blood pressure stabilized he was put back on
Losartan and Metoprolol. Lisinopril and Imdur were held.
.
BPH: He was continued on Flomax and Proscar.
.
Anemia: The patient's hematocrit ranged between 32-34 which
appears to be his baseline. Fe studies in [**11-6**] were consistent
with ACD. We recommend that the patient undergo outpatient
evaluation by hematology for chronically low hematocrit.
.
CAD: He did have one episode of epigastric abdominal discomfort
while in hospital for which he had serial EKGs and serial
enzymes, which did not show any evidence of an ongoing acute
coronary syndrome. He was continued on ASA but Imdur was held
given recent hypotension.
.
Diastolic dysfunction: Mr. [**Known lastname **] had a recent Echo on [**11-6**]
which showed an EF of 65%. His Is/Os and weights were closely
monitored and he remained asymptomatic from this perspective.
.
Depression: He was maintained on Lexapro for depression.
.
FEN: Maintained on a cardiac and diabetic diet and electrolytes
were repleted prn.
.
Code: Full code
Medications on Admission:
escitalopram 5 mg qam, 10 mg qhs
calcium carbonate 500 mg qam
lasix 60 mg daily
aspirin EC 325 mg daily
colace 100 [**Hospital1 **]
tamsulosin SR 0.8 mg daily
isosorbide mononitrate SR 60 mg daily
finasteride 5 mg daily
calcitriol 0.25 micrograms daily
lisinopril 5 mg daily
toprol 25 mg daily
protonix 40 mg [**Hospital1 **]
oxycodone prn
lantus 11 units qhs
regular insulin sliding scale
oxycontin 15 mg [**Hospital1 **] prn
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
3. Escitalopram 10 mg Tablet Sig: 0.5 Tablet PO QAM (once a day
(in the morning)).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QAM (once a day (in the morning)).
5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
Disp:*1 bottle* Refills:*1*
9. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
10. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO DAILY (Daily).
11. Topiramate 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
Disp:*30 Tablet(s)* Refills:*0*
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
15. Insulin Glargine 100 unit/mL Solution Sig: Seven (7) Units
Subcutaneous at bedtime.
Disp:*30 Units* Refills:*2*
16. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: ASDIR
per sliding scale Subcutaneous four times a day: per sliding
scale.
Disp:*qs * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Hypotension
Acute renal failure
Urinary retention
Chronic hip and shoulder pain
--------------
CHF
CAD
Type II DM
HTN
Anemia of chronic disease.
Sleep apnea on BiPAP, currently [**10-10**]
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
Please take all medications as prescribed. Please do not
continue to take Lisinopril. We started you on Losartan 50mg
instead.
You are now taking Isosorbide Mononitrate 30mg, NOT 60mg.
You have been started on Topiramate 25mg to take at bedtime, for
pain.
If you start to feel lightheaded or dizzy, please [**Name6 (MD) 138**] your MD.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] 1-2 weeks after discharge.
Please follow up with [**Hospital1 **] pain center.
Please continue to attend the Mind Body program.
Please follow up with Dr. [**First Name (STitle) 4102**] [**Name (STitle) 4090**] [**Telephone/Fax (1) 12142**] after
discharge.
|
[
"365.9",
"276.7",
"412",
"V58.67",
"584.9",
"V43.64",
"357.2",
"403.91",
"496",
"311",
"515",
"327.23",
"719.41",
"530.81",
"250.60",
"E947.9",
"285.29",
"715.90",
"600.01",
"428.0",
"458.9",
"719.45",
"276.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"57.94"
] |
icd9pcs
|
[
[
[]
]
] |
10912, 10970
|
4669, 8643
|
290, 296
|
11203, 11213
|
3371, 4646
|
11716, 12028
|
2833, 2904
|
9121, 10889
|
10991, 11182
|
8669, 9098
|
11237, 11693
|
2430, 2673
|
2919, 3352
|
239, 252
|
324, 1629
|
1651, 2407
|
2689, 2817
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,941
| 145,257
|
43098
|
Discharge summary
|
report
|
Admission Date: [**2187-6-8**] Discharge Date: [**2187-6-13**]
Date of Birth: [**2129-7-12**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Hyperkalemia
Major Surgical or Invasive Procedure:
Endotracheal intubation
Central Venous Line Placement
Paracentesis
Arterial Line placement
History of Present Illness:
57 yo F h/o Etoh/HCV cirrhosis with recent admission [**Date range (1) 23742**]
for SBP treated with CTX and hyponatremia felt secondary to
hypovolemia and discharged on decreased dose of spironolactone
and lasix (200 -> 100 and 100 -> 20 respectively). She was also
discharged home on cipro ppx for SBP. Since discharge, she has
felt her abdomen become more distended. She had labs drawn in
PCPs office [**6-7**] and was noted to have a potassium of 6.7 and Na
of 119, and she was advised by her PCP to go to the ED.
.
In the ED, initial VS: T 97.4, P 90, BP 96/50, R 20 and 100% on
room air. Her K+ was noted to be 6.3. EKG was notable for peaked
T waves. She was treated with calcium, insulin and dextrose. She
was given 30 mg kayexcelate. T waves resolved prior to transfer.
She was also found to have wbc of 24. She had a paracentesis
that showed 12,200 wbcs and 76% PMNs consistent with SBP. She
was given a dose of ceftriaxone and flagyl. She is being
transferred to the MICU for relative hypotension and
hyperkalemia management. VS prior to transfer: 98.2 83 93/53 16
99% on RA.
.
Upon arrival to the MICU, the patient was comfortable and denied
pain. She was requesting gingerale.
Past Medical History:
-Alcoholic and hepatitis C cirrhosis. She has decompensation
with jaundice and ascites. She has no esophageal varices and no
history of encephalopathy.
- Hepatitis C virus, genotype 1, viral load 70,000.
- Alcohol abuse.
- Severe esophagitis.
- Portal hypertensive gastropathy.
- Klebsiella Bacteremia in the setting of acute hepatic
decompensation
Social History:
Previously lived in VT, recently moved to St. [**Doctor Last Name **]. Family in
[**State 350**]. Patient reports cocaine use >20 years ago. She
denies tobacco. Per report she was drinking 1-2 drinks 4 times
a week up until 3 months ago and has been sober since then
Family History:
Renal failure [**3-7**] NSAIDS in mother, HTN in multiple family
members; no liver disease
Physical Exam:
ON ADMISSION:
Vitals: T:97 95/54 93 17 99%
General: Alert, oriented, no acute distress
HEENT: Sclera icteric, Jaundiced, tan, dry MM, oropharynx clear
Neck: supple, JVP not elevated,
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: markedly distended and tympanic, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
ON DISCHARGE:
Expired
Pertinent Results:
ADMISSION LABS:
.
[**2187-6-8**] 12:55AM BLOOD WBC-24.4*# RBC-2.10* Hgb-8.2* Hct-23.0*
MCV-109* MCH-38.9* MCHC-35.6* RDW-17.0* Plt Ct-67*
[**2187-6-8**] 07:41AM BLOOD WBC-23.3* RBC-2.05* Hgb-7.9* Hct-22.5*
MCV-110* MCH-38.6* MCHC-35.2* RDW-16.7* Plt Ct-67*
[**2187-6-8**] 12:55AM BLOOD Neuts-91* Bands-0 Lymphs-4* Monos-4 Eos-0
Baso-0 Atyps-1* Metas-0 Myelos-0
[**2187-6-8**] 12:55AM BLOOD PT-28.3* PTT-43.5* INR(PT)-2.7*
[**2187-6-8**] 07:41AM BLOOD PT-25.9* PTT-41.7* INR(PT)-2.5*
[**2187-6-7**] 04:20PM BLOOD UreaN-48* Creat-1.0 Na-119* K-6.7* Cl-87*
HCO3-21* AnGap-18
[**2187-6-8**] 07:41AM BLOOD Glucose-89 UreaN-48* Creat-0.8 Na-118*
K-6.1* Cl-93* HCO3-19* AnGap-12
[**2187-6-8**] 12:45AM BLOOD ALT-35 AST-68* AlkPhos-62 TotBili-10.5*
[**2187-6-8**] 07:41AM BLOOD ALT-36 AST-70* LD(LDH)-205 AlkPhos-65
TotBili-10.1*
[**2187-6-8**] 12:45AM BLOOD Lipase-125*
[**2187-6-8**] 07:41AM BLOOD Albumin-2.9* Calcium-8.6 Phos-4.0 Mg-2.1
[**2187-6-8**] 12:50AM BLOOD Na-116* K-6.0*
[**2187-6-8**] 03:47AM BLOOD Lactate-3.8* K-5.9*
IMAGING:
========
[**2187-6-8**]:
IMPRESSION:
1. Known cirrhosis with large amount of simple ascites. Small
foci of
intraperitoneal air likely relates to the recent paracentesis.
2. Significant gastric distention, without evidence of bowel
obstruction.
3. Marked distention of the gallbladder especially when compared
to [**2187-3-22**], if there is clinical concern for acute
cholecystitis, an ultrasound can be obtained.
EGD:
Varices at the lower third of the esophagus
Blood in the stomach body and fundus
No gastric varices were seen.
Congestion, petechiae and mosaic appearance in the stomach body,
fundus and antrum compatible with portal hypertensive
gastropathy
Congestion in the first part of the duodenum compatible with
duodenopathy
(ligation)
Otherwise normal EGD to second part of the duodenum
[**2187-6-10**] Chest X-Ray:
FINDINGS: Tip of endotracheal tube is low, located slightly more
than a
centimeter above the carina. Dr. [**Last Name (STitle) 12769**] has been informed of
these findings by telephone on [**2187-6-10**] at 8:25 a.m. Heart
size is normal. Worsening patchy and linear opacities at the
lung bases is very likely atelectasis, but coexisting aspiration
is possible. Small left pleural effusion. Marked gastric
distension.
[**2187-6-12**] Chest X-Ray:
1. New diffuse bilateral heterogeneous opacities, greater on the
right, are consistent with severe pulmonary edema. A concomitant
infectious process cannot be excluded.
2. Left IJ catheter overlies the expected course of a persistent
left SVC. For further assessment of this catheter's location, a
lateral radiograph could be obtained. If blood cannot be drawn
back through this catheter, the possibility that the catheter
tip is within the mediastinum should be considered.
3. Possible small bilateral pleural effusions.
4. Low lung volumes.
Brief Hospital Course:
57 y/o F with hx of etoh and hep C cirrohsis with chronic
ascites and recent SBP who presents to the ED after follow up
labs showed hyperkalemia.
.
# Sepsis: On [**6-12**] patient developed hypotension, tachycardia,
and respiratory distress. Patient was intubated by anesthesia.
Patient had arterial line and CVL placed. Peritoneal fluid
cultures grew enterococcus and yeast. Infectious disease was
following patient and recommended dapto, [**Last Name (un) 2830**], micafungin, and
po vanco. Patient received crysalloid and colloid fluid without
improvement in her blood pressure. She required pressors and
was treated with Phenylephrine, Vasopressin, and Norepinephrine.
A family meeting was held on [**2187-6-13**] and the patient's family
chose to focus on comfort measures. The patient was extubated
and pressors were stopped. Patient expired with family at
bedside.
.
# SBP: patient recently admitted with SBP and discharged on
cipro prophylaxis. Previous paracentesis resulted in bruising
and pain in area of entry in abdomen and she has had increased
distension since last discharge. In the ED, a diagnostic tap was
consistent with SBP and gram stain showed gram negative rods
initially She was started on vanco and zosyn for empiric
coverage. One possible etiology was thought to be
microperforation s/p recent paracentesis and a CT abdomen with
oral contrast was ordered to evaluate, this showed severe
gastric distension, bibasilar consolidations, large volume
ascites (no free air to suggest perforation) and small bowel
dilation due to ileus.
.
Infectious disease followed patient for treatment of infection
and recommended dapto, [**Last Name (un) 2830**], micafungin and PO vanco (to cover
empirically for c. diff). Patient became septic (see above).
.
# GI Bleed: On day 2 of hospitalization patient had evidence of
upper GI bleed. She was transferred back to the intensive care
unit for intubation for airway protection during endoscopy. She
was started on PPI gtt and octreotide. She had four esophageal
bands placed. Her HCT remained stable and she was called back
out to the medical floor. On [**6-11**] patient's HCT dropped to 24 and
she was transfused 2 units PRBC. Her HCT bumped appropriately.
.
# Hyperkalemia: K of 6.1 on admission with peaked T waves on
ECG. Likely secondary to spironolactone and taking potassium
supplmeents at home. Patient was given calcium gluconate and
kayexelate and T wave changes improved on ECG. Aldactone and
lasix were held and K was trended.
.
# Hyponatremia: Likely secondary to diuresis and intravascular
hypovolemia. S/P 2 liters NS in ED. It improved with fluids in
the MICU. Diuretics were held throughout admission.
.
# ETOH/hep C cirrhosis: Pt had liver ultrasound with dopplers
in AM to r/o thrombus. She had paracentesis during admission.
The liver consult service patient followed patient while she was
in MICU. She had complications of GI bleed and SBP as above.
.
# ARF: Patient had elevated creatinine and decreased in UOP.
FeNa was 0.3% consistent with prerenal etiology. In addition to
decreased UOP could be related to either being intravascularly
dry, HRS or abdominal compartment syndrome (abd pressure 24)
from large volume tense ascites. Urine output initially
improved after paracentesis, but it worsened when patient went
into septic shock.
Medications on Admission:
Vitamin D Daily
multivitamin Daily
spironolactone 100 mg DAILY
Furosemide 20 mg DAILY
Cipro 250 mg Daily
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"572.3",
"456.20",
"038.9",
"789.59",
"995.92",
"070.54",
"537.89",
"571.2",
"560.1",
"507.0",
"518.5",
"276.1",
"584.9",
"276.7",
"567.23",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"42.33",
"54.91",
"38.91",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9399, 9408
|
5865, 9211
|
323, 415
|
9459, 9468
|
2982, 2982
|
9524, 9670
|
2313, 2405
|
9367, 9376
|
9429, 9438
|
9237, 9344
|
9492, 9501
|
2420, 2420
|
2954, 2963
|
271, 285
|
443, 1634
|
2998, 5842
|
2434, 2940
|
1656, 2009
|
2025, 2297
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,445
| 185,498
|
28337
|
Discharge summary
|
report
|
Admission Date: [**2128-1-15**] Discharge Date: [**2128-1-30**]
Date of Birth: [**2100-7-26**] Sex: M
Service: MEDICINE
Allergies:
Zofran / Reglan / Compazine
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Respiratory Arrest
Major Surgical or Invasive Procedure:
Intubation/Extubation
History of Present Illness:
The patient is a 27 yo M with a h/o recurrent abdominal pain
thought secondary to enzyme negative chronic pancreatitis, who
is being transferred from an OSH after a respiratory arrest and
possible hypoxic brain injury. He presented to the OSH on
[**2128-1-13**] with abdominal pain that was similar in nature to his
usual episodes of pain. On the day of admission, he was treated
with 3-4 doses of 11am-6pm. He received another dose at 11pm.
At 4am the patient was found to be unresponsive; vital signs
showed HR in the 150's and an oxygen saturation of 34% (per
report BP normal). His oxygenation improved to 60% with NRB and
90% with ambu bag. He was urgently intubated. On exam he was
found to be decerebrating with pinpoint pupils. He was treated
with narcan without great response. A CT head at the time was
unremarkable. Per report, an EKG at the time showed sinus
tachycardia without evidence of other dysrhythmias. He was
transferred to the OSH ICU. A repeat CT 18 hours later showed
anoxic encephalopathy. Troponins returned positive and a
subsequent ECHO revealed biventricular systolic dysfunction, a
non-dilated LV with global hypokinesis (EF<30%). An EEG in the
ICU was suggestive of a diffuse encephalopathy.
He was treated with Flagyl 500mg/Levofloxacin 750mg daily(day #1
[**2128-1-14**]) for PNA from likely aspiration event during his
respiratory event. Per family request, the patient was
transferred to [**Hospital1 18**] for further care.
Per family report the patient was feeling well since he was
discharged from [**Hospital1 18**] on [**2127-11-29**]. His fiance reports he has not
taken any pain medication or anxiety medication since he was
discharged.
Past Medical History:
1. Pancreatitis - reportedly from a very young age. Unclear
inciting event. Sees Dr. [**Last Name (STitle) 174**] of GI as well as Dr. [**Last Name (STitle) **] of
surgery.
2. s/p appendectomy and laproscopic cholecystectomy complicated
by severe episode of pancreatitis after intraoperative
cholangiogram here with Dr. [**Last Name (STitle) **] [**2127**].
Social History:
Denies tob/etoh/illicit drug use. He works for his father as
retail sale for oil company. Finished culinary college, would
like to work as a chef. Lives with his fiancee in [**Location (un) 16843**].
Family History:
Mother with DM
Physical Exam:
Admission
Vitals - 99.8 120/69 92 19 O2 100% (AC 500x14 FIO2 70%)
General - young male, lying in bed, intubated, not following
commands (per nursing, he did open his eyes to command)
HEENT - pupils 4mm bilaterally and reactive, no dolls eyes, no
gag
Neck - supple, no lymphadenopathy
CV - tachycardic, no murmurs appreciated
Lungs - decreased breath sounds at left base, coarse breath
sounds throughout left lung, good airmovement on right
Abdomen - soft, non-distended
Ext - 2+ DP/PT puleses bilaterally, 1+ edema bilaterally
Neuro - intubated, not following commands, toes upgoing
bilaterally, moving all 4 extemities (non-purposeful movements),
no dolls eyes
Pertinent Results:
OSH Imaging:
[**2128-1-13**] KUB - There are surgical clips overlying the right
upper abdomen consistent with previous cholecystectomy. The
visulalized bony structures are unremarkable. There are no
abnormal calcifications demonstrated. The bowel gas pattern is
nonspecific with no evidence of obstruction or free air.
[**2128-1-14**] CT Head - consistent with anoxic encephalopathy
[**2128-1-15**] CXR - interval increase in infiltrate of left lung
[**2128-1-15**] CT Head - hypodensity noted within the bilateral globus
pallidus and caudate nucleus, more prominent on the left. This
appears slightly more prominent when compared to prior study.
Findings maybe secondary to anoxic ischemic encephalopathy.
OSH Micro:
Sputum - haemophilus influenza
OSH Labs:
Admission Tox screen - NEGATIVE
[**2128-1-14**] 4:00am 7.24/48/60 (100% NRB)
[**2128-1-15**] 10:40am 7.37/43/67 (on 50%)
[**2128-1-14**] INR 1.1
[**2128-1-15**] Lactate 1.3
[**2129-1-13**] [**2128-1-14**]
BUN 11 15
Creatinine 0.8 2.0
Na 140 139
Cl 107 106
CO2 21 18
AST 28 57
ALT 56 80
Amylase 37 140
Lipase 181 275
TB 0.4 0.3
AP 88 93
Troponin 1.45 --> 1.36 --> 1.08
CKMB 1.9
[**2128-1-16**] MRI Head - Findings are consistent with acute anoxic
brain injury involving the basal ganglia and deep white matter.
The appearances in the cerebellum are not typical for anoxic
injury and could be related to drug overdose. No hemorrhage is
identified. Although cerebellum appears slightly swollen no
herniation is identified.
[**2128-1-19**] MRA - Patent major intracranial arteries, common
carotid, cervical internal carotid arteries within the
limitations of the technique.
Brief Hospital Course:
The patient is 27 yo M with h/o pancreatitis transferred from
OSH after respiratory arrest, possible anoxic brain injury, and
depressed EF.
.
Respiratory Failure/Ventilator associated pneumonia - The
patient initial respiratory failure was most likely oversedation
by narcotics leading to respiratory failure and an aspiration
event. He was intubated at the OSH and sputum there grew
haemophilius influenza. He was treated with a 7 day course of
levofloxacin. He was transferred to [**Hospital1 18**] at that time and he
began having increased secretions and his sputum grew MSSA. He
was started on a 7 day course of nafcillin. He was successfully
extubated on [**2128-1-20**]. Repeat sputum cultures then grew MRSA
and he was switched to vancomycin. His last day of treatment
was [**2128-1-30**].
.
Anoxic Brain Injury - The patient was was unresponsive at the
OSH for an unknown period of time before being found to have O2
sat of 34%. He was emergently intubated. An original CT at
that time was normal (no evidence of bleed/herniation), but a
repeat Head CT 18 hours later showed diffuse anoxic brain
injury. He was transferred to [**Hospital1 18**] for further care. An MRI
here also showed diffuse anoxic brain injury specifically in the
basal ganglia. He was eventually extubated on [**2128-1-20**]. His
mental status continues to improve with attentional deficits and
delirium worse at night. He will be discharged to rehab. He
was followed by Neurology should have outpatient followup with
them as well as a repeat MRI within 2-3 weeks.
.
Cardiac myopathy - likely [**2-28**] hypoperfusion during inciting
event; ECHO at OSH with global hypokinesis. Repeat ECHOs here
were essentially normal, showing dramatic improvement.
.
Dysphagia - He was unable to safely swallow thin liquids. He was
able to tolerate nectar thick liquids. Also had hoarseness.
Considered vocal cord injury, so ENT consulted. Evaluation
showed unilateral paresis of left true vocal cord. He should
followup with ENT as an outpatient (Dr. [**First Name (STitle) **] for monitoring
and continue thickened liquids for now.
.
Anxiety - Intermittent associated with tremor and sinus
tachycardia. Has been very debilitating to patient. Reports
never having these symptoms prior to admit. ?CNS component
related to encephalopathy. Psychiatry followed him here. He
was started on nightime and prn seroquel with some improvement.
Low dose Ativan was tried with improved symptom relief. He will
be discharged on standing ativan and seroquel; this regimen can
be adjusted as needed at his rehab facility.
.
Sinus tachycardia: Rates up and down and at times up to 140's,
almost exclusively at night. Multiple ECGs showing sinus tach.
Ruled out for VTE, hyperthyroidism. Volume repleted, no other
evidence of infection. Possible anxiety related and occurring
primarily during times in which he is feeling anxious. He was
started on empiric metoprolol, which has since been changed to
propanolol to improve his tachycardia and tremor as well.
.
Chronic Pancreatitis - followed by Dr [**Last Name (STitle) 174**]. Once extubated
patient denied abdominal pain. He did have some transient
abdominal pain on [**1-29**] of unclear etiology, resolved
spontaneously. LFTs were reasonably normal and RUQ U/S unchanged
(stable fatty infiltrate).
Medications on Admission:
Medications at home: Creon
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
3. Amylase-Lipase-Protease 48,000-16,000- 48,000 unit Capsule,
Delayed Release(E.C.) Sig: Seven (7) Cap PO TID W/MEALS (3 TIMES
A DAY WITH MEALS).
4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
6. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day) as needed for anxiety.
7. Propranolol 10 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 68789**]
Discharge Diagnosis:
Respiratory Arrest
Anoxic Brain Injury
Ventilator associated MRSA PNA
Chronic Pancreatitis
Sinus tachycardia
Anxiety
Discharge Condition:
Stable; extubated since [**2128-1-20**]. Oxygenating well on room air.
Discharge Instructions:
You were admitted to another hospital because of abdominal pain.
We believe that you accidently received too much pain
medication and this subsequently caused you to stop breathing.
Unfortunately, there was a period of time when you were not
receiving enough oxygen to your brain. An MRI of your head
showed diffuse brain injury because of a lack of oxygen.
.
Also you developed a pneumonia while you were in the hospital.
You recieved an antibiotic called vancomycin while you were here
to treat this infection.
.
You have been having some anxiety and fast heart rate. We have
started a couple new medications to help with this. These will
likely need to be adjusted further at your rehab facility.
.
Please return to the hospital or call your doctor if you have
worsening abdominal pain, worsening diarrhea, headache,
seizures, or any new symptoms that you or your family are
concerned about.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) 1386**] [**Last Name (NamePattern1) **], MD (GI) Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2128-2-9**] 11:40
.
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2128-2-13**]
2:35
.
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 3523**] [**Name (STitle) 3524**] (Neurology)
Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2128-2-17**] 12:00
.
You should also followup with the ear nose and throat
specialists (Dr. [**First Name (STitle) **]. This is to followup on your vocal cord
injury. Your appointment is [**Last Name (LF) 766**], [**2-23**] at 3:15.
Please call [**Telephone/Fax (1) 2349**] if you have any questions.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"482.41",
"967.9",
"E852.9",
"425.4",
"507.0",
"787.91",
"787.20",
"577.1",
"V09.0",
"781.0",
"300.00",
"348.8",
"785.0",
"276.52",
"E849.7",
"348.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
9292, 9340
|
5247, 8578
|
306, 330
|
9501, 9576
|
3386, 5224
|
10523, 11370
|
2673, 2689
|
8655, 9269
|
9361, 9480
|
8604, 8604
|
9600, 10500
|
8625, 8632
|
2704, 3367
|
248, 268
|
358, 2057
|
2079, 2439
|
2455, 2657
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,811
| 134,119
|
8455
|
Discharge summary
|
report
|
Admission Date: [**2165-8-19**] Discharge Date: [**2165-8-23**]
Date of Birth: [**2089-6-12**] Sex: M
Service: MED
Allergies:
Codeine / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
76 yo with [**Hospital 23789**] transferred from [**Location (un) 620**] on [**2165-8-19**] s/p fall at
home with small parafalcine SDH. Patient had no recollection of
his fall, but was c/o occipital headache. Pt has a laceration
on back of head, ?LOC. No other obvious injuries. He stated to
have had some CP one day prior to admission. He denies any N/V,
F/C, SOB, back pain or neck pain. Admitted to NSICU and coags,
SDH stable overnight. Tx to medicine from neurosurg w/ stable
SDH on [**2165-8-21**] for management of CHF, ?SBP, ?hepatic
encephalopathy.
Past Medical History:
1. ischemic cardiomyopathy/CHF with EF 20-25%
2. CAD s/p CABG. last cath '[**60**] with patent LMCA, LAD but 100%
RCA and SVG x2 to RCA down.
3. CVA
4. DM
5. CRF (1.8-2.4)
6. VT s/p ablation and ICD
7. BiV pacer
8. HTN
9. Diverticulosis
10. COPD
11. newly dx'd hepatocell CA/hep C
Social History:
Lives with his wife.
Former [**Name2 (NI) 29798**].
Denies alcohol or smoking.
Family History:
Non-contributory
Physical Exam:
T 96.7 HR 80 BP 117/56 sat 99%RA
Gen: Pt very lethargic, difficult to arouse and to remain awake.
HEENT: Dry MM, OP clear, no LAD.
CV: RRR, 3/6 SEM
Pulm: Bibasilar crackles
Abd: Soft, NT/ND
Ext: 2+ pitting edema on L leg
Neuro: A&O x3, Moving all extremities.
Pertinent Results:
CT HEAD W/O CONTRAST [**2165-8-19**] 10:53 AM
FINDINGS: The small parafalcine subdural hemorrhage is unchanged
in size. There are no new foci of hemorrhage. The appearance of
the brain is unchanged.
IMPRESSION: Stable appearance of subdural hematoma seen on scan
five hours previously. No new hemorrhage. No acute infraction.
No evidence of skull fracture.
US ABD LIMIT, SINGLE ORGAN [**2165-8-21**] 9:44 AM
FINDINGS: Four quadrant ultrasound and single image of the lower
midline demonstrates trace ascites, not significantly changed
since [**2165-4-28**].
IMPRESSION: Trace ascites, insufficient for safe paracentesis.
VIDEO OROPHARYNGEAL SWALLOW [**2165-8-21**] 9:19 AM
Penetration and aspiration to thin liquids and nectar during
swallowing. Please see the speech pathologist complete report in
the note section of the patient's on line medical record for
further recommendations and findings.
WRIST(3 + VIEWS) RIGHT [**2165-8-20**] 5:05 PM
There is moderately severe diffuse osteopenia and marked
degenerative change at the first CMC joint. No fracture or
dislocation is identified.
[**2165-8-19**] 08:47AM PT-13.8* PTT-26.8 INR(PT)-1.2
[**2165-8-19**] 08:47AM PLT COUNT-182
[**2165-8-19**] 08:47AM NEUTS-82.4* LYMPHS-8.4* MONOS-5.8 EOS-3.1
BASOS-0.3
[**2165-8-19**] 08:47AM WBC-5.6 RBC-3.63* HGB-11.1* HCT-31.6* MCV-87
MCH-30.6 MCHC-35.2* RDW-14.7
[**2165-8-19**] 08:47AM GLUCOSE-98 UREA N-62* CREAT-2.1* SODIUM-130*
POTASSIUM-3.1* CHLORIDE-88* TOTAL CO2-26 ANION GAP-19
Brief Hospital Course:
1. CHF-
CXR on [**2165-8-20**] showed changes suggestive of mild CHF.
mild to mod CHF. dry wt 175#, currently 166#. 96% 2L. He was
fluid res 1.5L. Throughout, was treated with Bumex, Zaroxylin,
and Spironolactone. He did not c/o any SOB or other sxs of CHF
and was able to sleep on almost horizontal bed.
2. ALTERED MENTAL STATUS.
On admission on [**2165-8-19**], was fully oriented, able to follow
commands, and move all his extremities. By the next day, he was
disoriented to time and place and by [**8-21**], was very lethargic and
barely able to follow commands. This change was thought to be
multifacted with infxn, CA, meds (dilantin new), hypoxia,
?hepatic encephalopathy contributing.He had trace acites; not
amenable to paracentesis. Began SBP prophylaxis with ceftriaxone
and monitored for sxs; fever, hypotension. CXR w/o PNA. LFTs
were reassuring. Started on lactulose 30 TID for possible
encephalopathy. By [**2165-8-22**], he was back to his baseline of being
oriented x3, awake, and able to follow commands.
Upon discharge, he was switched to PO Levofloxacin for 7 days
for SBP prophylaxis.
3. SDH
Small parafalcine subdural hemorrhage s/p fall. Stable, no
change on rpt CT [**8-19**] and [**8-20**]. He was started on a 7d seizure
prophylaxis regimen of Dilantin on [**2165-8-21**].
4. CARDIAC
He had no sxs of cardiac distress. CK levels were wnl x3.
5. F/E/N
Hypokalemic. Takes KCl supplementation at home. Was
replenished by IV and PO Potassium. At discharge, his K level
was 3.3.
On day of discharge, he was awake and alert and able to sit on a
chair. He looked much improved.
Medications on Admission:
Neurontin 300 [**Hospital1 **]
[**Doctor First Name **] 60 [**Hospital1 **]
Advair 100/50 1 puff [**Hospital1 **]
NPH 12 units qAM
Aldactone 25 qD
Digoxin 0.125 qD
Aspirin 81 qD
Toprol XL 12.5 qD
Imdur 30 qD
Zaroxylin 2.5 qD
Nortriptyline 100 qHS
Aciphex 40 qD
Bumex 4 [**Hospital1 **]
Dulcolax 1 tab qD
Colace 100 [**Hospital1 **]
KCl 20 mEq qD
Tylenol 650 q6hrs PRN
Discharge Medications:
1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Fexofenadine HCl 60 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*2 Inhalers* Refills:*2*
4. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
5. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
0.5 Tablet Sustained Release 24HR PO QD (once a day).
Disp:*15 Tablet Sustained Release 24HR(s)* Refills:*2*
6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
7. Bumetanide 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
8. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
10. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO QD (once a day).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
11. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
12. Nortriptyline HCl 10 mg Capsule Sig: One (1) Capsule PO HS
(at bedtime).
Disp:*30 Capsule(s)* Refills:*2*
13. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
14. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
Disp:*30 Tablet(s)* Refills:*0*
15. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1)
Capsule PO TID (3 times a day) for 4 days.
Disp:*14 Capsule(s)* Refills:*0*
16. Potassium Chloride 20 mEq Packet Sig: One (1) packet PO
twice a day: Please check K levels biweekly.
Disp:*60 packets* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Subdural Hematoma
Liver cirrhosis (Hep C)/Hepatocellular carcinoma
r/o Spontaneous Bacterial Peritonitis
Congestive Heart Failure
Chrocnic Renal Failure
Diabetes Mellitus
VT s/p ablation and ICD
BiV pacer
Diverticulosis
Hypertension
Chronic Obstructive Pulmonary Disease
Discharge Condition:
Stable
Discharge Instructions:
Please check Potassium and creatinine biweekly.
Followup Instructions:
Follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of Neurosurgery in two weeks. His
office number is ([**Telephone/Fax (1) 88**].
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2165-8-23**]
|
[
"852.20",
"496",
"572.2",
"428.0",
"276.8",
"155.0",
"E884.4",
"403.91",
"070.54"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7239, 7336
|
3144, 4755
|
295, 302
|
7651, 7659
|
1624, 3121
|
7755, 8045
|
1311, 1329
|
5174, 7216
|
7357, 7630
|
4781, 5151
|
7683, 7732
|
1344, 1605
|
251, 257
|
330, 895
|
917, 1199
|
1215, 1295
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,492
| 135,447
|
6438
|
Discharge summary
|
report
|
Admission Date: [**2178-4-7**] Discharge Date: [**2178-4-14**]
Date of Birth: [**2109-4-20**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Oxycodone / Adhesive Bandage
Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
PICC
History of Present Illness:
CC: Shortness of breath and sore throat.
HPI:
Ms. [**Known lastname 6759**] is a 68 yo woman, with hx of lung cancer, throat
cancer, COPD, Afib, here with sore throat and shortness of
breath.
She was admitted in [**2-1**] with atrial fibrillation and pneumonia.
She thinks she improved from this.
In the past 3 days, she has not been sleeping as she has been
waking from sleep with feeling of being smothered. She has felt
this way before. She has not noticed any dyspnea on exertion.
She noticed small amount of lower extremity edema, new for her.
She has a dry cough, no fevers. She has had a sore throat,
which
feels dry. She has not had any chest pain or palpitations. She
has gained 6lbs in the past few months intentionally. She has
been eating normally, and has not been on any fluid restriction
at home. She feels thirsty. She also feels a bit off,
personality-wise.
She went to see her PCP and was sent to the ED for evaluation.
In the ED, she had possible thrush on exam. Vital signs were
stable. She received a nebulizer and was transported to 7
[**Hospital Ward Name 1950**].
Here she complains of shortness of breath and sore throat.
ROS notable for intentional weight gain as above, chronic
psoriatic rash, no abdominal symptoms, no other neurologic
symptoms, ROS otherwise in 13 other systems and negative.
Past Medical History:
PMH
Past Oncologic History:
Larygneal Carcinoma:
- diagnosed in [**9-/2175**], in [**2-/2176**], Had PEG placed, received XRT,
Carboplatin/Pacitazel
Lung Cancer:
- [**9-/2171**] - Squamous cell carcinoma of RUL treated with
neoadjuvant carboplatin and paclitaxel + XRT, then R upper
lobectomy, neg LN
Other Past Medical History:
- DMII
- CAD s/p MI [**9-/2162**], s/p RCA stent at [**Hospital1 2025**] [**9-/2162**], s/p LCx stent at
[**Hospital1 2025**] [**3-/2163**]
- SVT
- Atrial fibrillation
- CVA vs. TIA [**8-31**]
-hypothyroidism
-depression
Social History:
Lives in same house as her son. Continues to smoke [**12-22**] ppd. No
alcohol. Retired.
Family History:
Mother - MI at 60, diabetes
Father - MI at 73.
5 siblings, several with MIs and dementia, one with laryngeal
cancer
Physical Exam:
Admission Exam:
Physical exam
Vital signs: Tmax 98 BP 113/82 HR 99 98% on RA
General: in NAD, thin woman, appears older than stated age.
HEENT: No scleral icterus, PERRL, OP dry, no LAD, no thrush
visualized in oropharynx, JVP not elevated
Lungs: lungs diminshed, no wheezes, no rales, wheezes
CV: tachycardic, irregular, without murmurs
Abdomen soft, NT, ND, NABS
Ext: trace bilateral edema
Neuro: alert/oriented X3, CN 2-12 intact. Normal fast finger
movements, full strength in legs. no pronator drift. Gait not
tested. Normal attention.
Skin with psoriatic plaques
Psychiatric appropriate
.
Discharge Exam:
Afebrile on breathing comfortably on 2.5L
CV irregular rate, 70s
Lungs improved air movement with end expiratory wheezes
Exam otherwise unchanged
Pertinent Results:
Relevant data:
PT: 20.8 PTT: 41.9 INR: 2.0
120 81 7 115
------------
4.3 32 0.5
proBNP: 2347
wbc 7.9 hgb 13.6 hct 43.3 plts 310
N:81.0 L:11.9 M:5.6 E:1.3 Bas:0.3
[**2178-4-7**]:
IMPRESSION:
1. Stable post-surgical and post-radiation changes of the right
lung.
2. Interval improvement of previously seen right lower lobe
opacification.
3. No new opacity, effusion, or pneumothorax.
CTCHEST:[**2178-4-7**]
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Worsening opacities in the right lower lobe which had cleared
in early
[**Month (only) 956**]. New occlusions from secretions of the right middle
lobe and distal bronchi consistent with a picture of chronic
aspiration. Alternatively if the patient received chemotherapy
between [**Month (only) 404**] and [**Month (only) 956**] this could be a picture of
improving malignancy, but more likely it is infection caused by
chronic aspiration.
3. Right middle lobe collpase and concurrent infectious process
is improving.
The study and the report were reviewed by the staff radiologist.
[**2178-4-9**] ECHO:
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with basal inferolateral
hypokinesis. The remaining segments contract normally (LVEF =
50%). Right ventricular chamber size and free wall motion are
normal. 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. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. At least mild mitral regurgitation. Moderate pulmonary
hypertension.
Compared with the prior study (images reviewed) of [**2176-9-2**],
mitral and tricuspid regurgitation are both more prominent.
Pulmonary hypertension is now seen.
.
Discharge Labs:
[**2178-4-14**] 04:59AM BLOOD WBC-10.0 RBC-3.78* Hgb-10.4* Hct-33.6*
MCV-89 MCH-27.6 MCHC-31.0 RDW-13.9 Plt Ct-369
[**2178-4-14**] 04:59AM BLOOD Glucose-124* UreaN-15 Creat-0.5 Na-137
K-4.3 Cl-96 HCO3-37* AnGap-8
[**2178-4-13**] 04:48AM BLOOD Calcium-8.6 Phos-2.5* Mg-1.7
[**2178-4-7**] 10:50PM BLOOD TSH-6.1*
.
**FINAL REPORT [**2178-4-14**]**
GRAM STAIN (Final [**2178-4-9**]):
[**10-15**] PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2178-4-14**]):
SPARSE GROWTH Commensal Respiratory Flora.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
sensitivity testing performed by Microscan.
STAPH AUREUS COAG +. RARE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. SECOND
MORPHOLOGY.
sensitivity testing performed by Microscan.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| STAPH AUREUS COAG +
| | PSEUDOMONAS
AERUGINOSA
| | |
AMIKACIN-------------- S S
CEFEPIME-------------- 4 S S
CEFTAZIDIME----------- <=0.5 S <=1 S
CIPROFLOXACIN--------- <=0.5 S <=0.5 S
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=1 S <=0.5 S <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM------------- S S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
Brief Hospital Course:
Ms. [**Known lastname 6759**] is a 68-year-old female with a hx of COPD (not on
home O2), squamous lung cancer (s/p R upper lobectomy in [**2170**]),
laryngeal cancer s/p resection in [**2175**], stroke, diabetes (last
A1C at 6.6 in [**7-/2177**]), CAD (s/p MI [**9-/2162**] s/p RCA stent at [**Hospital1 2025**]
[**9-/2162**], s/p LCx stent at [**Hospital1 2025**] [**3-/2163**]), sleep apnea (not on CPAP),
SIADH, hypertension, afib, who presented ([**4-7**]) with shortness
of breath and found to have MRSA/Psuedomonoal PNA and an acute
COPD Exacerbation.
#) MRSA and Pseudomonal PNA: Patient presented with Hypoxemia.
Initial differential inclueded aspiration pneumonia/HCAP vs COPD
exacerbation vs viral brochiolitis. Speech and swallow 2 months
ago did not show aspiration. She was supratherapeutic on
coumadin and CT chest did not show PE. BNP elevated, doesn't
appear volume overloaded on exam. A trial of lasix was given
without any improvement. She was treated for a COPD exacebation
with steroids, nebulizers and azithromycin. She should undergo
a long steroid taper and follow up with pulmonology in 4 weeks
for repeat CT scan. She was covered with vanc/zosyn/azithro
which was narrowed to zosyn. A PICC line was placed on [**4-13**].
She also has a history of OSA but did not tolerate CPAP 10 years
ago and hasn't tried since. She was restarted on CPAP here.
The patient should complete a total of eight days of Vancomycin
coverage for MRSA Pneumnomia (started on [**4-9**] but missed one day
on [**4-12**]) and a full 14 days of antibiotics (started on [**4-9**]) for
Pseudomonas (Had been on Zosyn) and will switch to IV
Ciprofloxacin on discharge.
.
# Acute COPD Exacebration: Likely preciptated by PNA (as above).
Pt was treated with steroids in house and should be continued on
steroid taper. On the day of discharge the patient received
prednisone 60mg. This should be slowly titrated down over 10
days.
- Recommend Prednisone 40mg x2 days, 30mgx days x2 days etc.
.
# Hyponatremia: Appears to have combined SIADH and hypovolemic
hyponatremia (as evident by low Urine sodium). Underlying
etiology of SIADH unclear. It could be related to active
pulmonary process, but given smoking and cancer history there is
concern there was some concern of malignancy. Pt was treated
with hypertonic saline in the ICU with improvement in her sodium
to 129. She was subsequently started on salt tabs and continued
to be fluid restricted with normalization of her sodium.
Fluoxetine was held as it may have contributed. Na was 137 on
discharge. Her fluid restriction should be adjusted with
treatement of her pneumonia. On discharge she was limited to
1000ml but should be uptitrated to 1.5L. Can continue salt tabs
for now and down titrate.
- Recommend Na check on Thursday [**2178-4-16**] and adjust Fluid
Restriction and Nas Tabs accordingly.
.
# Coronary Artery Disease (s/p MI [**9-/2162**], s/p RCA stent at [**Hospital1 2025**]
[**9-/2162**], s/p LCx stent at [**Hospital1 2025**] [**3-/2163**]): Continued on Atorvastatin,
Metoprolol, Aspirin 81mg
.
# GERD: continued prilosec
.
# Atrial fibrillation: Her coumadin was initially held given a
supratherapeutic INR but was restarted when her INR drifted
below 2. She was continued on a BB and CCB.
- INR was however only 1.2 on discharge and decision was made
not to bridge with heparin. Pt should have INR rechecked on
Friday [**2178-4-16**]
.
CHRONIC ISSUES:
# Hyperlipidemia: Continued lipitor 40 mg po daily
.
# Type 2 Diabetes: Last A1C 6.6% in 8/[**2176**]. Metformin was held
and she was treated with an ISS.
.
# Tobacco Use: The patient was encouraged to stop smoking and
reports that she now intends to quit.
.
# Depression: Held fluoxetine because of SIADH,
- Reconsider restating fluoxetine at rehab if Na is stable.
.
# Hypothyroidism - continued levothyroxine
.
Contact: [**Name (NI) **] [**Name (NI) **] (HCP)
.
TRANSITIONAL ISSUES:
Direct verbal signout was provided directly to the accepting
physician at rehab via phone as well as the patients PCP on
discharge.
Medications on Admission:
Home Medications: may need to be confirmed - these are from omr.
albuterol inhaler/nebulizer
lipitor 40 mg po daily
diltiazem 120 mg po daily
fluoxetine 20 mg po daily
advair 250/50 1 puff [**Hospital1 **]
levothyroxine 25 mg po daily
metformin 850 mg po daily
prilosec 20 mg po daily
warfarin, per coumadin clinic
Discharge Medications:
1. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
2. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours).
3. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
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 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
6. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
7. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
9. metformin 850 mg Tablet Sig: One (1) Tablet PO once a day.
10. prednisone 20 mg Tablet Sig: Two (2) Tablet PO IN AM ().
11. pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
12. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
14. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO
twice a day.
15. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
16. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
17. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)
Discharge Diagnosis:
Primary Diagnosis
- MRSA Pneumonia
- Pseudomonal Pneumonia
- Acute COPD Exacerbation
- SIADH
.
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 [**Hospital1 18**] and found to have low oxygen levels
for which you were treated in an ICU. You are were treated for
pneumonia as well as a COPD exacerbation. Please continue to
take all of your medications.
Followup Instructions:
Department: CARDIAC SERVICES
When: TUESDAY [**2178-6-23**] at 10:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**Telephone/Fax (1) 127**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RADIOLOGY
When: TUESDAY [**2178-12-8**] at 11:30 AM
With: CAT SCAN [**Telephone/Fax (1) 590**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2178-12-8**] at 1:30 PM
With: [**Name6 (MD) 1532**] [**Name8 (MD) 1533**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,429
| 194,278
|
50476
|
Discharge summary
|
report
|
Admission Date: [**2173-11-22**] Discharge Date: [**2173-12-4**]
Date of Birth: [**2096-7-19**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Iodine; Iodine Containing / Lisinopril
Attending:[**First Name3 (LF) 3043**]
Chief Complaint:
DOE, weight gain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 77 yo with PMH significant for ESRD s/p transplant in
[**2170**], CKD with Cr of 2, DM, dCHF presented with DOE,
nonproductive cough and weight gain over the last month. She
presented to her outpatient provider yesterday for these sx's
and was found to desat to 85% on RA with ambulation, so was sent
to the ED.
Pt notes that she has found herself looking bloated (to self and
to sister) and pants felt tighter over last month, though no
dietary changes or indiscretion. Also, for past two weeks, has
had cough at night, non-productive. Very occasionally coughs
during the day. Denies orthopnea, PND, chest pain, fever chills.
Reports she is adherent with all meds. Sleeps with 2 pillows,
this is standard for years. She has never had sx of weight
gain/cough before.
Pt reports that she drinks 4 'jars' of water daily and that this
is steady since 4 years ago, when she was told to stay hydrated
for immunosupression drugs post transplant.
In the ED, CXR showed vascular engorgement. BNP was elevated to
2584.
Patient given nitropaste with some improvement in SOB and
transferred to floor for further management.
ROS:
Denies headache, vision changes, confusion, rhinorrhea,
congestion, sore throat, abdominal pain, nausea, vomiting,
diarrhea, constipation,
All other Review of systems as stated above in HPI.
Past Medical History:
HTN
DMII poorly controlled on insulin (reports takes BS 3x per day,
often high 100s to 200)
ESRD [**2-22**] DM/HTN s/p deceased donor renal transplantation in
[**3-26**].
-baseline Cr 2.0
-last bx [**12-27**]- high proportion of glomeruli sclerosed
-pt reports adherence to immunosuppressive meds
-hemodialysis for 1.5 yrs prior to txplant
-CAD s/p PCI--[**2163**] stenting of the RCA, restented in [**2170**]
-Hypothyroidism
-Hyperlipidemia
Social History:
widow, no children, retired from [**Hospital1 18**], lives with sister and
other family members, cares for [**Age over 90 **] year old mother at home. Able
to exercise with 15-20 minutes walking daily.
Smoking- quit smoking 15 years ago, prior had [**3-24**] cigs/day
ETOH- None
Illicits- None
Family History:
Brother died [**2-22**] cardiac arrest during a kidney transplant
surgery; other siblings with DM and HTN
Physical Exam:
Vitals - T: 98.4 BP:136/58 HR:62 RR:18 02 sat:94 on 3L
GENERAL: Pleasant, obese older woman in NAD
HEENT: Normocephalic, atraumatic. No scleral icterus.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVD of approximately 9cm above RA.
LUNGS: Crackles to midway up lung fields.
ABDOMEN: NABS. Soft, NT, ND. No HSM. No induration, tenderness
to palpation of renal transplant in lower right quadrant. No RLQ
erythema or ecchymoses. No bruits in RLQ.
EXTREMITIES: 1+ edema in lower extremities to knee bilaterally.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Gait
assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
Labs on admission:
WBC 5.2 peaked at 20.9 N66 L18.5 M9.7 E4.6 B1.1
Hct 34.9 MCV 85
Plts 358
Coags 13.1 27.1 1.1
140 97 56
---------------- Gluc 96
5.0 34 3.2
Ca 8.8 Mg 2.3 Phos 4.5
ALT/AST 16/27
LDH 308
CK 200
AlkP 49
Tbili 0.6
BNP 2584
MB's all normal x6
Trop <0.01 rose to 0.29 then back down to 0.14
Random [**Last Name (un) 104**] 26.2
TSH 1.1
Tacro 3.7
Lactates all normal
BK virus and strongyloides pending
BCx negative x6
UCx negative x2
CMV VL negative
DFA influenza negative
[**2173-11-23**] echo
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Left
ventricular systolic function is hyperdynamic (EF 70-80%).
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened. There is no valvular aortic stenosis. The
increased transaortic velocity is likely related to high cardiac
output. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Trivial mitral regurgitation is seen.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2172-8-14**], no major change is evident.
[**2173-11-23**] renal u/s
CONCLUSION: There is new deterioration in vascularization of the
renal
transplant, with markedly decreased diastolic flow, which is now
nearly
absent.The main renal transplant artery and vein are patent. The
most likely
causes for these findings include rejection in the appropriate
clinical
setting, drug toxicity or chronic low flow state.
.
There are two non-obstructing renal calculi.There is no
hydronephrosis.
[**2173-11-25**] CXR
CHEST, TWO VIEWS: Mild cardiomegaly persists. The aorta is
calcified and
tortuous. Mediastinal and hilar contours are normal and
unchanged. There is
cephalization of vessels, peribronchial cuffing and interstitial
edema
consistent with CHF. There is no pleural effusion, focal
consolidation or
pneumothorax.
Brief Hospital Course:
77F with PMH significant for ESRD s/p transplant in [**2170**], CKD
with Cr of 2, DM, diastolic CHF presented with DOE,
nonproductive cough and weight gain over the last month. Wet
crackles halfway up and bilateral LE edema; consistent with
first presentation of decompensated dCHF. Creatinine increase
off baseline on presentation, now returned to baseline,
transplant team following, feels transplant intact. She was
transferred to the MICU on [**11-27**] in respiratory failure and
managed with BiPAP and diuresis. She was trasnferred back to
the general medicine service [**11-30**]. Detailed hospital course by
problem.
# ICU course/respiratory failure/hypoxia: Patient admitted with
respiratory failure in the setting of nausea, vomiting and
elevated systolic blood pressures. Her initial ABG was
7.25/72/130/33 and she was started on BiPAP for acute
respiratory acidosis. She is a difficult stick and was followed
with VBGs. Her blood pressure was controlled with metoprolol
and she was diuresed further with a lasix drip. She was taken
off of BiPAP 11/09 when she was clinically improved. Her O2
sats were 93-95% on 4L by nasal cannula with a VBG of 7.38/CO2
72/O2 56/HCO3 44 at the time of transfer back to the floor. This
ABG was done while she was completely asymptomatic, and may be
her baseline. Her lung crackles on exam were stable and
unchanged throughout this time. At the time of discharge, she
still had a mild oxygen requirement (1-2L) to maintain O2 sats
>92%. She had an ABG done prior to discharge which was
7.48/55/64/42 consistent with a metabolic alkalosis with
respiratory compensation likely in the setting of significant
diuresis. She had a chest CT which was done prior to discharge
as well which showed some ground glass opacities which may be
consistent with pulmonary edema and some bronchial dilation
which may be seen in this age group. She will be seen in
pulmonary clinic with Dr. [**Last Name (STitle) **] in 1 month with PFTs to
evaluate any upderlying lung disease which may be present as
well. Room air saturations will be checked by VNA but also
should be checked by outpatient providers in clinic as well.
# CAD with recent NSTEMI: The patient had elevated troponins
from 0.01 on admission to 0.29 in the setting of her admission
to the ICU. She has known CAD s/p stenting. Her EKG was stable
and she did not have chest pain. She was started on an NSTEMI
protocol with heparin drip, aspirin 325mg and plavix loading and
cardiology was consulted. They felt this was mostly due to
cardiac strain and may have been worsening her diastolic failure
but did not feel that intervention was necessary. She stayed on
the heparin drip for 48 hours and was transitioned back to her
home medications of aspirin, metoprolol, and atorvastatin. Trops
trended down to 0.14 by time of d/c from MICU. She is being
discharged on Aspirin 325 mg daily, but should be transitioned
as an outpatient back to 81 mg daily for secondary prevention.
#. Transplant pyelonephritis: the patient had fever to 101.8,
bacteriuria, and pain over her graft site, suggesting
pyelonephritis. Her WBC count was 20 on [**11-26**] and pt was started
on vanc/cefepime and her urine culture was negative, though it
was drawn after antibiotics. Her WBC count trended down on ABx
and so they were continued on transfer to MICU. Her fever curve
trended down through MICU admission. The ID team was consulted.
Given her negative MRSA screen she was narrowed to cefepime only
with the course of 7 days completed during her hospitalization.
Her repeat UA did not show any evidence of infection, and at the
time of discharge, she was afebrile and asymptomatic.
#. Acute on Chronic Diastolic Heart Failure:
Pt initially difficult to diurese with IV Lasix and started on
gtt. No longer edema in LEs but still crackles in lung bases.
Per nephrologist to whom pt is well known, pt has rales at
baseline, so may be difficult to assess fluid status on this
basis. Pt not on home O2; desat to 84% on ambulation suggests
may still have some pulmonary edema vs some other intrinsic
pulmonary process. She was transitioned to Furosemide 80 mg
daily with metolazone 2.5 mg daily for maintenance diuresis. She
will continue on Norvasc, Atorvastatin, Toprol, and aspirin. Her
valsartan was initially held in the setting of her [**Last Name (un) **] on CKD,
though was restarted at the time of discharge with stable
creatinine.
#.Acute on chronic kidney injury s/p renal transplant [**2170**]: Most
likely due to poor forward flow in the setting of diastolic CHF.
Admitted with Cr in the 3's and while in the ICU, the patient's
Cr improved to 1.6 with diuresis. Her tacrolimus trough was low
at 3.6, so her dose was increased to 3mg [**Hospital1 **]. She was also
continued on home dose Cellcept. BK virus and CMV negative.
#.Hypothyroidism: TSH this admission 1.1 and pt was continued on
current dose of 88mcg daily.
#.Dyslipidemia: She will continue on fenofibrate and
atorvastatin.
# Diabetes type 2: Given episodes of hypoglycemia initially, her
insulin regimen was adjusted multiple times. At the time of
discharge, she is being discharged on insulin NPH 30 units [**Hospital1 **]
and humalog 6 units with breakfast/dinner.
# HTN: Currently on Metoprolol, amlodipine, valsartan, and
furosemide as above
# Diet: fluid restriction, low salt diet
# CODE: Full
# CONTACT: patient, sister [**Name (NI) **] [**Telephone/Fax (1) 105147**] (work) cell
[**Telephone/Fax (1) 105148**]
# DISPO: to home with home oxygen and VNA services
Medications on Admission:
Humalog insulin 15 units [**Hospital1 **]
NPH 36 units QAM, 36 units QPM
Cell cept 1000mg [**Hospital1 **]
tacrolimus 1.5mg [**Hospital1 **]
Bactrim 80-400 one daily
levothyroxine 88mcg daily
Norvasc 10mg daily
atorvastatin 20mg daily
Toprol XL 100mg daily
Diovan 160mg daily
furosemide 40mg daily
fenofibrate 144mg daily
ergocalciferol 50,000 units Qmonth
albuterol PRN
Os-Cal D 2 tabs daily
ASA 325mg daily
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 DAILY (Daily).
3. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day.
8. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Thirty
(30) units Subcutaneous twice a day.
9. Insulin Lispro 100 unit/mL Solution Sig: Six (6) units
Subcutaneous twice a day: to be taken with breakfast and dinner.
10. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
Disp:*180 Capsule(s)* Refills:*2*
12. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Oxygen
1L/min continuous flow portable oxygen to maintain O2 sat
greater than 92%; Room air sat 84% during inpatient stay
Diagnosis: diastolic heart failure
15. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Acute on Chronic Diastolic Heart Failure
Acute Renal Failure on Chronic Kidney Disease stage 4
Urinary Tract infection
Discharge Condition:
stable, requiring 1L oxygen to maintain sats >92%
Discharge Instructions:
You were admitted to [**Hospital1 18**] for shortness of breath. You were
found to be in heart failure. There was no evidence of a heart
attack, and the ultrasound of your heart was unchanged. It is
likely due to salt and water intake, and not enough furosemide
at home. We have increased your dose, as noted below. You
should weigh yourself daily and monitor your weights.
You also had some mild renal failure on your labwork. It
improved with the furosemide, though still was slightly elevated
at the time of your discharge. You should have repeat
electrolytes next week when are seen in your doctor's office.
During your hospitalization, you had a urinary infection which
was treated with a 7 day course of antibiotics while you were
here. You also had a short stay in the ICU due to significant
decreased oxygen saturations. During your hospitalization, you
also had a CT of your chest which showed possibly some more
fluid your lungs.
The following medication changes were made:
1) Furosemide 80 mg daily
2) Tacrolimus 3 mg twice daily
3) Metolazone 2.5 mg daily
4) Valsartan 80 mg daily
Please keep all scheduled appointments.
If you develop any of the following concerning symptoms, please
call your PCP or go to the ED: fevers, chills, nausea, vomiting,
decreased urine output, or difficulty breathing and worsening
swelling in your legs.
Followup Instructions:
Appointment #1
MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP
Specialty: PCP
Date and time: Tuesday, [**12-7**] at 2:00pm
Location: [**Hospital3 **] - [**Location (un) **], [**Hospital Ward Name 23**]
Bldg, [**Location (un) 895**], [**Location (un) 86**], MA
Phone number: [**Telephone/Fax (1) 250**]
Special instructions if applicable: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] is the Nurse
Practitioner you will see in [**Company 191**].
Appointment #2
MD: [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **], MD
Specialty: Pulmonary
Date and time: [**2174-1-11**] at 2:30 PM
Location: Medical Subspecialties: Pulmonary - [**Location (un) **],
[**Hospital Ward Name 23**] Bldg, [**Location (un) **], [**Location (un) 86**], MA
Phone number: [**Telephone/Fax (1) 612**]
Special instructions if applicable: Please show up to your appt
at 2:30 for pulmonary function testing prior to your visit with
Dr. [**Last Name (STitle) **] at 3 PM
Appointment #3
MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Specialty: Cardiology
Date and time: Tuesday, [**12-7**] at 2:00pm
Location: [**Location (un) **], [**Location (un) **], [**Location (un) 86**], MA
Phone number: [**Telephone/Fax (1) 62**]
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5250**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2174-1-11**] 2:00
|
[
"584.9",
"412",
"250.80",
"518.81",
"996.81",
"V45.82",
"276.4",
"272.4",
"V15.82",
"428.33",
"585.5",
"590.80",
"244.9",
"E878.0",
"414.01",
"410.71",
"E932.3",
"V58.67",
"403.91",
"592.0",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12991, 13048
|
5540, 11086
|
331, 338
|
13211, 13263
|
3371, 3376
|
14672, 16144
|
2484, 2592
|
11546, 12968
|
13069, 13190
|
11112, 11523
|
13287, 14649
|
2607, 3352
|
275, 293
|
366, 1690
|
3391, 5517
|
1712, 2156
|
2172, 2468
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,828
| 150,500
|
16183
|
Discharge summary
|
report
|
Admission Date: [**2138-2-26**] Discharge Date: [**2138-3-2**]
Service: CT [**Doctor First Name 147**]
HISTORY OF PRESENT ILLNESS: This 81 year old female with
known mitral valve prolapse for greater than 60 years and a
ten year history of dyspnea on exertion was admitted in
[**2137-9-15**] with congestive heart failure and pulmonary
edema. She was followed by Cardiology, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **],
for her mitral regurgitation.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Mitral regurgitation.
3. Chronic bronchitis.
4. Spinal stenosis.
5. Kyphosis.
6. Osteoporosis.
7. Paroxysmal atrial fibrillation.
8. Status post sinus surgery.
9. Status post tonsillectomy and adenoidectomy.
ALLERGIES: She had no known drug allergies.
MEDICATIONS AT THE TIME OF PREADMISSION TESTING:
1. Fosamax 70 mg p.o. q. day.
2. Atenolol 50 mg p.o. q. day.
3. Monopril 20 mg p.o. q. day.
4. Calcium.
5. Centrum vitamins.
6. Aspirin.
LABORATORY: Catheterization data revealed a left ventricular
ejection fraction of 58% with a pulmonary capillary wedge
pressure of 16, an left ventricular end diastolic pressure of
17, four plus mitral regurgitation; one to two plus aortic
regurgitation and no coronary artery disease.
REVIEW OF SYSTEMS: She denied any cerebrovascular accident
or transient ischemic attack symptoms. She had no history of
gastrointestinal bleed. She did have exertional dyspnea and
palpitations. No history of claudication, anemia or bleeding
problems.
PHYSICAL EXAMINATION: On examination, her blood pressure
was 101/57; respiratory rate 12; room air saturation of 97%
with sinus bradycardia at 57. She was alert and oriented and
neurologically grossly intact. She had a Grade IV-V/VI
holosystolic murmur and her heart was regular rate and
rhythm. Her breath sounds were clear bilaterally without any
wheezes, rhonchi or rales. She had positive bowel sounds.
Her abdominal examination was benign with no masses
appreciated. Her extremities were warm and well perfused
with two plus pulses throughout. Her carotids had no bruits
bilaterally.
She was referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] for mitral valve repair
versus replacement.
PREOPERATIVE LABS: On [**2-10**] showed a white blood cell
count of 7.1, hematocrit 39, platelet count 161,000. Sodium
143, potassium 4.6, chloride 102, carbon dioxide 31, BUN 19,
creatinine 1.0. INR was 0.9.
HOSPITAL COURSE: On [**2-26**], she underwent a mitral
valve annuloplasty repair by Dr. [**Last Name (STitle) 1537**] with a 26 millimeter
[**Doctor Last Name 405**] band. She also had inversion and suturing of her
left atrial appendage. She was transferred to the
Cardiothoracic Intensive Care Unit on a Propofol drip for
titration and Neo-Synephrine drip, in stable condition.
On postoperative day one, she had been extubated over that 24
hour period, was in sinus rhythm in the 70s with a blood
pressure of 96/32, central venous pressure 11, and cardiac
index of 2.7. She had a saturation of 97% on three liters,
remained on a Neo-Synephrine drip at 1 mic per kilo per
minute, started her aspirin again, was taking morphine for
pain control.
Postoperative labs as follows: White blood cell count of
13.3, hematocrit 29.3, platelet count 105,000. Sodium 134,
potassium 4.6, chloride 106, carbon dioxide 24, BUN 13,
creatinine 0.6 with a blood sugar of 156. She was
comfortable on examination. Her lungs were clear. Her heart
was regular in rate and rhythm. The Neo-Synephrine continued
to be weaned and her diet was advanced as tolerated. As soon
as her Neo was to be weaned, Lasix diuresis was begun and the
patient continued on her perioperative antibiotics.
Overnight on postoperative day one, the patient's urine
output dropped slightly. Her pacing rate was decreased to
allow her to intrinsically pace herself at a faster rate.
Neo-Synephrine drip was started to increase her blood
pressure and urine output. She was given some Hespan also on
postoperative day two as her neo-synephrine was back down to
0.5 with a blood pressure of 105/29 in sinus rhythm at 72.
She finished her antibiotics. White count came down to 12.7.
Potassium was 4.4, BUN 14, creatinine 0.5. She had decreased
lung sounds at the bases, but her heart was regular in
rhythm. Her examination was otherwise benign with attempts
continuing to be made to wean her neo-synephrine and she
remained in the Cardiothoracic Intensive Care Unit.
On postoperative day, she was transfused one unit of packed
red blood cells in the morning. Her blood pressure responded
appropriately with the volume and the Neo-synephrine was
weaned to off. The patient was out of bed and moving in the
Intensive Care Unit, and was transferred out of the Intensive
Care Unit to the floor on postoperative day two, alert and
oriented.
She was seen by Physical Therapy for evaluation and to
continue ambulation. On postoperative day three, she had no
events overnight, had a good blood pressure, was
hemodynamically stable, saturating at 92% on room air, with
good urine output. Her heart was regular rate and rhythm.
Her lungs were clear. She had trace peripheral edema. Her
chest tubes were pulled. Her pacing wires were discontinued.
She continued working out of bed with Physical Therapy. Her
incisions were clean, dry and intact and she was using
incentive spirometry for pulmonary toilet.
She continued to ambulate and increased to a level four. She
did have a couple of premature ventricular contractions but
remained stable with no additional ectopy. On the day of
discharge, postoperative day four, her lungs were clear. She
had no edema. Her heart was regular rate and rhythm with a
blood pressure of 120/64; sinus rhythm at 76. She continued
to ambulate to a level five and was discharged from the
hospital on postoperative day four in stable condition.
DISCHARGE DIAGNOSES:
1. Status post mitral valve repair with annuloplasty and
inversion and ligation of left atrial appendage.
2. Status post mitral regurgitation.
3. Hypertension.
4. Chronic bronchitis.
5. Spinal stenosis.
6. Kyphosis.
7. Osteoporosis.
8. Paroxysmal atrial fibrillation.
9. Prior moderate pulmonary hypertension.
10. Status post sinus surgery.
11. Status post tonsillectomy and adenoidectomy.
DISCHARGE MEDICATIONS: ([**Location (un) 1131**] from dictation by Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **])
1. Metoprolol 12.5 mg p.o. twice a day.
2. Colace 100 mg p.o. twice a day.
3. Aspirin 325 mg p.o. q. day.
4. Tylenol 325 mg times two, p.o. p.r.n. q. four hours for
pain.
5. Ibuprofen 400 mg p.o. p.r.n. q. six hours as needed.
6. Percocet 5/325 mg, one tablet p.o. p.r.n. q. four hours
as needed for pain.
7. Lasix 20 mg p.o. q. day.
8. Sennosides A and B, calcium 8.6 tablet, one tablet p.o.
Twice a day.
DISCHARGE STATUS: The patient was discharged to home.
CONDITION ON DISCHARGE: Stable condition.
DISCHARGE INSTRUCTIONS:
1. To follow-up with Dr. [**Last Name (STitle) 1537**] in approximately three to four
weeks for postoperative appointment.
2. To follow-up with her primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], in his office in approximately two weeks.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 76**]
MEDQUIST36
D: [**2138-7-14**] 11:58
T: [**2138-7-18**] 17:43
JOB#: [**Job Number **]
|
[
"496",
"416.0",
"396.3",
"398.91",
"428.0",
"733.00",
"401.9",
"724.00",
"737.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.12"
] |
icd9pcs
|
[
[
[]
]
] |
5944, 6344
|
6368, 6955
|
2492, 5923
|
7024, 7614
|
1547, 2473
|
1287, 1523
|
143, 479
|
501, 1267
|
6981, 7000
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,623
| 199,033
|
39084
|
Discharge summary
|
report
|
Admission Date: [**2189-2-12**] Discharge Date: [**2189-2-21**]
Date of Birth: [**2145-6-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
ascending Aortic aneurysm
Major Surgical or Invasive Procedure:
Bental Procedure (29mm Frestyle aortic valve),MAZE, ligation of
left atrial appendage
History of Present Illness:
This 43 year old white male has a known ascending aortic
aneurysm measuring 5 cm. H erecently developed abdominal pain
and required a laparoscopic cholecystectomy. He is admitted now
for Heparin bridging prior to aortic valve/ascending replacement
and MAZE.
Past Medical History:
Hypertension
Hyperlipidemia
Morbid obesity
non insulin dependent Diabetes Mellitus
chronic Atrial Fibrillation
Obstructive sleep apnea
Hypothyroidism
Depression
s/p Laparoscopic Cholecystectomy
s/p Tonsillectomy
s/p Bilateral carpal tunnel surgery
s/p left foot surgery
Social History:
Race: Caucasian
Last Dental Exam: [**11-22**] yrs ago
Lives with: wife
Occupation: [**Name2 (NI) **]
Tobacco: remote, quit 20 yrs ago
ETOH: denies use since [**96**] yrs ago
Family History:
non contributory
Physical Exam:
Admission:
Pulse: 95 Resp: 20 O2 sat: 96%
B/P Right: 111/82 Left: 119/75
Height: Weight: 319 lbs
General: well-developed obese male
Skin: Dry [X] intact [X] multiple skin tags
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema: trace
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 2+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: - Left: -
Pertinent Results:
[**2189-2-19**] 04:45AM BLOOD WBC-9.7 RBC-3.16* Hgb-10.0* Hct-29.0*
MCV-92 MCH-31.7 MCHC-34.5 RDW-13.1 Plt Ct-112*
[**2189-2-18**] 02:16AM BLOOD WBC-7.5 RBC-3.49* Hgb-10.6* Hct-31.5*
MCV-90 MCH-30.3 MCHC-33.5 RDW-13.0 Plt Ct-123*
[**2189-2-20**] 05:05AM BLOOD PT-13.7* INR(PT)-1.2*
[**2189-2-19**] 08:40AM BLOOD PT-13.3 PTT-26.5 INR(PT)-1.1
[**2189-2-18**] 02:16AM BLOOD PT-13.2 PTT-29.1 INR(PT)-1.1
[**2189-2-20**] 05:05AM BLOOD UreaN-22* Creat-0.7 K-4.6
[**2189-2-19**] 04:45AM BLOOD Glucose-124* UreaN-16 Creat-0.7 Na-135
K-4.7 Cl-102 HCO3-28 AnGap-10
[**2189-2-21**] 06:55AM BLOOD PT-15.6* INR(PT)-1.4*
Brief Hospital Course:
Following admission he was begun on Heparin and cCoumadin
discontinued. Dental clearance was necessary as were several
extractions prior to his cardiac procedure. After the
extractions he remaianed stable. On [**2-17**] he was taken to
the Operating Room where MAZE, a Bental procedure with a 27mm
Freestyle root valve and ligation of the left atrial appendage
were performed. He tolerated the operation well and was taken
to the ICU on Neo Synephrine and Propofol infusions in stable
condition. He awoke intact, was weaned from the ventilator and
pressors without problems.
He was transferred to the floor, where Physical Therapy worked
with him for strength and mobility. Coumadin was resumed for
atrial fibrillation, which persisted after surgery. CTs and
tempraory pacing wires were removed according to protocols.
He was ambulatory, wounds were clean and healing well after
surgery. Dr. [**First Name (STitle) 4553**] will continue to follow his Coumadin
after discharge (hospital INRs and Coumadin doses were faxed)
and the target INR is [**12-24**]. He is to take Coumadin 7.5mg [**2-21**] and
5mg [**2-23**].
Arrangements were made for follow up, medicatins were discussed
as well.
Medications on Admission:
Atenolol 100 qAM, 50qPM
Enalapril 10mg qd
Prozac 20mg qd
Metformin 500mg [**Hospital1 **]
Nasonex
Simvastatin 40mg qd
Coumadin- held since [**2-8**]
Ambien CR 10mg hs
synthroid 75 mcg qd
Discharge Medications:
1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 4 weeks.
Disp:*56 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever/pain.
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): two tablets twice daily for 4 weeks then one tablet
twice daily for 4 weeks. Then as directed by Dr. [**Last Name (STitle) 29908**].
Disp:*120 Tablet(s)* Refills:*2*
8. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal [**Hospital1 **] (2 times a day).
9. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
12. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: as
directed by dr.[**First Name4 (NamePattern1) 4553**] [**Last Name (NamePattern1) 86627**] with 4mg tablets.
16. Warfarin 4 mg Tablet Sig: as directed Tablet PO once a day:
alternate with 5mg tablets as directed by Dr. [**First Name (STitle) 4553**].
17. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] [**Hospital **] Home Health
Discharge Diagnosis:
Ascending Aortic Aneurysm
morbid obesity
hypertension
hyperlipidemia
chronic atrial fibrillation
hypothyroidism
depression
s/p cholecystectomy
s/p carpal tunnel surgery
s/ptonsillectomy
noninsulin dependent diabetes mellitus
obstructive sleep apnea
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating, gait steady
Sternal pain managed with Percocet 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:
Dr. [**Last Name (STitle) 914**] on Tues, [**3-3**] at 2PM ([**Telephone/Fax (1) 170**])
Please call for appointments:
Dr. [**Last Name (STitle) 39975**] in 4 weeks
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4553**] in [**11-22**] weeks ([**Telephone/Fax (1) 86628**])
Coumadin will continue to be monitored by Dr. [**First Name (STitle) 4553**] (FAX
[**Telephone/Fax (1) 86629**])
Completed by:[**2189-2-21**]
|
[
"424.1",
"250.00",
"429.89",
"277.7",
"401.9",
"V58.61",
"746.4",
"311",
"272.4",
"E878.2",
"285.9",
"327.23",
"278.01",
"244.9",
"427.31",
"521.00",
"441.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"23.09",
"39.59",
"35.21",
"39.61",
"38.45",
"37.36"
] |
icd9pcs
|
[
[
[]
]
] |
6006, 6080
|
2591, 3794
|
346, 434
|
6373, 6470
|
1960, 2568
|
7011, 7449
|
1225, 1243
|
4032, 5983
|
6101, 6352
|
3820, 4009
|
6494, 6988
|
1258, 1941
|
281, 308
|
462, 723
|
745, 1017
|
1033, 1209
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,350
| 196,931
|
6000
|
Discharge summary
|
report
|
Admission Date: [**2106-5-18**] Discharge Date: [**2106-6-9**]
Date of Birth: [**2039-6-30**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
cerebral angiogram [**2106-5-18**] Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Bilateral burr holes for evacuation of SDH
repeat cerebral angiogram [**2106-6-8**]
History of Present Illness:
This is a 66 year old man with a history of HTN, CAD, and DM
Type I, who presented with altered mental status, fever, and
elevated WBC. He was given triple antibiotics in the ER. His EKG
and troponin were negative for any cardiac events. The patient's
head CT revealed significant SAH in the Circle of [**Location (un) 431**].
Neurosurgery was consulted for further evaluation. The patient
reported no headache, dizziness, visual changes, numbness,
tingling, SOB, or chest pain. He did say, "I feel confused."
Past Medical History:
DIABETES MELLITUS [**2053**]
COLONIC POLYPS [**2099**]
CORONARY ARTERY DISEASE [**2093**]
HYPERTENSION
UMBILICAL HERNIA
ELEVATED PSA [**12/2103**]
Social History:
He lives alone and has sister who lives in [**Name (NI) 108**].
Family History:
3 brothers died of MIs, father died of MI, no history of
aneurysms.
Physical Exam:
PHYSICAL EXAM on Admission:
T:100.1 BP:110/66 HR:88 RR:18 O2Sats:100%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs-intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-3**] 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, 3 to 2 mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-5**] throughout. No pronator drift.
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Upon Discharge:
Alert to self
PERRL 4-3mm bilaterally
Face symmetrical
tongue midline
Motor: Full in BUE, [**4-5**] BLE, [**3-5**] R AT and [**Last Name (un) **]
Incision: c/d/i- no hematoma
Pertinent Results:
CTA Head [**2106-5-18**]:
Subarachnoid hemorrhage centered in the suprasellar cistern.
Dilation of
lateral and 3rd ventricles, concerning for hydrocephalus. No
definite aneurysm seen.
CT Torso [**2106-5-18**]:
1. Suboptimal bolus of the pulmonary arterial vasculature
slightly limiting evaluation. However, no evidence of central or
segmental pulmonary embolism. Cannot exclude small subsegmental
emboli.
2. No acute intra-abdominal or intrapelvic pathology.
MRI/MRA [**2106-5-22**]:
The head MRA demonstrates minimal irregularity of the mid
basilar artery which could be artifactual. Otherwise, the MRA is
normal for the arteries of anterior and posterior circulation.
No abnormal vascular structures are seen.
IMPRESSION: No significant abnormalities on MRA of the head.
MRA OF THE NECK:
The neck MRA demonstrates normal flow in the carotid and
vertebral arteries.
IMPRESSION: Normal MRA of the neck
CT head [**2106-5-24**]:
New blood along falx and cerebellar tentorium (this could be [**2-2**]
redistribution). bilat subdural collection-hemorrhage unchanged
since [**5-22**] but increased since [**5-19**]. Suprasellar hemorrhage
extending to cerebral cisterns and left sylvian fissure grossly
stable since [**5-22**]. 4mm midline shift, quadrogeminal plate
cistern effacement and mass effect on cerebral sulci stable
since [**5-22**] but increased since [**5-19**].
CAROT/CEREB [**Hospital1 **] [**2106-6-8**]
Aneurysm negative
Brief Hospital Course:
This is a 66 year old man who was admitted for a SAH after being
found to have mental status changes. A CTA upon arrival showed
SAH along the Circle of [**Location (un) 431**], but no aneurysm could be seen.
He was admitted to the ICU for close observation and started on
Nimpodipine and Keppra. On [**2106-5-18**] he underwent a diagnosit
cerebral angiogram which was negative for aneurysmal cause of
SAH.
On [**5-19**], the patient was observed to have a L facial droop, but
speech, strength, and mental status remain intact. A CTA was
ordered to r/o stroke and patient will remain in ICU. CTA was
negative for stroke but revealed interval development of
intermediate attenuation extraaxial collection, therefore an MRI
was ordered. A PICC was placed for difficult IV access. CXR
revealed developing pneumonia and he was started on levaquin.
On [**5-20**] the patients respiratory status declined requiring
intubation and Azithromycin was added to his antibiotic regimen.
Patient's neurological exam was stable except for marked
facial/scleral edema/redness which limited lateral ocular mvmts.
Previous facial droop has since resolved.
On [**5-21**], patient remained intubated, but follows commands and is
full strength off sedation. Repeat chest x-ray showed no change
from previos scan and ID changed abx to vanc/zoysn. MRI/MRA
showed no new abnormalities.
CT on [**5-24**] was relatively stable with redistribution of blood
along the falx and tentorium.
On [**5-25**] pt's Keppra was discontinued. Infectious Disease
recommending thoracentesis.
On [**5-26**], patient's exam declined, he was only opening his eyes
but not following commands. MRI/MRA was order to rule out acute
infarct and vasospasm. A CT of the chest was also ordered to
access fluid in lungs per ID. MRI/MRA results showed no infarct
or vasospasm. Neurology was consulted and questioned if B SDH
was causing increased pressure in the brain and if it should be
drained. Patient continued to be febrile while on abx.
On [**5-28**], patient was taken to the OR for bilateral burr holes to
evacuate SDHs. Pre-operatively exam was patient's eyes open to
voice and sticks tongue out to command. Bilateral withdrawl in
LE to noxious stimuli.
On [**6-1**], patient's exam improved, he was more alert but not
following commands. The question of trach and PEG was brought up
with HCP.
On [**6-2**] patient was following commands and wiggling toes as well
as showing a thumbs up. He was extubated and did well with a
face tent. He was then transferred to step down. Speech and
swallow was consulted and placed patient on a diet. His exam
continued to improved as he worked with PT.
On [**6-8**], patient was taken for a repeat angiogram. Angiogram was
negative for aneurysmal cause of hemorrhage. Patient post
operatively remained stable. He was alert to self, moving all
extremities. Incision was clean, dry and intact with no hematoma
or staining. Patient was screened for rehab on [**6-9**] and
discharged to [**Hospital1 **].
Medications on Admission:
ATENOLOL - 100 mg Tablet - 1 Tablet(s) by mouth once a day bp
ATORVASTATIN - 80 mg Tablet - 1 Tablet(s) by mouth at night
CLOMIPHENE CITRATE [CLOMID] - (Prescribed by Other Provider) -
50 mg Tablet - 1 (One) Tablet(s) by mouth once a day
HYDROCHLOROTHIAZIDE - 12.5 mg Tablet - 1 Tablet(s) by mouth
daily
For Blood Pressure
INSULIN LISPRO [HUMALOG] - Dosage uncertain
LISINOPRIL - 40 mg Tablet - 2 Tablets (80mg) by mouth once a day
ASPIRIN - 325 mg Tablet - 1 Tablet(s) by mouth once a day
FOLIC ACID - 0.8 mg Tablet - 1 Tablet(s) by mouth once a day
MULTIVITAMIN - (update) - Tablet - 1 Tablet(s) by mouth daily
NPH INSULIN HUMAN RECOMB [HUMULIN N] - 100 unit/mL Suspension -
twice a day
OMEGA-3 FATTY ACIDS [FISH OIL] - 1,200 mg-144 mg Capsule - 1
(One) Capsule(s) by mouth twice a day
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
4. Lisinopril 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
5. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
9. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
11. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times
a day).
12. Hydralazine 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for wheezing.
15. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
16. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. Famotidine 20 mg IV Q12H
18. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
19. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
20. Lorazepam 0.5 mg IV Q4H:PRN agitation
21. 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.
22. Insulin Glargine 100 unit/mL Solution Sig: Forty Four (44)
units Subcutaneous at bedtime.
23. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every
4 hours) for 1 days.
24. Insulin Regular Human Injection
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
SAH
Bilateral SDH
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:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
Followup Instructions:
Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in 4 weeks with a
noncontrast head CT.
Please call Takeisha for a appointment at [**Telephone/Fax (1) 4296**]
Completed by:[**2106-6-9**]
|
[
"507.0",
"293.0",
"781.94",
"715.90",
"518.81",
"430",
"V12.72",
"250.01",
"401.9",
"276.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6",
"01.31",
"38.91",
"96.72",
"88.41",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
10260, 10330
|
4316, 7322
|
338, 521
|
10392, 10392
|
2853, 4293
|
11117, 11338
|
1329, 1399
|
8165, 10237
|
10351, 10371
|
7348, 8142
|
10570, 11094
|
1414, 1428
|
277, 300
|
2658, 2834
|
549, 1061
|
1977, 2642
|
1442, 1685
|
10407, 10546
|
1083, 1232
|
1248, 1313
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,836
| 164,413
|
37793
|
Discharge summary
|
report
|
Admission Date: [**2153-10-9**] Discharge Date: [**2153-10-18**]
Date of Birth: [**2094-10-2**] Sex: M
Service: NEUROLOGY
Allergies:
Iodine-Iodine Containing
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Vertigo, double vision, tinnitus, headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
PER ADMITTING RESIDENT:
HPI: 59 M w/ hx prior MI, GERD, anxiety, and QOD spells of
vertigo, diplopia, sense of imbalance, and HA, was at work today
working on a computer when he felt sudden vertigo, ringing in L
ear, and a sense of dyscoordination. He felt as though he were
unable to coordinate either arm and endorses trouble reaching
with either arm to get the phone to call for help. At this time
he felt like there was an overall sense of doom and as though he
would die. He also endorses sx of horizontal binocular diplopia,
worse on distant gaze and possibly on R gaze, as well as N/V. He
feels there is some very slight dysarthria. He currently feels a
HA behind both of his eyes, described as a pressure sensation,
non-throbbing. The HA started some time after the other
symptoms.
There is also a sense of pins and needles tingling in the B/L
fingertips as well as his upper lip. He is uncertain whether it
also involved his lower lip, and at the time of exam, it is
dissipating. He denies any focal weakness or difficulty
producing
or understanding language.
Of note, he has experienced bizarre episodes approx every
other day for the last 5 years with a one year hiatus in the
middle. He describes the episodes as vertigo, a sense of
imbalance, and visual changes, described first as a "prism
effect" in both eyes that morphs to horizontal diplopia, and
usually lasts on the order of 12 minutes before dissipating.
Initially there was never any HA associated with these, but he
states more recently, it is not uncommon for these sx to end
with
a HA, typically behind his eyes. It is usually pressure, not
throbbing, but can be assoc with photophobia. Additionally, he
notes that bright lights can be a trigger for these episodes. He
cannot clearly define other triggers, though he feels
possibilites include stress and sometimes positional changes,
such as bending over. He has been evaluated for these in the
past
and completed an MRI at Shields about 1 month ago that he
reports
was normal.
Past Medical History:
- MI
- GERD
- anxiety
- QOD spells of vertigo, diplopia, sense of imbalance, and HA
Social History:
HABITS:
- Denies EtOH and drug use.
- Former tobacco 1 ppd x 15 years, but quit at age 30.
Family History:
Mother with stroke at age 88. Father was electrocuted.
Physical Exam:
ON ADMISSION:
T- not recorded, tactilely afebrile BP- 148/86 HR - 77 RR- 23
O2Sat 100% 1 L NC
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no c/c/e; equal radial and pedal pulses B/L
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Attentive, says
DOW backwards. Speech is fluent with normal comprehension and
repetition; naming intact. No dysarthria. [**Location (un) **] and writing
intact. Registers [**3-20**], recalls [**2-20**] in 5 minutes. No right left
confusion. No evidence of apraxia or neglect. Of note, during
exam, pt has a seconds-long episode where he was gazing off to
the R, seemed to lose attention, but responded appropriately
when
asked his name and location and broke his gaze.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Visual fields are full to confrontation.
Extraocular
movements intact bilaterally, (+) B/L horizontal nystagmus, more
prominent on R and with some intermittent down and left
component
on L gaze. Sensation intact V1-V3 to LT and PP. Facial movement
symmetric. Hearing intact to finger rub bilaterally, though
endorses ongoing L ear tinnitus. Palate elevation symmetrical.
Sternocleidomastoid and trapezius normal bilaterally. Tongue
midline, movements intact
Motor:
Normal bulk bilaterally. Somewhat increased tone in RLE. (+)
intermittent RUE tremor, almost appears pill-rolling
No pronator drift
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch, pinprick, and proprioception
throughout. No extinction to DSS
Reflexes:
+2 and symmetric throughout.
Toes downgoing bilaterally
Coordination: finger-nose-finger normal, heel to shin normal; FT
and RAMs normal.
Gait: Very reluctant to complete. Ultimately, narrow based, but
hesitant, small steps, but steady. reports feeling generalized
weakness.
Romberg: Negative
Pertinent Results:
WBC-7.4 RBC-5.50 Hgb-16.0 Hct-48.3 MCV-88 13.7 Plt Ct-276
PT-12.6 PTT-19.0* INR(PT)-1.1
UreaN-19 Creat-1.0
ALT-35 AST-22 CK(CPK)-69 AlkPhos-79 TotBili-0.3
TotProt-7.4 Albumin-4.6 Globuln-2.8 Calcium-9.5 Phos-3.0 Mg-2.2
ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
Glucose-123* Na-143 K-3.7 Cl-102 calHCO3-24
ALT 35, AST 22, Alk Phos 79, Tbil 0.3
.
Discharge Labs:
INR 1.8
.
Imaging:
CT HEAD W/O CONTRAST ([**2153-10-9**])
IMPRESSION: No acute intracranial process.
.
CT Head without contrast ([**2153-10-10**]):
.IMPRESSION:
1. Left cerebellar infarct causing mild amount of mass effect on
the fourth ventricle. No evidence of hydrocephalus at this time.
CT Head without contrast ([**2153-10-11**]):
IMPRESSION:
1. No significant change in large left cerebellar infarct with
adjacent mass effect upon the fourth ventricle.
.
MRA BRAIN W/O CONTRAST ([**2153-10-9**])
IMPRESSION:
1. Acute left cerebellar hemisphere infarct involving the entire
left PICA, majority of AICA, and some of the superior cerebellar
artery territories.
2. Irregularity involving the intradural segment of the left
vertebral artery as well as basilar artery likely representing
either atherosclerotic change or thrombus causing partial
occlusion.
3. Irregularity involving the posterior cerebral arteries likely
representing atherosclerotic change.
4. Narrowing of the right vertebral artery in its V3/V4 segment
demonstrates irregular narrowing and appears to terminate at the
PICA, however, the irregularity of this raises concern for
atherosclerotic change involving the proximal V4 segment.
.
EEG ([**2153-10-10**]):
IMPRESSION: Normal EEG in the waking state. There were no focal
abnormalities or epileptiform features.
.
Trans-thoracic Echocardiogram ([**2153-10-11**]):
IMPRESSION: Mild regional left ventricular systolic dysfunction
(LVEF 50-55%). No PFO/ASD identified.
Brief Hospital Course:
Mr. [**Known lastname **] is a 59 year old right handed man with a history of
coronary artery disease and basilar migraines who presented to
the [**Hospital1 18**] with the sudden onset vertigo, tinnitus, and headache
and was found to have a large left cerebellar infarct. He was
admitted to the stroke service from [**2153-10-9**] to [**2153-10-18**].
.
1. Left cerebellar infarct:
Due to concern for a stroke, an MRI was performed at the time of
admission. As noted above, the study revealed a left cerebellar
infarct. An MRA showed complete occlusion of the right
vertebral artery in addition to decreased flow in the left
vertebral artery. As an embolic etiology was suspected, a
heparin drip was started with a low PTT goal of 40-60, given the
risk of possible hemorrhage. In the course of the
hospitalization coumadin was started with a target INR of 2.0 to
3.0. Of note, the INR was minimally subtherapeutic at 1.8 at
the time of discharge, with a plan to take coumadin 7.5 mg po
[**2153-10-18**] and visit the PCP's office at 11 am [**2153-10-19**] for an INR
check.
.
To follow the initial evolution of the lesion, a CT of the head
was repeated within 24 hours of the patient's arrival. The
imaging showed a mild mass effect on the 4th ventricle with no
signs of hydrocephalus. Neurosurgery was consulted, and
indicated no surgical intervention was warranted. A repeat head
CT in the evening of [**10-10**] showed no significant change.
Clinically, the patient progressively improved. On the day of
discharge he denied vertigo, tinnitus, and headache; the
neurolgical examination was normal.
.
To evaluate modifiable risk factors for stroke, lipids and
glycosylated hemoglobin were measured. The LDL was found to be
elevated at 133, for which simvastatin was started. Although
the HBA1C was 5.7%, blood glucose was monitored regularly and an
insulin sliding was instituted to maintain normoglycemia.
.
A transthoracic echocardiogram was performed with the aim of
identifying any cardioembolic sources of stroke. There was no
evidence of thrombus, vegetation, PFO, or ASD noted. Mild
regional left ventricular systolic dysfunction was observed with
(EF 50-55%). Therefore, lisinopril (5 mg po daily) was chosen
as anti-hypertensive [**Doctor Last Name 360**].
.
2. Possible Seizure:
Given the right gaze deviation and posturing in the ED, the
patient underwent an EEG which was normal. It was suspected
that this episode may have been related to an embolic event in
the pontine region.
.
Members of the physical therapy team worked with Mr. [**Known lastname **] and
indicated he was fit for a safe discharge home.
.
3. Code: FULL on the day of discharge.
Medications on Admission:
None (had been recommended to take ASA and atenolol in the past,
however he had self discontinued these).
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Coumadin 2.5 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Left Cerebellar and pontine ifarcts secondary to total occlusion
of the right vertebral artery and poor flow in the left
vertebral artery.
Discharge Condition:
Stable. The neurological examination is normal; of note, there
is no evidence of nystagmus, finger-nose testing is accurate,
and gait is steady.
Discharge Instructions:
You presented to the [**Hospital1 18**] on [**2153-10-9**] with symptoms including
headache, ringing in the ear, and vertigo. Imaging of the brain
revealed a stroke in the left side of the cerebellum. The
stroke is thought to be related to blockages in the arteries
reposnsible for the blood supply to the cerebellum (the right
and left vertebral arteries). To help prevent future events, it
will be important to continue taking the blood thinner coumadin,
with a target INR value of two to three. Lisinopril has also
been started to better control your blood pressure.
* It will be very important to attend an appointment at Dr. [**Name (NI) 52848**] office [**2153-10-19**] at 11 am for an INR check. The target
value is 2.0 to 3.0. Tonight ([**2153-10-18**]) take the coumadin 7.5 mg
by mouth. Please work with your primary care doctor to dose the
coumadin for tomorrow and in the future.
* Since a statin has been started, it will also be important to
monitor your liver function tests.
* Please attend all follow-up appointments scheduled.
* Please take all medications as prescribed.
* Please seek medical attention if you develop lightheadedness,
headache, vertigo, neck pain, weakness- especially on one side
of your body, trouble seeing, difficulty speaking, gait
disturbance, chest discomfort, shortness of breath, or any other
symptom you find concerning.
Followup Instructions:
Please attend the following appointments:
* Dr.[**Name (NI) 56701**] office [**2153-10-19**] at 11:00 am for an INR check (goal
[**2-20**]).
* [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD (Phone [**Telephone/Fax (1) 44**]) on [**2153-11-19**] at
3:30 pm.
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
|
[
"300.00",
"414.01",
"412",
"433.31",
"346.00",
"437.0",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10019, 10025
|
6866, 9549
|
330, 336
|
10208, 10356
|
4965, 5336
|
11783, 12222
|
2605, 2661
|
9705, 9996
|
10046, 10187
|
9575, 9682
|
10380, 11760
|
5352, 6843
|
2676, 2676
|
248, 292
|
364, 2373
|
3693, 4946
|
2690, 3071
|
3110, 3677
|
3095, 3095
|
2395, 2481
|
2497, 2589
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,272
| 188,946
|
36830
|
Discharge summary
|
report
|
Admission Date: [**2113-8-2**] Discharge Date: [**2113-8-8**]
Date of Birth: [**2047-10-30**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
angina
Major Surgical or Invasive Procedure:
Endoscopic coronary artery bypass graft x1: Left
internal mammary artery to left anterior descending artery.
History of Present Illness:
65 year old female with known coronary artery disease, status
post LAD bare metal stent in [**5-6**], hypertension,
hypercholesterolemia, and diabetes mellitus requiring insulin,
reports intermittent chest pain, lasting approximately 20
minutes, radiating to back, that improves with rest.Pain located
in precordial
area with no exacerbating factors. Cardiac work up at OSH
revealed in stent stenosis.
Past Medical History:
CAD s/p stent [**4-/2113**] - LAD bare metal
Diabetes type 2
Hypertension
Hypercholesterolemia
Cervical Cancer stage 3 (squamous cell)
Cardiomyopathy EF 45-50%
Anemia
Social History:
Occupation: receptionist in laundry
Lives with: Alone
Tobacco: 2 pack year history, quit 50 years ago
ETOH: denies
Family History:
noncontributory
Physical Exam:
Pulse:80 SR Resp:18 O2 sat: 100% on 2Lpm
B/P Right: 114/68 Left:
Height: Weight:156LBs
General:A&Ox3
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema: none
Varicosities: LLE varicosities noted
Neuro: Grossly intact
Pulses:
Femoral (R) groin -cath site=C/D/I, no hematoma noted, soft
Right: Left:
DP Right:2+ Left:2+
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Carotid Bruit :none Right: 2+ Left:2+
Pertinent Results:
[**2113-8-2**] 09:20PM BLOOD WBC-12.9* RBC-4.65 Hgb-12.6 Hct-36.8
MCV-79* MCH-27.0 MCHC-34.2 RDW-14.6 Plt Ct-298
[**2113-8-6**] 03:01AM BLOOD WBC-16.2* RBC-3.55* Hgb-9.2* Hct-29.0*
MCV-82 MCH-25.9* MCHC-31.7 RDW-14.0 Plt Ct-201
[**2113-8-2**] 09:20PM BLOOD PT-12.2 PTT-25.2 INR(PT)-1.0
[**2113-8-5**] 02:51AM BLOOD PT-13.2 PTT-26.0 INR(PT)-1.1
[**2113-8-2**] 09:20PM BLOOD Glucose-157* UreaN-10 Creat-0.7 Na-141
K-3.5 Cl-104 HCO3-28 AnGap-13
[**2113-8-6**] 03:01AM BLOOD Glucose-130* UreaN-14 Creat-0.8 Na-135
K-4.1 Cl-105 HCO3-22 AnGap-12
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 83207**] (Complete)
Done [**2113-8-4**] at 11:13:35 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2047-10-30**]
Age (years): 65 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Abnormal ECG. Chest pain. Coronary artery disease.
Hypertension. Mitral valve disease.
ICD-9 Codes: 402.90, 786.51, 440.0, 424.0
Test Information
Date/Time: [**2113-8-4**] at 11:13 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5209**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW1-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aorta - Ascending: 3.0 cm <= 3.4 cm
Findings
LEFT ATRIUM: Mild LA enlargement. Good (>20 cm/s) LAA ejection
velocity. No thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA and extending into the RV. No
spontaneous echo contrast in the RAA. No thrombus in the RAA. No
ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Mild regional LV systolic dysfunction.
LV WALL MOTION: Regional left ventricular wall motion findings
as shown below; remaining LV segments contract normally.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Simple atheroma in ascending aorta.
Normal aortic arch diameter. Simple atheroma in aortic arch.
Normal descending aorta diameter. Simple atheroma in descending
aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets (?#). No AS. Trace AR.
MITRAL VALVE: No MS. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The patient received antibiotic prophylaxis. The
TEE probe was passed with assistance from the anesthesioology
staff using a laryngoscope. No TEE related complications.
patient.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
Off-Pump CABG planned:
1. The left atrium is mildly dilated. No thrombus is seen in the
left atrial appendage. No thrombus is seen in the right atrial
appendage No atrial septal defect is seen by 2D or color
Doppler.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is mild regional left
ventricular systolic dysfunction with anterior hypokinesis.. The
remaining left ventricular segments contract normally. LVEF is
50%.
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the ascending aorta. There are
simple atheroma in the aortic arch. There are simple atheroma in
the descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened (?#). There is no aortic valve
stenosis. Trace aortic regurgitation is seen between the LCC and
NCC.
6. . Trivial mitral regurgitation is seen.
7. There is no pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results.
After off-pump LIMA-LAD, there is improvement of the anterior
wall motion and global improvement of the LVEF to 60%.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2113-8-4**] 13:01
?????? [**2106**] CareGroup IS. All rights reserved.
Brief Hospital Course:
Transferred from outside hospital for surgical evaluation.
Underwent preoperative workup and management of chest pain
requiring heparin and nitroglycerin drips preoperatively. On
[**2113-8-4**] she was taken to the operating room and underwent
endoscopic coronary artery bypass graft surgery. See operative
report for further details. She received vancomycin for
perioperative antibiotics because she was in the hospital prior
to surgery. Post operatively she was taken to the intensive
care unit for hemodynamic management requiring vasoactive
medications for hypertension. She was weaned from sedation,
awoke neurologically intact, and was extubated without
complications. [**Last Name (un) **] was consulted for diabetes management
since on insulin regimen preoperatively and hgba1c 10. She
continued to do well and was transferred to the floor. Physical
therapy worked with her on strength and mobility. She was
provided diabetes education. She continued to do well and was
ready for discharge home with services on post operative day
four.
Medications on Admission:
Coreg 6.25 mg twice daily
Norvasc 5 mg daily
Aspirin 325 mg daily
Metoprolol 25 mg daily
Lisinopril 40 mg daily
Lipitor 80 mg daily
Iron 325 mg daily
Lantus 45 units daily
Novolog 8 units premeals
Plavix - last dose: stopped 1 month ago
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 months.
Disp:*30 Tablet(s)* Refills:*3*
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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
7. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
8. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for PAIN.
Disp:*40 Tablet(s)* Refills:*0*
9. Motrin 400 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours for 2 weeks.
Disp:*42 Tablet(s)* Refills:*0*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
11. Lopressor 100 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours.
Disp:*90 Tablet(s)* Refills:*0*
12. Humalog 100 unit/mL Solution Sig: Six (6) units Subcutaneous
before each meal .
Disp:*qs qs* Refills:*2*
13. Lantus 100 unit/mL Solution Sig: Thirty Five (35) units
Subcutaneous once a day: please take everyday at the same time .
Disp:*qs qs* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Coronary artery disease s/p Endoscopic CABG
hypertension
hyperlipidemia
Diabetes Mellitus
cervical cancer
anemia
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 4 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Blood glucose monitoring before meals and bedtime - please call
PCP if blood glucose greater than 200
Followup Instructions:
Please call to schedule appointments
Dr [**First Name8 (NamePattern2) **] [**Name (STitle) **] - [**Hospital3 **] clinic in [**12-30**] weeks
[**Telephone/Fax (1) 24107**]
Dr. [**Last Name (STitle) 14334**] in [**1-31**] weeks
Dr [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2113-8-8**]
|
[
"599.0",
"996.72",
"414.01",
"V45.82",
"272.0",
"180.9",
"401.9",
"E879.0",
"414.2",
"425.4",
"285.9",
"V58.67",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
9850, 9909
|
6997, 8053
|
326, 437
|
10066, 10073
|
1944, 5381
|
10685, 11102
|
1209, 1226
|
8342, 9827
|
9930, 10045
|
8079, 8319
|
10097, 10662
|
5430, 6974
|
1241, 1925
|
280, 288
|
465, 868
|
890, 1060
|
1076, 1193
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,923
| 101,866
|
38277+58202
|
Discharge summary
|
report+addendum
|
Admission Date: [**2166-6-25**] Discharge Date: [**2166-9-3**]
Date of Birth: [**2121-3-31**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Worsening angina
Major Surgical or Invasive Procedure:
[**2166-6-27**] Urgent coronary bypass grafting x2 with a reverse
saphenous vein graft from the aorta to the first diagonal
coronary artery; reverse saphenous vein graft from the aorta to
the left anterior descending coronary artery
[**2166-7-2**] Placement of PICC Line
[**2166-7-7**] Tracheostomy
[**2166-7-14**] PEG placement
History of Present Illness:
Mr. [**Known lastname 85300**] is a 44 year old Jehovah Witness with known coronary
artery disease s/p DES of OM lesion [**2166-3-6**], grade 1 diastolic
dysfunction, and chronic pericarditis who presented to outside
hospital with increasing angina on exertion. Cardiac
catheterization at [**Hospital6 **] revealed significant LM
disease. Patient was deemed to be poor surgical candidate and
was subsequently transferred to the [**Hospital1 18**] for further evaluation
and treatment.
Past Medical History:
- Coronary Artery Disease, s/p inferior MI(STEMI), s/p Drug
eluting stent to obtuse marginal
- History of positive PPD, negative CXR [**10-11**]
- Chronic pericarditis
- Hypertension
- Hyperlipidemia
- Type II Diabetes Mellitus
Social History:
Originally from [**Country 2045**], lives with wife and 2 children. Denies
tobacco and ETOH.
Family History:
Denies premature coronary artery disease
Physical Exam:
Pulse: 87 BP: 102/77 RR: 25 O2 sat: 100%
Height: 74 inches Weight: 86 kg
General:A&Ox3
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI []
Neck: Supple [x] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ []
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: Left:
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: Left:
Radial Right: 2+ Left:2+
Carotid Bruit none Right: 2+ Left:2+
Pertinent Results:
[**2166-6-26**] Echocardiogram: The left atrium is mildly dilated. Left
ventricular wall thicknesses and cavity size are normal. There
is moderate regional left ventricular systolic dysfunction with
akinesis of the basal to mid inferolateral wall, hypokinesis of
the anterolateral wall. Overall left ventricular systolic
function is mildly depressed (LVEF= 45 %). Tissue Doppler
imaging suggests a normal left ventricular filling pressure
(PCWP<12mmHg). 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 leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
[**2166-6-26**] Chest CTA: 1. Acute pulmonary embolus in the left
descending pulmonary artery, extending in the lingula, and basal
truncus, involving more than half of the vessel lumen. No
evidence of right heart strain. 2. No pneumonia. No evidence of
active, or chronic granulomatous disease.
[**2166-6-26**] Lower Extremity Ultrasound: No evidence of deep vein
thrombosis in either leg.
[**2166-6-26**] Carotid Ultrasound: Right ICA with no stenosis. Left ICA
with no stenosis.
[**2166-6-27**] Intraop TEE: PRE-CPB: 1. The left atrium is mildly
dilated. No spontaneous echo contrast is seen in the left atrial
appendage. No thrombus is seen in the left atrial appendage. 2.
No atrial septal defect is seen by 2D or color Doppler. 3. There
is moderate symmetric left ventricular hypertrophy. The left
ventricular cavity is mildly dilated. Overall left ventricular
systolic function is mildly depressed (LVEF= 40 %). There is
moderate lateral hypokinesis. 4. Right ventricular chamber size
and free wall motion are normal. 5. The ascending, transverse
and descending thoracic aorta are normal in diameter and free of
atherosclerotic plaque. There are simple atheroma in the aortic
arch. There are simple atheroma in the descending thoracic
aorta. 6. There are three aortic valve leaflets. The aortic
valve leaflets (3) are mildly thickened. There is no aortic
valve stenosis. No aortic regurgitation is seen. 7. The mitral
valve appears structurally normal with trivial mitral
regurgitation. The pericardium may be thickened. **Prior to
bypass, there was an episode of hypotension with EKG changes.
TEE showed severe hypokinesis of the anterior and anteroseptal
walls, with an LVEF of 10 %. CPR was initiated and the patient
emergently placed on cardiopulmonary bypass.** POST-CPB: On
infusions of vasopressin, Epi, Norepinephrine, Milrinone. In
sinus rhythm. Improved anterior wall on inotropic support, with
LVEF now 35%. MR [**First Name (Titles) **] [**Last Name (Titles) **] remain trace. There is no change in the
aortic contour post decannulation.
[**2166-7-1**] Head CT Scan: 1. Limited study due to patient motion. A
small hypodensity in the right parieto-occipital lobe is of
indeterminate age, likely chronic. No acute intracranial
hemorrhage or acute major vascular territorial infarction. 2.
Marked paranasal sinus disease as above.
[**2166-7-2**] EEG: This is an abnormal video EEG study because of
severe diffuse background slowing and disorganization. These
findings are indicative of severe diffuse cerebral dysfunction,
which is etiologically non-specific. There were no epileptiform
discharges or electrographic seizures.
[**2166-7-2**] MRI Head/Brain: 1. Innumerable punctate foci of signal
on the diffusion-weighted images, many of which are also bright
on FLAIR suggestive of multiple acute, likely embolic, infarcts.
A more confluent area of FLAIR signal abnormality in the right
posterior temporal lobe could be another area of older infarct.
2. Scattered punctate foci of susceptibility artifact could
represent areas of microhemorrhage or calcification.
[**2166-7-6**] Abd Ultrasound: Limited view of pancreas. No evidence of
cholelithiasis or intra-or extrahepatic biliary dilatation.
Radiology Report VIDEO OROPHARYNGEAL SWALLOW Study [**2166-9-1**] 1:25
PM
[**Hospital 93**] MEDICAL CONDITION: 45 year old man s/p decannulation
Final Report
INDICATION: Evaluate for aspiration in patient with history of
aspiration.
FINDINGS: Barium passes freely through the oropharynx without
evidence of
obstruction. The patient demonstrates a slow oral phase and weak
swallow with weak pharyngeal muscle contraction. There is
penetration and aspiration of thin barium without penetration or
aspiration of nectar or thick barium. The patient does sense the
aspiration and coughs appropriately. He has an increased residue
in both the valleculae and piriform sinuses, which spills over
in between swallows. For more details please see the speech and
swalllow division note in OMR.
There is again noted an opacity projecting over the tracheal air
column that likely represents an endoluminal lesion, possibly
tracheal polyp or other mass lesion. Recommend further
evaluation with direct visualization or Neck CT.
IMPRESSION:
1. Aspiration of thin barium without aspiration of thick or
nectar barium
which represents some improvement from the prior study.
2. Lesion projecting over the trachea that may represent
tracheal polyp or
other mass lesion. Recommend further evaluation with dedicated
CT of trachea or direct visualization for further evaluation.
Radiology Report CHEST (PA & LAT) Study Date of [**2166-8-12**] 10:26
AM
[**Hospital 93**] MEDICAL CONDITION: 45 year old man with s/p cabg
FINDINGS: In comparison with the study of [**7-31**], the lungs are
now essentially clear except for some mild atelectatic changes
at the left base. No vascular congestion. Tracheostomy tube
remains in good position, and the PICC line again extends to the
lower SVC or cavoatrial junction.
DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**]
Admission
[**2166-6-25**] 07:02PM BLOOD WBC-6.9 RBC-4.41* Hgb-12.6* Hct-38.9*
MCV-88 MCH-28.5 MCHC-32.3 RDW-15.0 Plt Ct-274
[**2166-7-7**] 01:46AM BLOOD WBC-17.9* RBC-1.66* Hgb-4.8* Hct-15.9*
MCV-96 MCH-28.7 MCHC-30.0* RDW-21.0* Plt Ct-515*
[**2166-8-4**] 05:00AM BLOOD WBC-6.4 RBC-3.09* Hgb-8.1* Hct-27.0*
MCV-87 MCH-26.2* MCHC-29.9* RDW-17.6* Plt Ct-544*
[**2166-6-25**] 07:02PM BLOOD PT-11.1 PTT-26.1 INR(PT)-0.9
[**2166-7-7**] 01:46AM BLOOD PT-14.8* PTT-29.2 INR(PT)-1.3*
[**2166-7-13**] 05:02AM BLOOD PT-15.7* INR(PT)-1.4*
[**2166-6-25**] 07:02PM BLOOD Glucose-131* UreaN-17 Creat-1.1 Na-142
K-3.9 Cl-105 HCO3-28 AnGap-13
[**2166-7-5**] 05:02AM BLOOD Glucose-143* UreaN-24* Creat-0.7 Na-148*
K-3.7 Cl-114* HCO3-29 AnGap-9
[**2166-8-4**] 05:00AM BLOOD Glucose-110* UreaN-15 Creat-0.5 Na-137
K-4.4 Cl-100 HCO3-30 AnGap-11
[**2166-6-25**] 07:02PM BLOOD ALT-23 AST-27 LD(LDH)-143 AlkPhos-63
Amylase-86 TotBili-0.2
[**2166-7-7**] 01:46AM BLOOD ALT-426* AST-267* LD(LDH)-569*
AlkPhos-588* Amylase-478* TotBili-0.4
[**2166-7-24**] 09:45AM BLOOD ALT-36 AST-33 LD(LDH)-259* AlkPhos-158*
Amylase-106* TotBili-0.3
[**2166-6-26**] 05:25AM BLOOD Calcium-9.4 Phos-4.2 Mg-2.0
[**2166-7-22**] 12:35PM BLOOD Albumin-2.7* Calcium-8.4 Phos-3.7 Mg-2.5
Discharge
[**2166-8-31**] 07:35AM BLOOD WBC-5.0 RBC-3.93* Hgb-10.3* Hct-32.4*
MCV-83 MCH-26.1* MCHC-31.7 RDW-17.1* Plt Ct-374
[**2166-8-31**] 07:35AM BLOOD Plt Ct-374
[**2166-8-18**] 06:13AM BLOOD PT-14.0* PTT-33.0 INR(PT)-1.2*
[**2166-8-31**] 07:35AM BLOOD Glucose-140* UreaN-25* Creat-0.8 Na-138
K-4.6 Cl-101 HCO3-30 AnGap-12
[**2166-7-24**] 09:45AM BLOOD ALT-36 AST-33 LD(LDH)-259* AlkPhos-158*
Amylase-106* TotBili-0.3
[**2166-8-31**] 07:35AM BLOOD Mg-2.0
[**2166-6-25**] 07:02PM BLOOD %HbA1c-8.3* eAG-192*
Brief Hospital Course:
Mr. [**Known lastname 85300**] was admitted to the cardiac surgical service. Given
severe left main disease and unstable angina, he remained on
Integrilin and Nitroglycerin. Preoperative evaluation was
notable for mildly depressed LV function and pulmonary embolus -
see result section for additional details. After extensive
discussion with the patient and his family about risks and
benefits especially refusal of blood products, he agreed to
proceed with surgical revascularization.
On [**6-27**], Dr. [**Last Name (STitle) 914**] performed coronary artery bypass
grafting surgery. Operative course was notable for hypotensive
cardiac arrest following induction of anesthesia. See operative
note for additional details.
Following surgery, he arrived to the CVICU in critical
condition, on multiple pressors. Given labile hemodynamics, he
required insertion of IABP. The IABP was eventually removed on
postoperative day two, and inotropic support was gradually
weaned over several days. Given severe anemia and refusal of
blood products, Epogen was administered.
Initially unresponsive, Neurology was consulted. Head CT scan
was unrevealing, and EEG showed no evidence of seizure activity.
Neurology initially attributed his severe obtundation to
possible hypoxic-ischemic injury related to hypotensive cardiac
arrest and persistently severe anemia. MRI of brain was notable
for multiple emboli and infarcts. Given that there was no
intervenable etiology of his unresponsiveness neuro initially
signed off.
Due to prolonged ventilation, Dobhoff feeding tube and PICC line
were placed. Tracheostomy was eventually performed on [**7-7**],
with subsequent PEG placment on [**7-14**]. Mr. [**Known lastname 85300**] transferred
from the ICU to the floor on [**7-16**] (POD #19).
He intermittently spiked fevers which subsided and he was
treated for staph PNA. Neuro was re-consulted to evaluated his
bilateral leg weakness on [**7-16**]. His leg weakness was believed to
be due to low flow state and profound anemia with a HCT of 9. No
clinical diagnostic evidence was found to support an etiology
for this persistant lower extremity immobility. Over the course
of his hopsital stay he slowly began moving his lower
extremities and is now able to move his lower extremities and
partial weight bear.
He was eventually weaned from the vent to a trach collar and
finally decanulated on [**2166-8-21**].He was evaluated and followed
throughout his hospital stay by speech and swallow pathologists
for Passy-Muir valve trails and he had mutiple video swallow
evaluations. He is presently taking po's and receiving cycled
tube feeds at night which can be weaned off when taking adeq
oral nutrition. His most recent video swallow [**9-1**] revealed a
tracheal lesion that Radiologist recommend follow up for
tracheal polyp vs mass. Per Dr.[**Last Name (STitle) 914**], Mr.[**Known lastname 85300**] should have
follow up done with his referring physician.
Physical therapy and Occupational therapy continued to work with
Mr.[**Known lastname 85300**]. He continues to make slow improvements toward
regaining his lower extremity strength and functioning.
[**Last Name (un) **] Diabetes service was consulted for glucose management.
He remains in stable condition.
Dr.[**Last Name (STitle) 914**] cleared Mr.[**Known lastname 85300**] on POD# 67 from his original
surgery, for discharge to [**Hospital **] rehabilitation.
All follow up appointments were advised.
Medications on Admission:
Aspirin
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY
(Daily).
5. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) PO DAILY (Daily).
6. Carvedilol 12.5 mg Tablet Sig: Four (4) Tablet PO BID (2
times a day).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid Sig: One (1)
PO TID (3 times a day).
9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime).
11. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
12. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
13. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-4**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
14. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
15. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Ibuprofen 100 mg/5 mL Suspension Sig: Four Hundred (400) mg
PO Q8H (every 8 hours) as needed for pain.
17. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
18. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
19. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
20. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
21. Insulin Glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous once a day.
22. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale Injection QAC&HS.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]
Discharge Diagnosis:
Coronary Artery Disease s/p Urgent coronary bypass grafting x2
with a reverse saphenous vein graft from the aorta to the first
diagonal coronary artery; reverse saphenous vein graft from the
aorta to the left anterior descending coronary artery.
Endoscopic vein harvesting of the left leg.
s/p cardiac arrest
s/p Percutaneous endoscopic gastrostomy tube
placement/Percutaneous tracheostomy tube placement
Intra-op Cerebral Vascular Accident
Anemia
Pneumonia
Past medical history:
Diabetes Mellitus
s/p inferior Myocardial Infarction(STEMI)
s/p DES to LCX OM1(90% stenosis)
PPD+ negative CXR [**10-11**]
Chronic pericarditis
Hypertension
Hyperlipidemia
Discharge Condition:
Alert and oriented x3
Upper extremities [**5-7**] strengths, full range of motion
Lower extremities limited motion and generalized weakness. Able
to stand.
Incisional pain managed with Ibuprofen
Incisions: Sternal - healed, no erythema or drainage
Edema - none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month 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**]
**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:
NEED UPDATED APPOINTMENT W/RH
Surgeon: Dr. [**Last Name (STitle) 914**] on Tuesday [**2166-9-16**] at 2:30 PM [**Hospital Ward Name **] 2A
Cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Wednesday [**10-1**] @ 8:00 AM
Please call to schedule appointments with:
Primary Care Dr. [**Last Name (STitle) 85301**] [**Doctor Last Name 85302**] in [**1-4**] weeks
******Please have tracheal lesion work up with referring/primary
care physician********
**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:[**2166-9-3**] Name: [**Known lastname 13519**],[**Known firstname 779**] J Unit No: [**Numeric Identifier 13520**]
Admission Date: [**2166-6-25**] Discharge Date: [**2166-9-3**]
Date of Birth: [**2121-3-31**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1543**]
Addendum:
the following medications have been discontinued:
Folate
Multivutamin
ferrous Sulfate
Thiamine
Ascorbic Acid
Ranitidine
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2166-9-3**]
|
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"415.19",
"427.5",
"997.1",
"272.4",
"414.01",
"250.00",
"482.49",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"96.72",
"36.12",
"33.22",
"38.93",
"96.04",
"39.61",
"37.61",
"31.1"
] |
icd9pcs
|
[
[
[]
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] |
18508, 18709
|
10118, 13584
|
336, 666
|
16223, 16486
|
2231, 6518
|
17240, 18485
|
1557, 1599
|
13642, 15461
|
7913, 10095
|
15548, 16006
|
13610, 13619
|
16510, 17217
|
1614, 2212
|
280, 298
|
694, 1180
|
16028, 16202
|
1447, 1541
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,591
| 119,828
|
54941
|
Discharge summary
|
report
|
Admission Date: [**2172-6-13**] Discharge Date: [**2172-6-24**]
Service: MEDICINE
Allergies:
atenolol / atorvastatin / Medrol / Nefazodone / Phenylbutazone /
trazodone
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
SAH/SDH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: Mr. [**Known lastname **] is a R handed 88yM with a history of early
stage
dementia and ETOH abuse who presented to OSH [**6-13**] s/p fall at
~445pm. It is unclear if it was a mechanical fall down stairs or
fall from standing near stairs. He was initially responsive and
coherent but had worsening mental status changes/confusion. He
was vomiting and incontinent of urine after the fall. His son
found him ~5 minutes after the fall. He was BIBA to [**Hospital 1121**]
Hospital. There, his imaging demonstrated SAH L>R in the frontal
and temporal regions and SDH small frontal. He was transferred
to
[**Hospital1 18**] for further management. He had ETOH in the afternoon ETOH
at OSH 52.
Past Medical History:
[**Name (NI) **] pt suffered MI [**85**] years ago; had arrythmias from that time
until underwent ablation in [**2169**] (?)
CHF - per pt's family, pt's EF: 30-35%. No known
hospitalizations for CHF exacerbation.
ICD - has had pacemaker+defibrillator for approximately 5 years.
Per family, defibrillator activated several times, prompting
ablation procedures. Previously, the pt had pacemaker only.
Sub-arachnoid hemorrhages - pt has a history of multiple bleeds
[**2-6**] falls. Pt underwent surgical repair at [**Hospital1 112**] in [**2170**].
EtOH Abuse- per son/caretaker, pt drinks 1.5oz QOD.
Left Meningioma
Double vision - pt has experienced diplopia since [**70**]/[**2172**]. As a
result, he keeps his left eye shut.
Hip replacement
Asthma
PSH:
Craniotomy at [**Hospital6 **] 1.5 years ago Dr. [**Last Name (STitle) **] [**Last Name (STitle) 112209**]
hematoma
L hip replacement
Social History:
Pt was born and raised in [**Country 22965**]. Was member of underground
military resistance during WWII. Worked as food scientist for
Necco and then as VP of Product Development for [**Location (un) 112210**]
Chocolates.
Per family, pt has history of EtOH abuse. Former smoker (quit 25
years ago). Lives with son (caretaker) [**Name (NI) **] ([**Telephone/Fax (1) 112211**]) and
wife.
Family History:
NC
younger brothers died of heart disease
Physical Exam:
EXAM ON ADMISSION TO NEUROSURGERY
GCS 11 E:4 V:2 Motor: 5
O: BP: 151 / 74 HR:69 R 18 O2Sats 99%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3->2 bilaterally Conjunctival hemorrhage on
Right
EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+ Umbo hernia reducible
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake non-cooperative
Orientation: not responding to any questions
Recall: unable to assess
Language: not answering questions. Per son since the fall he has
been speaking Norweigan only. (Native from [**Country 22965**], speaks
English
fluently)
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields unable to assess
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial symmetric.
VIII: Hearing: Pt deaf on Left
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-9**] throughout. No pronator drift
Sensation: Intact to light touch bilaterally
Reflexes: B Br Pa Ac
Right + + + +
Left + + + +
Toes upgoing bilaterally
Coordination: unable to assess
Handedness Right
Physical Exam on Discharge from Medicine Service
Vitals: 97.2 156/88 82 18 96%RA
General: Alert and Oriented x 0. NAD. Denies pain.
Skin: erythematous macules on back; large ecchymoses on upper
extremities and hands bilaterally.
HEENT: L pupil 3mm, R pupil 2mm. Subconjunctival hemorrhage in R
eye (lateral and medial to [**Doctor First Name 2281**]). Copious oral secretions. No
lymphadenopathy. Dop-off tube in place, and bridled. Neck
supple.
CV: RRR, no RMG; laterally displaced PMI.
Pulm: exam notable for upper airway sounds diffusely
transmitted. No wheezes, rhonchi, crackles. Pt breathing
comfortably. Occasional non-productive upper respiratory cough.
Abd: soft, non-tender, non-distended. Small umbilical hernia.
Ext: Cast on R wrist/forearm. 2+ upper and lower extremity
pulses. No lower extremity edema.
Neuro: A&Ox0. Able to follow some commands. Able to answer
questions, though comprehension very limited. No short-term
memory. Pupils stably asymmetric (L>R); both reactive.
Pertinent Results:
[**6-14**] Chest Xray: There is a left-sided AICD with lead tips in
the right atrium and right ventricle. There is a feeding tube
whose tip and side port are below the gastroesophageal junction.
Cardiomegaly which is stable. There is atelectasis at the left
base. There are no pneumothoraces. There is mild prominence of
the pulmonary vascular markings without overt pulmonary edema.
[**6-14**] CT head
1. Redemonstration of subarachnoid, subdural, and now
intraventricular
hematoma without significant interval change, or mass effect.
2. Left CP angle mass extending into the middle cranial fossa,
most
consistent with meningioma. This could be better evaluated with
MRI when
clinically appropriate.
[**6-14**] Abdominal xray:
NG within the stomach
[**6-16**] CT Head
1. No change in the subarachnoid, subdural, and
intraventricular hemorrhage. No new hemorrhage is appreciated.
2. Enlargement of the bilateral frontal extra-axial spaces is
most consistent with developing hygromas. There is no
significant mass effect from this change.
3. Stable hypodensity in the right cerebellum is consistent
with an
infarction of indeterminate age.
4. Stable left cerebellopontine angle meningioma
[**2172-6-16**] 10:57 PM
IMPRESSION: infrahilar atelectasis. There is no pulmonary
edema or appreciable pleural effusion. Severe cardiomegaly
including an apical ventricular aneurysm has not changed over
the past two days.
[**2172-6-18**] CXR
IMPRESSION: Stable left infrahilar atelectasis without new
airspace opacity concerning for pneumonia.
[**2172-6-19**]: WRIST 3 VIEWS BILATERALLY
LEFT WRIST: There are no signs for acute fractures or
dislocations. There are some mild degenerative changes of the
first CMC joint.
RIGHT WRIST: Subtle lucency involving the ulnar aspect of the
right distal radius which may represent a subtle non-displaced
fracture. Please correlate with direct pain at this site.
There are mild degenerative changes of the first CMC and
triscaphe joints.
[**2172-6-21**]: CT ABDOMEN W/O CONTRAST
Reason: Pre-PEG placement
IMPRESSION:
1. Isodense 1.6-cm renal lesion. This finding can be better
evaluated with ultrasound.
2. Small/trace bilateral pleural effusions, slightly greater on
the right.
[**2172-6-24**] 11:35 AM [**Last Name (un) **]-INTESTINAL TUBE PLACEMENT
IMPRESSION: Successful repositioning of Dobbhoff tube into the
post-pyloric position. The tube is ready to use.
CBC
[**2172-6-24**] 05:30AM BLOOD WBC-8.4 RBC-3.46* Hgb-11.1* Hct-35.4*
MCV-102* MCH-32.0 MCHC-31.3 RDW-15.1 Plt Ct-244
[**2172-6-23**] 05:34AM BLOOD WBC-8.8 RBC-3.26* Hgb-10.7* Hct-32.7*
MCV-101* MCH-32.8* MCHC-32.7 RDW-15.3 Plt Ct-230
[**2172-6-22**] 05:45AM BLOOD WBC-10.0 RBC-3.22* Hgb-10.8* Hct-32.5*
MCV-101* MCH-33.4* MCHC-33.1 RDW-15.2 Plt Ct-204
[**2172-6-21**] 05:55AM BLOOD WBC-9.8 RBC-3.16* Hgb-10.3* Hct-31.8*
MCV-101* MCH-32.7* MCHC-32.4 RDW-15.5 Plt Ct-174
[**2172-6-20**] 05:00AM BLOOD WBC-11.0 RBC-3.20* Hgb-10.3* Hct-32.9*
MCV-103* MCH-32.0 MCHC-31.1 RDW-15.3 Plt Ct-182
[**2172-6-19**] 05:00AM BLOOD WBC-12.0* RBC-3.14* Hgb-10.3* Hct-32.0*
MCV-102* MCH-32.8* MCHC-32.2 RDW-15.6* Plt Ct-143*
[**2172-6-18**] 07:14AM BLOOD WBC-11.9* RBC-3.43* Hgb-11.2* Hct-35.5*
MCV-104* MCH-32.6* MCHC-31.5 RDW-15.8* Plt Ct-142*
[**2172-6-17**] 07:30AM BLOOD WBC-10.2 RBC-3.37* Hgb-10.8* Hct-34.5*
MCV-103* MCH-32.2* MCHC-31.3 RDW-15.5 Plt Ct-159
[**2172-6-16**] 11:56AM BLOOD WBC-10.5 RBC-3.68* Hgb-11.8* Hct-38.0*
MCV-103* MCH-31.9 MCHC-31.0 RDW-15.3 Plt Ct-158
[**2172-6-14**] 04:43AM BLOOD WBC-12.4* RBC-3.56* Hgb-11.8* Hct-35.1*
MCV-99* MCH-33.1* MCHC-33.6 RDW-15.5 Plt Ct-152
[**2172-6-13**] 10:30PM BLOOD WBC-13.3* RBC-3.62* Hgb-11.8* Hct-35.8*
MCV-99* MCH-32.7* MCHC-33.0 RDW-15.5 Plt Ct-140*
[**2172-6-19**] 05:00AM BLOOD Neuts-87.8* Lymphs-7.6* Monos-3.4 Eos-0.9
Baso-0.2
[**2172-6-13**] 10:30PM BLOOD Neuts-93.2* Lymphs-3.3* Monos-3.2 Eos-0.1
Baso-0.1
CHEMISTRIES
[**2172-6-24**] 05:30AM BLOOD Glucose-93 UreaN-32* Creat-1.4* Na-144
K-5.0 Cl-110* HCO3-20* AnGap-19
[**2172-6-23**] 05:34AM BLOOD Glucose-101* UreaN-32* Creat-1.5* Na-145
K-3.8 Cl-107 HCO3-27 AnGap-15
[**2172-6-22**] 05:45AM BLOOD Glucose-113* UreaN-31* Creat-1.3* Na-141
K-3.9 Cl-103 HCO3-28 AnGap-14
[**2172-6-21**] 05:55AM BLOOD Glucose-130* UreaN-31* Creat-1.3* Na-143
K-4.0 Cl-105 HCO3-30 AnGap-12
[**2172-6-20**] 05:00AM BLOOD Glucose-153* UreaN-28* Creat-1.2 Na-144
K-3.7 Cl-106 HCO3-30 AnGap-12
[**2172-6-18**] 07:14AM BLOOD Glucose-155* UreaN-26* Creat-1.3* Na-147*
K-4.3 Cl-110* HCO3-26 AnGap-15
[**2172-6-17**] 07:30AM BLOOD Glucose-160* UreaN-27* Creat-1.5* Na-145
K-3.2* Cl-108 HCO3-26 AnGap-14
[**2172-6-16**] 11:56AM BLOOD Glucose-94 UreaN-20 Creat-1.2 Na-149*
K-2.9* Cl-108 HCO3-28 AnGap-16
[**2172-6-14**] 04:43AM BLOOD Glucose-141* UreaN-20 Creat-1.5* Na-142
K-4.1 Cl-102 HCO3-26 AnGap-18
[**2172-6-13**] 10:30PM BLOOD Glucose-147* UreaN-21* Creat-1.5* Na-144
K-3.1* Cl-104 HCO3-26 AnGap-17
LYTES
[**2172-6-24**] 05:30AM BLOOD Phos-3.7 Mg-3.0*
[**2172-6-19**] 05:00AM BLOOD Phos-2.5* Mg-2.1
[**2172-6-18**] 07:14AM BLOOD Calcium-8.6 Phos-2.1* Mg-2.1
[**2172-6-17**] 05:40PM BLOOD Calcium-8.7 Phos-1.6* Mg-2.1
[**2172-6-18**] 07:14AM BLOOD VitB12-668
ENZYMES
[**2172-6-19**] 05:00AM BLOOD ALT-28 AST-29 AlkPhos-79 Amylase-153*
TotBili-0.9
[**2172-6-19**] 05:00AM BLOOD TSH-2.4
TOX SCREEN
[**2172-6-13**] 10:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
MICROBIOLOGY - URINE
[**2172-6-19**] 12:00PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-7.0 Leuks-NEG
[**2172-6-15**] 10:56AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
URINE ELECTROLYTES
[**2172-6-19**] 12:00PM UreaN-490 Creat-42 Na-91 K-37 Cl-94
Brief Hospital Course:
88 M with history of prior subdural hemorrhages is admitted for
recurrent subdural and subarachnoid hemorrhage in setting of
mechanical fall.
#HEAD TRAUMA/INTRACRANIAL HEMORRHAGES
Mr. [**Known lastname **] was admitted to the Neurosurgical ICU for Q1 hour
neurochecks after having subdural and subarachnoid hemorrhages
in his brain after mechanial fall. Aspirin was held due to his
head injury. He was started on Keppra 500mg [**Hospital1 **] for seizure
prophylaxis given his extensive head injury. His neuroligical
exam fluctuated likely due to his head injury with underlying
cognitive slowing.
On the morning of [**6-14**] repeat head CT demonstrated stable
bilateral SAH and contusions and he was transfered to the
regular floor. He was unable to tolerate PO foods or pills so
an NG tube was placed. Speech and Swallow consult was obtained
and he was not able to control his secretions. On [**6-16**], a repeat
head CT was stable. At time of discharge, patient was still not
able to control oral secretions (failed speech and swallow the
day of discharge) and thus needed continued feeds through [**Last Name (un) 1372**]
gastric tube, a new [**Last Name (un) **]-gastric tube was placed post-pyloric
per IR on [**2172-6-24**].
# UPPER RESPIRATORY SECRETIONS/COUGH: Pt had some upper airway
crackles on exam. Serial CXRs were negative for pneumonia. Upper
airway crackles likely secondary to patient's poor ability to
control oral secretions. He was satting in high 90s on RA.
# ALTERED MENTAL STATUS: The patient had a persistently altered
mental status and was frequently A&Ox0. He was inattentive, and
clutched at gown and lines, and required soft restraints (mitts)
for several days to prevent injury to self. Mental status waxed
and waned daily; pt was occasionally able to engage in simple
conversation answering with 1 word. These deficits were likely
due primarily to recent head trauma, baseline deficits, and
delirium. [**2172-6-14**] EEG indicated mild diffuse encephalopathy. The
patient was maintained on his home regimen of Aricept, Zoloft,
and mirtazapine.
# Right upper extremity FRACTURE: The pt had marked bruising of
his upper extremities bilaterally, which prompted bilateral
upper extremity radiographs. Pt was found to have a right radial
fracture. Cast was placed, per orthopedics.
# THROMBOCYTOPENIA On admission, pt had a mild
thrombocytopenia, which resolved spontaneously during his
hospital course.
# RENAL INCIDENTALOMA: On abdominal CT (preparation for ?PEG
placement), the pt was noted to have an isodense 1.6-cm renal
lesion. According to readiology, this finding can be better
evaluated with ultrasound. We did not pursue this finding
further, given the patient's age, active medical issues and
comorbidities, and absence of renal/urologic symptoms. Can be
further addressed outpatient.
# ELEVATED CREATININE/Chronic Kidney Disease: During his
admission, the pt's serum creatine ranged from 1.3 to 1.5.
Baseline Cr unknown. Cr stable the last week of his
hospitalization. Pt likely has some degree of CKD.
# GOALS OF CARE: Family very actively involved in patient's
care. Decision was made to make him DNR/DNI, although
immediately prior to transport to the rehab facility the family
changed him to DNI but okay to rescucitate. Family is interested
in pursuing treatments at this time to see if his father's
mental status can be optimized (ex: physical therapy, [**Last Name (un) **]
gastric feeding). If he does not clinically improve over the
next 1-2 weeks, family has expressed interest in discussing
changing goals of care to focusing on comfort. These wishes are
consistent with patient's living will.
Transitional issues:
-adrenal incidentaloma
-right wrist non displaced fracture
Medications on Admission:
ASA 81
Amiodarone 200
Torsemide 10
Zoloft 112.5
Metoprolol 25
Zetia 10
Pravastatin 40
Flomax 0.4
Advair 100/50"
Proventil inh
Remeron 15
Abmien 5
Aricept ?5
MVI
Melatonin 5
Senna 8.5
Docusate 100
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
2. Amiodarone 200 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Heparin 5000 UNIT SC TID
5. LeVETiracetam 500 mg PO BID
6. Torsemide 10 mg PO DAILY
hold BP<100
7. Sertraline 75 mg PO DAILY
8. Pravastatin 40 mg PO DAILY
9. Senna 1 TAB PO HS
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Donepezil 5 mg PO HS
12. Ezetimibe 10 mg PO DAILY
13. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **]
14. Multivitamins 1 TAB PO DAILY
15. FoLIC Acid 1 mg PO DAILY
16. Mirtazapine 15 mg PO HS
17. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)
Discharge Diagnosis:
Bilateral traumatic Subarachnoid hemorrhage
Brain contusions
Subdural hematoma
Delirium
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a privilege to participate in your care.
You were admitted to the [**Hospital1 69**]
becaus you had fallen and hit your head, and were found to have
bleeding in your brain. You were admitted to the Neurosurgery
Service, where you were observed for several days. A tube was
put through your nose, into your stomach, so that you could
receive nutrients and medicines.
After several days, you were transferred to the General Medicine
Service, because of concerns about your breathing.
You were observed on the Medicine service for several days. You
did not have a lung infection (pneumonia), but you did have a
cough related to mucus and extra saliva in your throat. Because
you were unable to control your swallowing muscles, you
continued to be fed by a tube in your nose.
The Medicine Service discovered a fracture ("broken bone") in
your right wrist. This fracture probably occurred during your
recent fall. The Orthopedic Surgery service recommended that
your right arm be put in a cast.
Finally, you were often confused during your time on our
service. Often, you did not know your name or where you were. We
hope that this will improve, along with your physical health, in
the [**Hospital **] Hospital.
Neurosurgery provided the following recommendations:
- You must stop drinking alcohol
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 739**], to be seen in _4_weeks (from [**2172-6-18**]).
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
??????We recommend you see Dr [**First Name (STitle) **] in the Traumatic Brain Injury
(TBI) clinic the phone number is [**Telephone/Fax (1) 6335**]. If you have any
problems booking this appointment please ask for [**First Name8 (NamePattern2) 16367**] [**Last Name (NamePattern1) 16368**].
|
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icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.08"
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icd9pcs
|
[
[
[]
]
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,629
| 107,246
|
33587
|
Discharge summary
|
report
|
Admission Date: [**2138-1-15**] Discharge Date: [**2138-1-24**]
Service: MEDICINE
Allergies:
Aspirin / Iodine / Carafate / Tagamet / Mylanta
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Left Internal Jugular Vein Catheterization
PICC line placement
History of Present Illness:
Mrs. [**Known lastname 75980**] is an 85 year old female with a history of CAD,
atrial fibrillation and congestive heart failure who was
transferred from [**Hospital **] hospital with fevers, cough and
vomiting. The patient has recently been in and out of the
hospital four times over the past six weeks for urinary tract
infections and aspiration events now s/p PEG placement two weeks
ago. She currently presents from rehab with feves, cough and
congestion x 2 days and vomiting x 1 day. She was also noted to
have tachypnea and dizziness at her rehab.
Per the MICU admission note on presentation to [**Hospital **]
hospital she was noted to be afebrile, tachycardic to the low
100s with stable blood pressrue. She later spiked a fever to
102.4 and developed an oxygen requirement. Her labs were
notable for a sodium of 125, WBC count of 17.3 with 34% bands.
CXR at [**Hospital1 **] showed no focal infiltrates but was suggestive
of mild CHF. She was treated with ceftriaxone and azithromycin
for possible pneumonia. She received 500 cc IVF with increased
tachypnea and was subsequently given nitropaste for possible CHF
exacerbation. She was transferred to [**Hospital1 18**] for further
management.
In the [**Hospital1 18**] emergency room her initial vital signs were T; 99.3
HF: 130 (atril fibrillation), BP: 90/50 O2: 98% on RA. Initial
labs were notable for leukocytosis and bandemia (WBC count of
23.1 with 9% bands), BNP of 4181, initial lactate of 3.1 which
improved to 2.1 with gentle hydration. She had a negative UA.
Her CXR showed some questionable interstitial edema with no
focal infiltrates. She had blood cultures sent. She received
vancomycin in additio to the previously received ceftriaxone and
azithromycin. She alos received 2L of normal saline with
improvement in her blood pressure. She was transferred to the
ICU for further management.
While in the ICU her hemodynamics improved. Her antibiotics
were changed to vancomycin, cefepime and azithromycin. She had
left IJ central line placed for IV access. She had a negative
DFA. She had a sputum culture which was polymicrobial and
cultures are pending. Urine culture was negative. Blood
cultures were drawn and were negative to date. She was
transiently hypotensive the afternoon of MICU transfer in the
setting of receiving her home dose of diltaizem. Her blood
pressure quickly improved with 250 NS bolus. She is transferred
to the floor for further management.
On review of systems she denies fevers, chills, lightheadedness,
dizziness, chest pain, dyspnea, nausea, vomtiing, abdominal
pain, diarrhea, constipation, dysuria, hematuria, leg pain or
swelling. She does report fatigue. All other review of systems
negative in detail.
Past Medical History:
-CAD (per pt no h/o MI)
-CHF (per pt's son, due to "irregular HR")
-HTN
-Atrial Fibrillation on coumadin
-Catarcts
-Asthma
-G tube placed 2 weeks ago for recurrent aspiration event
-recent recurrent UTI
-dementia
Social History:
Lives at home w/ son and daughter-in-law, but as per HPI, recent
numerous hospitalizations so presents from rehab (per report,
came from ?[**Location (un) **] country manor nursing home). Never smoked.
Family History:
n/c
Physical Exam:
Vitals - T 96.1, HR 104, BP 91/47, RR 20, O2 98% on 3L NC
Gen - awake, alert, conversive, oriented to person, [**2137**],
hospital
HEENT - PERRL, EOMI, oropharynx clear, MMM
Neck - JVP approx 8-10 cm, no bruits
Heart: soft heart sounds, irregularly irregular, no appreciable
murmurs, rubs, gallops
Lungs - scattered crackles throughout, no wheezes or ronchi
Abd - soft, NT/ND, G tube in place, site without erythema or
purulence
Ext - WWP, 2+ pulses, trace edema bilaterally
Pertinent Results:
Hematology:
[**2138-1-15**] 05:28PM WBC-23.1* RBC-3.42* HGB-10.5* HCT-32.1*
MCV-94 MCH-30.8 MCHC-32.8 RDW-16.4*
[**2138-1-15**] 05:28PM NEUTS-78* BANDS-9* LYMPHS-4* MONOS-6 EOS-0
BASOS-0 ATYPS-0 METAS-2* MYELOS-1*
[**2138-1-15**] 05:28PM HYPOCHROM-NORMAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-OCCASIONAL
POLYCHROM-1+ OVALOCYT-OCCASIONAL
[**2138-1-15**] 05:28PM PLT SMR-VERY HIGH PLT COUNT-873*
[**2138-1-24**] 06:05AM WBC-20.4* RBC-3.34*# HGB-10.1*# HCT-30.5*#
MCV-91 MCH-30.1 MCHC-33.0 RDW-16.3* PLT-388
[**2138-1-23**] 05:54AM NEUTS-71* BANDS-1 LYMPHS-9* MONOS-3 EOS-12*
BASOS-0 ATYPS-0 2* METAS-2* MYELOS-1*
Chemistries:
[**2138-1-15**] 05:28PM BLOOD Glucose-123* UreaN-32* Creat-1.0 Na-132*
K-5.3* Cl-96 HCO3-21* AnGap-20
[**2138-1-15**] 05:28PM BLOOD Calcium-9.3 Phos-4.5 Mg-1.8
[**2138-1-18**] 05:00AM BLOOD Calcium-8.0* Phos-1.5* Mg-1.5*
[**2138-1-23**] 05:54AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.7
Cardiac Enzymes:
[**2138-1-15**] 05:28PM BLOOD CK-MB-NotDone proBNP-4181*
[**2138-1-15**] 05:28PM BLOOD cTropnT-0.02*
[**2138-1-15**] 05:28PM BLOOD CK(CPK)-26
[**2138-1-15**] 11:00PM BLOOD CK-MB-NotDone
[**2138-1-15**] 11:00PM BLOOD CK(CPK)-24*
[**2138-1-16**] 07:09AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2138-1-16**] 07:09AM BLOOD CK(CPK)-23*
Other Laboratories:
[**2138-1-22**] 05:43AM BLOOD calTIBC-177* VitB12-1337* Folate-19.3
Ferritn-442* TRF-136*
[**2138-1-18**] 05:00AM BLOOD Osmolal-271*
[**2138-1-15**] 05:40PM BLOOD Glucose-113* Lactate-3.1* Na-131* K-4.9
Cl-98*
[**2138-1-15**] 08:03PM BLOOD Lactate-2.0
[**2138-1-16**] 12:06AM BLOOD Lactate-1.3
[**2138-1-16**] 07:16AM BLOOD Lactate-0.9
[**2138-1-24**] 06:05AM BLOOD Vacomycin-26.6
Urinalysis:
[**2138-1-15**] 05:28PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-0.2 PH-9.0* LEUK-TR RBC-0-2 WBC-[**2-5**]
BACTERIA-MOD YEAST-NONE EPI-0 3PHOSPHAT-MOD
[**2138-1-18**] 01:05PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.011
Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR RBC-0-2 WBC-[**5-13**]*
Bacteri-OCC Yeast-FEW Epi-0
[**2138-1-18**] 01:05PM URINE Hours-RANDOM Creat-25 Na-108
[**2138-1-18**] 01:05PM URINE Osmolal-404
EKG [**2138-1-15**]: Sinus tachycardia. Borderline low limb lead
voltage. No previous tracing available for comparison.
Imaging:
CXR [**2138-1-15**]: Some pulmonary vascular congestion and blurring
with nterstitial edema. No overt edema or pleural effusion. No
focal consolidation.
Microbiology:
Blood cultures from [**2138-1-15**] x 2 - negative final
Blood cultures from [**2138-1-20**] x 2 - no growth to date at time of
discharge
Urine cultures from [**2138-1-15**] - negative
Urine culture from [**2138-1-18**] - yeast
DFA for Inflenza A/B [**2138-1-15**] - negative
Stool for Clostridium Difficile [**2138-1-18**], [**2138-1-19**], [**2138-1-20**] and
[**2138-1-22**] - negative
[**2138-1-16**] 3:04 am SPUTUM Source: Expectorated.
**FINAL REPORT [**2138-1-19**]**
GRAM STAIN (Final [**2138-1-16**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): YEAST(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
RESPIRATORY CULTURE (Final [**2138-1-19**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
PROTEUS MIRABILIS. MODERATE GROWTH. PRESUMPTIVE
IDENTIFICATION.
STAPH AUREUS COAG +. MODERATE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
| STAPH AUREUS COAG +
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 8 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ <=1 S
CIPROFLOXACIN--------- =>4 R
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ 4 S <=0.5 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
PIPERACILLIN---------- 8 S
PIPERACILLIN/TAZO----- <=4 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ 2 S
TRIMETHOPRIM/SULFA---- =>16 R <=0.5 S
VANCOMYCIN------------ <=1 S
Brief Hospital Course:
Mrs. [**Known lastname 75980**] is an 85 year old female with a history of CAD,
atrial fibrillation and recent recurrent hospitalizations for
urinary tract infections and aspiration pneumonia who presents
with fever, tachypnea, hypoxia and hypotension.
Fevers/Leukocytosis, likely due to septicemia, NOS, and
bacterial/aspiration pneumonia: The patient presented with
fevers to 102 degrees with a leukocytosis and bandemia. She
also had an elevated lactate on presentation to 3.1 with mild
hypotension in the setting of rapid atrial fibrillation. Her
only localizing symptoms were tachypnea and mild oxygen
requirement. A broad infectious workup was performed including
blood cultures, urine cultures, sputum cultures and c. difficile
toxin. On admission her UA was trace positive with a urine pH
of 9.0. Blood and urine cultures, however, were negative. She
had a negative DFA. She had four negative C. diff toxin assays.
She had a CXR which showed no focal consolidations. She had a
sputum culture which grew proteus and MRSA. On admission to
this hospital her antibiotic coverage was switched to
vancomycin, cefepime and azithromycin to cover hospital acquired
pneumonia as well as urinary pathogens. This was subsequently
changed to vancomycin and ceftriaxone given sensitivities of
organisms. Her mild hypotension and elevated lactate quickly
improved with fluid boluses. Her fevers quickly resolved. Her
leukocytosis however, persisted. On admission her WBC count was
23.1 with 78% neutrophils and 9% bands. After initiation of
broad spectrum antibiotics her WBC count decreased only slightly
despite improvement in her symptoms and resolution of her
fevers. Initially her differential was left shifted but prior
to discharge this had transitioned to a 12% eosinophilia with
rare myelocytes and metamyelocytes. It was thought that her
persistent leukocytosis was secondary to her antibiotics. She
has plans to complete a 14 day course of antibiotics with
vancomycin and ceftriaxone for her proteus and MRSA in the
sputum. Her vancomycin is being dosed by level. On discharge
her level was 26.6. Her vancomycin trough should be checked
daily and she should be given 1 gram of vancomycin when her
trough falls to below 20. Her CBC and differential should be
rechecked one week after completion of therapy to ensure
improvement in her leukocytosis. If she continues to have
immature cells in her peripheral blood differential or a
persistent leukocytosis, hematology consultation should be
considered as an outpatient.
Anemia: On admission the patient's hematocrit was 32.1 but this
decreased rapidly to 26.2 after gentle fluid hydration. For the
remainder of her hospitalization her hematocrit was stable
between 23 and 26. During this hosptilization her folate and
B12 were checked and were normal. Her iron was measured at 33
with a ferritin 442 consistent with anemia of inflammation.
Prior to discharge she was transfused one unit of PRBCs. Her
hematocrit should also be checked in one week to ensure
stability.
Hyponatremia: On presentation to the OSH the patient's serum
sodium was 125. With gentle fluid hydration this improved to 132
on arrival to this hospital. Studies performed on presentation
here revealed a serum osmolality of 271 with a urine osmolality
404 which was inappropriately elevated consistent with SIADH,
likely due to pulmonary process. She was continued on her
standard tube feeds. Her sodium remained between 130 and 134.
No further interventions were made.
Congestive Heart Failure: Per report the patient has a history
of congestive heart failure. There are no echocardiograms in
our system and it is unclear whether her heart failure is
systolic vs. diastolic. On presentation her initial CXR showed
mild pulmonary edema and her BNP was elevated in the 4000s. Her
oxygenation saturation on arrival here was 98% on RA. Initially
her home CHF regimen was held out of concern for hypotension and
possible sepsis. Her blood pressures remained in the 100s
systolic during her hospitalization and on discharge she was
tolerating metoprolol 12.5 mg [**Hospital1 **] but her home aldactone was not
able to be restarted. Her aldactone should be restarted as an
outpatient once her acute illness has resolved.
Coronary Artery Disease: Again, this is per patient history.
Her EKG on presentation had no changes concerning for ischemia.
She had three sets of negative cardiac enzymes. She was
continued on her home doses of lipitor and plavix. She was also
started on metoprolol 12.5 mg bBID.
Atrial Fibrillation: On arrival to this hospital the patient
was in atrial fibrillation with rapid ventricular response.
This was in the setting of acute infection. Previously she was
taking diltiazem for rate control. Given her history of heart
failure and coronary artery disease she was transitioned to
metoprolol 12.5 mg [**Hospital1 **] for rate control. She tolerated this
medication well. For the majority of her hospitalization she
was in sinus rhythm. She was continued on coumadin for
anticoagulation.
Nutrition: The patient had a PEG tube placed two weeks ago for
tube feeds given frequent aspiration events over the past six
months. On hospital day three the patient was noted to have
decreased potassium, magnesium and phosphorous concerning for
refeeding syndrome. The rate of her tube feeds was decreased
and her electrolytes were repleted aggressively. Her
electrolyte abnormalities quickly resolved. She was placed back
on her full rate of tube feeds which she subsequently tolerated
well.
Prophylaxis: she was continued on coumadin for her atrial
fibrillation was well as DVT prophylaxis.
Access: She currently has a single lumen PICC in place for IV
antibiotics.
FEN: Tube feeds at 55 cc/hr, NPO, aspiration precautions
Code Status: DNR/DNI confirmed with patient and patient's son
[**Name (NI) **] who is her health care proxy.
Communication: [**Name (NI) **] son who is pt's HCP, [**Name (NI) **], ([**Telephone/Fax (1) 77832**]
Medications on Admission:
Cardizem 120 mg TID
Plavix 75 mg Daily
Aldactone 50 mg Daily
Prevacid 15 mg Daily
Calcium Carbonate 1,000 mg TID
Albuterol 90 mcg INH QID
Lexapro 10 mg Daily
Lipitor 20 mg Daily
Coumadin 4 mg 2 times/week
Coumadin 2 mg 5 times/week
Discharge Medications:
1. Clopidogrel 75 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY
(Daily).
2. Calcium Carbonate 500 mg Tablet, Chewable [**Telephone/Fax (1) **]: Two (2)
Tablet, Chewable PO TID (3 times a day).
3. Albuterol 90 mcg/Actuation Aerosol [**Telephone/Fax (1) **]: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed.
4. Escitalopram 10 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY
(Daily).
5. Atorvastatin 10 mg Tablet [**Telephone/Fax (1) **]: Two (2) Tablet PO DAILY
(Daily).
6. Metoprolol Tartrate 25 mg Tablet [**Telephone/Fax (1) **]: 0.5 Tablet PO BID (2
times a day).
7. Warfarin 2 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY16 (Once
Daily at 16).
8. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
9. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback [**Telephone/Fax (1) **]:
One (1) Intravenous Q24H (every 24 hours).
10. Prevacid 15 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
11. Vancomycin 1,000 mg Recon Soln [**Last Name (STitle) **]: One (1) Intravenous
dosed by level for 6 days: Vancomycin level should be checked
[**2138-1-25**]. Dose should be given if trough < 20. Subsequently
should be dosed by level for trough 15-20. .
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
Pneumonia
Secondary:
Hypertension
Coronary Artery Disease
Chronic Congestive Heart Failure (ejection fraction unknown)
Asthma
Dementia
Atrial Fibrillation
Discharge Condition:
Stable. Breathing comfortably on room air. Requiring
significant assistance for ambulation.
Discharge Instructions:
You were seen and evaluated for your fevers and cough. You were
thought to have a pneumonia. You were treated with antibiotics.
You were found to have a high white blood cell count. Although
your symptoms improved your white blood cell count did not.
This should be rechecked after you complete your antibiotics for
your pneumonia.
Please take all your medications as prescribed. The following
changes have been made to your medication regimen.
1. Please take ceftriaxone 1 gram IV every 24 hours for 6 more
days
2. Please take vancomycin 1 gram for six more days. Dose will
need to be adjusted by level for target trough of 15-20.
Vancomycin level should be checked on [**2138-1-25**] and dosed as
appropriate.
3. Please take coumadin 2 mg daily instead of alternating with 4
mg. INR should be rechecked on [**2138-1-25**] and coumadin dosing
should be adjusted for a target INR between [**1-5**].
4. Please stop taking Cardizem
5. Please stop taking Aldactone. This medication should be
restarted as an outpatient once the patient has improved
clinically.
6. Please take metoprolol 12.5 mg two times per NGT a day
Please keep all your follow up appointments.
Please seek immediate medical attention if you experience any
fevers > 101 degrees, chest pain, trouble breathing, worsening
cough, significant diarrhea, or any other concerning symptoms.
Followup Instructions:
Please follow up with your primary care physician [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37063**]
within one week of discharge from rehab. His office phone
number is [**Telephone/Fax (1) 37064**].
Patient should have repeat CBC with differential one week after
completion of antibiotic therapy to assure resolution of her
leukocytosis and eosinophilia.
|
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"428.0",
"493.90",
"482.41",
"482.83",
"401.9",
"414.01",
"427.31",
"253.6",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
16919, 16991
|
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|
275, 340
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3600, 4077
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5046, 9159
|
216, 237
|
368, 3107
|
3129, 3344
|
3360, 3563
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,232
| 123,252
|
39022
|
Discharge summary
|
report
|
Admission Date: [**2156-1-31**] Discharge Date: [**2156-3-1**]
Date of Birth: [**2112-10-11**] Sex: F
Service: EMERGENCY
Allergies:
Metformin
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
cough, hypotension
Major Surgical or Invasive Procedure:
intubation, tracheostomy placement, PEG placement
History of Present Illness:
History obtained from nurse supervisor at [**Hospital3 **] and
patient's brother [**Name (NI) **] [**Name (NI) 86531**], HCP.
.
Ms. [**Name14 (STitle) 86532**] is a 43 yo woman with a history CVA, stage IV chronic
kidney disease, DM, HTN. She has received all of her prior care
through [**Hospital1 2177**] and currently lives at [**Hospital3 2558**] nursing home
since a CVA in [**2-17**]. Her baseline status since that time has
been bedbound but communacative. Since approximately [**9-18**], her
family has noted deteriorating ability to communicate. She is
unable to talk but alert. For one week her nurse [**First Name (Titles) 8706**] [**Last Name (Titles) 86533**]
mental status including repeating that she flet like dying. On
the morning of [**1-31**], she was at her recent baseline, alert,
responsive, underwent hd at 11 am. At 5 pm she was noted to have
an episode of yelling, followed by coughing. On exam she had
increasingly rhonchorus breath sounds and increased cough and
thought to be at risk for aspiration. No witnessed aspiration.
She was also noted to be febrile to 101.8 and hypoxic to 87% on
RA, BP 95/66 (baseline not recorded), RR 24. She was given
oxygen by 2L nasal canula with an increase to 93% on RA. FS 153.
Her brother requested transfer to the hospital.
.
From [**Hospital3 **], she was transferred to [**Hospital1 18**] despite
instructions from her brother to go to [**Hospital1 2177**] where she has
received all of her previous care. In the [**Hospital1 18**]. ED initial
vital signs were BP 84/49, HR 110, T 101.8, RR 30, O2 Sat 75%
NRB. Breath sounds were rhonchorus. She was given etomidate 20
mg IV and rocuronium 50 mg x 1 and easily intubated. She
required no further intubation once sedated. She was also given
vancomycin 1g, zosyn 4.5 g. SBP fell to 68 peri-intubation.
Levophed gtt was started with which SBP rose to the low 100s. 1L
NS to 40 meq K at 200 cc/h was started. She was admitted to the
ICU for further management.
Past Medical History:
CVA [**2-17**] with residual L hemiparesis
ESRD on HD T/Thurs/Sat x years ([**Location (un) **] [**Location (un) **])
HTN
DM
Social History:
From [**Country **] originally, emigrated to the US in the [**2125**].
Lifetime nonsmoker, occasional EtOH prior to decline during the
past year.
Family History:
no family history of renal disease or stroke
Physical Exam:
Admission exam:
VS: 110/66, HR 98, RR 23, O2 100% (vent settings 400/14, FiO2
.6, PEEP 5)
GEN:intubated, sedated, not arousable
SKIN: stage 2 coccygeal ulcer, b/l heel abrasions
HEENT: intubated
CHEST: diffusely rhonchorus L>R anteriorly.
CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.
ABDOMEN: No apparent scars. Non-distended, and soft without
tenderness
EXTREMITIES: RUE fistula with palpable thrill, R femoral
catheter clean and dry, no peripheral edeme
NEUROLOGIC: intubated, sedated, not responsive to voice or
painful stimuli. R pupil 4 mm and nonreactive, L pupil 3-->2 mm.
Pertinent Results:
Admission labs:
chemistry: 149/2.9/107/30/22/4.5<217
CBC: 19.4>8.9/29.2<397 (85% PMN, 11% lymphs)
coags: 13.2/38.8/1.1
lactate 2.1
urine tox negative, ucg negative
UA: [**10-30**] wbc, [**2-13**] rbc, negative nitrites, [**10-30**] epis
urine cx, blood cx pending
.
ABG (intubated on 100% FiO2) - 7.38 / 49 / 232
.
[**2156-2-4**] ECHO:
The left atrium is normal in size. No thrombus/mass is seen in
the body of the left atrium. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is low normal (LVEF 50-55%). 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) appear structurally normal with good leaflet
excursion and no aortic regurgitation. No masses or vegetations
are seen on the aortic valve. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. No mass or vegetation is seen on the
mitral valve. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
.
[**2156-2-19**] MRI brain:
1. Evolving bihemispheric watershed infarcts without evidence
for new infarct from the prior study.
2. Sequelae of extensive chronic microvascular white matter
ischemic disease throughout the supratentorial compartment and
brainstem.
3. Findings of retinal detachment with subretinal hematoma
and/or
proteinaceous fluid.
4. Right mastoid air cell effusion.
.
[**2156-2-24**] CXR: In comparison with study of [**2-12**], the endotracheal
tube has been removed and replaced with a tracheostomy tube. No
evidence of complication. Central catheter remains in place.
Nasogastric tube has been removed. There is some vague
opacification at the left base that could represent a focus of
consolidation. However, this is not much different from the
prior study. Overlying apparatus somewhat obscures detail.
Brief Hospital Course:
43 yo woman with hx ESRD [**1-13**] DM, CVA, presents with fever,
hypoxia, hypotension, and leukocytosis, most likely secondary to
sepsis.
.
# Possible Sepsis: Hypotension and leukocytosis were initially
concerning for infection. Source was never determined. CXR
with possible RLL infiltrate which could be consistent with her
history of high risk for aspiration. Sputum, blood, and urine
cultures as well as c diff toxin were persistently negative.
TTE was negative for vegetation. She was initially given
vancomycin and zosyn which was narrowed to vancomycin alone
after culture data were negative. Vancomycin was later stopped
given lack of definitive evidence of infection, but WBC
immediately rose and the patient became febrile. Vancomycin was
thus restarted and infectious work-up redone and was again
negative. Vancomycin was discontinued.
.
# Respiratory failure: After hypotension resolved, patient
easily passed spontaneous breathing trials while intubated.
However, when extubated she developed excessive secretions and
failed to hold her neck in a way that maintained adequate
ventilation. Thus, she repeatedly failure trials of extubation
and required reintubation. This was discussed with her brother,
and the decision was made to proceed with tracheostomy and PEG
placement. Because of a large thyroid, this could not be done
at the bedside but required a procedure in the OR by thoracics
on [**2156-2-16**]. Her respiratory status remained stable for the
remainder of her hospitalization.
.
# Altered mental status: Brother reported recently [**Date Range 86533**]
mental status for 3 months with an acute decline per nurse in
the past few days culminating in event the day of admission. Per
nurse, patient has been quite depressed, raising the question of
ingestion (? related to CXR findings), but tox screen here
negative. Later in her course, patient became more arousable and
was following commands and communicating in one-word phrases.
However, the day of planned discharge after tracheostomy, she
was noted to be progressively less responsive and displaying
repetitive grimacing movements. Neurology was consulted.
Repeat MRI showed no new stoke. EEG monitoring displayed
seizures (see below). At time of discharge patient remains
largely unresponsive (responds to painful stimuli only).
Neurology team followed patient throughout admission. The
etiology for her altered mental status at time of discharge was
not entirely clear. The decline likely represents continued
damage in the setting of new seizures and subacute strokes. No
clear metabolic or infectious cause of encephalopathy at time of
discharge.
.
# Seizure activity: Newly discovered in MICU, as above.
Neurology was following. She was given IV Ativan, loaded with
phenytoin and then, when seizures persisted, reloaded with
fosphenytoin. Standing keppra was started. Seizures persisted.
Keppra dose was adjusted and seizure activity on EEG resolved.
Last documented seizure activity on [**2156-2-19**]. Unfortunately,
with resolution of seizures her mental status did not improve.
Recommend continuing current keppra regimen and following up
with Dr. [**First Name (STitle) 437**] in epilepsy clinic on Monday [**4-7**] at 10 am.
To keep this appointment the patient's new "primary care
physician" must call the clinic for a referral.
.
# VAP: Patient developed low grade fever, and increased sputum
production on [**2156-2-24**]. She was started on empiric treatment for
ventilatory associated pneumonia (VAP). Sputum cultures grew E.
Cloacae. With initiation of antibiotics she became afebrile and
persistent leukocytosis started to decline. Recommend completing
a 14 day course of vancomycin (HD dosing) and meropenem (last
dose on [**2156-3-9**]).
.
# Stage IV chronic kidney disease. Undergoes HD at [**Location (un) **]
[**Location (un) **] T/Th/Sat. Got dialyzed today. No urgent electrolyte
indication for dialysis on admission. Fosrenal and nephrocaps
were continued. Thrice weekly dialysis was continued. She was
frequently mildly hypotensive and tachycardic after dialysis but
responded nicely to 250cc fluid boluses.
.
# DM: Home dose of lantus and SS insulin were continued. She
was initially hypoglycemic, so lantus was downtitrated. Glucose
stable on glargine 11 u qhs and sliding scale insulin.
.
# HTN: Metoprolol and lisinopril were held initially while
requiring pressors. Metoprolol was later restarted for mild
hypertension and sinus tachycardia. Just prior to discharge
patient's blood pressure became elevated and her home lisinopril
was restarted.
.
# hx CVA: with residual R hemiparesis. MRI on admission
demonstrated subacute strokes. The stroke service recommended
aspirin and plavix. These were started, but Plavix was held for
1 week awaiting trach/PEG. Patient to continue aspirin and
plavix indefinitely.
.
# NUTRITION: Continue patient on tube feeds. Due to some issues
with residuals she was started on narcan and reglan to increased
motility. Due to some concern that these mediations may
influence mental status these medications were discontinued and
she was started on erythromycin for motility. Currently doing
well without residuals. Would continue erythromycin for the
next several days and then do a trial without erythromycin to
insure gastric emptying. Patient is DMt1 and will require
adjustments in insulin regimen if feeds are changed. Patient
should also continue to receive multivitamins for micronutrient
support as this could also be contributing to mental status
dysfunction.
.
Full code status was discussed with the patient's brother, [**Name (NI) **]
[**Name (NI) 86531**]. Agreement to intubation was confirmed with patient the
day she was extubated (and reintubated). Family meeting was held
again to readdress goals of care. Because her neurologic
prognosis cannot be determined in the acute setting of recent
seizures and CVA the decision was made to readdress goals of
care (i.e. code status) in a few weeks when patient's mental
status may be more indicative of prognosis. At time of
discharge patient remained Full Code.
Medications on Admission:
metoprolol succinate 200 mg daily
cymbalta 60 mg daily
lidoderm patch x 12 hours daily
lisinopril 30 mg daily
ASA 81 mg daily
buspar 5 mg daily at 12 pm
bactroban nasal oinment [**Hospital1 **]
vitamin c 250 mg [**Hospital1 **]
fosrenal 1000 mg tid
humalog qac (can not read dose - 5 units)
humalog SS
lantus 24 units qhs
tylenol 650 mg 30 minutes prior to dressing change
ducolax 10 mg prn
MOM prn
[**Name2 (NI) 21330**] prn
simvastatin 80 mg daily
senna 8 mg daily
omeprazole 20 mg [**Hospital1 **]
colace 100 mg [**Hospital1 **]
heparin sc tid
reglan 10 mg qid
nephrocaps qd
vitamin d 50 000 IU qd
heparin
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
4. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash.
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
10. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
11. Erythromycin 250 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q6H (every 6 hours) for 3
days.
12. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
13. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram
Intravenous HD PROTOCOL (HD Protochol) for 8 days: Last dose
[**2156-3-9**].
14. Levetiracetam 100 mg/mL Solution Sig: Five Hundred (500) mg
PO BID (2 times a day).
15. Levetiracetam 100 mg/mL Solution Sig: Two [**Age over 90 1230**]y
(250) mg PO THREE TIMES PER WEEK (): FOLLOWING DIALYSIS.
16. Meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg
Intravenous Q24H (every 24 hours) for 8 days: GIVE EVERYDAY
(AFTER HD ON HD DAYS).
Last dose [**2156-3-9**]. mg
17. Insulin
Continue Insulin regimen of glargine 11 units qhs and sliding
scale humalog with meals.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary Diagoses:
Sepsis (unknown etiology)
Respiratory failure
Ventilatory associated pneumonia
Seizures
Secondary diagnoses:
Subacute CVAs
CKD Stage IV
HTN
DM1
Discharge Condition:
Patient is nonverbal, responsive only to painful stimuli. She
tolerates tube feeds. A tracheostomy is in place. Respiratory
status is stable on trach mask.
Discharge Instructions:
You presented to the hospital with low blood pressure and low
oxygen levels concerning for a serious infection. You required
intubation to help your breathing. Unfortunately you were not
unable to be extubated and you required a tracheostomy. Your
mental status was altered. Neurology was consulted and you were
found to be having seizures. You were started on seizure
medications and your seizures resolved. You remained largely
unresponsive. Because of your inability to eat a feeding tube
was surgically placed. You tolerated tube feeds well. During
your admission you had a fever and increased sputum. Sputum
cultures grew a bacteria and you were treated with IV
antibiotics. At the time of discharge you were no longer having
fevers or increased sputum. Your respiratory status was stable.
You remained unresponsive. The prognosis of your mental status
cannot be determined at this time. You will follow up with a
neurologist to review your prognosis next month.
Followup Instructions:
Please call [**Telephone/Fax (1) 876**] once a primary care physician has been
assigned at your rehab center to confirm your follow up
appointment at [**Hospital 875**] Clinic at [**Hospital1 18**] [**Hospital Ward Name 516**] for Monday
[**4-5**] 10am with Dr. [**First Name (STitle) 437**].
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69,483
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Discharge summary
|
report
|
Admission Date: [**2168-3-1**] Discharge Date: [**2168-3-12**]
Service: MEDICINE
Allergies:
Codeine / Vasotec / Cortisporin / Ciloxan / Atenolol
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
PICC line placement [**2168-3-4**]
History of Present Illness:
The patient is an 86 year-old woman with a history of CAD, HTN,
CHF, DM, and recent hospitalizations for NSTEMI/CHF exacerbation
([**2168-1-22**]) and generalized weakness ([**2168-2-10**]), who now presents
with increasing dyspnea on exertion and weight gain x 2 days.
The patient was discharged from rehab 4 days ago. She states
that she felt well over the weekend but noticed increasing
swelling in her legs over the past 2 days. VNA noted a 7lb
weight gain over the past 2 days. The patient reports fatigue
and shortness of breath with minimal exertion (walking a short
distance to the bathroom) since this morning.
.
She denies chest pain, chest pressure, fever, and chills. She
notes a baseline cough that has not changed. She denies dietary
indiscretion (including canned soup, [**Location (un) 6002**] meats, fast food,
excess salt) and reports compliance with all medications. She
does think that her furosemide dose is lower than it was before
the last admission. She was was on 40mg TID prior to the
[**2168-2-10**] admission but was discharged on 40mg daily and
continues to take this lower dose. Per her family, the patient
has not been herself ever since the [**Month (only) 1096**] admissions. They
note that she has been fatigued and less active.
.
Of note, the patient was admitted on [**2168-1-22**] for hyperkalemia.
While inpatient, she was found to have an NSTEMI. Cath showed
non-intervenable two vessel disease, which was managed medically
with beta blocker, aspirin, plavix, statin and blood pressure
control. She was also treated for CHF exacerbation. The
patient was admitted again on [**2168-2-10**] for fatigue and
generalized weakness, thought to be due to a combination of poor
glycemic control, orthostasis, and deconditioning.
.
In the ED, initial VS: T: 96.5 BP: 135/33 RR: 22 O2Sat: 95% RA.
Patient was given 40mg IV lasix, 15mg kayexalate, and 2gm IV
ceftriaxone. CXR showed intestitial edema and a small right
pleural effusion. ECG showed sinus bradycardia, no peaked T
waves, unchanged from priors.
.
Currently, the patient is sitting in bed comfortably. She
denies SOB at rest. She complain of thigh pain (chronic issue).
Past Medical History:
1. CAD, status post cardiac catheterization in [**2167-3-15**]
with bare metal stenting and PTCA of an ostial 90% RCA lesion,
complicated by dissection and pseudoaneurysm .
2. Peripheral [**Year (4 digits) 1106**] disease with lower extremity c/b
neuropathy
3. Insulin-dependent diabetes mellitus.
4. Hypertension.
5. Hyperlipidemia.
6. Asthma.
7. GERD.
8. Osteoarthritis.
9. Recent contrast-induced nephropathy after cardiac
catheterization with a peak creatinine of 4.4 requiring
transient
renal replacement therapy.
10. CRI baseline 1.1 - 1.2
11. Hyperparathyroidism
12. B12 deficiency anemia
13. Appendectomy
14. Bladder suspension
15. Right meniscectomy in [**2161-1-11**]
16. Excision of benign breast mass times two
Social History:
The patient currently lives in [**Location 107641**] with her [**Age over 90 **] year old
Husband. She has 1 son who lives in [**Name (NI) 701**]. At baseline she
walks with a cane, she is otherwise independent in all ADLs.
Tobacco: None
ETOH: None
Illicits: None
Family History:
-Father: heart problems, DM
-Mother: heart problems
-4 brothers: CAD, one with stroke
Physical Exam:
Vitals - T:92.8 orally (rectal temp did not register) BP:118/66
HR:50 RR:20 02 sat: 96% on 2L
GENERAL: Awake, sitting in bed, NAD, audible expiratory wheezes
HEENT: Sclera anicteric, EOMI, PERRLA, OP clear
CARDIAC: Slow rate, regular rhythm, normal S1 & S2, no murmurs,
rubs, or gallops
LUNG: Decreased breath sounds at bases bilaterally, some
crackles at bases, scattered wheezes throughout
ABDOMEN: Obese, soft, non-tender, non-distended, no guarding or
rebound, multiple bruises from subcutaneous medication
administration
EXT: Warm, well-perfused, 1+ distal pulses bilaterally, 2+
pitting LE edema bilaterally to mid shin
NEURO: A&Ox3, CN 2-12 intact, sensation intact to light touch
throughout
.
LABS: See below.
136 101 111 AGap=19
--------------<194
6.0 22 2.3
Comments: K: Not Hemolyzed
.
8.1
5.0>------<105
25.6
N:81.1 L:10.5 M:6.6 E:1.7 Bas:0.1
.
proBNP: 4159
.
Trop-T: 0.12
Pertinent Results:
[**2168-3-1**] 12:55PM BLOOD WBC-5.0 RBC-2.59* Hgb-8.1* Hct-25.6*
MCV-99* MCH-31.1 MCHC-31.5 RDW-14.9 Plt Ct-105*#
[**2168-3-2**] 05:10AM BLOOD WBC-4.6 RBC-2.48* Hgb-7.9* Hct-24.2*
MCV-98 MCH-31.7 MCHC-32.5 RDW-14.9 Plt Ct-110*
[**2168-3-1**] 12:55PM BLOOD Neuts-81.1* Lymphs-10.5* Monos-6.6
Eos-1.7 Baso-0.1
[**2168-3-1**] 12:55PM BLOOD Glucose-194* UreaN-111* Creat-2.3* Na-136
K-6.0* Cl-101 HCO3-22 AnGap-19
[**2168-3-1**] 09:10PM BLOOD Glucose-141* UreaN-111* Creat-2.3* Na-137
K-5.5* Cl-104 HCO3-21* AnGap-18
[**2168-3-2**] 05:10AM BLOOD Glucose-101* UreaN-107* Creat-2.3* Na-141
K-4.0 Cl-103 HCO3-24 AnGap-18
[**2168-3-1**] 12:55PM BLOOD CK(CPK)-104
[**2168-3-1**] 09:10PM BLOOD CK(CPK)-89
[**2168-3-2**] 05:10AM BLOOD CK(CPK)-73
[**2168-3-1**] 12:55PM BLOOD cTropnT-0.12*
[**2168-3-1**] 09:10PM BLOOD CK-MB-NotDone cTropnT-0.09*
[**2168-3-2**] 05:10AM BLOOD CK-MB-NotDone cTropnT-0.10*
[**2168-3-2**] 05:10AM BLOOD Calcium-8.3* Phos-6.5* Mg-3.6*
[**2168-3-1**] 09:10PM BLOOD Calcium-8.4 Phos-6.5*# Mg-3.8*
[**2168-3-2**] 10:05AM BLOOD Type-ART pO2-71* pCO2-37 pH-7.46*
calTCO2-27 Base XS-2 Intubat-NOT INTUBA
.
CXR [**2168-3-1**]:
FINDINGS: In comparison with the study of [**3-1**], there is
increasing
opacification involving portions of the right, mid and lower
lung zone,
consistent with pneumonia. A small area of opacification in the
retrocardiac region on the left could represent a second focus
of infection. The pulmonary vessels are not well defined,
raising the possibility of elevated pulmonary venous pressure in
this patient with persistent enlargement of the cardiac
silhouette.
Brief Hospital Course:
86 yo F with h/o history of CAD, HTN, CHF, DM, and recent
hospitalizations for NSTEMI/CHF exacerbation presents with
increased DOE, leg swelling and weight gain.
.
# Respiratory Distress/Pneumonia: Patient was admitted with
shortness of breath, and LE edema. She was found to have
significant expiratory wheezes on exam and was started on
Albuterol/Atrovent nebulizer treatments and as well as IV Lasix
with some improvement of her shortness of breath. CXR
demonstrated R sided opacities c/w pneumonia and she was started
on IV Vancomycin and Cefepime for hospital acquired pneumonia
coverage. On hospital day 2, her dyspnea progressed and she had
some chest pain with EKG changes and was transferred to the CCU.
There, the patient required high flow O2 and her antibiotic
coverage was expanded to include Levofloxacin. Her oxygen
requirement persisted so Pulmonary was consulted. They
recommended chest CT, which demonstrated bilateral infiltrates
concerning for aspiration pneumonia and tracheobronchomalacia. A
video swallow evaluation did not support a diagnosis of
aspiration and she slowly improved with broad spectrum
antibiotics in the context of a negative flu swab and negative
blood cultures. Her O2 was weaned to 2L of NC and she was
discharge to rehab after completing a 10 day course of
Vancomycin/Cefepime. She was discharged on Levofloxacin (day
[**10-21**]), bronchodilators, and close Pulmonary follow-up.
.
# NSTEMI: On hospital day two, patient developed [**9-20**] substernal
chest presure, consistent with prior epsiodes of angina. This
was associated with shortness of breath. An EKG demonstrated
sinus rhythm with ST depressions in V2, V3 and V4. ASA 325mg PO
and sublingual NTG were given with relief of chest pressure and
resolution of EKG changes. Later in the morning, she became
hypoxic (86% on 4L NC) and was placed on a venti mask. Repeat
EKG showed recurrence of the anterior ST depressions. She was
given an additional dose of IV lasix 40mg, and one inch of
nitroglycerin paste was placed. Cardiology recommended transfer
to CCU for further management. There, she eventually ruled in
for MI with elevated enzymes, but no chest pain or further EKG
changes. This was thought to be secondary to demand ischemia
from her respiratory distress and she was medically managed with
ASA, Carvedilol, Plavix, Simvastatin, Integrillin, and a Heparin
gtt as her coronaries were not amenable to intervention. Her
enzymes subsequently trended down and she remained chest pain
free for the remainder of her hospital stay.
.
# Acute on chronic systolic congestive heart failure: On arrival
to the floor, the patient was found to be fluid overloaded and
was diuresed with Lasix IV 40mg q6 hrs. She was continued on her
home doses of Carvedilol, Imdur, & Hydralazine. She then had an
episode of respiratory distress as detailed above and was
transferred to the CCU. In the CCU, it was felt that the
patient??????s presentation not consistent with a pure exacerbation
of sCHF, but was more consistent with a pneumonia and obtructive
pulmonary process. As a result, she was continued on her home
Imdur/Hydralazine, Amlodipine, and a decreased dose of
Carvedilol (dose limited by low heart rate). She was started on
Lisinopril 10mg daily. She received PRN dosing of IV Lasix with
good diuresis and was discharged on Lasix 60mg PO daily.
.
# Acute Kidney Injury on Chronic Kidney Disease: Patient has
stage III-IV CKD at baseline (Cr 1.6) and was admitted with a Cr
of 2.3. Her [**Last Name (un) **] was likely due to prerenal azotemia and poor
forward flow from systolic heart failure given 2:1 BUN to Cr
ratio. She was diuresed with IV Lasix to good effect and her Cr
trended down. It rose transiently in the context of
overdiuresis, but returned to her baseline of 1.6 at the time of
discharge.
.
# Anemia: Iron studies c/w iron deficiency & chronic
inflammation. Patient also has chronic kidney disease (baseline
Cr 1.6) that could contribute to her low hematocrit. In the CCU,
she required 3u pRBC??????s with an appropriate rise in Hematocrit.
She was given Ferrous Sulfate, Vitamin B-12, and a daily PPI as
an inpatient. Reviewing her records, she had a colonoscopy in
[**2162**] demonstrating grade 1 hemorroids and stools on this
admission were guaiac negative. Hemolysis labs also on this
admission were negative, but she has required blood transfusions
during each of her prior two [**Hospital1 18**] admissions. She is scheduled
for follow-up with her PCP to address this issue.
.
# Rhythm: Patient without a history of arrythmia. On admission,
patient had a K of 6.5 with an EKG demonstrating sinus
bradycardia without peaked T waves. She was given Kayexalate
with improvement in her potassium level. She was monitored on
telemetry throughout her hospitalization without arrythmia and
she was continued on Carvedilol at a decreased dose of 12.5mg PO
BID without incident.
.
# Diabetes Type II - Patient takes 18u NPH every morning at
home. This was increased to 28u NPH qAM as her blood sugars
required along with a Humalog sliding scale.
.
# Hypertension: Patient is was on a significant antihypertensive
regimen on admission. She was continued on her home
Hydralazine/Imdur, Amlodipine, and Clonidine, but her Carvedilol
was decreased to 12.5mg PO BID and she was started on Lisinopril
10mg daily.
.
# CODE: Patient remained FULL CODE throughout this
hospitalization.
.
# CONTACT: [**Name (NI) 3065**] [**Name (NI) **] (son)
([**Telephone/Fax (1) 107643**] (home)
([**Telephone/Fax (1) 107644**] (work)
([**Telephone/Fax (1) 107645**] (cell)
Medications on Admission:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO Daily.
2. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO Daily.
3. Clopidogrel 75 mg Tablet Sig: One Tablet PO Daily.
4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One Adhesive Patch, Medicated Topical Daily.
5. Lorazepam 0.5 mg Tablet Sig: One Tablet PO BID PRN as needed
for anxiety.
6. Mupirocin 2 % Ointment Sig: One Topical twice a day.
7. Miconazole Nitrate 2 % Powder Sig: One Appl Topical [**Hospital1 **] as
needed for rash.
8. Clonidine 0.1 mg Tablet Sig: One Tablet PO BID.
9. NPH Insulin Human Recomb 100 unit/mL Cartridge Sig: 18 units
Subcutaneous qam.
10. Simvastatin 20 mg PO Daily.
11. Novolog 100 unit/mL Cartridge Sig: One Subcutaneous sliding
scale.
12. Amlodipine 5 mg Tablet Sig: Two Tablet PO Daily.
13. Carvedilol 12.5 mg Tablet Sig: Four Tablet PO BID.
14. Calcium Carbonate 650 mg Tablet daily.
15. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One Tablet
PO Daily.
16. Cyanocobalamin 250 mcg Tablet Sig: Four Tablet PO Daily.
17. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Five Tablet Sustained Release 24 hr PO Daily.
18. Hydralazine 25 mg Tablet Sig: Four Tablet PO BID.
19. Furosemide 40 mg Tablet Sig: One Tablet PO Daily.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Acute on Chronic Congestive Heart Failure Exacerbation
bilateral Pneumonia
Hypertension
Insulin Dependent Diabetes Mellitus.
Coronary Artery Disease
Hyperlipidemia
? Asthma (pt denies)
B12 and Fe deficiency anemia
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You were admitted for shortness of breath and weight gain.
While here you developed chest pain. An EKG showed changes that
suggested heart damage. You developed a very severe pneumonia
that needed intravenous antibiotics to treat. You have slowly
improved but you still need close monitoring and frequent
nebulizer treatments. Your current oxygen requirement is 2L by
nasal prongs. We made many adjustments to your medicines to
control your blood pressure. Your kidneys also became worse with
your illness but have now recovered.
.
Medication changes:
1. Decrease your Carvedilol to 12.5 mg twice daily
2. Decrease Amlodipine to 5 mg daily
3. Increase Calcium to twice daily
4. Increase Furosemide to 60 mg daily
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please follow-up with the following appointments:
Pulmonology:
[**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **]
[**Hospital1 69**]
Pulmonary, Critical Care & Sleep Medicine
[**Location (un) 830**], [**Hospital Ward Name 23**] clinical Center, [**Location (un) 436**]
[**Location (un) 86**], [**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 612**]
Date/Time: [**4-18**] at 9:00am. The office will call Your son
[**Name (NI) 3065**] with an earlier appt.
.
Cardiology:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5855**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 285**] Date/Time:[**2168-3-25**]
10:30
.
Primary care:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2168-3-22**]
2:40
Please discuss with Dr. [**First Name (STitle) 216**] your low blood counts.
.
[**First Name (STitle) **] surgery:
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB)
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2168-7-18**] 11:15
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2168-7-18**] 11:50
|
[
"355.8",
"250.00",
"443.9",
"410.71",
"486",
"428.0",
"588.81",
"519.19",
"530.81",
"403.90",
"V58.67",
"414.01",
"585.3",
"272.4",
"276.7",
"285.21",
"428.23",
"584.9",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13092, 13164
|
6220, 11791
|
279, 316
|
13422, 13422
|
4593, 6197
|
14429, 15818
|
3566, 3653
|
13185, 13401
|
11817, 13069
|
13599, 14133
|
3668, 4574
|
14153, 14406
|
220, 241
|
344, 2520
|
13436, 13575
|
2542, 3268
|
3284, 3550
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,929
| 100,687
|
46456+46457
|
Discharge summary
|
report+report
|
Admission Date: [**2127-7-12**] Discharge Date: [**2127-7-14**]
Date of Birth: [**2060-9-26**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 66 year old female
admitted on [**2127-7-11**], mid afternoon, four days after
discharge from the Thrombus Service where she had had a right
pneumothorax and right-sided rib fractures due to a motor
vehicle accident. At that time she had been discharged to a
rehabilitation facility, primarily due to her social
situation where she was considered to a fall risk and she
lives at home alone without any social support. One day
prior to admission, staff at the skilled nursing facility
noticed increased drainage from the chest tube wound sight
and today the patient was noted to have a temperature of
101.6. The patient has also noticed worsening shortness of
breath. She was transported back to [**Hospital6 649**] and admitted back to the Trauma Service.
PAST MEDICAL HISTORY: Status post motor vehicle crash ten
days prior with multiple right rib fractures, status post
right-sided chest tube, glaucoma, chronic neuritic pain,
depression and otherwise nonspecified psychiatric history,
most likely a paranoid personality disorder.
PAST SURGICAL HISTORY: Status post left open reduction and
internal fixation of the tibial plateau and status post
bilateral hip replacement.
MEDICATIONS ON ADMISSION: Timolol, eye drops for glaucoma,
Nortriptyline 75 mg q.d., Neurontin 600 mg t.i.d., Colace,
Celexa 10 mg q.d., Percocet prn and Ibuprofen.
ALLERGIES: The patient has stated allergies to Effexor,
Penicillin and Topamax, none of which were related to rash or
shortness of breath by her history.
PHYSICAL EXAMINATION: Physical examination on arrival showed
temperature 97.6, heartrate 98, blood pressure 145/37 and
respiratory rate 18. Oxygen saturations were 82% on room air
and 99% on nonrebreather. The patient was awake and alert in
no acute distress, not tachypneic. There was a right-sided
chest crepitus palpated and auscultated. Left side of the
lung, decreased breathsounds as well at the base. There was
no jugulovenous distension. Heart had a regular rate. The
abdomen was soft, nontender, and had good bowel sounds. The
left knee had an area of ecchymosis but was not tender to
palpation nor warm to the touch. Left eye also had some
ecchymosis from a prior hematoma on the left anterior portion
of her scalp.
LABORATORY DATA: Initial laboratory data were significant
for a white count of 19.8, hematocrit 28, the patient having
a baseline hematocrit at discharge between 28 and 30.
Urinalysis with numerous white blood cells. Initial
radiology, chest x-ray was obtained showing left lower lobe
and right lower lobe consolidation, as well as a right lower
lobe effusion. Electrocardiogram was performed which showed
no acute change from her prior electrocardiogram.
HOSPITAL COURSE: The patient was admitted to the floor for
possible empyema versus pneumonia versus urinary tract
infection and started on Vancomycin and Ceftriaxone. It was
difficult to maintain the patient's oxygenation due to her
pain. A chest tube was attempted to be placed but was placed
in the chest wall and not in the intrapleural space. Said
chest tube was discontinued and upon thoracic surgery
consultation was not felt to be needed. The chest
computerized tomographic angiography was required to rule out
pulmonary embolism which showed the patient to be without
emboli. Chest computerized tomography scan did reveal a
small right apical pneumothorax as well as a small right
hydropneumothorax near the pulmonary artery and atelectasis
versus pneumonia at the right middle lobe. Aggressive chest
physical therapy and antibiotics gradually improved the
patient's oxygenation until she was sating well on simple
nasal cannula. Antibiotics were switched over to Levaquin
and as her condition has improved, she is stable for transfer
back to the rehabilitation facility where it is crucial that
she use incentive spirometry, has gotten out of bed as often
as possible and that her pain is managed well to prevent
relapse of possible pneumonia. She should follow up at the
Trauma Clinic in one to two weeks and should have an
outpatient colonoscopy scheduled as she has a persistent
anemia with heme positive stools. After she is done
completing her course of Fluoroquinolones it is recommended
that she be started on iron therapy but not prior to
finishing her Levaquin as Fluoroquinolone levels are reduced
in the face of concurrent iron therapy. At this time the
patient is discharged with the following diagnoses.
DISCHARGE DIAGNOSIS:
1. Right rib fractures from prior motor vehicle accident
status post second chest tube insertion
2. Urinary tract infection
3. Pneumonia
4. Loculated hydropneumothoraces on the right times two
5. Anemia
DISCHARGE MEDICATIONS:
1. Nortriptyline 75 mg h.s.
2. Neurontin 600 mg t.i.d.
3. Docusate 100 mg b.i.d.
4. Celexa 10 mg q.d.
5. Dilaudid 2 to 4 mg p.o. q. 6 hours prn for ten days
6. Levaquin 500 mg q.d. for nine days
DISCHARGE INSTRUCTIONS: Chest physiotherapy one to two times
per day as well as physical therapy for general strengthening
and gait safety. It is expected that as her condition
improves she will be safe to be discharged back home.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Last Name (NamePattern1) 4791**]
MEDQUIST36
D: [**2127-7-14**] 19:19
T: [**2127-7-14**] 19:34
JOB#: [**Job Number 98696**]
Admission Date: [**2127-7-14**] Discharge Date: [**2127-7-22**]
Date of Birth: [**2060-9-26**] Sex: F
Service: [**Hospital1 212**]
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 97368**] is a 66 year-old
female status post motor vehicle accident on [**2127-7-3**]
sustaining right rib fractures and pneumothorax. She was
hospitalized from [**7-3**] to [**7-8**] and treated with a chest tube,
which was removed after five days. The patient was
discharged to a rehab on [**2127-7-8**]. She represented with fever,
cough, shortness of breath and right rib pain on [**2127-7-11**] with
hypoxia. She had an elevated white blood cell count and
blood cultures were drawn showing no growth. She was
admitted to the trauma service and please refer to separate
discharge summary number [**Serial Number 98697**] for her hospital course while
on the surgery service.
PAST MEDICAL HISTORY:
1. Status post motor vehicle accident on [**2127-7-3**] with
multiple right rib fractures.
2. Status post right sided chest tube.
3. Glaucoma.
4. Chronic neuritic pain.
5. Depression.
6. Psychiatric history NOS.
PAST SURGICAL HISTORY:
1. Status post left open reduction and internal fixation
tibial fracture.
2. Status post bilateral hip replacement.
MEDICATIONS ON ADMISSION:
1. Timolol eye drops for glaucoma.
2. Nortriptyline 75 mg q.d.
3. Neurontin 600 mg t.i.d.
4. Colace 100 mg b.i.d.
5. Celexa 10 mg q.d.
6. Percocet prn.
7. Ibuprofen prn.
ALLERGIES: The patient has allergies to Effexor, Penicillin
and Topamax.
SOCIAL HISTORY: The patient lives alone, occasionally drinks
alcohol and has a significant smoking history, however, she
quit six years ago.
FAMILY HISTORY: Her father has diabetes and had an
myocardial infarction. Mother had an myocardial infarction.
Brother had an myocardial infarction. Negative for cancer.
PHYSICAL EXAMINATION UPON TRANSFER TO [**Hospital1 212**] MEDICINE
SERVICE: Temperature 97.7. Heart rate 85. Blood pressure
92/palpable. Respiratory rate 18. O2 sat 100% on 4 liters.
General the patient appears comfortable and in no acute
distress. Neck 8 cm JVD. Positive hepatojugular reflex.
Chest clear at apices. Decreased breath sounds at right
base. Coarse crackles half way up bilaterally. Heart
irregular, clicking noises when resolved when holding breath.
Regular rate and rhythm. Normal S1 and S2. No murmurs, rubs
or gallops. Abdomen positive bowel sounds, all quadrants,
soft, nontender, nondistended. No hepatosplenomegaly.
Extremities 2+ pedal pulses bilaterally, trace edema, cool
extremities, no cyanosis, Pneumoboots in place.
PERTINENT LABORATORIES/X-RAYS/EKGS AND OTHER TESTS: On
[**2127-7-15**] hematocrit was 23.0. On [**2127-7-15**] the patient was
ruled out for an myocardial infarction. Her CKs were 86,
112, 89, troponin was 0.18, 0.2, 0.14. Swab taken [**2127-7-12**]
from right chest tube site revealed 1+ polys on gram stain,
carinii bacteria and coag negative staph with two colonial
morphologies. Chest x-ray on [**2127-7-21**] showed no evidence of
cardiac failure, multiple right sided rib fractures, soft
tissue thickening consistent with stable versus resolved
hematoma, loculated right pleural effusion with atelectasis
at right base, no pneumothorax, left lung is well aerated.
HOSPITAL COURSE: On the early morning of [**2127-7-15**] the patient
was transferred from the surgery service to the trauma CICU
for increased respiratory stress and agitation. Her O2 sats
dropped to 70% when not on O2, but improved to 100% on 4
liters by face mask. She was also found to be hypercarbic on
blood gas. She was confused, tachycardic and tachypneic. A
chest x-ray showed no changes with no congestive heart
failure and no pneumothorax. A Foley was placed and an A
line was placed for access for repeated arterial blood gas.
She was transfused 2 units of packed red blood cells for a
hematocrit of 23.0 on [**7-15**]. She also was ruled out for an
myocardial infarction. Her CKs and troponins increased
slightly, however, this was not felt to be consistent with a
myocardial infarction. On [**7-16**] she was started on a beta
blocker, Captopril and aspirin. Her neurological examination
fluctuated from being calm to restless and agitated. A CTE
was performed revealing prior anterior septal and apical
akinesis with global hypokinesis and an EF of 25 to 30%. On
[**7-17**] she was transferred to the MICU. She demonstrated
evidence of decompensated heart failure and had hypotension
to systolic blood pressures of 70 with codeine. She showed
she was very sensitive to Captopril and beta blockers and
subsequently dropped her systolic blood pressures and
required several boluses of intravenous fluids.
On [**7-18**] she was transferred to the regular medical floor and
her beta blockers and ace inhibitors were held given her
history of hypotension. She was diuresed with Lasix, which
improved her O2 requirements and her tachypnea. On [**7-19**] she
demonstrated an elevated white blood cell count from 12 to 19
and underwent a repeat chest x-ray, repeat blood culture and
urinalysis and urine culture. Her chest x-ray showed no
change from previously seen right loculated effusion and
showed no evidence of congestive heart failure. Her urine
culture showed 10 to 100,000 yeast. Her blood cultures are
negative to date. On [**7-21**] the patient remained afebrile and
continued to clinically improve. Her O2 requirements
decreased to 2 and then 1 liter of oxygen by nasal cannula.
She was seen by physical therapy who felt she needed further
rehab. They recommended she needed ability training,
therapeutic exercises and monitoring of her pulmonary status.
On [**7-22**] she continued to clinically improve. Her breathing
was subjectively improving. She received a bed at the [**Hospital 533**]
Rehab.
CONDITION ON DISCHARGE: Fair.
DISCHARGE STATUS: To rehab facility.
DISCHARGE DIAGNOSES:
1. Right rib fractures status post chest tube insertions
times two.
2. Urinary tract infection.
3. Right lower lobe pneumonia.
4. Loculated pleural effusion.
5. Anemia.
DISCHARGE MEDICATIONS:
1. Nortriptyline 75 mg q.h.s.
2. Gabapentin 600 mg t.i.d.
3. Colace 100 mg b.i.d.
4. Citalopram 10 mg q.d.
5. Levofloxacin 500 mg q.d. times five days.
6. Aspirin 325 mg.
7. Timolol 0.25% eye drops b.i.d.
8. Guaifenesin 100 mg per 5 ml syrup 5 to 10 ml q 6 hours as
needed.
9. Codeine 15 to 30 mg q 4 to 6 hours prn.
10. Bisacodyl 10 mg po q.d. prn.
11. Nitroglycerin sublingual 0.3 mg prn chest pain.
12. Metoprolol 12.5 mg b.i.d.
FOLLOW UP PLANS: The patient was instructed to follow up
with the trauma clinic in one to two weeks after discharge.
She is also instructed to follow up with her primary care
physician in two weeks following discharge. Also she was
instructed to make an appointment with a cardiologist
regarding her newly diagnosed decreased systolic ejection
fraction.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Last Name (NamePattern1) 98698**]
MEDQUIST36
D: [**2127-7-22**] 11:41
T: [**2127-7-22**] 12:01
JOB#: [**Job Number 98699**]
|
[
"786.50",
"599.0",
"511.9",
"486",
"428.0",
"428.21",
"518.82",
"496",
"458.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
7288, 8881
|
11518, 11693
|
11716, 12767
|
4633, 4842
|
6875, 7128
|
8899, 11426
|
5092, 5730
|
6730, 6849
|
1700, 2874
|
5759, 6466
|
6488, 6707
|
7145, 7271
|
11451, 11497
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
878
| 192,358
|
3251
|
Discharge summary
|
report
|
Admission Date: [**2137-11-24**] Discharge Date: [**2137-12-3**]
Date of Birth: [**2061-8-17**] Sex: F
Service: MEDICINE
Allergies:
Lasix / Diuril / Keflex / Iodine
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
76 yo F with IPF, COPD on 4L O2 on chronic prednisone, CHF,
mechanical mitral valve, s/p pacemaker placement, known high
grade colonic adenoma with GIB (not resected), gastric varix (no
history of liver disease) recently admitted with nocardia
pneuomina, now presented with AMS. Patient is transferred to
the MICU given + melena and likely need for endoscopy which may
need intubation for airway protection.
Of note, per EMS, she was at baseline EMS on their arrival to
the rehab. She was hypoxic to the high 80s on RA.
In the ED inital vitals signs were 80 106/65 26 100% 12L
Non-Rebreather. Pt denies any confusion and is A&O to self,
place. Patient denies any complaints other than shortness of
breath, which is typical for her. Pt declined NG lavage. Rectal
with heme postive dark stool. Labs notable for WBC count 15, Hct
18, creatinine 2.9 from baseline 2.0, metabolic alkylosis on VBG
(chronic). She was crossed for four units. 97.4, 80 (AV-paced),
100/56, 18, 100%
On arrival to the floor she had a small melanotic BM visualized,
also with dried blood in the right nare. Her repeat Hct prior
to transfusion was 26. Given melena, patient completed 1 uit of
pRBC and is getting her 2nd FFP prior to transfer. She is also
getting 1x dose of Bumex given she triggerred and required NRB
with O2Sat in the mid 80s, which was weaned to 4L at low 90%.
ROS: She reported wanting to sleep. Increased frequency of BMs
recently which she describes a dark, but not bloody. Cannot
recall if they are sticky. Denies fevers, chills, chest pain,
shortness of breath, abdominal pain, nausea, vomiting, or
anything else.
Past Medical History:
- s/p mechanical mitral valve [**2125**]
- sinus node dysfunction s/p DDD pacemaker placement [**2125**]
- atrial flutter s/p ablation [**2-/2132**] and cardioversion [**11-3**]
- congestive heart failure, Last Echo [**2137-8-26**], mildly
depressed (LVEF= 40-45%) systolic function
- chronic obstructive pulmonary disease: 4LO2 trach at home at
rest
- idiopathic pulmonary fibrosis on chronic prednisone
- chronic kidney disease; baseline creatinine 1.3-1.6
- anemia due to mechanical valve and chronic kidney disease
- hypertension
- hypercholesterolemia
- hypothyroidism
- meniere??????s disease (HOH)
- spinal arthritis
- breast cancer radical mastectomy right breast [**2095**]. Partial
left [**2097**].
- s/p hysterectomy [**2101**]
- s/p nasal embolization for refractory epistaxis [**6-30**]
- lower GI bleed secondary to high grade colonic adenoma s/p
biopsy (but not resection) [**10/2137**]
Social History:
- Recently from [**Hospital1 100**] MACU.
- Lived with her husband, who suddenly passed away while the
patient was intubated. Patient is aware of this.
-requires assistance with ADLs and IADLs
-tobacco: smoked 36 years, quit in [**2111**].
-alcohol: social
-drugs: no IVDU.
Family History:
Father had polymyositis and coronary artery disease; mother had
metastatic bone cancer. She has several cousins with breast
cancer.
Physical Exam:
Admission Exam:
Vitals: Tmax: 35.3 ??????C (95.5 ??????F)
Tcurrent: 35.3 ??????C (95.5 ??????F)
HR: 84 (80 - 84) bpm
BP: 105/62(73) {84/47(55) - 107/64(73)} mmHg
RR: 15 (14 - 17) insp/min
SpO2: 99%
General: lethargic, oriented to person and place, trying to pull
things off
HEENT: Sclera anicteric, mucous membrane dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally anteriorly, no wheezes
or ronchi
CV: Regular rate and rhythm, normal S1 + S2, + mechanical click
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: cool, 1+ pulses, no clubbing, cyanosis or edema
.
.
Discharge PEx:
Vitals: 98/96.7 106/68 81 18 99%4L
General: alert, aao, sitting in bed
HEENT: Sclera anicteric, mucous membrane moist, oropharynx clear
Lungs: improved wheezing.
CV: RRR, normal S1 + S2, + mechanical click
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, 1+ pulses, no clubbing, cyanosis or edema
Pertinent Results:
Admission Labs:
[**2137-11-24**] 08:30PM BLOOD WBC-15.3*# RBC-1.98*# Hgb-6.0*#
Hct-18.4*# MCV-93 MCH-30.4 MCHC-32.7 RDW-16.9* Plt Ct-299
[**2137-11-24**] 08:30PM BLOOD Neuts-83.8* Lymphs-10.1* Monos-3.7
Eos-2.0 Baso-0.4
[**2137-11-24**] 10:16PM BLOOD PT-29.1* PTT-32.2 INR(PT)-2.8*
[**2137-11-24**] 08:30PM BLOOD Glucose-86 UreaN-53* Creat-2.9* Na-139
K-4.1 Cl-91* HCO3-36* AnGap-16
[**2137-11-24**] 08:30PM BLOOD Calcium-8.7 Phos-4.5 Mg-2.3
[**2137-11-24**] 08:30PM BLOOD Type-[**Last Name (un) **] pO2-47* pCO2-57* pH-7.47*
calTCO2-43* Base XS-14 Comment-GREEN TOP
[**2137-11-24**] 08:30PM BLOOD Glucose-71 Lactate-1.6 K-4.1
[**2137-11-24**] 08:30PM BLOOD Hgb-6.8* calcHCT-20 O2 Sat-77 COHgb-3
MetHgb-0
[**2137-11-25**] 12:29AM BLOOD Hct-26.3*#
Urine:
[**2137-11-24**] 08:30PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008
[**2137-11-24**] 08:30PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-7.5 Leuks-NEG
[**2137-11-24**] 08:30PM URINE RBC-23* WBC-3 Bacteri-NONE Yeast-NONE
Epi-0
Other Pertinent Labs:
Micro:
[**2137-11-25**] BCx: Negative x2
.
Studies:
[**2137-11-24**] CXR:
Single AP upright portable view of the chest was obtained. The
patient is rotated to the left. The patient's chin partially
obscures the left lung apex. Dual-lead left-sided pacemaker is
again seen, unchanged in position. Again, the pacer wires are
seen to traverse a stent, presumably in the SVC. The patient is
status post median sternotomy and cardiac valve replacement.
Abandoned epicardial leads are again noted on the left lower
hemithorax/left upper quadrant, stable. Surgical chain sutures
are again seen at the right lung apex. Evidence of basilar
fibrosis is again seen. There is persistent blunting of the
costophrenic angles and trace effusions would be difficult to
exclude. No new focal consolidation or evidence of pneumothorax
is seen.
Discharge Labs:
[**2137-12-3**] 06:06AM BLOOD WBC-4.9 RBC-3.56*# Hgb-10.6*# Hct-32.0*#
MCV-90 MCH-29.7 MCHC-33.0 RDW-17.6* Plt Ct-72*
[**2137-12-3**] 06:06AM BLOOD PT-13.6* PTT-24.7 INR(PT)-1.2*
[**2137-12-3**] 06:06AM BLOOD Glucose-76 UreaN-55* Creat-3.0* Na-142
K-4.8 Cl-105 HCO3-28 AnGap-14
[**2137-12-3**] 06:06AM BLOOD LD(LDH)-450*
[**2137-12-3**] 06:06AM BLOOD Hapto-52
[**2137-12-3**] 06:06AM BLOOD Calcium-7.6* Phos-5.2* Mg-2.5
Brief Hospital Course:
76yo female with extensive medical including gastric varix and
colonoic adenoma with Hct drop and small melena, s/p
transfusions with appropriate Hct bump, likely [**2-27**] to chronic
bleeding from colonic adenoma.
.
# Goals of care: patient has been made DNR/DNI, confirmed with
daughter/HCP after multiple family meetings. Patient not to have
escalation of care, will only treat with acute blood loss
through transfusion and supportive care. Overall plan is to
eventually move towards comfort, but patient and family would
still like time to deliberate. Patient is eating a regular diet
and knows that this may increase her risk of bleeding. Also, lab
draws will be limited to daily, even in setting of transfusion
for decreased Hematocrit. Also, after lengthy discussion about
risks and benefits of taking anti-coagulation (given mechanical
mitral valve), patient and family have decided to stop
anticoagulation. They are willing to accept the risks of stroke.
We are currently continuing to offer transfusions as well as
antibiotics as below.
.
# Melena/Dysplastic Adenoma: In ED, initial hct 18, which rose
to 26 with 1 unit PRBC. Started on pantoprazole and an
octreotide gtt. Given therapeutic INR, patient was also given 2
units of FFP. Slightly hypotensive on arrival with SBP mid 80s
after having received her Bumex. Her daughter and HCP, [**Name (NI) **]
stated that her mother would not want to have another
colonoscopy or endoscopy. Pressures improved with 250 cc fluid
bolus. Patient has a known malignant colonic mass and gastric
varices. The colonic mass was proven malignant on biopsy, but GI
felt that endoscopic resection carried a high risk of
perforation (documented in [**10-31**] d/c summary). GI was consulted,
but no intervention was done. [**11-27**] she had a drop in her Hct
with a large melanotic BM. [**11-29**] with concern for
thrombocytopenia, the octreotide was stopped despite continued
slow bleeding. Patient was then transferred to the medicine
floor. Patient had one more episode of a 5-point hematocrit drop
to 21, which bumped up to 32 after two units of packed red
cells. Thrombocytopenia has been stable in the 50-70s range and
may be secondary to medications (?meropenem).
.
# [**Last Name (un) **]- patient had worsening creatinine through her stay. FeNA
>10%, suggesting an intrinsic cause. Urine eosinophils were
negative and there was no peripheral eosinophilia. Meropenem was
stopped; Bactrim continued after discussion with ID service,
which may elevate Cr falsly without changes to GFR. At time of
discharge, Cr has improved somewhat from 3.5 (peak) to 3.
.
# Thrombocytopenia: patient had worsening thrombocytopenia
beginning on admission. Fibrinogen was normal and she had no
schistocytes. Heparin products were stopped and a HIT antibody
sent, which was negative. Octreotide was stopped [**11-29**] as there
have been case reports of octreotide-associated
thrombocytopenia.
.
# Nocardia PNA: Diagnosed from BAL on previous admission.
Treated with imipenem and bactrim as outpatient for two weeks
based on suspicion of possible dissminated Nocardia. With plan
to just do Bactrim for additional extended course per ID
recommendations. Patient to follow up with ID as outpatient for
future management.
.
# Altered mental status: Mental status waxed and waned,
sometimes more confused, but generally oriented to person, place
and year. Often did not recall events from day to day.
Neurologic exam was non-focal. It was felt that for most
decisions she had decision-making capabilities.
.
# Systolic congestive heart failure, chronic - Per [**2137-8-26**]
Echo, mildly depressed (LVEF= 40-45%) systolic function. Does
not appear volume overloaded on exam presently. Echo on [**11-14**]
shows dilated right heart, severe TR, moderate MR w/ functional
mechanical prosthesis. Given transfusions and hemodynamically
stable, patient has been restarted on bumex @ home dose 5mg
daily. Metolazone held for now and can be restarted per acute
care facility/nursing facility.
.
# Mechanical MVR Valve: Anticoagulation held indefinitely after
lengthy discussion with patient and HCP, as noted above, despite
risks of annual stroke given mechanical mitral valve.
.
# Bullous upper extremity rash:Continued hydrocortisone 1%
cream.
.
# COPD/IPF: continued nebs and steroids.
.
# HYPOTHYROIDISM: continued home levothyroxine
.
# HYPERTENSION: restarted bumex, holding metolazone for now.
.
.
.
Transitional Issues:
-Please evaluate need for rectal tube and foley daily and remove
asap
-Please check CBC every day for 3 days and then every other day
or as determined by physician at acute care facility.
-Please d/c PICC in 5 days at the discretion of the MACU.
-Please continue Bactrim, double strength, two tablets [**Hospital1 **] until
re-evaluated by ID team as an outpatient.
-Will need to reinitiate metolazone 5mg every other day as an
outpatient pending volume status and lung exam.
.
Medications on Admission:
-albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization q4h prn
-cholecalciferol 1,000 unit daily
-ferrous sulfate 325 mg daily
-fluticasone 110 mcg/Actuation Aerosol, 2 puffs [**Hospital1 **]
-ipratropium bromide 0.02 % Solution Q6H prn
-levothyroxine 125 mcg daily
- multivitamin daily
- nadolol 20 mg daily
-warfarin 1 mg daily : Goal INR 2.5-3.5.
-prednisone 10 mg daily
- cortisone 1 % Cream qid
-Bactrim DS 800-160 mg Tablet, 2 tabs tid X 14 days
-nystatin 100,000 unit/g Cream daily
-zinc oxide daily
-MS Contin 15 mg qhs
-oxycodone 5 mg, 0.5-1 tabs q4-6 hours prn
-imipenem-cilastatin 500 mg, q8h X 2 weeks
-bumetanide 5mg daily
-metolazone 5 mg qod
-omeprazole 40 [**Hospital1 **]
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) treatment Inhalation Q6H (every 6
hours) as needed for sob/wheeze.
2. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. ipratropium bromide 0.02 % Solution Sig: One (1) treatment
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
6. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO at bedtime.
7. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
8. cortisone 1 % Cream Sig: One (1) Appl Topical QID (4 times a
day).
9. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
10. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: Two (2)
Tablet PO BID (2 times a day).
12. nystatin 100,000 unit/g Cream Sig: One (1) application to
affected areas Topical once a day.
13. MS Contin 15 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO at bedtime.
14. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO every six (6)
hours as needed for pain.
15. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H
(every 8 hours) as needed for pain.
16. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
17. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
18. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
19. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
20. bumetanide 2 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily):
Please hold for SBP<100.
21. Labs
Please check CBC daily for at least 3 days; then every other day
or as determined by your physician at your acute care facility.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
gastrointestinal bleeding
colonic mass
nocardia pneumonia
acute on chronic kidney failure
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you at the [**Hospital1 771**]. You were admitted to the hospital for
an acute gastrointestinal bleed. We were able to stabilize you
with blood transfusions. It is likely that this bleeding
originated from the colon, where it is known that you have a
mass. Also, you have a history of esophageal varices and these
may bleeding as well. After multiple discussions with the
MICU/medical and GI teams in conjunction with your daughter in
law, you have decided to not pursue any further diagnostic or
interventional procedures. You have declined any
EGD/colonoscopy. You will be transferred to a MACU, where you
will be able to receive supportive care with blood product
transfusion as necessary. You have also decided to change your
code status to do not resuscitate or intubate.
.
We have also treated your pneumonia with antibiotics, which you
will continue until you follow up with infectious disease
physician as an outpatient.
.
We hope that you will be able to regain some strength at rehab
and feel better soon.
.
-STOP imipenem-cilastatin 500 mg, q8h X 2 weeks
-We are currently holding your metolazone 5 mg every other day
for now; your physician at [**Hospital1 100**] [**Name9 (PRE) 15159**] will evaluate you in
regards to reiniation of this medication as an outpatient based
on your vital signs and breathing.
.
Please follow up with your appointments as listed below.
Followup Instructions:
You have the following appointments:
.
Please follow up with your primary care physician, [**Name10 (NameIs) 7476**],[**Name11 (NameIs) **]
[**Telephone/Fax (1) 7477**], within one week of discharge from your
rehabilitation facility. They will help you make an appointment
upon discharge.
.
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2137-12-25**] at 9:10 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital Ward Name 1570**]
When: WEDNESDAY [**2137-12-25**] at 9:30 AM
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2137-12-25**] at 9:30 AM
With: DR. [**Last Name (STitle) 91**] & 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
Department: INFECTIOUS DISEASE
When: MONDAY [**2137-12-16**] at 10:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14492, 14558
|
6798, 10063
|
298, 306
|
14692, 14692
|
4442, 4442
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6354, 6775
|
3338, 4423
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11248, 11727
|
255, 260
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334, 1956
|
4458, 5487
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5510, 6337
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14707, 14848
|
1978, 2882
|
2898, 3174
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,155
| 188,684
|
36583
|
Discharge summary
|
report
|
Admission Date: [**2126-9-11**] Discharge Date: [**2126-9-13**]
Date of Birth: [**2055-3-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Left lower extremity swelling
Major Surgical or Invasive Procedure:
IVC filter placement ([**2126-9-12**])
History of Present Illness:
Mr. [**Known lastname 3069**] is a 71 year old male with a history of metastatic
melanoma to brain, lung and liver s/p ten sessions of cranial
radiation in [**Month (only) 205**] who presented to outpatient oncology clinic
for a scheduled appointment this morning and noted for the past
three days that he has had left lower extremity swelling. He
does not have pain in his leg although this leg has felt heavy
for the past 2 months which prompted his initial CT scan which
diagnosed his brain metastases. He has not had any fevers,
chills, chest pain, difficulty breathing, nausea, vomiting,
abdominal pain, dysuria, hematuria, leg pain. He does have left
sided leg weakness but this has been stable. All other review
of systems negative in detail. He was referred to the emergency
room directly from oncology clinic for evaluation of potential
DVT.
.
In the ED, initial vs were: T: 94.1 P: 90 BP: 120/80 R: 18 O2
sat 100% on RA. He had a left lower extremity ultrasound which
was positive for DVT. He had a CTA which was preliminarily
negative for pulmonary embolism. He had a non-contrast CT of
the head which showed three hemorrhagic metastases (unclear how
these compare in size post-radiation). Given findings on CT
head he was not started on anticogulation. He was seen by
vascular surgery for consideration of IVC filter. He was also
seen by neurosurgery, official recommendations pending. He was
transferred to the ICU for close monitoring.
.
On arrival to the ICU he has no specific complaints. Left lower
extremity weakness is unchanged. He denies other numbness,
tingling, weakness, fatigue, leg pain. No blurry vision. Gait
has been unstable since diagnosis of metastatic lesions. He
endorses 10 lb weight loss over past two months. All other
review of systems negative.
Past Medical History:
Metastatic Melanoma to brain, lung, liver s/p 10 cycles XRT in
[**2126-7-31**]
Hypertension
Hyperlipidemia
Steroid induced hyperglycemia
Social History:
6 pack year smoking history in his twenties. No alcohol. No
IVDU. Lives with his wife in [**Name (NI) **], [**Name (NI) **]. Works in the window
industry.
Family History:
Sister died of breast cancer. Brother died of asbestos related
lung cancer.
Physical Exam:
Vitals: T: 97.1 BP: 117/79 P: 82 R: 15 O2: 99% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses. Erythema over left leg
with non-pitting edema. No calf tednerness. No clubbing or
cyanosis.
Neurologic: CN II-XII tested and intact. Strength 5/5 in the
upper extremities. Strength 4/5 in the left lower extremity,
[**6-4**] in the right lower extremity, sensation intact throughout,
reflexes 2+ in the upper extremities, 1+ in left lower
extremity, 2+ right lower extremity, decreased tone in left
lower extremity. Gait not tested.
Pertinent Results:
Labs on admission [**2126-9-11**]:
WBC-5.6 RBC-4.74 Hgb-14.9 Hct-43.8 MCV-92 MCH-31.5 MCHC-34.1
RDW-13.1 Plt Ct-95*
Neuts-83* Bands-1 Lymphs-6* Monos-8 Eos-0 Baso-0 Atyps-2*
Metas-0 Myelos-0
Hypochr-NORMAL Anisocy-OCCASIONAL Poiklo-NORMAL Macrocy-NORMAL
Microcy-NORMAL Polychr-1+
Coags WNL
Albumin-3.9 Calcium-10.4* Phos-2.4* Mg-2.5
.
Labs on discharge [**2126-9-13**]:
WBC-5.9 RBC-3.99* Hgb-12.8* Hct-37.1* MCV-93 MCH-32.0 MCHC-34.5
RDW-13.3 Plt Ct-101*
PT-11.8 PTT-22.1 INR(PT)-1.0
Glucose-162* UreaN-28* Creat-0.6 Na-142 K-4.1 Cl-110* HCO3-23
AnGap-13
Calcium-9.0 Phos-3.1 Mg-2.4
.
CTA CHEST W&W/O C&RECONS: 1. Small right subsegmental pulmonary
embolism in the right posterior lower lobe pulmonary artery, no
dissection or aortic aneurysm. 2. Large left upper lobe soft
tissue mass with pulmonary nodules in the right upper lobe and
left lower lobe as described. 3. Probable metastasis in the
spleen.
.
HEAD CT W/O CONTRAST ([**2126-9-11**]) Multifocal high-attenuation foci
with the perilesional vasogenic edema, in setting of known
metastases suspicious for hemorrhagic intracranial metastases.
If further evaluation is desired, please consider
gadolinium-enhanced MRI. No prior comparisons available to
assess for change.
.
UNILAT LOWER EXT VEINS LEFT ([**2126-9-11**]) Extensive DVT in the left
lower extremity extending from common femoral vein to posterior
tibial veins.
Brief Hospital Course:
71 year old male with a history of metastatic melanoma to brain,
lung and liver who presents with a left lower extremity DVT.
.
# LLE DVT and small PE: DVT found in LLE with small subsegmental
PE, but patient also has hemorrhagic brain metastases shown on
head CT preventing anticoagulation. Vascular was consulted,
recommended IVC filter placement if primary team decided against
anticoagulation. Patient has an extensive clot burden in the
LLE, but anticoagulation was held in light of the hemorrhagic
potential of the brain metastasis. IVC filter was placed by IR
on [**2126-9-12**]. Pt tolerated procedure well without complications.
He was ambulatory the next day.
.
# Metastatic Melanoma: Hemorrhagic brain metastasis with
surrounding vasogenic edema demonstrated on CT head. Patient is
s/p 10 sessions of XRT. On admission to ICU neurologic exam was
notable for left lower extremity weakness and decreased
reflexes. Neuro exams were performed every 4 hours. Pt was
continued on home dose decadron 4 mg TID. Neurosurgery was
consulted and left decision re: anti-coagulation to the primary
team.
.
# Steroid Induced Hyperglycemia: Patient is usually on oral
agents and long acting insulin at home, but these were held
while patient was NPO. RISS was used for glycemic control with
good results.
.
# Hypercalcemia: Likely related to malignancy. Pt's latest
albumin of 3.9. Given 1 L IVF, calcium monitored with decrease
to 9.0 at time of discharge.
.
# Thrombocytopenia: Latest platelet count 93K. Baseline
platelet count unknown. Also likely related to malignancy. No
evidence of bleeding. Platelets monitored with plt of 101 at
discharge.
.
# Hypertension: Patient was continued on home dose of
lisinopril
.
# Hyperlipidemia: Patient was continued on home dose of
simvastatin
.
# Code: Full (discussed with patient)
.
# Communication: Patient, wife [**Name (NI) 2411**] [**Telephone/Fax (1) 82794**] (home),
[**Telephone/Fax (1) 82795**] (cell 1), [**Telephone/Fax (1) 82796**] (cell 2)
Medications on Admission:
Multivitamin
Lisinopril 10 mg daily
Simvastatin 40 mg daily
Famotidine 10 mg daily
Glyburide 10 mg daily
Levemir 10 U at 5 PM
Dexamethasone 4 mg TID
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
5. Famotidine 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO once a day.
7. Levemir 100 unit/mL Solution Sig: Ten (10) units Subcutaneous
at 5PM.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Deep venous thrombosis and small PE with IVC filter
placement.
.
2. Metastatic Melanoma to brain, lung, liver s/p 10 cycles XRT
in [**Month (only) 205**]
.
3. Hypertension , Hyperlipidemia, Steroid induced hyperglycemia
Discharge Condition:
Stable, ambulatory, afebrile
Discharge Instructions:
You were admitted to the hospital for Left leg swelling. It was
determined that you have a deep venous clot in your leg. Imaging
also showed you have a very small clot in your lungs. Your
oxygen saturation was good during your hospitalization. Due to
the melanoma in your brain, the risks of anti-coagulation
outweigh the benefits. Thus, interventional radiology placed a
filter in the vein between your legs and heart to prevent more
clot from going to your lungs. You tolerated the procedure well
without any problems. [**Name (NI) **] changes were made to your medications.
.
Please call your PCP or return to the emergency room if you
develop fevers, chills, shortness of breath, pain with
breathing, palpitations, worsening leg swelling, , or abdominal
pain.
Followup Instructions:
Please call the oncology office at [**Telephone/Fax (1) 82797**] (Assistant is
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8320**]) to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4151**] within 1-2 weeks, next
week if possible.
|
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icd9cm
|
[
[
[]
]
] |
[
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
7705, 7711
|
5004, 7014
|
345, 385
|
7978, 8009
|
3599, 4981
|
8821, 9096
|
2571, 2650
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7214, 7682
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7732, 7957
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7040, 7191
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8033, 8798
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2665, 3580
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276, 307
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413, 2216
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2238, 2377
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2393, 2555
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,964
| 115,118
|
26021
|
Discharge summary
|
report
|
Admission Date: [**2157-11-13**] Discharge Date: [**2157-11-25**]
Date of Birth: [**2105-6-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
hypotension and hypoxia
Major Surgical or Invasive Procedure:
VATS
History of Present Illness:
52yo man with history of Rheumatoid arthritis on gold
injections, hepatitis C, and pulmonary fibrosis was trasferred
from [**Hospital6 204**] for worsening dyspnea/hypoxemia and
for potential lung biopsy. He was admitted there on [**2157-11-7**]
where he presented after one to two weeks of chills and low
grade fevers with progressive shortness of breath. This is in
the setting of previously asymptomatic chest CT findings dating
back to [**8-28**] with nodules, scarring, and chest/abdominal
lymphadenopathy. His initial ABG was 7.49/34/65/94% on 4L nc.
His CT chest demonstrated multiple abnormal findings with
evidence of bullous disease, honeycombing in the bases and a
mosaic pattern of interstitial infiltrates. He reportedly was
presented options of going for lung biopsy or having an empiric
course of corticosteroids at that time. He opted for empiric
steroid treatment.
.
His hospital course was notable for worsening dyspnea to the
point of not being able to speak in sentences and progressive
hypoxemia. He was admitted on room air, and steadily progressed
to 40% mask -> 100% NRB with oxygen saturation of 95%; ABG
demonstrated 7.53/27/65. Throughout his hospital course, he
remained afebrile. He was initially treated with ceftriaxone and
azithromycin. This was later tapered down to only azithromycin.
Chest films did not show any evidence of focal consolidation.
Rather, they demonstrated bilateral ground glass opacities.
.
In [**Hospital Unit Name 153**] respiratory status was monitored and intubated yesterday
for progressive hypoxia and in anticipation of VATS for lung
biopsy and bronch today. While in OR today developed increasing
hypoxia and difficulty oxygenating, Swan was attempted
unsuccessfully and Right IJ cordis was placed. Eventually thick
secretions were noted in ETT which was pulled and a LMA was
placed for airway support. He was then transferred to ICU for
further management. Here is ventilated on AC 600/30/10/100%FiO2.
Preliminary pathology on biopsy results is consistent with dense
fibrosis. He is currently on Propofol gtt and appears
comfortable.
.
Past Medical History:
1. Rheumatoid arthritis - on gold treatments; last was few weeks
ago
2. Hepatitis C
3. Pulmonary fibrosis
4. Epilepsy - first diagnosed as a child; ? trauma
5. h/o Lyme disease
6. h/o anal fissure repair
7. distant etoh abuse
8. right knee surgery
9. By report, normal pulmonary function tests and TTE in [**7-30**].
Social History:
Notable for smoking history and occupational exposure to
concrete (works in swimming pool business). About 50pack year
smoking history.
.
Family History:
NC
Physical Exam:
gen: sedated, nad
heent: perrl, MMM, LMA in place
neck: right IJ cordis in place
cv: RRR, tachy, no murmurs
resp: CTAB with diffuse bilateral crackles
abd: soft, NT/ND, +BS
extr: no edema
Pertinent Results:
[**2157-11-14**] 01:54AM BLOOD WBC-10.1 RBC-3.69* Hgb-10.8* Hct-32.3*
MCV-88 MCH-29.3 MCHC-33.4 RDW-12.7 Plt Ct-439
[**2157-11-14**] 01:54AM BLOOD Neuts-83.7* Lymphs-12.5* Monos-2.6
Eos-1.2 Baso-0.1
[**2157-11-14**] 01:54AM BLOOD PT-12.9 PTT-24.4 INR(PT)-1.1
[**2157-11-14**] 01:54AM BLOOD Glucose-107* UreaN-17 Creat-0.8 Na-140
K-4.4 Cl-103 HCO3-28 AnGap-13
[**2157-11-17**] 05:15PM BLOOD ALT-93* AST-40 LD(LDH)-385* AlkPhos-109
TotBili-0.2
[**2157-11-14**] 01:54AM BLOOD Calcium-8.6 Phos-4.2 Mg-2.4
[**2157-11-15**] 04:45AM BLOOD calTIBC-165* Ferritn-277 TRF-127*
[**2157-11-17**] 05:15PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2157-11-17**] 05:15PM BLOOD ANCA-NEGATIVE B
[**2157-11-17**] 05:15PM BLOOD C3-171 C4-39
[**2157-11-17**] 05:15PM BLOOD RheuFac-101*
[**2157-11-19**] 04:26AM BLOOD HIV Ab-NEGATIVE
[**2157-11-18**] 06:36PM BLOOD Glucose-172* Lactate-1.6 Na-133* K-4.8
Cl-95*
Brief Hospital Course:
52yo man with history of RA, hepatitis C, and pulmonary fibrosis
of uncertain etiology admitted to MICU with progressive hypoxia
after VATS. Progressive hypoxia secondary to pulmonary fibrosis
and worsening hypoxia despite maximum oxigenation. Pt was
continued on supportive O2 ventilation with paralysis.
Complicating matters. patient with growing pneumothorax after
VATS requiring re-initiation of chest tube to suction. Biopsy
pathology demonstrated change consistent with organizing stage
of diffuse alveolar damage, possibly complicating a
bacterial/viral infection, over a background of chronic
interstitial lung disease. In workup echo remarkable for right
to left interatrial shunt; which under consultation from
cardiology felt to be of little clinical significance as well as
Pt not being a candidate for closure. Given patient's disease
process, only potential "cure" would be heart lung transplant
but patient a poor candidate, contributing to very poor
prognosis. Family meeting held where goals of care were
discussed. Pt made CMO and transplant service consulted for
possible candidancy. Pt was taken off ventilatory support and
died shortly thereafter. Patient subsequently taken to the OR
for organ harvest.
Medications on Admission:
Medications on transfer:
Humibid DM 1 po BID
Tolmetin 600mg po BID
Lovenox 40mg daily
protonix 40mg daily
Zithromax 250mg qD
Prednisone 60mg daily
Regular insulin sliding scale
.
Medications from [**Hospital Unit Name 153**]:
Methylprednisolone Na Succ 50 mg IV BID
Midazolam HCl 0.5-2 mg/hr IV DRIP TITRATE TO sedation
Acetaminophen 325-650 mg PO Q4-6H:PRN
Morphine Sulfate 0.5-2 mg IV Q3-4H:PRN
Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION
Pantoprazole 40 mg IV Q24H
Heparin 5000 UNIT SC TID
Ibuprofen 400 mg PO Q8H:PRN
Sodium Chloride Nasal [**11-28**] SPRY NU QID:PRN
Insulin SC Sliding Scale
Sulfameth/Trimethoprim 370 mg IV Q8H
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Pulmonary fibrosis
Hepatitis C
Rheumatoid arthritis
Discharge Condition:
deceased
Discharge Instructions:
N.A.
Followup Instructions:
N.A.
|
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icd9cm
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[
[
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[
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[
[
[]
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|
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|
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|
6198, 6208
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2831, 2971
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,989
| 124,029
|
35848
|
Discharge summary
|
report
|
Admission Date: [**2178-11-1**] Discharge Date: [**2178-11-14**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Cholangitis, Biliary obstruction
Choledocholithiasis.
Biliary obstruction.
Postprocedural duodenal perforation.
Retroperitoneal/peritoneal abscess.
Major Surgical or Invasive Procedure:
1. Choledochoduodenostomy biliary bypass.
2. Open common bile duct exploration.
3. Extensive lysis of adhesions.
4. Drainage of retroperitoneal abscess.
5. Gastrostomy tube placement.
History of Present Illness:
The patient is a [**Age over 90 **] year old female who was initially admitted
to [**Hospital3 1280**] hospital with abdominal pain, dark urine, and
fever. The patient had evaluation performed including CT Abdomen
which revealed intra and extrahepatic biliary dilatation with
hyperdensity located within the CBD presumed to be an impacted
stone. The patient was treated with Zosyn for cholangitis. ERCP
there was attempted but unsuccessful for which the patient was
transferred to [**Hospital1 18**]. Attempt at ERCP today was similarly
unsuccessful. Cannulation of the ampulla was performed but the
biliary tree could not subsequently be wired. The patient was
subsequently sent to IR for PTC drainage. Per report the patient
had successful placement of external drain but wiring into the
small bowel was unsuccessful from obstruction. The patient is
now admitted to the medical service for ongoing management.
The patient confirms history as above. He reports
intermittent symptoms of abdominal pain in his RUQ radiating to
his back, similar to that which first brought him to the
hospital. He reports feeling weak, nauseous, and now with
intermittent pain across his right shoulder and upper chest
since returning from PTC.
Past Medical History:
s/p ccy
s/p removal of basal cell cancer on chest
Social History:
The patient lives in [**Location 47**] with his wife. [**Name (NI) **] helps take
care of her as she has many cardiac ailments. He has a home
healthaide twice a week for cleaning. He walks without
assistance, and swims 3-4 times per week. He is independent in
all ADL.
Tobacco: Quit 45 years ago, 20 pack-year previously
ETOH: 1 glass wine/month
Illicits: None
HCP: [**Name (NI) 53767**] [**Name (NI) **] [**Name (NI) 81487**]
Family History:
NC
Physical Exam:
Vitals: 97.8, 160/72, 72, 20, 95% 2L NC (repeat BP after
morphine for pain, 110/66)
General: Patient is an elderly male, appears younger than stated
age. Appears to be in mild discomfort but NAD
HEENT: NCAT, EOMI, sclera mildly icteric
Neck: No JVD
Chest: Small bibasilar crackles, left > right
Cor: RRR, no M/R/G
Abdomen: healed ccy scar. + PTC drain with brown fluid in bag.
Mild/mod RUQ tenderness, no guard or rebound. Remainder of
abdomen Soft, non-tender
Ext: no edema
Pertinent Results:
Admission labs: Labs:
[**Age over 90 **]|103| 9 < 100
3.4| 31|0.7
Ca: 8.2 Mg: 1.9 P: 2.1
ALT: 126 AP: 279 Tbili: 2.9
AST: 38
8.2 > 33.5 < 251
INR 1.2 PT 13.7 PTT 23.7
CK MB 3 Trop .03 ([**11-2**])
Pathology: pigment type calculi
Cultures:
[**2178-11-12**] C diff : neg
[**2178-11-11**] Cath Tip No sig growth (prelim)
[**2178-11-10**] URINE Cx NG
[**2178-11-10**] BLOOD Cx P
[**2178-11-10**] BLOOD Cx P
[**2178-11-4**] SWAB E COLI pan [**Last Name (un) 36**]
[**11-10**] CTA:
1. No drainable fluid collection, definable abscess or biloma.
Extensive
fat stranding in RUQ likely secondary ro recent surgery.
2. Status post choledochoduodenostomy biliary bypass with
expected
pneumobilia.
3. Persistent right greater than left pleural effusions with
associated
compressive atelectasis, moderate-sized hiatal hernia, colonic
diverticulosis,
vascular calcifications, and prostatic enlargement.
Brief Hospital Course:
11/16-18/08: The patient failed multiple ERCP events and was
unable to
[**2178-11-4**]: The patient underwent a choledochoduodenostomy biliary
bypass, open common bile duct exploration, extensive lysis of
adhesions, drainage of retroperitoneal abscess and a gastrostomy
tube placement. He tolerated the procedure well. He was
empirically started on an 8 day course of Zosyn for EColi in
bile. The patient was transferred to the SICU post-op for fluid
management and observation.
[**2178-11-5**]: The patient was started on TPN. Transferred to the
floor
[**11-6**]: Pt kept NPO, IVF with NGT in place.
[**11-7**]: Foley dc'd without problems voiding. G tube to gravity.
TPN continued with sips for comfort.
[**11-8**]:Pt consulted. PTC fell out with follow up LFTs without
elevation. No evidence of bleeding from site.
[**11-9**]; G tube clamped. Normal follow up LFTs after PTC pulled
out. Slight leakage of site monitored and dressed with small
ostomy bag around former PTC site.
[**11-10**]: Spiked to 101.4, pain c/w diaphragmatic irritation on R;
CTA - no obvious collection; CXR-bibasilar atelectasis; UA neg.
Vancomycin and Cipro stated empirically.Pt advanced to clears in
am. NPO for fever workup and CT scan then brought back to sips.
[**11-11**]: Afebrile for 24 hours. Advanced from sips to clears.
Ambulating with physical therapy. JP amylase of 7, drain
removed. CVL removed with no growth from catheter tip. C Diff
sent [**Doctor Last Name **] to 5 loose BM, returned negative.
[**11-12**]: Advanced from clears to fulls. Well tolerated.
Ambulating regularly. Afebrile. Discussion with family regarding
home services and importance of help at home to help pt care for
wife> [**Name (NI) 1094**] niece to stay with him for help around the house.
[**11-13**]: Advanced to regular diet. Staples removed. Pt discharged
home with VNA, HHA and home PT services.
Medications on Admission:
B-12 supplementation
Discharge Medications:
1. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
1. Choledocholithiasis.
2. Biliary obstruction.
3. Postprocedural duodenal perforation.
4. Retroperitoneal/peritoneal abscess.
Discharge Condition:
VSS, tolerating a regular diet, Pain well controlled on PO pain
meds, Ambulating.
Discharge Instructions:
Incision Care: Keep clean and dry.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to ambulate several times per day.
* No heavy ([**9-30**] lbs) until your follow up appointment.
Followup Instructions:
Please call Dr.[**Doctor Last Name **] office for follow up in [**12-17**] weeks
([**Telephone/Fax (1) 14347**].
Completed by:[**2178-11-14**]
|
[
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icd9cm
|
[
[
[]
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] |
[
"51.41",
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icd9pcs
|
[
[
[]
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] |
5952, 6011
|
3832, 5716
|
410, 596
|
6182, 6266
|
2903, 2903
|
7995, 8140
|
2389, 2393
|
5787, 5929
|
6032, 6161
|
5742, 5764
|
6290, 6290
|
6306, 7972
|
2408, 2884
|
222, 372
|
624, 1856
|
2919, 3809
|
1878, 1929
|
1945, 2373
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,577
| 126,661
|
337
|
Discharge summary
|
report
|
Admission Date: [**2145-5-17**] Discharge Date: [**2145-5-24**]
Date of Birth: [**2101-3-21**] Sex: F
Service: MEDICINE
Allergies:
Clindamycin / Zemplar / Levofloxacin / Trazodone / Doxycycline /
Haldol
Attending:[**First Name3 (LF) 603**]
Chief Complaint:
Hypoxia, altered mental status
Major Surgical or Invasive Procedure:
HD translumen cath
History of Present Illness:
Ms. [**Known lastname 3123**] is a 44 yoF with DM1, ESRD [**12-26**] diabetic nephropathy
on HD, hx MRSA HD line infections, hx of CABG and AAA repair who
presented to the ED on [**2145-5-17**] with multiple vague complaints.
Patient was reportedly hypoxic, confused, and febrile at her
nursing home. She is anuric, so no urine sample was sent. CXR
was clear. Given her h/o AAA, she underwent a CT torso with IV
contrast, which demonstrated no evidence of PE, aortic
dissection, or AAA. No parenchymal lung process other than
dependent atelectasis and a small right pleural effusion. She
was hypotensive in the ED but intially responded to fluids. BCx
drawn prior to vancomycin 1gm IV.
Past Medical History:
1. CAD s/p CABG x 3 in [**10-27**]
2. CHF - EF 20-25% Severe regional and moderate global LV
systolic dysfunction.
3. Mild mitral and tricuspid regurgitation.
4. DM1 since age of 6
5. ESRD on HD. Failed R and L AVG, now has tunneled HD catheter
LIJ, most recently replaced [**3-2**]. Changed from RIJ [**10-31**]. MRSA
infection [**1-1**], catheter changed (clot in R IJ), Rx vanc til
[**2145-1-23**]. Then another line change [**3-2**] for infected tunneled
line.
6. h/o MRSA rt stump infection
7. anemia
8. PVD s/p TMA
9. h/o epistasis from right nostril
10. Bell's Palsy (right side, s/p valtrex x 7 days, last [**1-2**])
11. AAA repair in '[**39**]
12. h/o previous tunelled line infection.
Social History:
No tobacco, alcohol or illicit drug use
Family History:
Mother: [**Name (NI) 2481**] disease and CAD
Father: deceased from prostate CA
Siblings are all alive and well
Physical Exam:
Physical Exam:
Vitals: T 98.0, BP: 109/68, HR: 97, RR: 18, SaO2: 99% 2L NC
General: pleasant, chronically ill appearing, A&Ox3
Neck: Supple. No LAD. JVP ~ 11 cm H2O.
CV: RRR nl S1, S2 no murmurs, rubs or gallops. No tenderness at
recently removed L sided tunnelled line site, CDI
Lungs: Crackles at bases bilaterally, no wheezes
Abd: Soft, NT, ND. +BS
Ext: No c/c/e. s/p R foot amp. +multiple small, shallow ulcers,
all appearing clean with no purulent discharge.
Skin: multiple excoriations at various stages of healing over
arms, legs, and back
Pertinent Results:
[**2145-5-17**] 12:30PM WBC-9.7# RBC-3.69* HGB-11.8* HCT-36.8
MCV-100* MCH-32.1* MCHC-32.1 RDW-18.3*
[**2145-5-17**] 12:30PM NEUTS-89.6* LYMPHS-6.3* MONOS-3.5 EOS-0.1
BASOS-0.4
[**2145-5-17**] 12:30PM GLUCOSE-271* UREA N-38* CREAT-5.9* SODIUM-135
POTASSIUM-5.0 CHLORIDE-90* TOTAL CO2-29 ANION GAP-21*
[**2145-5-17**] 12:30PM CALCIUM-8.8 PHOSPHATE-2.6* MAGNESIUM-1.9
[**2145-5-17**] 12:30PM ALT(SGPT)-19 AST(SGOT)-35 CK(CPK)-46 ALK
PHOS-267* TOT BILI-2.9*
[**2145-5-17**] 12:30PM PT-17.0* PTT-35.1* INR(PT)-1.5*
[**2145-5-17**] 12:30PM cTropnT-0.31*
[**2145-5-17**] 09:28PM CK-MB-3 cTropnT-0.32*
[**2145-5-17**] 09:28PM CK(CPK)-113
-------------------
**FINAL REPORT [**2145-5-20**]**
Blood Culture, Routine (Final [**2145-5-20**]):
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations
Rifampin
should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- =>4 R
PENICILLIN G---------- =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
Aerobic Bottle Gram Stain (Final [**2145-5-18**]):
REPORTED BY PHONE TO JINI [**Doctor Last Name 3136**] @ 0656 ON [**2145-5-18**].
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Anaerobic Bottle Gram Stain (Final [**2145-5-18**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Brief Hospital Course:
Sepsis: On arrival to the floor, she became hypotensive which
was unresponsive to IVF and she was transferred to the ICU. She
received a few hours of IV dopamine but was then weaned off with
spontaneous improvement in her blood pressures. While in the
unit, [**2-28**] blood culture bottles grew out GPCs in pairs and
clusters. She was continued on vanco for presumed recurrent MRSA
line infection. Her tunnelled HD line was removed for a line
holiday, then replaced by interventional radiology once repeat
blood cultures were negative for growth. Patient currently on
DAY [**7-8**] of treatment with Vancomycin. She will need to complete
a full course for 14 days and then have blood cultures checked a
few days later to ensure resolution of the infection.
.
Elevated transaminases: Pt was also noted to have elevated
transaminases and direct bilirubin, likely due to cholestasis.
Pt was very itchy without jaundice. PBC was ruled out as
anti-mitochondrial antibody was negative. RUQ u/s ruled out
cholelithiasis/cholecystitis. Pt was symptomatically treated
with benadryl with improvement of symptoms.
.
CHF: The importance of ACE inhibitors and beta blockers as a
part of her heart failure regimen was discussed with patient but
pt refused to take lisinopril. Beta blockers were not started
because of pt's low-normal blood pressure. These medications
should restarted as tolerated at rehabilitation facility.
.
Diarrhea: Pt developed diarrhea while receiving Vancomycin for
her line infection. Stool was checked for C. diff toxin and was
negative x 2.
.
Diabetes: Pt's blood sugars were labile throughout her hospital
stay. We are discharging her on Insulin NPH 8 units in the
morning and Insulin Lispro sliding scale. Her insulin regimen
should be titrated up or down at the rehabilitation facility
according to her finger sticks, and she should be kept on a
consistent diet.
Medications on Admission:
ASA 325mg
folic acid 1g QD
renagel
CaC03 500mg TID
NPH 12 u qAM
Lispro SSI
Loperimide 2mg q4-6prn
Biscodyl prn
Senna 8.6
Benadryl 25mg
Heparin 5000u SQ TID
Protonix 40mg QD
MVI
Cinacalcet
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
9. Cinacalcet 30 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
10. Insulin Lispro 100 unit/mL Cartridge Sig: sliding scale
Subcutaneous four times a day.
11. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed: for itching.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
13. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain or temp>101: Not to exceed 4 gm per
day.
15. Vancomycin 1,000 mg Recon Soln Sig: One (1) grm Intravenous
HD protocol for 6 days: currently DAY [**7-8**] on [**2145-5-24**].
16. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Eight
(8) units Subcutaneous QAM.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 3137**] Care Center
Discharge Diagnosis:
primary dx:
1. Methicillin-resistant line infection
secondary dx:
1. CAD s/p CABG x 3 in [**10-27**]
2. CHF - EF 20-25% Severe regional and moderate global LV
systolic dysfunction.
3. Mild mitral and tricuspid regurgitation.
4. DM1 since age of 6
5. ESRD on HD. Failed R and L AVG, now has tunneled HD catheter
LIJ, most recently replaced [**3-2**]. Changed from RIJ [**10-31**]. MRSA
infection [**1-1**], catheter changed (clot in R IJ), Rx vanc til
[**2145-1-23**]. Then another line change [**3-2**] for infected tunneled
line.
6. h/o MRSA rt stump infection
7. anemia
8. PVD s/p TMA
9. h/o epistaxis from right nostril
10. Bell's Palsy (right side, s/p valtrex x 7 days, last [**1-2**])
11. AAA repair in '[**39**]
12. h/o previous tunelled line infection
Discharge Condition:
fair
Discharge Instructions:
You had a HD line infection which caused you to become septic -
making your blood pressure low, and caused you to go to the ICU.
The infected line was removed and you were treated with
antibiotics - Vancomycin. While we waited for the new blood
cultures to come back we placed a temporary line, and then you
had the line replaced with the permanent one before you were
sent back to the rehabilitation center.
If your symptoms worsen, or you develop a fever > 100.5 please
return to the ED immediately.
Please keep all follow up appointments
Please take all medications as directed
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3138**] upon leaving. Call
[**Telephone/Fax (1) 3135**] to schedule an appointment.
Please return to your dialysis center to resume regular dialysis
(your last dialysis: [**2145-5-24**])
Completed by:[**2145-5-24**]
|
[
"414.00",
"V49.73",
"996.62",
"038.11",
"V45.81",
"V09.0",
"428.23",
"995.91",
"428.0",
"250.43",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.05",
"38.95",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
8178, 8236
|
4489, 6376
|
362, 383
|
9042, 9049
|
2585, 4466
|
9680, 9984
|
1890, 2002
|
6614, 8155
|
8257, 9021
|
6402, 6591
|
9073, 9657
|
2032, 2566
|
292, 324
|
411, 1098
|
1120, 1816
|
1832, 1874
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,254
| 147,886
|
31596
|
Discharge summary
|
report
|
Admission Date: [**2190-7-9**] Discharge Date: [**2190-7-17**]
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Gastrointestinal bleed
Major Surgical or Invasive Procedure:
Endovascular stent graft repair of abdominal aortic aneurysm.
History of Present Illness:
[**Age over 90 **] F w/ HTN, hyperlipidemia, h/o breast cancer, 7cm AAA and Afib
with RVR started on coumadin, lopressor and diltiazem for
management of Afib prior to discharge from [**Hospital1 18**] on [**2190-7-5**]. Pt
presented to OSH w/ abdominal pain, melena/hematemesis in
setting of supratherapeutic INR (5.2).
Initially pt was hypotensive with systolic BP of 70-100s. Got
PRBCs and FFP and was transferred to [**Hospital1 18**].
.
In [**Hospital1 18**] ED vitals: 96.6, 101, 91/67, 20 97% ?O2. Received 2 L
NS, 2 units prbcs, 6 units ffp, vit K 10 mg iv x1. WBC 23 w/ 6%
bands. Vanc one gram, levoflox 500 mg iv, flagyl 500 mg iv. CTA
A/P showed stable infrarenal AAA extending into iliac
bifurcation and evidence of ischemia in ascending colon and
splenic flexure.
.
Past Medical History:
HTN
Hyperlipidemia diet controlled
Hx CHF
Osteoarthritis
Cholelithiasis
? Breast CA s/p R mastectomy
Social History:
Lives at home by herself. Widowed. Used to work in a mill in MA.
Hx of tobacco use 1 ppd x 40 yrs, quit many yrs ago. Hx of occ
etoh in the past
Family History:
two brothers had [**Name2 (NI) **] in 50's
Physical Exam:
PE: T 98.7 BP 110/78 HR 100s-140s Resp 20-30 92-99% 6L nc
Gen - Alert, no acute distress
HEENT - PERRL, EOMI, anicteric, mucous membranes dry
Neck - no JVD
Chest - CTAB
CV - Normal S1/S2, RRR, III/VI systolic murmur throughout
precordium and to R clavicle
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds
Extr - No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally
groin inc - C/D/I
Neuro - Alert and oriented x 3
Skin - No rash
Pertinent Results:
[**2190-7-16**] 05:30AM BLOOD
WBC-12.3* RBC-3.15* Hgb-9.7* Hct-29.4* MCV-93 MCH-30.8 MCHC-33.1
RDW-15.8* Plt Ct-296
[**2190-7-16**] 05:30AM
BLOOD Plt Ct-296
[**2190-7-16**] 05:30AM
BLOOD Glucose-101 UreaN-8 Creat-0.3* Na-139 K-3.7 Cl-102 HCO3-31
AnGap-10
[**2190-7-10**] 05:15AM
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
URINE Mucous-RARE
Brief Hospital Course:
GIB: Likely secondary to duodenal ulcer and supratherapeutic
INR. Patient is H. Pylori + - currently being treated.
- INR now wnl 1.3 (after FFP and Vit k)
- Follow serial hcts - on Dc stable
- iv ppi [**Hospital1 **]
- large bore ivs in place - Dc'd on discharge
- check coags each day.
- transfuse for a goal of >28
- volume resuscitate
- cont broad spectrum abx - Dc on discharge
- Hold Coumadin
AAA: Endovascular stent graft repair of abdominal, tolerated
the procedure no complications. progressed with PT, recommended
rehab.
A fib : Pt on oral Diltiazem and coumadin as out-pt. r/o with
enzymes. Cardiology consulted - before admission pt was on
coumadin.
CHADS score = 2 (HTN, age) therefore, risk of embolic CVA from
afib 4% per year. Given age, recent massive GIB, known PUD,
risks of restarting coumadin outweigh benefits. [**Month (only) 116**] consider
restarting aspirin in future once PUD resolved, but would defer
at present.
EKG changes: in setting of hypotension/bleed. 2 sets CE's
negative. 1 Trop 0.04. Likely demand ischemia
Medications on Admission:
asa 81 mg daily
atorvastatin 10 mg daily
lisinopril 5 mg daily
coumadin 7.5 mg daily
diltiazem sr 240 mg daily
toprol 100 mg daily
Discharge Medications:
1. Diltiazem HCl 30 mg Tablet [**Month (only) **]: Two (2) Tablet PO QID (4
times a day).
2. Ipratropium Bromide 0.02 % Solution [**Month (only) **]: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
3. Acetaminophen 325 mg Tablet [**Month (only) **]: One (1) Tablet PO Q6H (every
6 hours) as needed.
4. Metronidazole 500 mg Tablet [**Month (only) **]: One (1) Tablet PO BID (2
times a day) for 14 days. Tablet(s)
5. Clarithromycin 250 mg Tablet [**Month (only) **]: Two (2) Tablet PO Q12H
(every 12 hours) for 14 days.
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day) for 14 days.
7. Aspirin 81 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] hospital tcu
Discharge Diagnosis:
AAA
A fib
EKG changes: demand ischemia
Leukocytosis
GI bleed - melena, abdominal pain
Supratheuraputic INR
.
CHF (EF?)
hyperlipidemia
OA
breast CA
HTN
Discharge Condition:
stable
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Endovascular Abdominal Aortic Aneurysm (AAA) Discharge
Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**2-6**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**4-9**] weeks for
post procedure check and CTA
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
Followup Instructions:
Cal Dr [**Last Name (STitle) 8888**] office anf follow up in 3 weeks. He can be
reached at [**Telephone/Fax (1) 74276**]
Follow up in the [**Hospital **] clinic in 6 weeks, Call [**Telephone/Fax (1) 11048**]. Dr
[**Last Name (STitle) 1407**].
Please make an appointment in 0n week with your PCP, [**Name10 (NameIs) **],[**Name11 (NameIs) **]
[**Telephone/Fax (1) 74277**].
Completed by:[**2190-7-16**]
|
[
"557.9",
"715.90",
"272.0",
"574.20",
"428.0",
"441.4",
"790.92",
"427.31",
"444.0",
"V58.61",
"276.0",
"553.3",
"E934.2",
"V10.3",
"009.0",
"532.40",
"401.9",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16",
"99.04",
"39.71",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
4484, 4539
|
2441, 3494
|
240, 304
|
4735, 4743
|
1948, 2418
|
7348, 7754
|
1415, 1459
|
3676, 4461
|
4560, 4714
|
3520, 3653
|
4767, 6768
|
6794, 7325
|
1474, 1929
|
178, 202
|
332, 1112
|
1134, 1236
|
1252, 1399
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,486
| 121,832
|
41394
|
Discharge summary
|
report
|
Admission Date: [**2153-12-12**] Discharge Date: [**2153-12-25**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2758**]
Chief Complaint:
s/p unwitnessed fall
Major Surgical or Invasive Procedure:
Right sided Craniotomy for Evacuation of Subdural Hematoma
History of Present Illness:
Ms. [**Known lastname **] is an 86 yo woman with multiple medical problems,
including CAD s/p CABG and valve repair about 5 years ago. Since
then, she has been maintained on warfarin. There is also the
question of A-fib. She has a h/o breast CA and is s/p lumpectomy
about 10 years ago. Lastly, she appears to have mild baseline
dementia. She lives with her adult son [**Name (NI) **], upon whom she is
reliant for advanced ADLs.
The patient was in this state of health until the afternoon of
[**12-12**]. At that time her son was preparing to take her out when he
heard a loud thud upstairs. He came to find the patient down,
but
still alert. Of note, it seems she had at least [**11-18**] falls in the
past several months. She was taken to [**Hospital6 **]. There
she abruptly complained of a severe HA, and, shortly thereafter,
became obtunded.
A head CT showed a Right fronto-temporal-parietal SDH, about 2cm
in maximal thickness with layering suggestive of acute on
chronic
components. There was also evidence of subfalcine herniation
with
about 1.4cm of MLS. There was also evidence of uncal herniation
on the right. Patient was intubated and received 10mg Vitamin K
and 1 unit of FFP. Pt then transferred to [**Hospital1 18**].
Here, we repeated a CT which was largely unchanged. I had an
extensive discussion with her three sons about the risks and
benefits of drainage, including the fact that she is unlikely to
have a full functional recovery, even if the operation is
performed. Whereas one of her sons opted to make her
comfortable,
the other two decided they wanted to do everything possible, so
the decision was made to proceed with the case.
Patient recived Profyl 9 prior to surgery. Dr. [**Last Name (STitle) **] performed
the operation this evening without complications. A post-op CT
showed full evacuation of the SDH and significant improval of
MLS
Past Medical History:
[**2142**] CABGx1, RCA anomalous fistula/PA
Mitral valve repair
Afib on Coumadin
chronic anemia d/t intravascular hemolysis (on epo)
renal dysfunction (glomerulonephritis)
Breast Ca w/ portacath ([**2148**])
S/p CVAx2
Pseudogout
Social History:
lives with her son
Family History:
noncontributory
Physical Exam:
O: T: Afeb BP: 108/72 HR: 102 R 12
Gen: WD/WN, comfortable, NAD.
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neurological: Off of propofol for 5 minutes: No commands, no
verbalizations. Pupils 2.5mm and largely non-reactive. No BTT.
Mildly Doll's past midline. Grimaces to noxious. Extensor
posturing in both arms. Triple flexion in legs.
[**12-23**]
Afeb, 140/80, 120, 20, 100%2L
HEENT: left facial droop, + edema on L side of face>right side,
+ conjunctival edema
CV: tachycardic, irregularly irregular, no murmur
Pulm: Anterior rhonchi
Abd: Soft, NT, ND
Extrem: No LE edema, + UE edema, prominent in hands
Neuro: L facial droop, dysarthria,
Pertinent Results:
CT Head [**12-12**]
Similar appearance of acute on subacute R SDH/EDH. 2.3 cm L
subfalcine
herniation, 1.4-cm L shift at 3rd ventricle, L temporal [**Doctor Last Name 534**]
entrapment,
early R uncal hernation.
Old R parietal infarct.
No fx or new hemorrhage.
CT Head [**12-12**]:
1. Expected post-operative changes status post right subdural
hematoma
evacuation with significantly improved mass effect. There is no
acute
hemorrhage.
2. Hypodense area in the left parietal infarct- indeterminate
chronicity and uncertain nature-No remote priors are avaialble
for comparison. Consider MR [**Name13 (STitle) 430**] for better assessment if not
CI; if CI, followup with CT Head without and with contrast.
CT Head [**12-13**]:
Status post evacuation of right frontoparietal subdural hematoma
and craniotomy with persistent pneumocephalus and small subdural
collection as described in detail above with persistent
effacement of the sulci and midline shifting towards the left,
slightly smaller since the prior study measuring approximately
7.6 mm, previously 8.4 mm. Continuous followup with CT is
recommended until obtained a complete resolution of the hematoma
and pneumocephalus.
MRI Head [**12-14**]:
Small right frontal lobe acute infarction. Otherwise no
significant change
compared to the prior CT from one day prior. Changes status post
evacuation of a right hemispheric subdural are again noted.
Stable extra-axial collections bilaterally
MRI C-Spine [**12-15**]
There is loss of disc height from C4 through C7. No cord
contusion is seen. There are disc osteophyte complexes from C4
through C7 with mild central stenosis. Foramina are difficult to
evaluate due to motion artifact. There is no evidence for cord
contusion, epidural hematoma or compression fracture. There is
no evidence for ligamentous injury.
CXR [**2153-12-23**]
The Port-A-Cath catheter tip is at the level of cavoatrial
junction,
unchanged. Cardiomediastinal silhouette is unchanged. Bilateral
opacities
mostly focusing in the perihilar and lower lobes are unchanged.
It might
represent a combination of pulmonary edema and potentially
present infectious process in particular in the lung bases and
should be correlated clinically.
No interval worsening of pulmonary edema is demonstrated, but on
the other
hand, no interval improvement has been seen.
TTE [**2153-12-25**]
The right atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. Overall
left ventricular systolic function is low normal (LVEF 50-55%).
There is no ventricular septal defect. The right ventricular
cavity is moderately dilated with mild global free wall
hypokinesis. 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 moderately thickened.
A mitral valve annuloplasty ring is present. Moderate (2+)
mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. The end-diastolic pulmonic regurgitation
velocity is increased suggesting pulmonary artery diastolic
hypertension. There is no pericardial effusion.
IMPRESSION: Symmetric left ventricular hypertrophy with
borderline systolic function. Dilated and hypokinetic right
ventricle. Moderate mitral and tricuspid regurgitation. Moderate
pulmonary hypertension.
[**2153-12-25**] 09:27AM BLOOD WBC-10.7 RBC-2.34* Hgb-7.5* Hct-23.2*
MCV-99* MCH-32.2* MCHC-32.5 RDW-19.2* Plt Ct-456*
[**2153-12-12**] 07:15PM BLOOD WBC-14.8* RBC-2.51* Hgb-8.3* Hct-26.7*
MCV-107* MCH-33.0* MCHC-30.9* RDW-25.0* Plt Ct-253
[**2153-12-25**] 09:27AM BLOOD PT-14.9* PTT-30.6 INR(PT)-1.3*
[**2153-12-12**] 07:15PM BLOOD PT-26.7* PTT-26.6 INR(PT)-2.6*
[**2153-12-25**] 09:27AM BLOOD Glucose-142* UreaN-25* Creat-1.4* Na-140
K-4.0 Cl-106 HCO3-26 AnGap-12
[**2153-12-12**] 07:15PM BLOOD Glucose-169* UreaN-27* Creat-1.7* Na-137
K-4.6 Cl-101 HCO3-24 AnGap-17
[**2153-12-23**] 09:55AM BLOOD CK(CPK)-140
[**2153-12-13**] 06:33PM BLOOD CK(CPK)-295*
[**2153-12-23**] 09:55AM BLOOD CK-MB-3
[**2153-12-13**] 06:33PM BLOOD CK-MB-4 cTropnT-0.05*
[**2153-12-25**] 09:27AM BLOOD Calcium-8.2* Phos-3.2 Mg-1.8
[**2153-12-24**] 05:03AM BLOOD calTIBC-137* Ferritn-506* TRF-105*
[**2153-12-22**] 08:39AM BLOOD Phenyto-13.1
[**2153-12-24**] 2:13 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2153-12-25**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2153-12-25**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
Brief Hospital Course:
86 year old woman with history of atrial fibrillation on
coumadin, CVA's, and hypertension who was admitted on [**12-12**] for
subdural hematoma, now s/p right craniotomy and evacuation of
SDH ([**12-12**]) and treatment of CHF exacerbation.
Subdural hematoma: Patient presented to [**Hospital1 18**] ER from an OSH
after being found to have a large right sided subdural hematoma
with midline shift and subfalcine herniation. She was taken to
the operating room urgently for evacuation of the subdural via a
right sided craniotomy. She tolerated the procedure well and
remained intubated and was trasnferred to the ICU for further
care. In the ICU, over the next several days her exam showed
only minimal signs of improvement. She was unable to be
extubated. Her INR was continued to be corrected to below 1.5
with Vit K and platelets. She was placed on Dilantin for
seizure prophylaxis. On [**12-17**] an MRI of her Head and C-Spine were
obtained, which demonstrated possible infarct near the site of
the craniotomy. She had no ligamentous injury or fracture on
her C-Spine, and her cervical collar was removed. Her Dilantin
level came back on [**12-17**] at 27.8, and was therefore held. She
was started on free water boluses for a serum sodium of 150. She
was extubated on [**12-17**]. On [**12-19**] the patient was transfered to the
step down unit. On [**12-20**] the pt had a PEG tube placed due to
swallow difficulties. The procedure was without complication.
On [**12-21**] her exam was slightly improved as she was brighter and
more interactive and was moving the LUE minimally which had been
flaccid prior. The pt's exam continued to improve through the
rest of the hospitalization, and on discharge the pt was able to
interact, though was not oriented to date or place (saying she
was in [**Hospital1 8**]). On discharge the pt was able to lift all
extremities, and cranial nerves appeared to be symmetric.
Acute on chronic congestive heart failure: Per the pt's PCP last
echo was in [**2146**] which showed a systolic ejection fraction of
30%. On [**12-22**] the patient was noted to be increasingly tachypnic
and hypoxic. She was given 40IV lasix, and improved slightly. On
[**12-23**] pt was again noted to be tachypnic and with dependent edema
of the face, flank and upper thighs with elevated JVP. The
patient was transferred to the medicine service for CHF
exacerbation. Chest xray indicated pulmonary edema. The patient
was diuresed with 40 IV lasix [**Hospital1 **] on [**12-23**] and [**12-24**]. Her
respiratory status and edema improved dramatically.
Transthoracic echocardiogram on [**2153-12-25**] showed moderate tricuspid
regurgitation and moderate mitral regurgitation. Ejection
fraction was low normal at 50%. The echo was suggestive of more
right-sided heart failure, with high pulmonary arterial
pressures.
The patient is being discharged on an increased dose of lasix
(40mg po bid). Please check creatinine and electrolytes on [**12-27**].
If creatinine is <1.6, please restart the patient's home
lisinopril, 10mg daily. Discharge weight is 140lbs, if pt gains
3 or more pounds please increase lasix.
Atrial fibrillation: The pt developed rapid rates of afib during
the episodes of tachypnea on [**12-23**]. Heart rate improved with
metoprolol 50 qid. At home the patient takes 100mg metoprolol.
Pt was discharged on metoprolol succinate 200mg daily. She is
currently off her diltiazem, which should be added back on if
heart rate is >100.
In terms of anticoagulation, the patient is currently off of
coumadin.
Urinary catheter: Please discontinue the patient's bladder
catheter when she arrives at rehab. Bladder scan 8 hours
post-discontinuation, and if more than 400cc is present in
bladder, please re-catheterize.
Medications on Admission:
Coumadin 5mg daily except Tue 2.5mg
diltiazem 120 mg daily
lisinopril 10mg daily
colchicine 0.6mg daily
lasix 20mg daily
digoxin 0.125mg daily
epogen [**Numeric Identifier **] subcut q4wk
folic acid 1mg daily
metoprolol succinate 200mg daily
vitamin E 400u daily
melatonin 3mg qhs
womens daily multivit
vitamin C 500mg daily
aspirin 81mg daily
Discharge Medications:
1. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed for pain, fever.
7. Heparin Flush (10 units/ml) 5 mL IV PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN
per lumen.
8. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
Indwelling Port (e.g. Portacath), heparin dependent: When
de-accessing port, instill Heparin as above per lumen.
9. 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.
10. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Indwelling Port (e.g. Portacath), non-heparin dependent: Flush
with 10 mL Normal Saline daily, PRN, and when de-accessing, per
lumen.
11. metoprolol succinate 200 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
12. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
13. Epogen 20,000 unit/mL Solution Sig: [**Numeric Identifier **] ([**Numeric Identifier **]) u
Injection q4weeks.
14. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day.
15. insulin regular human 100 unit/mL Solution Sig: see attached
sliding scale Injection four times a day.
16. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
17. Outpatient Lab Work
Please check Electrolytes and creatinine on [**12-27**].
18. Outpatient Speech/Swallowing Therapy
Pt will need re-eval for speech and swallow this week.
19. Tubes
Please d/c foley on [**2153-12-25**]. Bladder scan 8 hours after and if
>400cc in bladder re-place catheter.
20. Weights
Pt's discharge weight is 140lbs. If weight increases to 143,
please give more lasix [**Name6 (MD) **] covering MD's orders.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Subdural Hematoma
Acute on chronic systolic heart failure (EF 305% [**2146**])
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Ms. [**Known lastname **], you were admitted with bleeding in your brain due to a
fall and being on a blood thinner. You had a surgery called a
craniotomy to remove the blood from the brain. During the
admission you were off of your home lasix and you developed
shortness of breath. This improved dramatically with
administration of lasix. You are being discharged to continue
your rehabilitation.
During this admission the following medications were STOPPED:
diltiazem, lisinopril, coumadin, aspirin, vitamin E, vitamin C,
multivitamin and melatonin.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
?????? You will need a CT scan of the brain without contrast on the
day of your appointment with Dr. [**Last Name (STitle) **].
You will need to follow up with Dr. [**Last Name (STitle) 3142**] 2 weeks after your
discharge from rehab.
|
[
"V58.61",
"276.0",
"V45.81",
"285.9",
"427.31",
"434.91",
"E888.9",
"428.0",
"V10.3",
"428.23",
"852.21",
"414.00",
"348.4",
"263.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"96.72",
"02.12",
"96.6",
"01.31"
] |
icd9pcs
|
[
[
[]
]
] |
14390, 14460
|
7969, 11733
|
274, 335
|
14582, 14582
|
3311, 7946
|
15752, 16123
|
2544, 2561
|
12127, 14367
|
14481, 14561
|
11759, 12104
|
14716, 15729
|
2576, 3292
|
214, 236
|
363, 2239
|
14597, 14692
|
2261, 2492
|
2508, 2528
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,974
| 125,235
|
19680
|
Discharge summary
|
report
|
Admission Date: [**2101-12-31**] Discharge Date: [**2102-2-25**]
Date of Birth: [**2034-10-10**] Sex: F
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old
female who suffered a severe onset of headache with nausea
and vomiting. The patient was taken to an outside hospital
where a head demonstrated a intraventricular hemorrhage and
subdural hemorrhage.
The patient deteriorated at the outside hospital. The
patient was intubated and sedated and transferred to [**Hospital1 1444**] where she was found to have a
grade 5 subarachnoid hemorrhage.
BRIEF SUMMARY OF HOSPITAL COURSE: The patient was
transferred to [**Hospital1 69**] where a
ventricular drain was placed. The patient was monitored in
the Intensive Care Unit for close neurological observation.
An angiogram showed a large basilar tip aneurysm of 1.5 mm X
9 mm with a 9-mm neck.
Neurologic examination on admission revealed the patient was
not following commands. The right pupil was nonreactive from
the earlier accident. The left pupil was 3.5 down to 3 and
brisk. The patient was localizing in the right upper
extremity greater than the left upper extremity and was
withdrawing both bilateral lower extremities. The patient
underwent coiling of the basilar tip aneurysm.
The patient had a protracted Intensive Care Unit stay with
multiple complications, including meningitis, pneumonia, and
sepsis. The patient's vent drain was removed on [**2102-1-25**] secondary to Pseudomonas in her cerebrospinal fluid
without clearing.
On [**2102-1-30**] the patient had a new extensive
intraventricular hemorrhage with effacement of the lateral
ventricles. The patient's condition did not improve. Her
neurologic status continued to remain as it was when she was
first admitted. She was not following commands. She was
withdrawing her lower extremities and withdrawing her upper
extremities.
The patient's family therefore made the patient comfort
measures only, and she was transferred to the regular floor.
On [**2102-2-8**] the patient was made do not
resuscitate/do not intubate and comfort measures only. The
patient was transferred to the regular floor. The patient
remained on comfort measures only and passed on [**2102-2-25**].
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2102-2-27**] 11:02
T: [**2102-2-27**] 11:11
JOB#: [**Job Number 53263**]
|
[
"482.1",
"038.19",
"276.1",
"320.82",
"996.63",
"599.0",
"331.4",
"995.92",
"430"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"02.2",
"99.04",
"38.93",
"31.1",
"03.31",
"96.72",
"38.91",
"39.72"
] |
icd9pcs
|
[
[
[]
]
] |
629, 2515
|
171, 600
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,780
| 164,002
|
9698
|
Discharge summary
|
report
|
Admission Date: [**2192-3-19**] Discharge Date: [**2192-3-20**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
found down
Major Surgical or Invasive Procedure:
none
History of Present Illness:
86 yo man with h/o ESRD on HD (since [**2187**]), who became acutely
short of breath on his way to HD. When EMS arrived was found
down and unresponsive. Patient asystolic, AED - no shocks
advised. CPR started, ET tube placed. Found to be in PEA. First
round of meds - epi 1 mg and atropine 1 mg - given via ET tube,
then given epi 1 mg x 2 and atropine 1 mg given IV push through
HD cath. When he arrived in the ED, he continued to be in PEA
arrest. He was resuscitated multiple times in the ED (total 1.5
hours) - receiving multiple rounds of calcium, sodium bicarb,
atropine and epinephrine and CPR. He resumed spontaneous
respirations over the vent. In the ED weaned of pressors,
breathing over vent, on amio gtt. He now may have subclavian
hematoma [**3-9**] CVC placement attempts, HD cath on L.
.
Noted blurry vision few weeks ago, stopped driving. Last night
diaphoretic after dinner, looked terrible, refused medical
intervention, recovered to baseline independently.
Past Medical History:
- ESRD - ? polycystic kidney disease - on HD since [**2187**]
(although HD first recommended 10-15 years ago), gets HD MWF x
3.5 hrs at [**Hospital1 882**]. Has L arm graft which clotted recently so
had tunneled cath in R chest placed last week. His dry weight
is 77 kg. Per HD nurse, BP on Fri [**3-16**] was 57/31 - BP usually
70-80s - so they did not take as much off of him. On Fri [**3-16**] -
his weight was 79 kg and his BP was 101/50 when he left.
- BPH s/p TURP 01
- HTN
- hypothyroid
- h/o chronic knee pain: significantly limits ambulation and
quality of life
- s/p laminectomy
Social History:
Retired electrical contractor, lives alone but sees daughter [**Name (NI) **]
regularly, quit smoking [**2125**]'s, remote etoh, no illicit drug
use.
Family History:
FH: Father unknown, mother lived to >[**Age over 90 **] years.
Physical Exam:
VS: BP: 100/46 mmHg T 97.6 HR 87 RR 16 SpO2 100% on AC with Vt
650 rate 16 PEEP 5
Gen: unresponsive, not sedated on vent
HEENT: scleral edema, anicteric, OP with ETT
Neck: JVP difficult to assess [**3-9**] neck edema, left neck
ecchymosis
Resp: slighltly rhonchorus but no wheezes or rhonchi, equal bs
bilat
CV: RRR, S1, S2 present, no m/r/g, unable to palpate DP or PT
pulses
Abd: soft, NT, ND, +BS, no masses
Ext: LUE with fistula (no thrill or bruit), 1+ PE to knees
Neuro: Unresponsive to pain, disconjugate gaze with no corneal
blink reflex, no occulocephalic reflex, pupils minimally
reactive to light, areflex at biceps, triceps, brachioradialis,
patellar, achilles, babinski, noted to have episodes of clonic
jerks with eye-opening
Pertinent Results:
[**2192-3-19**] Head CT: No evidence of acute intracranial hemorrhage.
.
[**2192-3-19**] CXR: New patchy right lower lobe opacity likely
representing overlying shadows. Recommend repeat radiographs to
evaluate as atelectasis; or aspiration pneumonitis appear
similar. appearance.
.
[**2192-3-19**] ECG: NSR 88, left axis deviation, LBBB, ST depressions
V4-V6, TWI I, aVL.
Brief Hospital Course:
86 yo Man with ESRD on HD with collapse and s/p lengthy code for
asystole/PEA with NSR but not spontaneously breathing,
unresponsive without sedation, neuro exam concerning for brain
injury but no acute changes on head CT. Lengthy discussion with
the daughter determined he would not want to live with any kind
of deficits and therefore should continue to be treated DNR/DNI,
no pressors. There was no improvement in his neurologic exam
and extubation was planned once the rest of his family could
arrive from out of town. The patient was extubated and had
respiratory arrest. He was pronounced on [**2192-3-20**] at 18:25.
Medications on Admission:
Medications at home:
asa 81 po qd
synthroid 137mcg po qd
lipitor 10mg po qhs
phoslo tid
renagel tid
flomax 0.4mg qd
.
Medications on transfer:
amiodarone gtt
Discharge Medications:
n/a
Discharge Disposition:
Expired
Facility:
[**Hospital1 18**]
Discharge Diagnosis:
Patient expired during this admission
Discharge Condition:
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
[
"518.81",
"719.7",
"428.0",
"244.9",
"719.46",
"410.91",
"404.93",
"753.12",
"585.6",
"600.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.60",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
4142, 4181
|
3276, 3905
|
229, 235
|
4264, 4264
|
2879, 2895
|
4316, 4322
|
2039, 2103
|
4114, 4119
|
4202, 4241
|
3931, 3931
|
4288, 4293
|
3952, 4049
|
2118, 2860
|
179, 191
|
263, 1241
|
2904, 3253
|
4074, 4091
|
1263, 1855
|
1871, 2023
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,994
| 177,546
|
33157
|
Discharge summary
|
report
|
Admission Date: [**2152-7-25**] Discharge Date: [**2152-8-7**]
Date of Birth: [**2082-11-30**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Keflex / Diovan
/ Ciprofloxacin / Ace Inhibitors / Quinine / Levaquin / Novocain
/ Lidocaine / Heparin Agents / Zosyn / Xylocaine / Lipitor /
vancomycin
Attending:[**First Name3 (LF) 1899**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
PICC placement
Hemodialysis
History of Present Illness:
A 69 y/o woman with DM, HTN, HLD and HD dependent ESRD who is
transferred from [**Hospital **] hospital to the CCU for hypotension and
continued management following high risk intervention with
stents placed in the LAD and left main coronary artery.
.
According to the report the patient had been experiencing
dyspnea and weakness x 3 days which was believed to be related
to heart failure. She underwent hemodialysis on Sunday and again
on Monday to remove fluid. Today, she went for hemodyalisis and
became hypotensive to 70/50 she complained of presyncope and
dyspnea and was sent to her routine cardiology follow up
appointment with Dr. [**Last Name (STitle) 8579**] where she was hypotensive to
70/doppler and was referred to the [**Location (un) **] ED.
.
On presentation to [**Location (un) **] her vitals were 98.2 73 60/40 100%
2L, she endorsed worsening SOB but denied CP. She was started on
dopamine and dobutamine drip, and given 3L IVNS. While in the
ED, she complained of chest pain. EKG showed ventricular pacing
at 71 BPM with known LBBB, TWI in aVL. Labs were significant for
Cr. 3.0, K 2.9, Troponin I 0.61 and Hct of 30.9. She was unable
to lay flat and was intubated prior to cardiac catheterization,
which showed the patent SVG-->OM and SVG-->PDA grafts, known
occluded LIMA, RCA and LCX. A 90% L main occlusion and 80%
proximal LAD occlusion were found and 2 DES were placed. RA
pressure was 29mmHg, wedge pressure was 38mmHg.
.
She was then transferred to [**Hospital1 18**] for further management
following high risk intervention. She was received in the CCU
intubated on dopamine and dobutamine Vitals were T 95.9 HR 74 BP
95/43 O2 Sat 100%Vent settings AC 500/16/5/100% FiO2. She was
unable to contribute to the history.
.
BACKGROUND History
She has recently been treated for a chronic ulcer at the base of
her left greater toe x 1 month. She was treated [**2152-7-20**] with
baloon angioplasty to the SFA and anterior/posterior tibial
arteries were found to be occluded. PTA was incompletely opened.
Of note, on [**2152-7-20**] she underwent LLE arteriography and
angioplasty that showed total occulsion of the anterior and
posterior tibial arteries that could not be intervened upon. Her
SFA was partially occluded and was successfully dialted without
complication.
.
She has an extensive cardiac history significant for CABG
'[**39**](LIMA/LAD, SVG/OM1, SVG/RCA) c/b occlusion of LIMA/LAD graft,
s/p DES to LAD '[**46**], NSTEMI due to LAD in-stent stenosis [**2-22**] s/p
repeat DES, and AVR/MVR with [**Hospital 923**] Medical Biocor Epic Supra in
[**3-23**] and s/p pacemaker insertion. She had a recent cath at [**Hospital1 18**]
([**4-24**]) that showed 70% stenosis of the distal LMCA, 90% ostial
stenosis of the LAD, and widely patent mid arterial stents. The
LCx and RCA were totally occluded. She had a successful DES of
distal LAD and successful DES of distal L main/ostial LAD.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: x3 in [**2139**] LIMA/LAD, SVG/OM1, SVG/RCA c/b occlusion of
LIMA/LAD graft s/p DES to LAD '[**46**]
-PERCUTANEOUS CORONARY INTERVENTIONS: NSTEMI due to LAD in-stent
stenosis [**2-22**] s/p repeat [**Name Prefix (Prefixes) **]
-[**Last Name (Prefixes) 12539**]/ICD:
3. OTHER PAST MEDICAL HISTORY:
MVR/AVR in [**3-23**]
ESRD on HD T/T/S
DM
TIA
GIB with ischemic colitis
depression
PVD s/p R BKA
HIT
Social History:
Patient lives iwth her daughter and son-in-law as well as
granddaughter. She does not work. She reports recent significant
stressors as 2 family members have died in the last month and a
great-grandaughter was born.
Tobacco: smoked as a teenager
EtOH: rare glass of wine
Drugs: denies
Family History:
Mother died of colon ca; she also had diabetes. Father died of
heart disease.
Physical Exam:
PHYSICAL EXAM ON ADMISSION
VS: T 95.9 HR 74 BP 95/43 O2 Sat 100%
GENERAL: Elderly female intubated and mildly sedated, responding
to commands and moving all extremities.
HEENT: PEERLA, EOMI. ET tube in place.
NECK: JVP not assessed due to body habitus
CARDIAC: S1, S2. holosystolic murmur at the LLSB. No S3
apprecited.
LUNGS: Right sided pacer in place. Coarse breath sounds in the
anterior lung fields BL. Equal air entry BL, no wheezes rales or
rhonchi.
ABDOMEN: Overweight, abdominal striae present. Soft,
nondistended normoactive bowel sounds.
EXTREMITIES: S/p right Above Knee Amputation. Right venous
sheath in place. a 2cm diameter eschar is present over medial
aspect of the base of the left greater toe.
PULSES:
Right: s/p BKA
Left: Dopplerable posterior tib/DP
PHYSICAL EXAM ON DISCHARGE
VS: T 99 BP 100/60 HR 83 RR 18 O2 Sat 97% RA
GENERAL: NAD
HEENT: NCAT, MMM
NECK: JVP difficult to asses [**2-16**] plethoric neck
CARDIAC: S1, S2. holosystolic murmur at the LLSB. No S3
apprecited.
LUNGS: Right sided pacer in place. Crackles in dependent lung
fields
ABDOMEN: Overweight, abdominal striae present. Soft,
nondistended normoactive bowel sounds.
EXTREMITIES: S/p right Above Knee Amputation. LLE with lambs
wool dressing between toes and loose dry dressing.
PULSES:
Right:
Left: Dopplerable posterior tib/DP
Pertinent Results:
ADMISSION LABS
[**2152-7-25**] 08:16PM BLOOD WBC-18.4*# RBC-3.32* Hgb-11.0* Hct-33.0*
MCV-100* MCH-33.1* MCHC-33.2 RDW-17.9* Plt Ct-321
[**2152-7-25**] 08:16PM BLOOD Neuts-90* Bands-0 Lymphs-5* Monos-5 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-1*
[**2152-7-25**] 08:16PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-1+ Burr-1+
[**2152-7-25**] 08:16PM BLOOD PT-16.3* PTT-33.4 INR(PT)-1.4*
[**2152-7-25**] 08:16PM BLOOD Glucose-244* UreaN-23* Creat-3.6* Na-137
K-4.2 Cl-96 HCO3-20* AnGap-25*
[**2152-7-25**] 08:16PM BLOOD ALT-7 AST-28 LD(LDH)-270* CK(CPK)-76
AlkPhos-110* TotBili-0.3
[**2152-7-25**] 08:16PM BLOOD CK-MB-10 MB Indx-13.2* cTropnT-1.62*
[**2152-7-25**] 08:16PM BLOOD Albumin-3.5 Calcium-9.5 Phos-4.4 Mg-2.1
[**2152-7-26**] 01:12AM BLOOD Lactate-3.7*
DISCHARGE LABS
WBC 11.9 RBC 3.14 Hb 10.6 Hct 33.0 MCV 105 MCV 33.6 Plt 564
Glu 154 Cr 26 K 4.3 Na 134 3.8 Cl 89* HCO3 28 AG 21
PERTINENT LABS
[**2152-7-28**] 04:50AM BLOOD ESR-77*
[**2152-7-31**] 03:31AM BLOOD Ret Aut-7.6*
[**2152-8-2**] 04:55AM BLOOD Fact V-146 FacVIII-362*
[**2152-7-28**] 04:50AM BLOOD ALT-1 AST-16 LD(LDH)-211 AlkPhos-90
TotBili-0.2
[**2152-7-25**] 08:16PM BLOOD CK-MB-10 MB Indx-13.2* cTropnT-1.62*
[**2152-7-26**] 05:20AM BLOOD CK-MB-7 cTropnT-1.78*
[**2152-7-31**] 03:31AM BLOOD VitB12-754 Folate-GREATER TH Hapto-236*
[**2152-8-3**] 04:31AM BLOOD TSH-4.8*
[**2152-7-27**] 05:30AM BLOOD Cortsol-43.0*
[**2152-8-3**] 04:31AM BLOOD Cortsol-18.1
[**2152-7-28**] 04:50AM BLOOD CRP-162.8*
PERTINENT STUDIES
# [**7-26**] TTE
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is severe regional
left ventricular systolic dysfunction with akinesis of the
septum, dyskinesis of the distal inferior wall and apex, and
severe hypokinesis of the lateral wall Overall left ventricular
systolic function is severely depressed (LVEF= 25 %). No masses
or thrombi are seen in the left ventricle. The right ventricular
cavity is mildly dilated with mild global free wall hypokinesis.
A bioprosthetic aortic valve prosthesis is present. The aortic
valve prosthesis appears well seated, with normal leaflet/disc
motion and transvalvular gradients. No aortic regurgitation is
seen. A bioprosthetic mitral valve prosthesis is present. The
prosthetic mitral valve leaflets are thickened. The transmitral
gradient is normal for this prosthesis. There is probable small
vegetation on the mitral valve which appears to be attached to
the posterior mitral leaflet and prolapses through the valve
orifice during the cardiac cycle. Cannot exclude degeneration of
the prosthetic valve but appears consistent with vegetation.
Trivial mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. No masses or vegetations are seen on the
tricuspid valve, but cannot be fully excluded due to suboptimal
image quality. Moderate [2+] tricuspid regurgitation is seen.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
IMPRESSION: Prosthetic mitral valve vegetation. Well-seated and
normally functioning Severe regional left ventricular systolic
dysfunction c/w CAD. Moderate tricuspid regurgitation. Mildly
dilated and borderline hypokinetic right ventricle.
Compared with the prior study (images reviewed) of [**2151-3-29**],
left ventricular function has significantly declined. Two
bioprosthetic valves are present, with a probable vegetatation
on the mitral valve.
# [**7-26**] TEE
Conclusions
No spontaneous echo contrast or thrombus/mass is seen in the
body of the left atrium. Mild spontaneous echo contrast is
present in the left atrial appendage but no thrombus is seen. No
spontaneous echo contrast or thrombus is seen in the body of the
right atrium or the right atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. LV systolic function
appears depressed. The right ventricular cavity is dilated with
normal free wall contractility. There are simple atheroma in the
ascending aorta and aortic arch. A bioprosthetic aortic valve
prosthesis is present. The prosthetic aortic valve leaflets
appear normal. The aortic valve prosthesis leaflets appear to
move normally. No masses or vegetations are seen on the aortic
valve. No aortic valve abscess is seen. No aortic regurgitation
is seen. A bioprosthetic mitral valve prosthesis is present. The
prosthetic mitral leaflets appear normal. The motion of the
mitral valve prosthetic leaflets appears normal. There is small
vegetation or mass on the left ventricular aspect of the MVR
strut which is not affecting the leaflets (seen starting at
clips 41-44). No mitral valve abscess is seen. Trivial mitral
regurgitation is seen. No masses or vegetations are seen on the
tricuspid valve, but cannot be fully excluded due to suboptimal
image quality. Moderate to severe [3+] tricuspid regurgitation
is seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Small, highly mobile vegetation/mass on the inferior
surface of the bioprosthetic MVR which appears to be attached to
the left ventricular aspect of the posterior strut and is not
involving the leaflets. Cannot exclude chordal structures from
prosthetic valve surgery. Trivial mitral regurgitation. No
abscess is visualized adjacent to the MVR or AVR. Depressed LV
function with moderate to severe TR.
When compared to prior intraoperative TEE study ([**2152-4-1**]),
small, linear, mobile structures were seen in a similar location
after mitral valve prosthesis was placed. This finding is now
more apparent and the structure is larger in size.
[**7-27**] Foot X-ray
FINDINGS: Three views of the left foot demonstrate an
age-indeterminate
fracture at the head of the fifth metatarsal. There is no
cortical
destruction to suggest osteomyelitis. However, cannot exclude
early
osteomyelitis on this radiograph. Extensive arterial
calcifications are
present. A plantar based lucency within the soft tissue, best
seen on the
lateral view, may represent an ulcer. The bones are diffusely
osteopenic.
Hallux valgus is present. There is enthesopathy of the
calcaneus.
IMPRESSION: No chronic osteomyelitis present. Age-indeterminate
fracture at the head of the fifth metatarsal.
# [**7-28**] Arterial study
FINDINGS: The right lower extremity was not evaluated due to an
above-knee
amputation. On the left, ABI measurements are considered
inaccurate due to
vessel non-compressibility. Doppler tracings appear monophasic,
volume
recordings appear widened with amplitude loss and are extremely
low at the
metatarsal level.
IMPRESSION: Findings indicating severe arterial insufficiency,
etiology is
proximal to the popliteal artery.
# [**8-3**] Bone scan
FINDINGS: Three views of the left foot demonstrate an
age-indeterminate
fracture at the head of the fifth metatarsal. There is no
cortical
destruction to suggest osteomyelitis. However, cannot exclude
early
osteomyelitis on this radiograph. Extensive arterial
calcifications are
present. A plantar based lucency within the soft tissue, best
seen on the
lateral view, may represent an ulcer. The bones are diffusely
osteopenic.
Hallux valgus is present. There is enthesopathy of the
calcaneus.
IMPRESSION: No chronic osteomyelitis present. Age-indeterminate
fracture at the head of the fifth metatarsal.
# [**8-4**] TTE
Conclusions
Left ventricular wall thicknesses and cavity size are normal.
There is mild to moderate regional left ventricular systolic
dysfunction with mid- and distal septal/apical akinesis. The
remaining segments contract normally (LVEF = 35%). No masses or
thrombi are seen in the left ventricle. The right ventricular
cavity is mildly dilated with normal free wall contractility. A
bioprosthetic aortic valve prosthesis is present. The aortic
valve prosthesis appears well seated, with normal leaflet/disc
motion and transvalvular gradients. There is no aortic valve
stenosis. A bioprosthetic mitral valve prosthesis is present.
The prosthetic mitral valve leaflets are thickened. The
gradients are higher than expected for this type of prosthesis.
There is a small echodensity adjacent to the mitral prosthesis
ring; this likely represents a lookse suture. Moderate to severe
[3+] tricuspid regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild to moderate regional left ventricular systolic
dysfunction, most c/w CAD. Mildly dilated right ventricle with
preserved systolic function. Slightly increased prosthetic
mitral valve gradients, normal AVR/MVR function otherwise.
Moderate to severe functional tricuspid regurgitation. At least
moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2152-7-26**], LV
function has slightly improved. Tricuspid regurgitation is more
severe and estimated pulmonary pressures are higher.
Brief Hospital Course:
A 69 y/o woman with DM, HTN, HLD and HD dependent ESRD who is
transferred from [**Hospital **] hospital to the CCU for hypotension and
continued management following high risk intervention with
stents placed in the LAD and left main coronary artery.
.
# Hypotension
It is thought that patient's hypotension is related to
cardiogenic shock. Cardiac catheterization at [**Location (un) **] showed
elevated PCWP and right atrial pressures consistent with
biventricular failure. Pt was started on Dopamine gtt and was
repeatedly hypotensive with hemodialysis. After extubation
attempt to wean Dopamine gtt was initially unsuccessful. Patient
was started on digoxin and midodrine, and was eventually able to
be temporarily weaned off dopamine with a MAP of 40-50 mmHg.
However, without pressor she was only marginally stable, and had
difficulty tolerating ambulation or hemodialysis.
OUTPATIENT ISSUES
- Started midodrine 10 mg tid
.
# Coronary artery disease
Patient had CABG and multiple PTCA. Cardiac cath at [**Location (un) **]
showed patent SVG-->OM and SVG-->PDA grafts, known occluded
LIMA, RCA and LCX and tight stenosis of Left main and LAD which
were treated with 2x DES. Chest pain and elevated troponins
likely represent demand ischemia in the setting of heart failure
and cardiogenic shock. She is not on statin due to myalgias. We
continued her full dose aspirin and plavix and held
nitrates/beta blockers secondary to hypotension. Echo showed
severe regional left ventricular systolic dysfunction with
akinesis of the septum, dyskinesis of the distal inferior wall
and apex, and severe hypokinesis of the lateral wall and an
interval decrease in EF from 45% in [**2149**] to 25-35% on this
admission.
OUTPATIENT ISSUES
- Discontinued Gemfibrozil given change of goal of care.
.
# Congestive heart failure with systolic dysfunction:
On the recent ECHO, patient had LVEF of 25-35%, a decrease from
45% in 3/[**2151**]. Improvement was observed prior to discharge after
multiple attempts of reomval of preload by dialysis and
ultrafiltration. We started digoxin during hospitalization, but
thought it will be unsafe to continue if patient will not have
hemodialysis. Patient's current blood pressure could not
tolerate beta-blockers or ACE inhibitors.
OUTPATIENT ISSUES
- Discontinued digoxin, metoprolol.
.
# ESRD
Patient has ESRD that has receives hemodialysis at [**Location (un) 77066**]with Dr. [**Last Name (STitle) 14252**] ([**Telephone/Fax (1) 77067**]) in the past. Patient
received multiple ultrafiltration and hemodialysis during this
hospitalization in an attempt to remove fluid and increase her
cardiac function. For most of the time, dopamine was needed for
successful completion of these sessions.
.
# Arterial insufficiency ulcer
Patient presented with a nonhealing ulcer at the base of left
greater toe, secondary to arterial insufficiency. She recently
underwent an angioplasty to left SFA. Workup for the ulcer
during this hospitalization include foot x-ray, arterial studies
and bone scan. No evidence of osteomyelosis was found. Patient
recent wound care including lamb's wool and Santyl for chemical
debridement. The wound was found to be stable.
.
# Goal of care
Per discussion with patient and her family, patient expressed
wish to discontinue heoric attempts of care given the prognosis
of her heart failure. Patient was seen by palliative care team,
and decide to continue hospice at as she returns home.
OUTPATIENT ISSUES
- Patient will be followed by hospice care.
.
CHRONIC ISSUES
# Depression
Patient has a documented history of depression and was on
citalopram prior to this hospitalization. We tapered citalopram
given her stable mood and potential detrimental effect from the
medication.
.
# Anemia
Patient has a documented history of anemia, macrocytic in
nature, likely secondary to chronic kidney disease. Patient has
normal levels of folate and vitamin B12.
.
TRANSITIONAL ISSUES
- Patient changed her status to DNR/DNI during this
hospitalization.
- We stopped Nephrocaps, Cinacalcet, Renagel, Metoprolol,
Citalopram, Nitrostat, Gemfibrozil given her change of the goal
of care.
- She will be discharged to home hospice and will stop receiving
HD treatments.
Medications on Admission:
-Nephrocaps 1cap qday
-Cinacalcet 30mg qday
-Colace 100mg [**Hospital1 **] PRN
-Gemfibrozil 600mg [**Hospital1 **]
-Renagel 600mg tid w meals
-Omeprazole 40mg qday
-Metoprolol 25mg [**Hospital1 **]
-Citalopram 30mg qday
-Plavix 75mg qday
-ASA 325 mg qday
-Diclofenac eye drops 0.1% in each eye [**Hospital1 **]
- Nitrostat PRN dose uncertain
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. collagenase clostridium hist. 250 unit/g Ointment Sig: [**1-16**]
Appls Topical DAILY (Daily).
Disp:*60 gram* Refills:*2*
4. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-16**]
Drops Ophthalmic PRN (as needed) as needed for dry eye.
Disp:*1 bottle* Refills:*2*
5. midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. diclofenac sodium 0.1 % Drops Sig: One (1) Ophthalmic twice
a day: Please apply one drops to each eye twice a day.
Discharge Disposition:
Home With Service
Facility:
Steward Home Care and Hospice
Discharge Diagnosis:
End stage renal disease, dialysis dependent.
PICC line placement
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You came to our hospital for evaluation of your low blood
pressure during hemodialysis. Since admission, you received
medication to increase your blood pressure at the cardiac
intensive care unit. Based on the ECHO studies you underwent,
it appeared that your cardiac function decreased significant
since [**2151-3-15**], which might be a result of heart attack, or
gradually worsening of your ongoing heart condition. As part of
the treatment, you received repeated hemodialysis and
ultrafiltration to remove fluid from your body and to facilitate
the recovery of your heart function. However, after multiple
attempts, it seemed difficult to maintain a minimal blood
pressure without giving you medication that can only be provided
in an intensive care unit. On a separate note, we also looked
at the infection in your left toe. On multiple studies,
including a bone scan, we did not find evidence of infection to
the bone, which might have required a more intensive antibiotics
treatment.
As we understand, it is your wish to go home with hospice
service, who would continue to provide comfort care for you. We
have made the following changes to your medication that would
maximize your comfort at home.
- Please START taking midodrine 5 mg two tablets orally, three
times a day.
- Please START using collagenase clostridium hist Ointment daily
to the lesion of your foot.
- Please STOP taking Nephrocaps.
- Please STOP taking Cinacalcet.
- Please STOP taking Gemfibrozil.
- Please STOP taking Renagel.
- Please STOP taking Metoprolol.
- Please STOP taking Citalopram.
- Please STOP taking Nitrostat unless absolutely necessary for
chest pain.
Most importantly, the hospice team will help you when you need
changes to your medication needs.
It has been a great privilege to provide you care during you
stay at [**Hospital1 18**]. [**Month (only) 116**] peace and happiness be with you and your
family as you return home.
Followup Instructions:
None
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**]
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,886
| 171,996
|
4055
|
Discharge summary
|
report
|
Admission Date: [**2102-2-26**] Discharge Date: [**2102-3-6**]
Date of Birth: [**2073-6-23**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 2159**]
Chief Complaint:
Syncope, chest pain, shortness of breath
Major Surgical or Invasive Procedure:
femoral line
History of Present Illness:
28 yo F on oral contraceptive pills with 10 day history of
decreased mobility secondary to right ankle sprain, PMH of
asthma, HTN, [**First Name3 (LF) 2320**], hyperlipidemia, and obesity presents with
syncope, pleuritic chest pain, and SOB. On Saturday evening
([**2-25**]), pt had syncopal event associated with diaphoresis, chest
pain, and SOB while walking to the bathroom. Apparently no fall
or head trauma. She tore a ligament in her right ankle ~10 days
ago causing decreased mobility; she has been ambulating on
crutches. She had been having right calf pain as well, but
attributed it to her ankle sprain. Otherwise, she had been in
her USOH prior to this event w/o fever, chills, or sweats.
.
Pt found by EMS with BP 90/60. Upon arrival to [**Name (NI) **], pt afebrile,
HR 143 (sinus), BP initially 126/52 with O2 sats 94% on 2L NC.
CXR unremarkable. ECG with ?S1, Q3, T3. D-dimer 5958. Right
groin femoral line was placed under sterile technique. Given
concern for PE she was started on a heparin gtt at 10 PM (9500
unit bolus and then 2200 units per hour). Bedside echo done by
cardiology fellow revealed dilated RV, RV hypokinesis, and no TR
jet. CTA revealed large bilateral PE in main pulmonary artery.
Her SBP subsequently decreased to the 70's, and she was
therefore intubated. Pt was started on TPA 100 mg over 2 hrs at
12:40AM and heparin gtt was stopped. Neo gtt was started;
Dopamine gtt was added when pt lost radial pulse and BP. She
received a total of 9 liters of fluid.
.
Upon transfer to the MICU, pt was changed from Neo and dopamine
to Levophed. Cardiology team was aware; cath lab activated,
however, it was felt thrombectomy was not indicated given
thrombolysis with subsequent hemodynamic stability. Pt with
episode of vomiting. OGT put to suction.
.
MICU Course: The pt underwent TPA, was titrated off Levophed.
She was re-started on IV heparin gtt with goal PTT 60-100. She
was extubated yesterday (Sunday) morning without difficulty,
transitioned to nasal cannula then room air. Her oxygen
saturations have been stable at 96-99%. HIT antibody was sent
as the pt had a plt drop from 275 to 147, which has returned
negative. The pt underwent bilateral LENIs, which revealed a
non-occlusive right popliteal vein thrombus. Femoral line was
removed. She has a negative HCG.
Past Medical History:
- Asthma, stress and allergen-induced, on Advair, Flonase,
albuterol prn, and Zyrtec at home. Has never required oral
steroids or been hospitalized for asthma.
- HTN, on lisinopril.
- [**Name (NI) 2320**], on metformin.
- Hyperlipidemia, on Tricor. Per pt report, total cholesterol
160, TG wnl.
- Obesity
- OCP use with Kariva for past 8-9 years w/o prior
complications.
- Recent torn right ankle ligament (10 days ago) with decreased
mobility since, on crutches.
- s/p cholecystecomy, no complications.
- s/p salpingectomy for tubal cyst, no complications.
Social History:
Denies past or present Tob, EtOH, or illicit drug use. Lives
with her husband. [**Name (NI) **] children.
Family History:
No known h/o clotting or PE. However, two sisters with h/o
bleeding problems: one s/p cholecystectomy and the other with
uterine bleeding necessitating hysterecomy. Father with [**Name2 (NI) 2320**],
s/p quadruple bypass. Mother with h/o breast CA.
Physical Exam:
Vitals: Tm: 100.6 Tc: 100.6 BP: 136/67 P: 108 RR: 19 O2sat: 96%
RA. I/O 1007/2210 -1.2L
General: Pt is an pleasant, obese, Caucasian female in NAD.
Breathing comfortably on RA.
Skin: Large ecchymoses on forearms bilaterally at sites of
PIV's.
HEENT: Sclera anicteria, conjunctiva pink. EOMi. Moist mucous
membranes. Oropharnyx erythematous secondary to ETT, no thrush
or exudates.
Neck: Supple. No JVD.
Pulm: CTAB, no rhonchi, rales, or wheezes.
Cardiac: RRR, normal S1,S2, no murmurs, rubs, or gallops.
Abd: Soft, obese, NT, ND. NABS.
Ext: Warm and well-perfused. 2+ edema in R LE, 1+ edema in L
LE. Mild calf tenderness on R, no calf tenderness on L. No
palpable cords. No clubbing or cyanosis. 2+ pedal pulses.
Neuro: Awake, alert, and oriented. No focal deficits
Pertinent Results:
Studies:
ECG: sinus tach, rate 140, borderline RAD, nl intervals,
S1,Q3,T3, no ST-T changes.
.
CXR [**2-25**]: No consolidation.
.
CTA [**2-25**]: There are large proximal filling defects present
within both the right and left main pulmonary arteries extending
into
segmental branches of the right lower lobe, right middle lobe,
left lower lobe, and left upper lobe consistent with massive
bilateral pulmonary embolism. The right upper lobe segmental
branches are poorly visualized, also possibly suggesting embolic
involvement. There are patchy peripheral opacities in both the
right and left lower lobes most consistent with atelectasis. No
pneumothorax is present. The airways appear patent to the level
of the segmental bronchi bilaterally.
.
LENI's [**2-26**]: [**Doctor Last Name **]-scale and Doppler son[**Name (NI) 1417**] demonstrate normal
compressibility, augmentation, flow, and waveforms within the
common femoral, superficial femoral veins bilaterally. A small
partially occluding clot is seen within the right popliteal
vein. The left popliteal vein is unremarkable.
IMPRESSION: Nonocclusive right popliteal vein thrombus.
.
Brief Hospital Course:
A/P: 28 yo F on oral contraceptive pills with 10 day h/o
decreased mobility secondary to ankle sprain, asthma, HTN, [**Name (NI) 2320**],
hyperlipidemia, and obesity admitted for bilateral massive
pulmonary emboli c/b hemodynamic collapse.
.
1. Bilateral massive pulmonary emboli: She had several risk
factors for developing PE, including OCP's, decreased mobility x
10 days secondary to right ankle sprain (with concomitant right
calf pain for several days), and obesity. It was complicated by
shock. She got TPA, was weaned from pressors and was
hemodynamically stable. Gt heparin Drip and coumadin for at
least three days until discharged on Coumadin. Her goal INR is
2.0-3.0. SHe will need anticoagulation for 6 months. LENI's
revealed non-occlusive right popital thrombus. She was advised
not to continue oral contraceptivs, abd that she should find
another acceptable contraceptive measure as she should ot get
pregnant while on coumadin. Her O2 sat was int he upper 90's on
dicharge and she did not require oxygen. Counseled to use
alternate contraception (OCPs held) and to avoid pregnancy while
on coumadin. Will need out patient evaluation for underlying
hypercoagulable states (in addition to those above), as this
would potentially affect long term management.
.
2. Thrombocytopenia: Hemodilution. She was HIT negative. her
platelet count returned to [**Location 213**] before discharge.
.
3. Asthma: She was continued on beclomethasone, fluticasone, and
ipratropium and albuterol MDI's.
.
4. Hypertension: Her lisinopril was restarted once she was off
pressors.
.
5. [**Location 2320**]: She was monitored with FS QID and treated with Insulin
drip in the ICU, which was switched to SC insulin. Her Metformin
was restarted prior to discharge.
.
6. Hyperlipidemia: She continued her home anti cholesterol
medication.
Medications on Admission:
- Advair 250/50 1 puff [**Hospital1 **]
- Flonase
- albuterol prn
- Zyrtec 10 mg daily
- lisinopril 20 mg daily
- metformin 500 mg [**Hospital1 **]
- Tricor 145 mg daily
- Kariva
Discharge Medications:
1. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
qd ().
Disp:*30 Tablet(s)* Refills:*2*
4. Outpatient Lab Work
Please have blood drawn and INR checked on Wendesday. Please
call results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17860**] Heuvel at [**Telephone/Fax (1) 17861**].
5. Zyrtec 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation twice a day.
Disp:*3 inh* Refills:*2*
7. Flonase 50 mcg/Actuation Aerosol, Spray Sig: Two (2) sprays
Nasal once a day.
Disp:*1 inh* Refills:*2*
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. Coumadin 2.5 mg Tablet Sig: Three (3) Tablet PO at bedtime.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. bilateral pulmonary embolism
2. right deep venous thrombosis
3. iron deficiency anemia
4. asthma
5. hyperlipidemia
6. type II diabetes mellitus
7. hypertension
Discharge Condition:
Ambulating, inr therapeutic, on room air, pain free.
Discharge Instructions:
If you experience any worsening of your symptoms, please report
to the emergency room immediately. Please take all of your
medications as directed. Please follow up with your Primary
Care physician, [**Name10 (NameIs) 788**] info below. Please make an appointment with
the Orthopedic Surgeon to have your ankle evaluated.
Please stop the oral contraceptive pills and use alternative
method of birth control until you speak with your primary care
doctor, as these medications can cause blood clots to occur.
Please call you doctor and make an appointment for the end of
the week so you can have your INR checked.
Followup Instructions:
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17860**] Heuvel. You
will need to see her the end of this week. Her office number
is: [**Telephone/Fax (1) 17861**]. You will need to have your INR checked
(outpatient lab work). Please bring the prescription to [**Hospital Ward Name 23**]
building, [**Hospital Ward Name 516**], [**Hospital1 18**] laboratory to have labs drawn.
Please call the orthopedic surgeon at ([**Telephone/Fax (1) 2007**] to make an
appointment to have your ankle evaluated.
Completed by:[**2102-3-13**]
|
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15,817
| 116,979
|
44832
|
Discharge summary
|
report
|
Admission Date: [**2178-2-20**] Discharge Date: [**2178-2-26**]
Date of Birth: [**2132-2-26**] Sex: M
Service: Cardiac Surgery
HISTORY OF PRESENT ILLNESS: This is a 45 year old gentleman
who had new onset of angina six days ago, referred for a
stress test which was positive for inferolateral ischemic
changes, referred for cardiac catheterization. On cardiac
catheterization he was found to have an ejection fraction of
60%, 70% left main lesion, 50% proximal left anterior
descending lesion, 70% diagonal lesion and 95% circumflex
lesion and 90% ramus. The patient was admitted to [**Hospital6 1760**] for cardiac surgery.
PAST MEDICAL HISTORY: 1. Hypertension; 2. Peripheral
vascular disease; 3. Status post bilateral femoral popliteal
bypass; 4. Hypercholesterolemia; 5. History of hepatitis C.
SOCIAL HISTORY: The patient was married with three children.
He smoked cigarettes, one pack per day times 25 years. He
denies alcohol. He works for the city of [**Hospital1 **] Fire
Department.
PREOPERATIVE MEDICATIONS:
1. Diovan 160 mg p.o. b.i.d.
2. Lipitor 20 mg p.o. q. day
3. Alprazolam .25 mg p.o. b.i.d. prn
4. Ultram 50 mg p.o. q.i.d. prn
5. Aspirin 325 mg p.o. q. day
ALLERGIES: No known drug allergies.
HOSPITAL COURSE: The patient was admitted to [**Hospital6 1760**] on [**2-20**] and on [**2-21**],
he was taken to the Operating Room with Dr. [**Last Name (STitle) 70**] for
coronary artery bypass graft times four, left internal
mammary artery to left anterior descending, right internal
mammary artery to right coronary artery, saphenous vein graft
to ramus and saphenous vein graft to obtuse marginal.
Immediately postoperatively, upon reversal of anesthesia, the
patient was noted to be extremely agitated and combative.
There was some concern that the patient had a history of
substance abuse. A Pain Service Consult was obtained, the
patient was started on a prosthetic infusion and Valium and
Clonidine for control of blood pressure. The patient was
subsequently weaned and extubated from mechanical ventilation
and initially required a moderate amount of pulmonary toilet
with significant hypoxia which resolved. Over the course of
postoperative day #2, the patient was weaned from his
prosthetic infusion, had good pain control with Dilaudid.
The patient continued to have moderate hypertension which was
controlled with the addition of oral medications. The
patient began ambulating in the Intensive Care Unit and on
postoperative day #4 was transferred from the Intensive Care
Unit to the regular part of the hospital. On postoperative
day #4, the patient was seen and evaluated by physical
therapy. At that time he was able to ambulate 500 feet and
climb one flight of stairs without requiring oxygen and
remaining hemodynamically stable, and on postoperative day
#5, the patient was cleared for discharge to home.
Temperature maximum 98.7, pulse 76 in sinus rhythm, blood
pressure 146/67, respiratory rate 16, room air oxygen
saturation 100%.
Laboratory data revealed white blood cell count 11.2,
hematocrit 25.4, platelet count 174. Sodium 141, potassium
4.3, chloride 103, bicarbonate 28, BUN 16, creatinine 0.8 and
glucose 95. The patient is awake, alert and oriented times
three and neurologically nonfocal. Heart: Regular rate and
rhythm without rub or murmur. Breath sounds are clear
bilaterally. Abdomen shows positive bowel sounds, soft,
nontender, nondistended. Sternal incision is clean, dry and
intact. Sternum is stable. Bilateral vein harvest site is
clean and dry. There is no erythema or drainage. Distal
extremities have 1 to 2+ pitting edema.
DISCHARGE MEDICATIONS:
1. Lopressor 75 mg p.o. b.i.d.
2. Lasix 20 mg p.o. b.i.d. times seven days
3. Potassium chloride 20 mEq p.o. b.i.d. times seven days.
4. Zantac 150 mg p.o. b.i.d.
5. Enteric coated Aspirin 325 mg p.o. q. day
6. Imdur 60 mg p.o. q. day
7. Dilaudid 2 to 6 mg p.o. q. 4-6 hours prn
8. Folate 1 mg p.o. q. day
9. Thiamine 100 mg p.o. q. day
10. Clonidine 0.1 mg p.o. b.i.d.
11. Valsartan 160 mg p.o. b.i.d.
12. Lipitor 20 mg p.o. q. day
13. Nicotine patch 21 mcg transdermally q. day times one
month.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease.
2. Status post coronary artery bypass graft.
3. Hypertension.
CONDITION ON DISCHARGE: The patient is to be discharged to
home in stable condition.
FOLLOW UP: The patient is to follow up with his primary care
physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] in one to two weeks. The patient is to
follow up with Dr. [**Last Name (STitle) 2912**] in one to two weeks. The patient
is to see Dr. [**Last Name (STitle) 70**] in five to six weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 1541**]
MEDQUIST36
D: [**2178-2-26**] 12:53
T: [**2178-2-26**] 13:25
JOB#: [**Job Number 95917**]
|
[
"272.0",
"443.9",
"305.1",
"414.01",
"411.1",
"305.90",
"401.9",
"070.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
3672, 4179
|
4200, 4294
|
1273, 3649
|
4393, 5005
|
1054, 1255
|
177, 650
|
673, 830
|
847, 1028
|
4319, 4381
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,718
| 133,741
|
10465
|
Discharge summary
|
report
|
Admission Date: [**2180-10-15**] Discharge Date: [**2180-10-22**]
Date of Birth: [**2137-5-3**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 9871**]
Chief Complaint:
SOB/Bloody pleural effusion
Major Surgical or Invasive Procedure:
[**2180-10-19**]: IVCgram
History of Present Illness:
43 F with met breast cancer, c/b brain mets, malignant pleural
effusion s/p left pleurodesis and R pleurex catheter placed
[**12-3**], liver mets, s/p plastic surgery for right chest wall
wound, presenting with bloody pleural effusion. Patient reports
that at her baseline she removes ~200 cc of pleural fluid
through the Pleurex catheter every 2 days and it is never
bloody. However, yesterday she had 250 cc and today 100 cc of
bloody fluid. No cough/hemoptysis. (+)
weakness/lightheadedness/SOB. Using O2 (4 lt) at home at
baseline. No F/C/diarrhea/constipation. Sweats a lot. (+)
nausea. (+) dry mouth, very thirsty. Reports increased LE
swelling X [**2-3**] wks, recently started on Lasix+Zaroxolyn for
that. No other complaints.
.
Currently on weekly Velban. Last chemo was last Tuesday.
.
In the [**Name (NI) **], pt afebrile, SBP in the 70s, HR 107, received 500 cc
NS, Vanc/Levoflox, hydrocortisone 100 mg IV X1, and had a CTA.
.
All: PCN
Past Medical History:
Past Medical History:
1. Breast cancer-s/p right tumor ressection and left partial
mastectomy
-dx in [**2176**] after pt discovered a golf ball sized lump in left
breast
-path: ER neg, Her2 neg, infiltrating ductal carcinoma
-s/p 4 cycles of cytoxan and adriamycin and chest radiation
-metastatic to supraclavicular nodes and liver, brain mets (XRT)
-taxotere and gemcitabine (no response to this med), back on
taxotere
-effusions bilaterally s/p left pleurodesis, s/p R Pleurex
catheter placement [**12-3**].
-pleural bx concerning for poorly diff tumor cells
-nodule in right lung, LLL consolidation, pericardial effusion,
ground glass on CT [**6-7**] all concerning for tumor spread vs
infection
-MRI [**5-22**] with no new lesions, post radiation temporal lobe
changes
-Followed by Dr [**Last Name (STitle) 2036**], Dr [**Last Name (STitle) 724**] (neuro onc)
- Currently receiving chemotherapy weekly.
.
2. GYN hx: menarch age 13, s/p tubal at age 31, G1P1
3. Pilonidal cyst
4. Fibroids s/p ablation
5. Low back pain
Social History:
Lives with husband in supportive environment, has a 13 yo son.
She does not smoke cigarettes or drink alcohol
Family History:
positive for diabetes, otherwise non-contributory
Physical Exam:
VS: 97.6, 107, 88/41, 20, 92% on 5lt NC--> 99% on 4lt NC.
General: Chronically ill appearing female, lying in bed, NAD.
AOX3
CV: RRR, nl S1S2, no m/g/r
Pulm: crackles on left base, decreased BS at right base, pleurex
catheter w/dressing
Abdomen: Mildly distended, non-tender, soft.
Extremities: +3 LE edema bilat
Pertinent Results:
Admission Labs:
.
[**2180-10-15**] 03:30PM PLT COUNT-266
[**2180-10-15**] 03:30PM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-1+
MICROCYT-3+
[**2180-10-15**] 03:30PM NEUTS-86.3* LYMPHS-8.7* MONOS-4.3 EOS-0.4
BASOS-0.3
[**2180-10-15**] 03:30PM WBC-8.1 RBC-4.22 HGB-8.5* HCT-29.2* MCV-69*
MCH-20.0* MCHC-29.0* RDW-21.8*
[**2180-10-15**] 03:30PM GLUCOSE-116* UREA N-42* CREAT-1.5*
SODIUM-128* POTASSIUM-4.8 CHLORIDE-90* TOTAL CO2-28 ANION GAP-15
[**2180-10-15**] 04:47PM LACTATE-1.8
[**2180-10-15**] 07:35PM PLEURAL WBC-100* RBC-6200* POLYS-6* LYMPHS-55*
MONOS-39*
[**2180-10-15**] 09:50PM URINE GRANULAR-[**3-4**]*
[**2180-10-15**] 09:50PM URINE RBC-0 WBC-[**6-9**]* BACTERIA-FEW YEAST-NONE
EPI-0
[**2180-10-15**] 09:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2180-10-15**] 09:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2180-10-15**] 10:45PM PT-13.4* PTT-29.6 INR(PT)-1.2
[**2180-10-15**] 10:45PM PLT COUNT-218
[**2180-10-15**] 10:45PM HYPOCHROM-3+ ANISOCYT-3+ POIKILOCY-1+
MICROCYT-3+
[**2180-10-15**] 10:45PM NEUTS-81.4* LYMPHS-11.8* MONOS-5.6 EOS-1.1
BASOS-0.3
[**2180-10-15**] 10:45PM WBC-6.4 RBC-3.82* HGB-7.8* HCT-26.1* MCV-68*
MCH-20.3* MCHC-29.8* RDW-22.4*
[**2180-10-15**] 10:45PM ALBUMIN-2.2*
[**2180-10-15**] 10:45PM UREA N-40* CREAT-1.3*
Pertinent Labs/Studies:
.
[**2180-10-16**] 05:20AM BLOOD Osmolal-272*
[**2180-10-17**] 05:39AM BLOOD Cortsol-14.4
[**2180-10-15**] 04:47PM BLOOD Lactate-1.8
.
.
Imaging:
[**2180-10-15**]: CTA Chest - 1. No pulmonary embolism. 2. Bilateral
loculated pleural effusions. 3. Progressed mediastinal
lymphadenopathy. Progressive liver metastases, and probably
osseous metastases.
.
[**2180-10-16**]: Portable Chest - Increasing interstitial pattern on
the left lung. Small apical pneumothorax associated with right
chest tube.
.
[**2180-10-17**]: Echocardiogram - The left atrium is normal in size.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
moderate pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion. There is a long (at
least 8-8 cm long) echodense structure in the IVC suggestive of
tumor or thrombus. Compared with the prior study (tape
reviewed) of [**2180-6-19**], the pericaridal effusion is now smaller.
The echodense mass in the IVC was not previously seen.
.
[**2180-10-19**]: IVC-gram - 1. Stenosis of the intrahepatic portion of
the inferior vena cava with appearances of extrinsic
compression. No filling defect in the right common iliac vein or
inferior vena cava. 2. Although, the inferior vena cava is
stenotic superiorly, there was no opacification of collateral
veins and there was free flow of contrast into the right atrium.
3. Following discussion with Dr. [**Last Name (STitle) **]. [**Last Name (LF) 2036**], [**First Name3 (LF) **] IVC filter was not
placed based on the findings of the venogram.
.
.
Pathology:
[**2180-10-15**]: Pleural FLuid - ATYPICAL. Numerous atypical lymphoid
lymphocytes. Rare mesothelial cells.
.
.
Microbiology:
Blood Cultures - [**2180-10-15**] - No growth
Urine Cultures - [**2180-10-15**] - No growth
Discharge Labs:
.
[**2180-10-21**] 07:05AM BLOOD WBC-10.7 RBC-4.29 Hgb-9.3* Hct-31.4*
MCV-73* MCH-21.6* MCHC-29.5* RDW-23.9* Plt Ct-271
[**2180-10-21**] 07:05AM BLOOD Glucose-92 UreaN-34* Creat-0.9 Na-132*
K-4.4 Cl-91* HCO3-26 AnGap-19
[**2180-10-21**] 07:05AM BLOOD ALT-14 AST-74* LD(LDH)-2296* AlkPhos-644*
TotBili-0.7
[**2180-10-21**] 07:05AM BLOOD Albumin-2.7* Calcium-7.5* Phos-3.9 Mg-2.3
Brief Hospital Course:
A/P: 43 F with met breast cancer with brain mets, bone mets with
vertebral compression fractures, malignant pleural effusion s/p
left pleurodesis and R pleurex catheter, liver mets, presenting
with SOB and bloody pleural effusion. (Patient passed away
[**2180-10-21**]).
.
#. Shortness of breath/Pleural effusion: Patient is a 43 year
old female who was originally admitted to the [**Hospital Unit Name 153**] for symptoms
of increasing shortness of breath and bloody discharge from her
pleurex catheter. The patient had a CTA on admission that
demonstrated no PE. Given increasing blood effusion, it was
thought that the patient's symptoms were most likely
attributable to local progression of her malignancy. The patient
was transfused one unit of blood with appropriate bump in
Hematocrit. A pleuracentesis was performed initially on
presentation to the ED which demonstrated predominantly a bloody
effusion (no cultures available). Despite no additional bloody
output form the catheter, the patient continued to report
ongoing shortness of breath, again unfortunately likely due to
local progression of her known malignancy. The patient was
supported with oxygen to maintain an O2 sat > 90%.
The patient had a number of plain films performed which
demonstrated increased interstitial markings, likely
representing edema vs. lymphangiectasia.
The cardiothoracic surgeon, Dr. [**Last Name (STitle) **], who placed the pleurex
catheter was contact[**Name (NI) **] to ensure the catheter was in good
position and functioning properly. Cardiothoracic team evaluated
patient and determined that the catheter was in place,
functioning properly, without any further recommendations.
Unfortunately, through the course of her admission the patient
continued to have worsening dyspnea and hypoxia. Conversation
between the patient's Oncologist and family resulted in decision
to make the patient DNR/DNI, and ultimately CMO. Aggressive
measures were not carried out and the patient was made
comfortable with morphine per her request. The patient passed
away from respiratory failure on [**2180-10-21**]. The patient's family
was present at the patient's bedside and offered support. An
autopsy was offered but declined.
.
#. Hypotension: The patient was additionally noted on admission
to be hypotensive with SBP in the 70s, which was thought to be
secondary to hypovolemia and malnutrition. This was additonally
in the setting of recent initiation of lasix and zaroxolyn for
anasarca, which were held given the patient's hypotension. The
patient did not appear to be septic as she was afebrile without
any leukocytosis, elevated lactate, or obvious source of
infection. All blood cultures throughout admission were
negative. The patient was given small boluses of fluid as
needed, but aggressive IV hydration was avoided given the
patient's gross anasarca. The patient had undergone an
echocardiogram that was first interpreted to reveal an echogenic
intrluminal mass, thought to represent thrombus. Review of the
study and ultimately a venogram revealed instead extraluminal
compression of the IVC, likely from her metastatic disease.
Given the patient's poor prognosis and rapid deteriation, as
described above, the patient was ultimately made CMO. THe
patient was no longer given fluid boluses, but made comfortable.
.
# ARF: On admission the patient demonstrated an elevated
creatine, increased from 0.5 to 1.5 after starting diuretics.
This was thought likely to represent renal failure from a
prerenal etiology and improved with volume resuscitation.
.
#. Metastatic Breast Ca: As above, the patient on admission was
known to have widely metastatic breast cancer. Given her rapid
clinical deteriation throughout her admission, it was deemed
that additional chemotherapy was not appropriate as toxicity
would far outweigh any benefit. She was made DNR/DNI, ultimately
CMO per her request, and allowed to pass with minimal to no
distress.
Medications on Admission:
Toprol XL 25 mg QHS
Decadron 4 mg QD
Prilosec 20 mg [**Hospital1 **]
colace 100 mg TID
senna 2 QHS
Ativan prn
[**Doctor First Name **]
Paxil 20 mg po qd
Oxycontin 120 mg Q12H
oxycodone 20-40 mg Q2-4H
compazine 10 mp PO q6h; prn
Gabapentin 300 mg TID
Bisacodyl 5-10 mg DAILY as needed
Ibuprofen 800 mg TID
Provigil
Lasix
Zaroxolyn
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Metastatic Breast Cancer
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
|
[
"197.2",
"198.5",
"197.7",
"518.81",
"V10.3",
"276.50",
"198.3",
"584.9",
"196.3",
"263.9",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.51"
] |
icd9pcs
|
[
[
[]
]
] |
11210, 11219
|
6861, 10801
|
301, 328
|
11287, 11297
|
2894, 2894
|
11350, 11357
|
2494, 2546
|
11181, 11187
|
11240, 11266
|
10827, 11158
|
11321, 11327
|
6459, 6838
|
2561, 2875
|
234, 263
|
356, 1305
|
2910, 6443
|
1349, 2351
|
2367, 2478
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,108
| 182,092
|
5165
|
Discharge summary
|
report
|
Admission Date: [**2126-9-29**] Discharge Date: [**2126-10-8**]
Date of Birth: [**2048-6-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
[**2126-9-25**] - Right thoracotomy, Mitral Valve Repair(28mm ring)
History of Present Illness:
78 year old male with history of previous heart surgery status
post previous CABG/Redo CABG now with a several month history of
shortness of breath. He has had known mitral valve regurgitation
over the past several years followed by serial echocardiograms.
Most recent echo shows moderate to severe mitral regurgitation.
He is admitted for surgical management of his mitral valve
disease.
Past Medical History:
Mitral Regurgitation s/p minimally invasive Mitral valve
replacement
Coronary Artery Disease s/p Coronary Artery Bypass Graft '[**99**] and
again in '[**11**] (LIMA->D1, SVG->LAD, SVG->RCA)
Peripheral [**Year (2 digits) **] Disease s/p stents to left renal artery,
bilateral iliacs, and distal aorta
Diabetes Mellitus II
Atrial Fibrillation
Hypertension
Hypercholesterolemia
Congestive Heart Failure, EF < 25%
Chronic Renal Insufficiency (baseline Cr 1.6-1.9)
Renal Artery Stenosis
Gastroesophageal Reflux Disease
Chronic Obstructive Pulmonary Disease
Benign Prostatic Hypertrophy
s/p Bilateral carotid endarterectomies
s/p Laproscopic Cholecystectomy
s/p hernia repair
Social History:
The patient lives with his wife in [**Name (NI) 1475**], MA. He is a
retired custodian. He denies tobacco or alcohol at present but
formerly smoked [**3-8**] ppd x 30 years.
Family History:
Noncontributory
Physical Exam:
NEURO: Awake and alert
HEENT: PERRL, EOMI, OP benign
HEART: RRR, + murmur. Well healed sternotomy
CHEST: Clear lungs
ABD: soft and nontender
Extermities: warm, no edema, 1+ DP/PT pulses
Pertinent Results:
[**2126-9-29**] 06:13PM PT-13.7* PTT-26.8 INR(PT)-1.3
[**2126-9-29**] 06:13PM PLT COUNT-174
[**2126-9-29**] 06:13PM WBC-4.2 RBC-3.95* HGB-11.8* HCT-36.1*# MCV-91
MCH-29.8 MCHC-32.7 RDW-18.7*
[**2126-9-29**] 06:13PM ALBUMIN-4.2 CALCIUM-8.2* PHOSPHATE-3.9
MAGNESIUM-2.3
[**2126-9-29**] 06:13PM ALT(SGPT)-48* AST(SGOT)-47* ALK PHOS-155* TOT
BILI-0.8
[**2126-9-29**] 06:13PM GLUCOSE-128* UREA N-56* CREAT-2.2* SODIUM-140
POTASSIUM-5.5* CHLORIDE-106 TOTAL CO2-24 ANION GAP-16
[**2126-9-29**] 06:39PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2126-9-29**] 06:39PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2126-10-7**] 09:30AM BLOOD WBC-8.9 RBC-3.56* Hgb-10.4* Hct-32.3*
MCV-91 MCH-29.4 MCHC-32.3 RDW-17.3* Plt Ct-176#
[**2126-10-8**] 06:55AM BLOOD PT-14.6* INR(PT)-1.5
[**2126-10-8**] 06:55AM BLOOD Glucose-110* UreaN-65* Creat-2.5* Na-138
K-4.9 Cl-104 HCO3-28 AnGap-11
[**2126-10-4**] 09:22PM BLOOD ALT-28 AST-55* LD(LDH)-336* AlkPhos-84
Amylase-97 TotBili-1.0
[**2126-10-7**] CXR
Persistent moderate loculated right pleural effusion. Improving
atelectasis in the right middle and right lower lobes.
[**2126-10-1**] EKG
Normal sinus rhythm. Intraventricular conduction delay. Probable
old inferior wall myocardial infarction. Low limb lead voltage.
Compared to the previous tracing of [**2126-9-29**] no diagnostic
interim change.
[**Last Name (NamePattern4) 4125**]ospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2126-9-29**] for elective
surgical management of his mitral valve regurgitation. He was
started on heparin as his INR was allowed to drift down for
surgery. On [**2126-10-1**], Mr. [**Known lastname **] was taken to the operating
room where he underwent a mitral valve repair utilizing a 28mm
annuloplasty ring via a right thoracotomy. Postoperatively he
was taken to the cardiac surgical intensive care unit for
monitoring. He underwent a bronchoscopy for secretions. On
postoperative day one, Mr. [**Known lastname **] [**Last Name (Titles) 5058**] neurologically intact
and was extubated. Beta blockade and aspirin were started. He
developed rapid atrial fibrillation which converted to normal
sinus rhythm with amiodarone and lopressor. On postoperative day
two, he was transferred to the step down unit for further
recovery. He was gently diuresed towards his preoperative
weight. The physical therapy service was consulted for
assistance with his postoperative strength and mobility. He had
a mild bump in his creatinine which stabilized with holding his
lasix. The endocrinology service was consulted for assistance
with his diabetes medication management and acute hypoglycemia.
As his oral intake increased to normal, he had no further
episodes of hypoglycemia on glyburide. As Mr. [**Known lastname **] continued
to have paroxysmal atrial fibrillation, coumadin was started for
anticoagulation. Mr. [**Known lastname **] continued to make steady progress
and was discharged home on postoperative day seven. He will
follow-up with Dr. [**Last Name (Prefixes) **], his cardiologist and his primary
care physician as an outpatient.
Medications on Admission:
Lipitor 8omg daily
Zetia 10mg daily
DIovan 80mg daily
Toprol XL 200mg daily
Cardura 2mg daily
Prilosec 20mg daily
Aspirin 81mg daily
Proscar 5mg daily
Glyburide 2.5mg twice daily
Lasix 40mg daily
Coumadin
Epogen
Iron
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*120 Tablet Sustained Release 24HR(s)* Refills:*2*
5. Doxazosin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. 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*
8. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
12. Glyburide 1.25 mg Tablet Sig: One (1) Tablet PO once a day:
Take once in AM, and [**1-6**] tab in PM.
Follow-up with PCP for diabetes management this week.
Disp:*45 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Mitral valve regurgitation in the setting of two previous
cardiac surgeries.
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
Check blood glucose when you wake up before breakfast, and
before you go to sleep at night, call PCP if BS<70 ir >200.
[**First Name8 (NamePattern2) **] [**Last Name (un) **]: Call Dr . [**Doctor Last Name **] for questions. Pager [**Numeric Identifier 21126**].
You should not lift more than 10 lbs for 3 months.
You should not drive for 4 weeks.
You should shower daily, let water flow over wounds, pat dry
with a towel.
Do not use creams, lotions, or powders on wounds.
Call our office for sternal drainage, temp>101.5
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) **] for one week.
Make an appointment with Dr. [**Last Name (STitle) 1290**] for 4 weeks.
Make an appointment with your caridologist to 2-3 weeks.
Completed by:[**2126-11-27**]
|
[
"600.00",
"427.31",
"272.0",
"250.00",
"424.0",
"V45.81",
"593.9",
"530.81",
"496",
"414.00",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"99.04",
"35.12"
] |
icd9pcs
|
[
[
[]
]
] |
6879, 6934
|
329, 398
|
7054, 7062
|
1955, 3394
|
7678, 7908
|
1717, 1734
|
5423, 6856
|
6955, 7033
|
5182, 5400
|
7086, 7655
|
1749, 1936
|
3445, 5156
|
282, 291
|
426, 816
|
838, 1509
|
1525, 1701
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,110
| 198,342
|
1437
|
Discharge summary
|
report
|
Admission Date: [**2171-10-24**] Discharge Date: [**2171-11-6**]
Date of Birth: [**2097-8-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2171-10-25**] Left and right heart Catheterization,coronary angiogram
[**2171-10-31**] Redo sternotomy(3rd), Mitral Valve Replacement(27mm St.
[**Male First Name (un) 923**] tissue)
History of Present Illness:
74 year old male with history of s/p CABG x2 [**2152**], s/p porcine
MVR/MAZE at [**Hospital1 18**] in [**2164**], stable small aortic aneurysm. He
presented to [**Hospital **] hospital with cough and shortness of breath
and was found to have wide open mitral regurgitaition and was
transfered to [**Hospital1 18**] for further management.
Past Medical History:
Mitral Regurgitation s/p 3rd time redo, Mitral valve replacement
Past history:
COPD/Asthma
Hypertension
Hyperlipidemia
Atrial fibrillation
PUD
Descending aortic anuerysm 2.8cm (followed by Dr. [**Last Name (STitle) **]
last seen in [**8-/2171**])
Bladder CA s/p removal of tumor [**2166**] (last seen in [**7-/2171**])
s/p coronary artery bypass
s/p redo sternotomy, mitral valve replacement
s/p redo redo sternotomy, mitral valve replacement, MAZE
Social History:
-Tobacco history: quit 20 years ago, 65 pack year history
-ETOH: occasional wine with dinner
-Illicit drugs: no reported illicit drug use
Retired UPS trailer driver (20 years), lives at home with wife.
3 children, 1 grandchild. Active lifestyle (rides bikes,
motorcycles, golfs)
Family History:
Family history is significant for a mother who died in her 60s
of cardiac causes, a father who died in his 40s of unknown
(?cancer) causes, a sister who died in her 40s from an MVC (with
known CAD) and a brother who has significant CAD
Physical Exam:
Pulse:70 Resp:23 O2 sat:97/RA
B/P Right:135/66 Left:139/68
Height:5'[**71**]" Weight:164 lbs
General: awake alert oriented
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]; well healed sternotomy
incision
Heart: RRR [x] [**3-10**] soft systolic decrescendo Murmur best at R
parasternal border with radiation to Axilla
Abdomen: Soft [x] non-distended [x] non-tender [x] + bowel
sounds
Extremities: Warm [x], well-perfused [x] no Edema []
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: very soft bruit Left: no
Pertinent Results:
[**10-24**] Cardiac Cathterization: 1. Three vessel coronary artery
disease. 2. Severe mitral regurgitation. 3. Normal ventricular
function.
.
[**10-31**] [**Month/Year (2) **]:PRE-BYPASS: The left atrium is dilated. No spontaneous
echo contrast or thrombus is seen in the body of the left atrium
or left atrial appendage. The right atrium is dilated. No atrial
septal defect is seen by 2D or color Doppler. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is mildly dilated. Regional left ventricular wall motion
is normal. Overall left ventricular systolic function is
moderately depressed (LVEF= 30-35%). The right ventricular
cavity is moderately dilated with moderate global free wall
hypokinesis. There are simple atheroma in the ascending aorta.
There are complex (>4mm) 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 are moderately thickened. There is mild aortic
valve stenosis (valve area 1.2-1.9cm2). Mild to moderate ([**1-6**]+)
aortic regurgitation is seen. A bioprosthetic mitral valve
prosthesis is present. A mitral valve annuloplasty ring is
present. There is mild valvular mitral stenosis (area
1.5-2.0cm2). Moderate to severe (3+) mitral regurgitation is
seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified
in person of the results at time of surgery.
POST-BYPASS: The patient is on a Norepinephrine drip @ 0.2
mcg/kg/min,Epinephrine drip @0.15 mcg/kg/min. The patient is s/p
27 St. [**Male First Name (un) 923**] Bioprosthetic mitral valve replacement. The valve is
well seated with no peri or paravalvular regurgitation. The
cardiac index is 2.3 with a mean gradient of 3mm hg across the
mitral valve. The LVEF is now 35% with akinesis in the
inferior/inferoseptal distribution likely from air down the RCA-
weaning from cardiopulmonary bypass.
.
[**11-6**] CXR:
Brief Hospital Course:
MEDICINE COURSE:
Mr. [**Known lastname 8520**] is a 74 year old male with known CAD s/p CABG
([**2152**]), HLD, rheumatic vavlular disease s/p MVR (porcine) at
[**Hospital1 18**] ([**2164**]), COPD, Afib s/p MAZE, AAA who presented to OSH one
week before transfer with complaints of 3 weeks of worsening SOB
and DOE and newly discovered 4+ MR [**First Name (Titles) 151**] [**Last Name (Titles) 7968**] LVEF (50%) and
global hypokinesis.
.
# SEVERE MITRAL REGUGITATION: Mr. [**Known lastname 8520**] on [**Known lastname **] was noted to
have 4+ MR [**First Name (Titles) **] [**Last Name (Titles) **]. He presented with 5 months of SOB and DOE,
worsening over the 3 weeks prior to admission with significant
change in TTE and mitral valve function. (He had a TTE in
[**Month (only) **] with 1+MR). He was transferred to [**Hospital1 18**] for
evaluation. During his hopsitilization had a LHC that
demonstrated severe MR [**First Name (Titles) **] [**Last Name (Titles) 8574**] vessels (see report above). He
was diursesed gently with 20mgIV lasix for 2 days, and
afterwards his diuresis was stopped. Cardiac Surgery was
consulted who recommended replacement of his biprosthetic valve.
His surgery was performed.
.
# COPD: Patient was diagnosed with exacerbation at OSH, and he
reported wheezing on admission to OSH. He was started on
Azithromycin, Cefppodoxime, and Solumderol at the OSH for 4 days
which was stopped on admission due to his clear lung exam and
the thought that his DOE was likely due to his severe MR.
[**Name13 (STitle) **] was continued on his home Advair, Spiriva, and given
Ipratropium and Albuterol PRN for control of COPD.
.
# HISTORY OF AFIB: AFib s/p MAZE procedure. Patient was
asymptomatic, maintained a regular rate, without any
palpitations. His home dose of Verapmil 240mg was split into
80mg Q8hrs due to the severe MR and concern for decompensation.
# CAD S/P CABG: Patient had a CABG in [**2152**] with repeat cath in
[**2164**] showing 3 [**Year (4 digits) 8574**] vessels and 1 diffusely diseased graft.
LHC on this hopitilization demonstrated [**Year (4 digits) 8574**] vessels (see
report above). He was continued on his ASA 81 qdaily, and also
continued on his home dose of lovastatin 40mg.
# Leukocytosis to 14. Patient asymptomatic, afebrile, admission
WBC of 12 with neutrophilia (pt was on steroids previously). He
had a negative urine culture, and a CXR on [**10-26**] that did not
demonstrate any cardipulm abnormality.
.
# INSOMNIA: Patient was on melatonin at home. He was given
standing trazodone QHS 25mg to help with insominia.
.
# Hypertension: Patient had elevated blood pressure on transfer
to [**Hospital1 18**]. He was started on lisinopril 2.5, and then increased
to 10mg QD, but then had systolic BP in 90's upon ambulation.
His lisinopril was [**Hospital1 7968**] to 2.5.
SURGICAL COURSE:
The patient was brought to the Operating Room on [**2171-10-31**] where
the patient underwent Redo Sternotomy (3rd time cardiac
surgery), Redo Mitral Valve Replacement (27mm St. [**Male First Name (un) 923**] Epic
tissue). Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
The patient has a long-standing history of COPD. He was
extubated, but quickly developed respiratory distress and was
re-intubated. He underwent bronchoscopy- which did not reveal
mucous plugging. He eventually was weaned from the vent and was
extubated on POD 3. Vasopressor support was weaned and the
patient remained hemodynamically stable. He had brief bursts of
AFib. Amiodarone was started. 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. ACE
Inhibitor was not resumed, as blood pressure would not tolerate
it. This should be re-addressed as an outpatient. By the time
of discharge on POD 6 the patient was ambulating, yet
deconditioned, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged to [**Location (un) 931**]
House in good condition with appropriate follow up instructions.
Medications on Admission:
MEDICATIONS (at home):
ASA 81 mg daily
Advair 1 puff [**Hospital1 **]
Verapamil SR 240 mg daily
Lovastatin 40 mg daily
Melatonin 1mg QHS
.
MEDICATIONS (on transfer):
Senna 1 tab PRN constipation
Simvastatin 10 mg QHS
Spiriva 1 puff daily
Albuterol q6 hours PRN SOB
Tramadol 50 mg q6 PRN pain
Verapamil SR 240 mg daily
Lisinopril 2.5 mg daily
Ativan 0.5 mg q8 hours PRN anxiety
Melatonin 1 mg QHS PRN insomnia
Solumedrol 40 mg TID (since [**10-18**])
Reglan 10 mg q8 hours PRN nausea/vomiting
MOM 30 cc daily PRN constipation
Omperazole 40 mg daily
Percocet 2 tabs q4 hours PRN pain
Tylenol 600 mg q4-6 hours PRN pain
Aspirin 81 mg daily
Azithromycin 250 mg daily (since [**10-18**])
Cefpodoxime 200 mg [**Hospital1 **] (since [**10-18**])
Advair 1 puff [**Hospital1 **]
Lasix 20 mg IV BID
Guaifenasen 200 mg q6 hours PRN
Mucinex 200 mg [**Hospital1 **]
Motrin 600 mg TID PRN pain
Discharge Medications:
1. lovastatin 40 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
2. melatonin 1 mg Tablet Sig: One (1) Tablet PO at bedtime.
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
7. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 1 week, then 400mg daily for 1 week, then
200mg daily .
9. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours).
10. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: Two (2) Puff Inhalation QID (4 times a day).
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain: for severe pain.
13. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
14. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
15. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
16. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
17. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
18. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 931**] House Nursing & Rehabilitation Center - [**Location (un) 932**]
Discharge Diagnosis:
Mitral Regurgitation s/p 3rd time redo, Mitral valve replacement
Past history:
COPD/Asthma
Hypertension
Hyperlipidemia
Atrial fibrillation
PUD
Descending aortic anuerysm 2.8cm (followed by Dr. [**Last Name (STitle) **]
last seen in [**8-/2171**])
Bladder CA s/p removal of tumor [**2166**] (last seen in [**7-/2171**])
s/p coronary artery bypass
s/p redo sternotomy, mitral valve replacement
s/p redo redo sternotomy, mitral valve replacement, MAZE
Discharge Condition:
Alert and oriented x3 nonfocal
Deconditioned
Incisional pain managed with Tylenol, Ultram
Incisions:
Sternal - healing well, no erythema or drainage
Edema- trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on [**12-4**] at 2PM
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**12-2**] at 11AM
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 8446**] in [**4-9**] 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:[**2171-11-6**]
|
[
"996.02",
"414.2",
"V10.51",
"E878.1",
"272.4",
"401.9",
"783.21",
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"V45.81",
"V70.7",
"416.8",
"V15.82",
"493.20",
"427.31",
"518.0",
"780.52",
"414.01",
"398.91",
"V17.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.57",
"35.23",
"37.23",
"33.24",
"33.23",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
11817, 11931
|
4687, 9056
|
295, 481
|
12423, 12587
|
2689, 4664
|
13510, 14033
|
1636, 1873
|
9986, 11794
|
11952, 12402
|
9082, 9963
|
12611, 13487
|
1888, 2670
|
236, 257
|
509, 850
|
872, 1323
|
1339, 1620
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,932
| 172,163
|
13087
|
Discharge summary
|
report
|
Admission Date: [**2161-1-31**] Discharge Date: [**2161-2-3**]
Date of Birth: [**2101-7-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4028**]
Chief Complaint:
Lightheadedness
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
This is 59 y/o M with a history of migraines, BPH, and no prior
cardiac history who presents with a new syncopal episode on day
of admission. Pt works as a basketball coach for [**University/College 40002**], and reports that he felt faint throughout yesterday
morning. He was sitting at a basketball game when he started to
feel lightheaded. He had not had much to eat all day except a
small breakfast. He ate some candy and soda with improvement of
symptoms, but when they persisted, he went out to the lobby and
asked security for help. The next thing he remembers is being
treated by EMTs. He denies any preceding headache, chest pain,
or palpitations. He denies any history of melena, hematochezia,
or hemetemesis. He has had nausea accompanying the
lightheadedness, but no vomiting. He denies fever, chills, or
abdominal pain. He regularly takes Advil 2-4 tabs daily for R
knee pain (will be having a partial TKR in [**Month (only) 547**].) He has
recently been more SOB with exertion, and has recently had to
stop doing basketball drills early. He denies weight gain, SOB
at rest, or LE edema.
.
In the ED, initial vs include T not recorded, P 78, BP 93/66, R
18, O2 sat 100%RA. Patient was given 2L NS, and transferred to
the floor. Crit was 31. CE x 3 were negative. EKG did not show
ischemic changes.
.
On the floor, pt continued to feel lightheaded and queasy. He
denies back pain, abdominal pain. His last BM was 2 days prior
and without gross blood. He continues to denies CP or SOB.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough. Denied chest pain or tightness,
palpitations. Denied vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
BPH
Migraines
Hernia surgery x 2, Meniscus surgery x 2 in R knee
Social History:
Works as a basketball coach at [**University/College 16939**]. Lives with
his wife and 3 children. Denies smoking or other drug use. Occ
ETOH.
Family History:
Mother has a history of anemia.
Physical Exam:
Vitals: T:96.7 BP:101/60 P:80 R:16 O2: 99%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, 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:
***LABS ON ADMISSION***
[**2161-1-31**] 03:20PM WBC-8.1 RBC-3.73* HGB-11.4* HCT-31.0* MCV-83
MCH-30.7 MCHC-36.9* RDW-13.4
[**2161-1-31**] 03:20PM NEUTS-76.9* LYMPHS-18.8 MONOS-3.3 EOS-0.7
BASOS-0.3
[**2161-1-31**] 03:20PM PLT COUNT-195
[**2161-1-31**] 03:20PM PT-15.0* PTT-26.1 INR(PT)-1.3*
[**2161-1-31**] 03:20PM CALCIUM-8.6 PHOSPHATE-2.2* MAGNESIUM-1.9
[**2161-1-31**] 03:20PM cTropnT-<0.01
[**2161-1-31**] 03:20PM CK-MB-5
[**2161-1-31**] 03:20PM CK(CPK)-246*
[**2161-1-31**] 03:20PM GLUCOSE-120* UREA N-53* CREAT-1.0 SODIUM-139
POTASSIUM-4.5 CHLORIDE-107 TOTAL CO2-26 ANION GAP-11
[**2161-1-31**] 03:31PM GLUCOSE-112* LACTATE-2.2* NA+-138 K+-4.3
CL--104 TCO2-25
[**2161-1-31**] 09:20PM cTropnT-<0.01
[**2161-1-31**] 09:20PM CK-MB-4
[**2161-1-31**] 09:20PM CK(CPK)-186*
***LABS DURING HOSPITAL STAY***
[**2161-2-1**] 01:30PM BLOOD WBC-7.9 RBC-2.61*# Hgb-8.0*# Hct-21.9*#
MCV-84 MCH-30.8 MCHC-36.7* RDW-13.7 Plt Ct-182
[**2161-2-1**] 03:40PM BLOOD Hct-17.1*
[**2161-2-3**] 03:25PM BLOOD Hct-29.5*
[**2161-2-3**] 07:20AM BLOOD Glucose-92 UreaN-13 Creat-0.9 Na-142
K-3.8 Cl-110* HCO3-27 AnGap-9
[**2161-2-1**] 01:30PM BLOOD ALT-15 AST-19 LD(LDH)-161 CK(CPK)-115
AlkPhos-39 TotBili-0.7
[**2161-2-1**] 01:30PM BLOOD CK-MB-4 cTropnT-<0.01
[**2161-2-1**] 01:30PM BLOOD calTIBC-230* VitB12-215* Folate-11.8
Hapto-76 Ferritn-50 TRF-177*
[**2161-1-31**] 03:31PM BLOOD Glucose-112* Lactate-2.2* Na-138 K-4.3
Cl-104 calHCO3-25
***IMAGING***
EKG [**2161-1-30**]
Sinus rhythm. No previous tracing available for comparison.
Rate PR QRS QT/QTc P QRS T
79 152 70 [**Telephone/Fax (2) 40003**] 44
CXR [**2161-1-30**]
IMPRESSION: No pneumonia.
EGD 1/
Brief Hospital Course:
Assessment and Plan: 59M with history significant for 3 months
of consistent NSAID was admitted with syncope and GI bleed,
found to have Dieulafoy lesion, was was clipped by GI, now
hemodynically stable.
.
# Upper GI Bleed: Pt has no prior history of GI bleeds or
gastritis. On admission, he was found to have a crit of 31, that
on re-check dropped to 21 then 17. On exam on the floor, pt was
guiaic negative, and had had no recent melena, hematochezia, or
hematemesis. Pt also remained hemodynamically stable as he was
assessed by GI and prepared for ICU transfer. NG lavage showed
possible coffee grounds vs. food contents, but no gross blood.
He was subsequently transferred to the ICU, where GI performed
an emergent EGD. Pt was found to have a bleed secondary to a
Dieulafoy lesion. This was clipped, and pt had no subsequent
signs or symptoms of recurrent bleed. He had no signs of
gastritis on EGD. Following stabilization, pt was transferred
back to the floor, where he remained hemodynamically stable and
asymptomatic. Crit stabilized, and was 29.5 on day of discharge.
Pt was tolerating PO solids. He will be following up with his
PCP [**Name Initial (PRE) 176**] 1 week for crit re-check.
.
# Anemia- Iron studies show a likely iron deficiency anemia with
low ferritin, b12, and tibc. He was started on ferrous sulfate
325mg po daily. He was advised to follow-up with his PCP for
further evaluation of this anemia.
.
# BPH: He was continued Tamsulosin after discharge, as he was
hemodynamically stable.
.
# FEN: PO solids were tolerated.
.
# Prophylaxis: pneumoboots given bleeding, PPI was switched to
PO and d/c'ed on discharge given no previous hx of gastritis
.
# Access: 1 16g, 1 18g, 2 20g PIVS
.
# Code: Full
.
# Communication: Patient
.
# Disposition: home today given stable crit, lightheadedness
resolved. Will f/u as outpt with PCP [**Last Name (NamePattern4) **] 1 week for crit re-check
and monitoring of anemia.
Medications on Admission:
Tamsulosin 0.4mg PO qhs
Sumatriptan 100mg PO daily PRN migraines
Discharge Medications:
1. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
2. Sumatriptan Succinate 100 mg Tablet Sig: One (1) Tablet PO
once a day as needed for migraine.
3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Dieulafoy's lesion
Anemia
Discharge Condition:
Good, hemodynamically stable, hematocrit stable at 29.5
Discharge Instructions:
You were admitted for evaluation of fainting. This required
transfer to the ICU temporarily for management, as you were
found to have rapidly dropping blood counts. You were evaluted
by GI by EGD (upper GI endoscopy) and uou were found to have a
bleeding Dieulafoy's lesion in your stomach. This was treated
by clipping. You have done well since the procedure, and your
hematocrit level has been stable, so you will be able to go home
today. Please make sure you follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
within 1 week to have a re-check of your hematocrit and discuss
your anemia.
.
The following changes were made to your medications:
1. Start Ferrous sulfate 325mg PO qday.
.
If you experience any recurrence in your lightheadedness, black
stools, bright red blood per rectum, vomiting, nausea, or have
any other concerns, please call your PCP or return to the ED.
Followup Instructions:
Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 7532**])
within 1 week to have a re-check of your hematocrit.
- Please also follow-up with your PCP regarding your anemia. You
were found to have a low ferritin level. You have been started
on daily iron supplements. Please discuss this with your doctor.
Completed by:[**2161-2-8**]
|
[
"715.36",
"285.1",
"346.90",
"537.84",
"600.00",
"E935.6",
"780.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7163, 7169
|
4755, 6698
|
330, 336
|
7238, 7296
|
3063, 4732
|
8255, 8693
|
2497, 2530
|
6813, 7140
|
7190, 7217
|
6724, 6790
|
7320, 8232
|
2545, 3044
|
275, 292
|
1881, 2232
|
364, 1863
|
2254, 2321
|
2337, 2481
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,373
| 153,287
|
30554
|
Discharge summary
|
report
|
Admission Date: [**2161-3-9**] Discharge Date: [**2161-3-17**]
Date of Birth: [**2126-1-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
left wrist aspiration
Trans-esophageal echocardiogram
PICC line placement
History of Present Illness:
History obtained from [**Name (NI) **], pt's father and records from [**Hospital 28941**]. Patient is a poor historian.
.
Mr. [**Known lastname **] is a 35 year old right handed man with a history of
hypertension and gout, who was in a GSOGH until 4 days ptp when
he developed rhinorrhea, fevers to 102, L foot pain (which the
patient attributed to gout), decreased appetite and po intake x
3-4 days. (Pt usually has a v good appetite). No sore throat or
cough. His parents thought that he had the flu. He treated his
sx with otc meds including tylenol. Parents do not report
diarrhea but OSH ED notes do, nausea or emesis. On the morning
PTP he reported strange dreams - being a pitcher in baseball
game and strange comments "I've got to rest up and go to spring
training with the Red Sox" but pt is not a baseball fan. "He
also couldn't put a sentence together and was lethargic". He had
one episode of incontinence of stool on the day prior to
presentation. Reported L shoulder pain x 2 days with difficulty
lifting it, but no headache, vomiting, or stiff neck. He was
confused -along with comments liste above he also had a change
in personality such that he was distant, much less tallkative
than at baseline the morning ptp per his parents, with whom he
lives, and was so weak that he could not come down the stairs of
his house. They didn't notice any particular focal weakness of
arms or legs but they had to give him step by step commands to
move each extremity in order to enable him to come down the
stairs. His parents called EMS and he was brought to [**Hospital3 **].
His vitals on presentation were: 121/70, HR = 68->111, RR = 18
and T = 99 -> 101 with O2 sat = 99% on RA. ECG demonstrated
sinus tachycardia in the 120's, as well as LVH. His K was 2.0.
He had an LP there that revealed (in tube 3) 170 WBC (91 PMNs 2
Lymph, 7 Mono), 18 RBC, Prot 52, and Gluc 81. Gram stain was
negative. Serum glucose at the time was 162. HSV PCR, Lyme ab
and VDRL was sent on the CSF. Other notable labs included wbc of
13 with 87% PMNs and 3.4 lymphs, sodium of 125, K of 2.6, BUN of
28, and Cr of 1.6. Lyme antibodies were sent as well and are
pending. He had a head CT there that revealed areas of
hypodensity in the right frontal lobe and in both thalami.
Prior to transfer to [**Hospital1 18**], he was given acyclovir 800 mg,
ceftriaxone, and potassium.
In the ED he was given given vancomycin 1 g, Hydrocortisone 500
mg, Acyclovir 800 mg IV, Lorazepam 2mg IV prior to MRI
.
He has no history of recent travel, no ill contacts, and no
known
history of tick bites. He has no known history of
immunosupression.
.
ROS per father Mr. [**Known lastname **]
[**Last Name (Titles) **] night sweats or recent weight loss or gain. Denied headache,
sinus tenderness, denied cough, shortness of breath. Denied
chest pain or tightness, palpitations. Denied nausea, vomiting,
diarrhea, + constipation, no abdominal pain. No dysuria. + L
shoulder pain x 2 days- new never complained of shoulder paiin
previously. Grimaces when I touch base of R toe which is red and
erythematous- first noticed 1 day ptp by father. + rash on L
hand x 2days and rash on ankles x 1 day. No h/o recent trauma,
falls, seizures or headaches.
Past Medical History:
Hypertension
Gout- first episode 1 year ago - joint not tapped per patient
s/p R arm surgery after injury sustained during opening the day
in [**2139**]
Social History:
Lives with his parents in [**Location (un) 7661**] (lives with them due to
convenience-per parents at baseline is independently
functioning). Employed in cellular phone sales- manager of cell
phone store x 6-8months- employed at the same company for 4
years. Occasional cigar q week, 1-2 beers q months at most, per
friends no recreational drug use, including no IV drug use. Not
married without children. Last travel was to [**State 108**] in
[**Month (only) **]/[**2160-3-12**]. Since then in MA/[**Location (un) 5131**]. Does not spend
much time outdoors. Practices archery in the backyard. Meets
with a group of friends who play board games q week. Completed
high school. Has taken classes at a local community college. No
pets. Aunt next door with a cat but does not visit her
regularly.
Family History:
Father had TIA's in his 50's. No migraines, seizures, learning
problems.
One brother aged 41 in good health. No nieces or nephews.
Physical Exam:
VS Tm = 103.4 in ED Tc=99.8, P = 69-112, BP = 113-150s/40-80s
117/58 RR O2Sat = 90% on RA, 95% on 4L.
GENERAL: Young, ill appearing male, with rapid shallow
breathing.
HEENT: NC/AT, PERRL, EOMI without nystagmus, + injected sclerae
without scleral icterus noted, dry MM, no lesions noted in OP
Neck: supple- no mengismus, no JVD
Pulmonary: Lungs CTA bilaterally anteriorly
Cardiac: tachy, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted.
Skin: no rashes or lesions noted.
Neurologic:
-mental status: Alert, oriented x 1. "I'm in [**Hospital1 189**]. I'm in
[**Hospital1 3597**] NH" "I haven't the faintest idea why I am at the [**Hospital1 **]"
-cranial nerves: II, III, IV, VI, X1, XII intact
-motor: normal bulk and tone throughout. No abnormal movements
noted. Strenght difficult to assess since pt could not obey
commands consistently.
-sensory: No deficits to light touch throughout.
-cerebellar: No nystagmus, dysarthria, intention or action
tremor,
-DTRs: 2+ biceps, triceps, brachioradialis, 3+ R patellar and 2+
L patellar reflexes. Plantar response was flexor bilaterally.
Pertinent Results:
[**2161-3-9**] 05:00PM WBC-14.8* RBC-4.56* HGB-13.3* HCT-38.2*
MCV-84 MCH-29.1 MCHC-34.7 RDW-14.6
[**2161-3-9**] 05:00PM NEUTS-83* BANDS-3 LYMPHS-4* MONOS-10 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2161-3-9**] 05:00PM PLT SMR-LOW PLT COUNT-105* LPLT-1+
[**2161-3-9**] 05:00PM PT-14.5* PTT-27.3 INR(PT)-1.3*
[**2161-3-9**] 05:00PM FIBRINOGE-936*
[**2161-3-9**] 05:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2161-3-9**] 05:00PM GLUCOSE-129* UREA N-28* CREAT-1.3*
SODIUM-130* POTASSIUM-3.5 CHLORIDE-96 TOTAL CO2-22 ANION GAP-16
[**2161-3-9**] 05:00PM ALT(SGPT)-69* AST(SGOT)-89* ALK PHOS-123* TOT
BILI-1.1
[**2161-3-9**] 05:00PM ALBUMIN-3.1* CALCIUM-7.7* PHOSPHATE-1.8*
MAGNESIUM-2.3
[**2161-3-9**] 05:56PM LACTATE-1.5
.
Brief Hospital Course:
35 y.o. male with htn, gout p/w altered mental status, fever,
diarrhea, uri sx x 6 days now found to have MSSA bacteremia with
MV vegetation.
MSSA endocarditis: The patient developed septic emboli to the
brain, liver and joits. He had altered mental status and
neurology was consulted. His liver enzymes were elevated but
trended down during his hospital stay. The patient also had
swollen joints and had an aspiration of his left wrist done by
orthopedics but did not require a washout in the OR. A repeat
TEE was performed which showed resolution of the vegitation but
persistent regurgitation. The patient was treated with
nafcillin and gentamycin but the gentamycin was discontinued.
ID was consulted to assist with medical managment. An MRI spine
was done but did not reveal osteomyleitis or abscess. Serial
blood cultures were negative. A PICC line was placed and the
patient was discharged on IV nafcillin.
# Altered Mental Status probably secondary to septic emboli to
brain. Neurology was consulted and followed the patient during
the hospital course. The patient's mental status and strength
improved during the hospital course. PT worked with the patient
and cleared him for home discharge.
Medications on Admission:
Atenolol 25 mg daily started 6-8 months ago
Tylenol prn for HA
No recent NSAID or abx use.
Discharge Medications:
1. Outpatient Lab Work
Please have a complete blood count (CBC), BUN, creatinine and
liver function tests (LFT's) drawn weekly. Please fax the
results to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) **].
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: One (1) 2 grams
Intravenous Q4H (every 4 hours) for 6 weeks.
Disp:*qs * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Therapies
Discharge Diagnosis:
MSSA Endocarditis with septic emboli
Discharge Condition:
Stable, afebrile, improved mental status
Discharge Instructions:
You were diagnosed with endocarditis with septic emboli. You
ahve been and will be treated with antibiotics for a long
course.
Rest, drink plenty of fluids, take all medications as
prescribed.
Call your primary care provider or return to the emergency
department for any of the following:
Fever >101.4, chills, chest pain, shortness of breath, new
weakness or changes in sensation, inability to control bowel or
bladder, seizures, worsening joint pain or swelling, nausea,
vomiting, diarrhea, abdominal pain, changes in mental status or
other concerning symptoms.
Please keep your PICC line clean and dry. If the PICC line
begins to come out, please call your primary care provider, [**Name10 (NameIs) **]
infectious disease physician or return to the emergency
department.
We changed your medications while you were in the hospital. We
discontinued the atenolol and started lisinopril for your
hypertension. Please see your primary care provider in the next
two weeks for any further adjustments in your medications.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2161-3-30**] 4:00
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2161-4-20**] 10:30
Follow up with your primary care provider Dr [**Last Name (STitle) **] in two weeks.
|
[
"041.11",
"276.1",
"711.03",
"287.5",
"276.52",
"323.81",
"421.0",
"274.9",
"401.9",
"038.10",
"276.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"81.91",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
8786, 8855
|
6926, 8142
|
324, 400
|
8936, 8979
|
6122, 6903
|
10053, 10474
|
4659, 4792
|
8283, 8763
|
8876, 8915
|
8168, 8260
|
9003, 10030
|
5681, 6103
|
4807, 5503
|
275, 286
|
428, 3652
|
5518, 5664
|
3674, 3829
|
3845, 4643
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,479
| 134,640
|
220
|
Discharge summary
|
report
|
Admission Date: [**2148-2-3**] Discharge Date: [**2148-2-7**]
Date of Birth: [**2087-6-7**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
Pedestrian struck by motor vehicle
Major Surgical or Invasive Procedure:
[**2147-2-3**]: Chest tube insertion
History of Present Illness:
60 year old female pedestrian struck at ~30 mph. Per witnesses
patient was lifted off her feet and thrown through the air. She
was alert and oriented at the scene, taken by Fire/Rescue to
[**Hospital1 18**] in stable condition. Upon arrival she was conversant and
hemodynamically stable. Due to the mechanism of her injury she
was taken to the CT scanner and underwent
Head/Neck/Chest/Abdomen/Pelvis evaluation
Past Medical History:
PMH: hyperlipidemia, BRCA1 carrier
PSH: C-section, bilateral mastectomies with implant
reconstruction, TAH, BSO
Social History:
SH:
Activity Level: community ambulator
Mobility Devices: none
Occupation:
Tobacco: denies
EtOH: denies
Family History:
N/C
Physical Exam:
On admission:
PE:
T-97 HR-60 BP-140/70 RR-16 SaO2-99% RA
A&O x 3
Agitated
RLE intact w/ large ecchymotic area about the posterior aspect
of
the thigh. Tenderness w/ log roll and ROM of both the hip and
knee. No gross deformity.
Thighs and legs are soft
No pain with passive motion
Saph Sural DPN SPN MPN LPN [**First Name9 (NamePattern2) 2189**]
[**Last Name (un) 938**] FHL GS TA PP Fire
1+ PT and DP pulses
LLE skin clean and intact
No tenderness, deformity, erythema, edema, induration or
ecchymosis
Thighs and legs are soft
No pain with passive motion
Saph Sural DPN SPN MPN LPN [**First Name9 (NamePattern2) 2189**]
[**Last Name (un) 938**] FHL GS TA PP Fire
1+ PT and DP pulses
On discharge:
Pertinent Results:
[**2148-2-3**]:
TRAUMA #3 (PORT CHEST ONLY):
IMPRESSION: Known right-sided pneumothorax seen on subsequent
chest CT is not clearly visualized on the current radiograph.
Fractures of the right
posterior 11th and 12th ribs.
CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST:
IMPRESSION:
1. Grade 3 liver laceration involving segment VII and
hemoperitoneum, without
evidence of active extravasation.
2. Small right pneumothorax.
3. 11 and 12 right rib fractures.
4. Right transverse process fractures of L2 and L3.
5. Left sacral alar and left superior pubic ramus fractures
CT C-SPINE W/O CONTRAST:
IMPRESSION:
1. No evidence of C-spine fracture or subluxation.
2. Tiny right apical pneumothorax.
3. Sclerotic focus in the right C7 pedicle. While this may
represent a bone island, please correlate with any prior history
of malignancy and consider a bone scan for further evaluation.
CT HEAD W/O CONTRAST:
IMPRESSION: No acute intracranial process
FEMUR (AP & LAT) RIGHT:
IMPRESSION: No fracture or dislocation
[**2148-2-4**]:
CHEST (PORTABLE AP):
The NG tube tip is in the stomach. Right apical pneumothorax is
noted, small unchaged since the prior CT torso (within the
limitations of comparison between different modalities). Heart
size and mediastinum are unremarkable. Bibasal atelectasis is
noted. No appreciable pleural effusion is seen. Bilateral
breast prostheses are noted.
[**2147-2-5**]:
CHEST (PORTABLE AP):
Small right apical pneumothorax is decreasing. New opacification
at the
periphery of the left lung is due at least in part to breast
prosthesis.
There could be a new small left pleural effusion or even
consolidation.
Followup advised. Normal cardiomediastinal silhouette. No right
pleural
effusion.
Brief Hospital Course:
Ms. [**Known lastname 2190**] was admitted under the acute care surgery service on
[**2148-2-3**] for further evaluation and management of her injuries.
She was initially admitted to the trauma ICU for close
monitoring given her rib fractures, and was transferred to the
floor on HD#1 as she remained stable.
Neuro: She remained alert and oriented throughout her
hospitalization. Her pain level was routinely assessed. She was
initially administered IV narcotics for pain control, and was
transitioned to an oral regimen when tolerating PO's. Prior to
discharge, she reported adequate pain control on an oral
regimen.
CV: Her vital signs were monitored routinely and she remained
afebrile and hemodynamically stable. Serial hct's were checked
given her liver lac, initially q6h on admission and then [**Hospital1 **].
They remained stable, and she remained without evidence of blood
loss.
Pulm: Given the small size of her pneumothorax, no chest tube
placement was necessary. Agressive pulmonary toileting and
incentive spirometry were encouraged. Nebulizer treatments were
administered. Her supplemental oxygen was able to be weaned.
Prior to discharge, her oxygen saturation was within normal
limits on room air. She remained without respiratory compromise.
GI: She was initially kept NPO with IV fluids for hydration and
an NG tube was placed on admission given her liver laceration.
Her hematocrit remained stable and abdominal exam remained
benign, so the NG tube was removed on [**2-4**] and she was started on
clear liquids. Her diet was slowly advanced over the next 24
hours and she was tolerating a regular diet at discharge. She
was started on a bowel regimen given her narcotic intake.
GU: A foley catheter was placed on admission. Her intake and
output were closely monitored. On [**2-5**] it was removed and she
voided without difficulty.
Musk: Orthopedics was consulted given her pelvic fractures and
lumbar transverse process fractures. These injuries were
determined to be stable requiring no surgical intervention.
Follow up in the orthopedic clinic was scheduled for 2 weeks
from discharge.
Physical therapy was consulted to evaluate her mobility, given
her injuries determined she was best suited going to rehab. The
patient was discharged to rehab in stable condition, pain
controlled on oral medication, tolerating a regular diet, and
urinating without difficulty.
Medications on Admission:
simvastatin 40mg daily, lorazepam 0.5 mg prn, multivitamins
daily
Discharge Medications:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H () as
needed for pain.
4. tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
5. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
9. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO q3h as needed for
pain.
10. ibuprofen 400 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Polytrauma: pedestrian struck
R posterior thigh hematoma
R apical pneumothorax
Grade 3 liver laceration
R 11-12th rib fx.
R L1-2 transverse fx.
L sacral alar fx.
L sup pubic ramus fx
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital after being struck by a motor
vehicle. As a result of this accident you sustained multiple
injuries as listed below.
Your multiple rib fractures can cause severe pain and
subsequently cause you to take shallow breaths because of the
pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non steroidal antiinflammatory drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ).
Followup Instructions:
Department: ORTHOPEDICS
When: THURSDAY [**2148-2-15**] at 2:40 PM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: THURSDAY [**2148-2-15**] at 3:00 PM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: THURSDAY [**2148-2-22**] at 2:30 PM
With: ACUTE CARE CLINIC/ DR. [**Last Name (STitle) 2194**]
Phone:[**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
|
[
"300.00",
"805.6",
"272.4",
"860.0",
"808.2",
"864.03",
"924.00",
"V88.01",
"276.8",
"V45.71",
"807.02",
"E814.7",
"805.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6915, 6985
|
3582, 5978
|
334, 373
|
7213, 7213
|
1831, 3559
|
8972, 10004
|
1088, 1093
|
6095, 6892
|
7006, 7192
|
6004, 6072
|
7396, 8949
|
1108, 1108
|
1812, 1812
|
260, 296
|
401, 813
|
1122, 1796
|
7228, 7372
|
835, 950
|
966, 1072
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,735
| 182,095
|
29951
|
Discharge summary
|
report
|
Admission Date: [**2121-1-15**] Discharge Date: [**2121-1-24**]
Date of Birth: [**2074-4-6**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ceftriaxone
Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
46 yo female with history of poorly controlled HIV/AIDS ([**2120-11-26**]
CD4: 3; VL: >100,000), not on HAART who presents from her
nursing home with decreased mental status. Finished cipro 500mg
[**Hospital1 **] on [**2121-1-12**]. Patient was recently admitted to [**Hospital1 18**]
[**Date range (1) 71533**] for a clogged PEG tube. Patient was recently
admitted to [**Hospital1 18**] 1/1-14-07 for UTI and ? meningitis.
.
In the ED the patient was afebrile and hemodynamically stable.
Blood glucose was off range and patient was started on an
insulin gtt. Patient given 4L NS, flagyl 500mg, levoflox 750mg.
Seen by PCP who was concerned for pancreatitis and/or
infection.
.
On arrival to the MICU patient was confused.
.
MICU COURSE:
[**1-15**]: LP overnight. broad abx and antifungals given.
[**1-16**]: RUQ ultrasound only sig. for sludge in GB. narrowed
coverage. will d/w id re haart and pelvic abscesses (seen on
CT). will d/w pcp and hcp re code status. Started on gentamycin
for better GNR coverage. GI- MRCP shows HIV cholangiopathy, will
not do ERCP. R/O for TB started per ID. d/c ambisome, acyclovir,
bactrim. Restarted on prophylactic dose of bactrim.
.
ABX:
[**1-16**]: started on gentomycin and levaquin d/c'd
ambisome d/c'd (no crypto in CSF), acyclovir d/c'd (no HSV in
CSF).
.
[**Hospital **] transferred to the floor for continued care.
Past Medical History:
HIV/AIDS: CD4 3, VL >100,000 not on HAART
- ? AIDS dementia/FTT
- PPD negative [**2120-11-3**]
- Pneumovax [**2120-10-24**]
Seizure Disorder
S/p Right MCA CVA [**2116**]
Pancytopenia
GERD
Bladder Incontinence
Social History:
The patient is a resident at [**Hospital **] [**Hospital 731**] nursing home. She is
reported to follow commands but have altered communication at
baseline.
Tobacco: Previous use, unknown
ETOH: Previous abuse, amount unknown
Illicits: None reported
Family History:
NC
Physical Exam:
VS - 95.7(ax) 108 131/85 17 100@ 3LNC
Gen - confused, agitated, patient extremely uncooperative with
exam. Flailing and contracting.
HEENT - dry MM
Neck - supple, + cervical LAD
Cor - tachy, no murmurs
Chest - clear but poor airmovement and moaning
Abd - tender to palpation, + BS, no rebound, no guarding
Ext - no edema, R heel with decub ulcer, decub on coccyx and
breakdown of skin around labia.
Neuro - L hemiparesis, unable to eval pupils because patient is
clamping eyes down. seems to be neglecting L side.
.
Pertinent Results:
Reports:
EKG: sinus tach 120 NA/NI, peaked T's V2-4 with <1mm ST elev
.
CT Chest/Abd/Pelvis:
1. Bilateral pneumonia, in a pattern suggesting aspiration.
(tree and [**Male First Name (un) 239**])
2. Multiple small abscesses in musculature of pelvis.
3. Hypoenhancing pancreatic tail, without focal fluid
collection. Evidence of background chronic pancreatitis, with
diffuse pancreatic calcifications and dilation of pancreatic
duct to 4 mm.
.
CT Head:
1. Left mastoid air cell opacification, indicating probable
mastoiditis.
2. Limited study, but no gross intracranial hemorrhage.
.
CXR: Unresolving left lower lobe/retrocardiac opacity. Given
stability of findings dating back to [**2120-11-25**], A CT
examination is recommended to rule out a postobstructive
process.
.
[**2121-1-16**] 03:03AM BLOOD calTIBC-164* VitB12-1508* Folate->20
Hapto-99 Ferritn-GREATER TH TRF-126*
[**2121-1-15**] 01:55PM BLOOD Lipase-260*
[**2121-1-16**] 02:10PM BLOOD Lipase-666* GGT-1138*
[**2121-1-21**] 08:20AM BLOOD Lipase-240* GGT-1298*
[**2121-1-15**] 01:55PM BLOOD ALT-188* AST-499* AlkPhos-1400*
Amylase-258* TotBili-0.6
[**2121-1-15**] 01:55PM BLOOD Glucose-685* UreaN-40* Creat-1.1 Na-139
K-4.7 Cl-104 HCO3-25 AnGap-15
[**2121-1-22**] 05:00AM BLOOD Glucose-221* UreaN-8 Creat-0.4 Na-141
K-3.7 Cl-114* HCO3-19* AnGap-12
[**2121-1-17**] 08:05AM BLOOD Fibrino-407* D-Dimer-2757*
[**2121-1-15**] 01:55PM BLOOD Plt Ct-166
[**2121-1-15**] 01:55PM BLOOD WBC-6.0# RBC-2.60* Hgb-9.3* Hct-27.3*
MCV-105* MCH-35.8* MCHC-34.1 RDW-17.5* Plt Ct-166
[**2121-1-22**] 05:45PM BLOOD WBC-5.7# RBC-2.04* Hgb-7.1* Hct-20.9*
MCV-102* MCH-34.6* MCHC-33.7 RDW-18.7* Plt Ct-118*
[**2121-1-16**] 12:34AM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 Polys-0
Lymphs-100 Monos-0
[**2121-1-16**] 12:34AM CEREBROSPINAL FLUID (CSF) TotProt-104*
Glucose-228
.
FINDINGS: The examination is limited due to patient motion.
There is bibasilar airspace disease which may be atelectasis or
infection. Again seen is trace pericholecystic fluid which was
seen on CT scan. There is no evidence of gallstones. There is no
intra- or extra-hepatic biliary ductal dilatation. No focal
intrahepatic lesions are demonstrated. There is no evidence of
choledocholithiasis. There is a slight strandy increased T2
signal intensity surrounding the tail of the pancreas, most
consistent with pancreatitis as seen on CT scan. No focal mass
is demonstrated, although the images are limited due to patient
motion. There is no evidence of pancreatic duct dilatation. The
adrenal glands and left kidney are unremarkable. There is a 5-mm
cyst at the interpolar region of the right kidney. There is no
lymphadenopathy. A transpyloric tube is seen which is coiled in
the duodenum as seen on CT scan.
Edema is seen within the musculature of the lower extremities
bilaterally, only partially imaged. There is normal bone marrow
signal intensity.
IMPRESSION:
1. No evidence of intra- or extra-hepatic biliary ductal
dilatation. No evidence of choledocholithiasis.
2. Trace pericholecystic fluid without evidence of gallstones or
gallbladder wall thickening or distention.
3. Findings consistent with edema in the region of the
pancreatic tail, most likely secondary to pancreatitis. The
examination is limited due to patient motion; however, no
definite pancreatic mass is demonstrated.
4. Bibasilar airspace disease, atelectasis or infection.
5. Bilateral edema within the lower extremity musculature.
Brief Hospital Course:
The patient was initially admitted to the ICU for further
workup, had multiples studies done including MRCP, CT head, LP.
Workup disclosed ?AIDS cholangiopathy and pancreatitis.
Eventually called out to floor. Family meeting held between PCP
(Dr. [**Last Name (STitle) 5762**], Dr. [**Last Name (STitle) 1299**] and Family. Decision was made to make
pt [**Name (NI) 3225**] given extremely poor prognosis. Pt expired at 16:05 on
[**1-24**]/7.
Medications on Admission:
1. Ascorbic Acid 500mg [**Hospital1 **]
2. Azithromycin 600 mg PO QThurs
3. Bisacodyl 10 mg qhs prn
4. Ciprofloxacin 500 PO Q12H 7 days (finished [**1-12**])
5. Hyoscyamine Sulfate 0.125 mg QID
6. Keppra 500mg [**Hospital1 **]
7. Magnesium Hydroxide 400mg/5mL - 30ml q6h prn
8. MVI
9. Senna 8.6mg qhs
10. Zinc Sulfate 220mg qday
11. Bactrim 80-400mg qday
12. Humalog Insulin per sliding scale
13. Jevity 1.2 goal 60cc/hr
.
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
AIDS Dementia
HIV
?AIDS cholangiopathy
AIDS Dementia
HIV
?AIDS cholangiopathy
Discharge Condition:
expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"577.0",
"263.9",
"599.0",
"486",
"276.2",
"294.10",
"614.4",
"707.07",
"345.90",
"042"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"96.6",
"03.31",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7193, 7202
|
6244, 6691
|
307, 313
|
7325, 7335
|
2789, 3235
|
7387, 7394
|
2227, 2231
|
7165, 7170
|
7223, 7304
|
6717, 7142
|
7359, 7364
|
2246, 2770
|
246, 269
|
341, 1711
|
3244, 6221
|
1733, 1944
|
1960, 2211
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,008
| 162,597
|
24618
|
Discharge summary
|
report
|
Admission Date: [**2172-4-30**] Discharge Date: [**2172-5-6**]
Date of Birth: [**2111-5-16**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Colchicine / Bactrim
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
Dyspnea.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. [**Known lastname 805**] is a 60 year old female with a history of
neurofibromatosis, COPD on 2L home O2, systolic HF 40-45%, PE,
adrenal insufficiency due to chronic steroids, who was
transferred to the MICU from the ED for management of dyspnea
and evaluation of high lactate. Of note she has been admitted 20
times just in the past year. This am she reports chest
heaviness/pressure, no radiation. Also with SOB and difficulty
expiring air. She took some nebs this morning with only a
"teeny" amount of response, and notes she usually takes nebs at
9a, noon, 3p, 6p, 9p. She thinks the exacerbating factor was a
hot shower this morning.
.
Initial vitals in the ED were T 97.7 HR 80 BP 126/72 RR 24 Sat
100% 4L Nasal Cannula. She had a leukocytosis to 13.2 with 92%
neutrophils. Her lactate trended from 3.2 to 4.0 while in the
ED, but was down to 2.8 by tranfer. Antibiotics received in the
ED includes azithromycin 250mg po once and levofloxacin 750mg iv
once. Narcotics administered in the ED included oxycodone 5mg po
once and morphine 4mg iv twice. She also recieved aspirin 325mg,
several nebulizer treatments, and solumedrol 125mg iv (of note
she is in the middle of a steroid taper, was down to 5mg daily).
EKG: TWI in 1, AVL, unchanged from previous. The morphine was
administered for chest pain that occurred at some point in the
ED, first set of troponins were negative and EKG was
unremarkable.
.
Due to difficult stick and elevated lactate, a RIJ CVL was
placed. Her lactate was then noted to go from 4.0 to 2.8 just
before admission to MICU.
.
She had a recent admission to [**Hospital1 18**] from [**2172-4-15**] to [**2172-4-17**] for
evaluation of chest pain and presyncope, which were thought to
be non-cardiac in origin -- COPD vs musculoskeletal. She was
treated for a COPD exacerbation with a steroid taper. She had
been taking prednisone 5mg daily currently. She was also treated
for c-diff, which was confirmed by pcr in a prior admission, and
she completed a course of PO Vancomycin.
Past Medical History:
1. Coronary artery disease s/p revascularization, with STEMI
[**3-19**], BMS x 2 in [**2165**], [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2, in [**2165**] and [**2170**] (RCA)
2. Congestive heart failure with LVEF 30%
3. Moderate COPD on home oxygen
4. Pulmonary embolism [**2158**]
5. Neurofibromatosis Type 1
6. Malignant nerve sheath tumor (s/p removal from left anterior
chest wall [**6-18**] and radiation [**2172**])
7. Depression
8. Hypothyroidism
9. Adrenal insuficiency [**12-18**] chronic steroid use for COPD
exacerbation
10. Hypercalcemia
11. Alcoholism per omr (patient denies current ETOH abuse)
12. Schizoaffective disorder
13. Gout
14. C. diff colitis [**1-/2172**], recurred [**3-/2172**]
Social History:
Ms. [**Known lastname 805**] lives with her boyfriend in a trailer in [**Name (NI) 3146**],
MA. Boyfriend has MR secondary to seizures. She is on
disability, used to work as a nursing aide. Is visited 2x/week
by VNA.
Tobacco: Quit smoking in past 2.5 weeks. Smoked for >30 years.
ETOH: Reports <1 drink a week.
Drugs: Denies IVDU.
Family History:
Mother/sister/nephew/son with Neurofibromatosis, Type I.
Father w/COPD.
Sister w/COPD.
Mother w/asthma.
Mother died of MI at age 72.
Father died of MI at age 86.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.3 p99-103 116/75 11 97% 2L NC
Short obese woman in no distress, conversant and speaking full
sentences without difficulty. Has obvious fleshy colored papules
covering her entire body, consistent with known NF.
EOMI, sclera clear. Eyes are squinting. Can't guage JVD
Poor air movement but no obvious crackles, wheezes or rhonchi
Almost inaudible S1/S2, likely due to habitus, no m/g
Abd obese, NT ND, benign
No BLE edema noted, extrems are warm well perfused
CN 2-12, no focal neuro deficits noted.
DISCHARGE PHYSICAL EXAM:
VS: 97.6 93 105/75 20 96% 2L NX
GENERAL: Obese woman, sitting in bed, conversant and speaking in
full sentences
NECK: No JVD appreciated, neck is supple and without LAD
RESP: Good air movement, faint inspiratory bibasilar crackles,
no wheezes or rhonchi
CARDIO: Nml S1/S2, no murmurs, rubs, or gallops appreciated
ABDOMEN: Obese, non-tender, non-distended. Normoactive bowel
sounds present.
EXTREMITIES: Mild, non-pitting upper and lower extremity edema
Skin: Flesh-colored, 0.5-1 cm nodules over entire body
(consistent with known NF-1), ecchymoses over sites of trauma
and injections on all 4 limbs.
NEURO;
Pertinent Results:
ADMISSION LABS:
[**2172-4-30**] 06:49PM [**Month/Day/Year 3143**] Glucose-127* UreaN-39* Creat-1.0 Na-141
K-5.1 Cl-101 HCO3-27 AnGap-18
[**2172-5-1**] 06:33AM [**Month/Day/Year 3143**] Calcium-8.8 Phos-3.6 Mg-2.0
[**2172-4-30**] 06:49PM [**Month/Day/Year 3143**] WBC-13.2* RBC-3.73* Hgb-11.6* Hct-34.7*
MCV-93 MCH-31.0 MCHC-33.4 RDW-18.4* Plt Ct-289
[**2172-4-30**] 06:49PM [**Month/Day/Year 3143**] ALT-49* AST-32 AlkPhos-157* TotBili-0.2
[**2172-4-30**] 06:49PM [**Month/Day/Year 3143**] Lipase-28
[**2172-4-30**] 06:49PM [**Month/Day/Year 3143**] cTropnT-<0.01
[**2172-5-1**] 03:02AM [**Month/Day/Year 3143**] cTropnT-<0.01
[**2172-5-1**] 06:33AM [**Month/Day/Year 3143**] CK-MB-3 cTropnT-<0.01
[**2172-4-30**] 06:49PM [**Month/Day/Year 3143**] pO2-169* pCO2-36 pH-7.49* calTCO2-28 Base
XS-5
[**2172-4-30**] 01:15PM [**Month/Day/Year 3143**] Lactate-3.2*
[**2172-4-30**] 06:49PM [**Month/Day/Year 3143**] Lactate-3.7*
[**2172-4-30**] 10:23PM [**Month/Day/Year 3143**] Lactate-4.0*
[**2172-5-1**] 01:57AM [**Month/Day/Year 3143**] Lactate-2.8*
[**2172-5-1**] 06:46AM [**Month/Day/Year 3143**] Lactate-4.1*
[**2172-5-1**] 05:02PM [**Month/Day/Year 3143**] Lactate-2.4*
[**2172-5-2**] 04:58AM [**Month/Day/Year 3143**] Lactate-2.0
DISCHARGE LABS:
[**2172-5-6**] 05:17AM [**Month/Day/Year 3143**] Glucose-185* UreaN-24* Creat-0.8 Na-139
K-4.4 Cl-99 HCO3-31 AnGap-13
[**2172-5-6**] 05:17AM [**Month/Day/Year 3143**] Calcium-9.2 Phos-3.1 Mg-1.9
[**2172-5-6**] 05:17AM [**Month/Day/Year 3143**] WBC-14.6* RBC-3.36* Hgb-10.5* Hct-31.7*
MCV-94 MCH-31.2 MCHC-33.1 RDW-18.4* Plt Ct-301
CXR [**2172-4-30**]:
Suspect underlying emphysema. No acute pulmonary process
identified within
limitations.
CXR [**2172-5-1**]:
In comparison with study of [**4-30**], there has been placement of a
right IJ catheter that extends to the mid-to-lower portion of
the SVC. No
evidence of pneumothorax. Bibasilar areas of opacification could
reflect
merely atelectasis and small effusions. In the appropriate
clinical setting, however, the possibility of supervening
pneumonia would have to be considered.
CXR [**2172-5-1**]:
In comparison with the study of earlier in this date, the
questioned opacification at the right base is less prominent and
may merely
represented fortuitous overlap of normal pulmonary vessels.
LENI [**2172-5-1**]:
1. No evidence of deep venous thrombosis involving the left
lower extremity.
2. Slightly dampened respiratory variation within the left
venous system,
however, this is likely due to compression from the patient's
pannus which was asymmetrically positioned overlying the left
groin.
Brief Hospital Course:
60 year-old female with a history of COPD on 2L home O2 (with
multiple recent admissions for COPD exacerbation),
neurofibromatosis, systolic HF with EF 40-45%, PE, history of
adrenal insufficiency due to chronic steroids, initially
transferred to the MICU for management of dyspnea and elevated
serum lactate, transferred to floor without intubation and O2
sat 96-98% prior to discharge with normalized lactate.
#) COPD exacerbation: Patient presented from home [**2172-4-29**] with
dyspnea with O2 sat 100% on 4L and tight, non-radiating chest
pain. Her last outpatient PFTs on [**2172-4-27**] with FEV1/FVC of 66%
and FEV1 of 41% predicted with DLCO 27%, indicating moderate to
severe disease. She was continued on oxygen via nasal canula
with stable O2 saturation 96-98% on 2-4L. She was treated with
standing Albuterol nebulizer treatments, high-dose prednisone,
and antibiotics. On HD #7, per the request of her outpatient
pulmonologists, she underwent supine and upright spirometry to
evaluate for diagphragmatic weakness given previous reduced
MIPs/MEPs, but the session was terminated prematurely due to
chest pain, later felt to be musculoskeletal. She was discharged
with the plan to continue prednisone 40 mg qday along with
albuterol, fluticasone/salmeterol and tiotropium inhalers, and
nitrofurantoin for a 5-day course (until [**2172-5-10**]). Prednisone
dosing will be re-evaluated at outpatient [**Hospital 2182**] clinic [**2172-5-7**]
and at PCP [**Name Initial (PRE) 648**] ([**2172-5-13**]). Will reschedule [**Month/Day/Year 1570**] testing as
an outpatient.
.
#) UTI: Patient treated for UTI with symptoms of polyuria and
dysuria, started on 7-day course of Levofloxacin for complicated
UTI given history of immune suppression. UTI treatment with
Levofloxacin was concurrent with treatment for COPD. Final urine
cultures returned as E. coli resistant to Levofloxacin, so
patient was started on 5-day course of Nitrofurantoin (until
[**2172-5-10**]).
.
#) Elevated Lactate: Serum lactate with high of 4 on [**2172-4-30**]
which normalized with IVF. Initial elevation was likely
secondary to dehydration. Upon presentation, ABG was not
acidotic with pH 7.49 and pCO2 36.
.
#) Low [**Date Range **] pressures: Patient with SBP in low 100s and
remained in 105-120 range with holding home lisinopril and
metoprolol. On discharge, SBP 105; not orthostatic by vitals nor
symptomatic and Hct stable. Has h/o adrenal insufficiency but
already on higher dose prednisone. We continued to hold
metoprolol and lisinopril on discharge; they should be restarted
on an outpatient basis as tolerated.
.
#) Recurrent chest pain: The patient endorsed chronic chest
"tightness." Myocardial infarction was ruled out with no EKG
changes and negative cardiac enzymes x3. Repeat EKGs at time of
pain showed no change from baseline. Given reproducible
tenderness to palpation, this was felt to be musculoskeletal v.
tightness from COPD exacerbation. She was pain-free on
discharge.
.
#) History adrenal insufficiency [**12-18**] chronic steroid use for
COPD exacerbation: Patient was begun on steroid taper with 40 mg
x3 and 20 mg x1, then dose increased to 40 mg qday given
worsening of symptoms with plan for prednisone taper. She was
continued on Atovaquone ppx and Vitamin D/Calcium
supplementation.
.
#) Coronary artery disease s/p revascularization, with STEMI
[**3-19**], BMS x 2 in [**2165**], [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2, in [**2165**] and [**2170**] (RCA): Patient
was continued on home anticoagulants, [**Year (4 digits) **] 325 mg qday,
Rosuvastatin 5 mg qday, and Clopidogrel, 75 mg qday. Home beta
blocker and ACE-I held on discharge but should be restarted as
BP tolerates.
.
#) Congestive heart failure with LVEF 40-45%. Creatinine upon
admission was elevated to 1.6 but at time of discharge was 0.8.
Lasix was continued at home dosage of 10 mg qday, and
Spironolactone was continued at 25 mg qday. Home Metoprolol and
Lisinopril were held in the setting of relative hypotension (SBP
105-120).
.
#) Hypothyroidism: Patient was currently asymptomatic and
well-controlled throughout admission, was continued on home dose
of Levothyroxine.
.
#) Recent C. diff infection: Patient has history of two recent
C. diff infections, completing PO vancomycin course [**2172-4-21**]. She
was started on PO vancomycin for prophylaxis secondary to
receiving Levofloxacin as risk factor for recurrent infection.
Discharged with plan to continue PO Vancomycin until [**2172-5-4**]
(end of 5-day course of Levofloxacin).
.
#) Ambulation: Patient is ambulatory at home, was evaluated by
PT during admission, and was found to be weak and at times have
right knee pain that limited ambulation. She states that she
fell from bed approximately 1 month ago and has had knee pain
that has not limited ambulation since she fell. Physical exam
was notable for positive right knee medial joint line tenderness
without swelling, erythema, or effusion. The patient consented
to home PT evaluation.
.
Issues for outpatient management:
1.) Determination of prednisone taper and maintenance dose
2.) [**Month/Day/Year **] pressure monitoring and restarting Metoprolol and
Lisinopril as tolerated
Medications on Admission:
1.) Calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Two (2) Tablet, Chewable PO BID (2 times a day).
2.) Atovaquone 750 mg/5 mL Suspension Sig: Ten (10) ml PO DAILY
3.) Lisinopril 5 mg PO DAILY (Daily)
4.) Furosemide 20 mg PO BID
5.) Oxycodone 5 mg Tablet PO every four (4) hours as needed for
pain.
6.) Albuterol sulfate neb Q6H prn SOB, wheezing
7.) Ferrous sulfate 300 mg (60 mg iron) PO DAILY (Daily).
8.) Loperamide 2 mg Capsule PO TID prn diarrhea
9.) Vancomycin 125 mg PO Q6H to be completed [**2172-4-21**].
10.) Gabapentin 300 mg Capsule PO q8 hr
11.) Prednisone 10 mg Tablet:
*[**Date range (1) 49148**] 3 pills (30mg total)
*[**Date range (1) 29219**] 2 pills (20mg total)
*[**Date range (1) 62161**] 1 pill (10mg total)
*[**Date range (1) 15899**] [**11-17**] pill (5mg total)
12.) Metoprolol tartrate 25 mg PO BID
Discharge Medications:
1. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
11. atovaquone 750 mg/5 mL Suspension Sig: One (1) PO DAILY
(Daily).
12. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 4 days.
[**Hospital1 **]:*16 Capsule(s)* Refills:*0*
13. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
14. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
15. furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
16. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 7 days.
[**Hospital1 **]:*14 Tablet(s)* Refills:*0*
17. nitrofurantoin monohyd/m-cryst 100 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day) for 4 days.
[**Hospital1 **]:*8 Capsule(s)* Refills:*0*
18. loperamide 2 mg Capsule Sig: One (1) Capsule PO TID:PRN.
19. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
20. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
21. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation 6am, 9am, 12pm,
3pm, 6pm qday as needed for Shortness of breath.
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Health Systems
Discharge Diagnosis:
Primary diagnosis: COPD exacerbation
Secondary diagnoses:
Urinary tract infection
Systolic heart failure exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
O2 saturation: 96-100% on 2L at rest, 91-95% with ambulation.
Discharge Instructions:
You were admitted to [**Hospital1 69**] for
shortness of breath. You were taken to the intensive care unit
for close monitoring, and then you were brought to the medicine
service. During your time here, you were treated with
antibiotics, an increased dose of steroids (prednisone), and
nebulizer medications for your breathing. You will discuss your
steroid taper at your [**Hospital 2182**] clinic appointment. You were also
diagnosed with a urinary tract infection, and treated with
antibiotics for this. You had several episodes of chest
tightness with shortness of breath, which we evaluated with
imaging of your chest (chest x-ray), and heart (EKG and
telemetry), which were negative for heart attack. You also had
imaging of your legs to look for [**Hospital **] clots (LENI), which was
negative as well. You had diarrhea, so we sent your stool to
look for C. difficile, an type of infection that you had before;
that test is still pending at the time of your discharge from
the hospital, but your diarrhea has resolved. On the last two
days of your hospital stay, your [**Hospital **] pressure was lower
running, so we held your [**Hospital **] pressure medications (Metoprolol
and Lisinopril) when you left the hospital. Because you have a
history of heart failure, we recommend that you follow up
closely with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], to
discuss these changes, as well as your increased dose of
Prednisone. To monitor your heart condition, please weigh
yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3
lbs.
The following changes were made to your medications:
1.) We STOPPED Metoprolol
2.) We STOPPED Lisinopril
3.) We INCREASED Prednisone
4.) We STARTED Nitrofurantoin (ends [**2172-5-10**]) for urinary tract
infection
5.) We STARTED Vancomycin while on nitrofurantoin (ends [**2172-5-10**])
Followup Instructions:
You have an appointment in the [**Hospital 2182**] clinic. Please discuss your
prednisone dose.
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2172-5-7**] at 1:30 PM
With: [**Name6 (MD) **] [**Name8 (MD) 611**], M.D. [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
**You will need a breathing test before this appointment. PLease
call the office for the time of your breathing test
It is important for you to follow up with your primary care
physician to review the changes made to your medications. You
have an appointment scheduled for your upcoming appointment with
Dr. [**Last Name (STitle) 48120**] [**Name (STitle) **] on [**5-13**].
Department: [**Hospital3 249**]
When: WEDNESDAY [**2172-5-13**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) 39446**], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
|
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11,148
| 185,007
|
17568
|
Discharge summary
|
report
|
Admission Date: [**2172-4-17**] Discharge Date: [**2172-5-5**]
Date of Birth: [**2098-5-23**] Sex: M
Service: Vascular Surgery
CHIEF COMPLAINT: Asymptomatic abdominal aortic aneurysm.
HISTORY OF PRESENT ILLNESS: 73-year-old white male with
history of hypertension, hypercholesterolemia, had an episode
of apparent presyncope in his PCP's office in early [**Month (only) 958**] of
this year. The patient was hospitalized and evaluated. A
large abdominal aortic aneurysm was found. CT scan of the
head and ultrasound of the carotids were negative. The
patient was seen at [**Hospital **] Hospital for AAA repair but was
deemed an extremely high surgical risk and was referred to
Dr. [**Last Name (STitle) **] for a second opinion.
The patient was seen in the office and referred to Dr. [**First Name4 (NamePattern1) 919**]
[**Last Name (NamePattern1) 911**] for cardiology clearance preoperatively. The patient
underwent a Persantine mibi study on [**2172-3-16**] which was
negative and showed an ejection fraction of 60%. The patient
was cleared for surgery.
PAST MEDICAL HISTORY:
Hypertension.
Hypercholesterolemia.
Chronic obstructive pulmonary disease.
Severe spinal stenosis with chronic low back pain.
Peripheral neuropathy.
PAST SURGICAL HISTORY:
Tonsillectomy.
Appendectomy.
Inguinal hernia repair times three.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: Patient lives with his wife. [**Name (NI) **] smokes 1??????
packs of cigarettes per day. He was unable to tolerate
Wellbutrin to help him stop smoking. He uses alcohol
socially.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Pulse 75, respirations 16, blood
pressure 85/52 on the right, blood pressure 94/59 on the
left, height 5 feet, 10 inches, weight 226 lbs. In general,
alert, cooperative, white male in no acute distress. HEENT,
sclera anicteric. Neck, range of motion within normal
limits, carotids palpable. No bruits. Chest, lungs clear
bilaterally. Heart, regular rate and rhythm without murmur.
Abdomen, obese, grossly nontender. Patient unable to lie
down in the supine position secondary to low back pain.
Extremities, mild ankle edema bilaterally. Pulse exam not
done. Neurological exam non focal. Gait cautious and
somewhat unsteady.
MEDICATIONS ON ADMISSION:
Atenolol 50 mg po q d.
Aspirin q d.
Tylenol prn.
Vitamin B.
Vitamin E.
LABORATORY DATA: On [**2172-4-9**], WBC 5.4, hemoglobin 10.8,
hematocrit 31.5, platelet count 102,000, PT 13.0, PTT 35.4,
INR 1.1, sodium 139, potassium 3.8, chloride 104, CO2 24, BUN
59, creatinine 1.7, glucose 91. Chest x-ray showed a 1 cm
nodule projecting over the left lung laterally, probable
right infrahilar bronchiectasis. EKG showed a normal sinus
rhythm at a rate of 75; a technically limited study. No
previous tracings for comparison.
HOSPITAL COURSE: The patient was admitted to the hospital
following resection of a 12 cm abdominal aortic aneurysm with
a tube graft. Surgery was complicated by intraoperative
bleeding with an estimated blood loss of 6 liters. The
patient was transfused 8 liters of blood products, 10 units
of platelets, 3 units of fresh, frozen plasma and 12 liters
of crystalloid in total. At the end of surgery patient had
palpable DP pulses bilaterally. He was treated with Kefzol
perioperatively. An epidural had been placed for pain
control. However, due to metabolic acidosis, the patient was
kept intubated. The patient did not use his epidural but
because of his coagulopathy, the catheter was continued until
his coagulopathy was treated. The patient was treated with
Vitamin K. He was transfused with platelets and fresh frozen
plasma.
Gram negative rods in the patient's sputum were cultured and
grew Serratia marcescens. The patient was treated with a 10
day course of Levofloxacin for tracheobronchitis.
Due to massive fluid repletion, the patient became volume
overloaded and was in congestive heart failure. He was then
aggressively diuresed with IV Lasix. He could not be
extubated until postoperative day #9.
While intubated, the patient was started on TPN to avoid
postoperative malnutrition. He was able to start taking sips
by mouth on postoperative day #9 following extubation. His
diet has been advanced as tolerated without difficulty.
The patient's abdominal surgical staples were removed and the
incision was Steri-Stripped. He was evaluated by physical
therapy and short term rehabilitation stay was recommended.
The patient had very specific requirements for accepting a
rehabilitation bed. On [**2172-5-5**] the patient agreed to be
transferred to [**Location (un) 582**] of [**Location (un) 620**] which was also agreeable to
his wife.
At time of dictation, patient's abdominal incision is clean,
dry and intact. He has bilaterally warm feet with palpable
BP pulses bilaterally. He will follow-up with Dr. [**Last Name (STitle) **]
after he is discharged from the short term rehab.
DISCHARGE MEDICATIONS:
Lopressor 37.5 mg po tid.
Nicotine 14 mg topically q d.
Ipratropium 4 puffs qid.
Heparin 5000 units subcu q 12 hours.
Miconazole powder 2%, one application tid prn.
Colace 100 mg po bid.
Dulcolax 10 mg po/pr q d prn.
Tylenol 325-650 mg po q 4-6 hours prn.
Percocet 1-2 tabs po q 4-6 hours prn.
Protonix 40 mg po q 12 hours.
Ambien 5-10 mg po q h.s. prn.
CONDITION ON DISCHARGE: Satisfactory.
PRIMARY DIAGNOSIS:
Asymptomatic 12 cm AAA.
AAA resection with tube graft on [**2172-4-17**].
SECONDARY DIAGNOSES:
Blood loss anemia, status post transfusion.
Coagulopathy, treated.
Thrombocytopenia.
Congestive heart failure secondary to fluid overload.
Tracheobronchitis treated with 10 day course of Levaquin.
Postoperative malnutrition treated with TPN.
Prolonged postoperative intubation secondary to volume
overload and COPD.
Hypertension.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**]
Dictated By:[**Last Name (NamePattern1) 3954**]
MEDQUIST36
D: [**2172-5-5**] 13:54
T: [**2172-5-5**] 13:56
JOB#: [**Job Number 48990**]
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4,653
| 144,894
|
24765
|
Discharge summary
|
report
|
Admission Date: [**2120-10-12**] Discharge Date: [**2120-11-14**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
tx from OSH with resp failure and left hum fracture.
Major Surgical or Invasive Procedure:
intubation x 2
History of Present Illness:
This is a pleasant 83 year-old woman with history of htn,
hypothyroidism, parox afib, hip fracture 4 years ago and s/p b/l
mastectomy for breast cancer transferred from [**Hospital3 12594**] after fracturing her left humerus on [**9-28**] s/p ORIF,
anemia-guiaic positive requiring transfusion-neg
egd-(esophagitis and gastroparesis), no colonoscopy done due to
instability, with d/c to rehab on [**10-3**], then re-admitted [**10-4**] with
resp distress, initially thought [**3-6**] pneumonia, placed on broad
spectrum abx, spiked fever on [**10-5**], ICU stay without intubation,
but [**3-6**] high o2 requirement serial CT's done and revealed
interstitial fibrosis and b/l ground glass opacities. Has been
afebrile since [**10-5**], on zosyn/vanc until [**10-11**], switched to
levoquin at that time. Because of CT findings, diff expanded to
possible amio toxicity (for afib on for years w/o previous
problems), pulm fibrosis, alv proteionisis, fat embolism and
steroids were started. Amio d/ced on [**10-10**], steroids started 9/
Now on 40 prednisone daily with plan for quick taper. Before
transfer, by report 94% on 4 liters. On arrival here, on
5liters 86-87%-->93% on non-rebreather. Not tachypneic. ABG
shows 7.48/34/64.
.
She reports no fevers over past few days, stable largely
non-productive cough. otherwise she says sob has been improving
and currently with non-rebreather she feels comfortable.
..
Concerning her humeral fracture, she continues to have
significant pain, says she was told pins had "slipped" and she
needed further repair. By report, discharge summary, shoulder
is misaligned and patient needs correction. Patient primarily
transferred for further management of shoulder.
..
She feels comfortable, has some pain in left arm which is better
after iv pain meds. No other sign complaints at this time.
Past Medical History:
hypertension
hypothyroidism
paf
?ischemic coronary disease by records (only 1 note--no details)
hip fracture 4 years ago
s/p b/l mastectomy for breast cancer, on tamoxifen.
depr/anxiety
Social History:
Former smoker-quit >20 years ago, says about [**2-4**] pack per day
for approx 20 years, very infr. alcohol, no drugs. Lives at
home, had been very functional until this humeral fracture.
Family History:
non-contributory
Physical Exam:
VS: Temp: 99.4 BP: 130 /62 HR:66 RR: 93% on
non-rebreather, desats to low-mid 80's on 5liters O2sat
general: Non-rebreather, speaks in full sentences, not
significantly tachypneic or working hard to breath, discomfort
[**3-6**] to left humeral fracture
HEENT: PERLLA, EOMI, anicteric, no scleral icterus, no sinus
tenderness, MMM, op without lesions, no supraclavicular or
cervical lymphadenopathy, no jvd, no carotid bruits, no
thyromegaly or thyroid nodules
lungs: mild inspiratory crackles at the right mid lung field,
o/w no wheezes or rhonchi, moving air well
heart: RR, S1 and S2 wnl, II/VI SEM at RUSB without radiation,
rubs or gallops appreciated
abdomen: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
extremities: no cyanosis, clubbing or edema
skin/nails: no rashes/no jaundice/no splinters
neuro: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing
on finger to nose.
rectal: deferred at this time, known guiaic positive.
Pertinent Results:
wbc 33.3 when last checked
.
IMAGING:
Chest CT [**2120-10-13**]: ground glass opacities with upper lobe
predominance, septal thickening, associated pleural effusions,
small mediastinal lymphadenopathy, dilated esophagus,
cardiomegaly
.
CTA [**2120-10-16**]:
1. Comminuted left humeral head fracture, not transfixed by the
large indwelling pins.
2. Small fracture fragments within the shoulder joint.
3. Diffuse abnormalities within the left lung worrisome for
infectious/inflammatory process. Would correlated with the
dedicated CT of the chest from [**2120-10-13**].
.
Chest CT [**2120-10-24**]:
1. Diffuse ground glass opacities with traction bronchiectasis
consistent with the diagnosis of ARDS, with associated
organizing fibrosis. Although the etiology of ARDS is uncertain,
hyperdensity of the liver raises the concern for drug reaction
from amiodarone toxicity as a potential cause of ARDS.
2. Increasing dense consolidation in the right upper lobe and
medial right lower lobe, which could represent superimposed
acute infection.
3. Increasing bilateral pleural effusions with a
moderate-to-severe right pleural effusion and a moderate
left-sided pleural effusion.
4. Increased CT attenuation of the liver could be due to
amiodarone toxicity given that the patient had been on
amiodarone.
CXR [**2120-11-12**]: Tip of the NG tube is in the stomach. Tip of the
right IJ line is at the junction of the SVC and right atrium.
Since the prior study, there has been improvement in the right
lower lobe and left perihilar opacities, although there is
persistent opacity in the lateral aspect of the left mid lung.
Most likely this represents a degree of infiltrate superimposed
on increased interstitial markings consistent with CHF.
IMPRESSION: Overall, there has been a slight improvement in the
degree of pulmonary opacities bilaterally. Underlying
interstitial process remains essentially unchanged.
Bronchial washings: Rare atypical epithelial cells, numerous
neutrophils and bacteria. No hemosiderin-laden macrophages are
seen.
ECHO [**2120-10-16**]: The left atrium is normal in size. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets are
mildly thickened. The aortic valve is not well seen. There is no
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
MICROBIOLOGY:
c diff neg x 3, toxin B: pending
VRE UTI by cx [**2120-11-7**]
[**2120-11-2**]: mod MRSA in sputum
pl fld [**2120-10-26**]: rare MRSA
BAL [**10-14**] and [**2120-10-25**]: HSV 1, 10-100K MRSA
Brief Hospital Course:
Assessment and Plan: This is an 83 year-old woman with history
of htn, hypothyroidism, paf who suffered humeral fracture on
[**9-28**] s/p ORIF at [**Hospital6 19155**] which failed. Patient
was sent to rehab [**10-3**] but returned the following day with
hypoxic respiratory failure and was then transferred to [**Hospital1 18**]
for further management. She suffered progressive respiratory
failure and was eventually made CMO and passed.
# Fever/ID: Was not spiking fevers during first week of
hospitalization at [**Hospital1 18**] while off of antibiotics. Pneumonia not
thought to be bacterial, initially.
- started acyclovir 400mg tid on [**2120-10-19**] for HSV 1 cultured
from lungs. We treated given we had no other diagnosis. Stopped
[**10-28**].
- Gave fluconazole for [**Month/Year (2) 1065**] uti (x2days =[**2034-10-19**])
- Pt extuabed [**10-21**], but had further resp distress and vomiting,
possible aspiration. Started Levaquin/Flagyl [**10-22**] and completed
14 day course.
- BAL showed GPC in pairs, started vanco [**10-26**] and completed 14
day course.
- wbc back on the rise prior to being made CMO, cx remain NGTD -
? new PNA vs C diff (toxin B pending)
.
..
# Resp failure: Initial CXRs upon admission to the OSH were
unremarkable, so this process is acute. CT w/ground glass
opacity. Pt was intubated [**10-14**] for bronch and kept intubated for
ARDS. Pt placed on ARDSnet settings then entered in ARDS study.
Per path, hemosiderin and fat laden macrophages have ddx =
alveolar hemorrhage; Wegeners; GBM, also can be fat emboli.
- s/p bronch [**10-14**] with BAL to r/o PCP, [**Name10 (NameIs) 1065**] PNA. [**2-4**] has HSV=I
- Tapered steroids that were started at OSH for ?eosinopholic
pna, off after [**10-21**]. steroids (methylpred 40qd) restarted [**10-22**]
given decompensation.
- extubated [**10-21**] but not doing well on 100% face mask,
decompensation due to derecruitment. CXR consistent with
aspiration vs derecruitment. levo/flagyl started empirically
[**10-21**].
- Chest CT showed worsening of parenchyma but also bilateral
effusions. Pt was aggressively diuresed.
- Reintubated [**10-25**] for worsening sats. Sats in low 90's despite
100% fio2. Second bronch performed but cx negative. Chest tube
placed 9/23-4 overnight for pneumo post bronch or due to
coughing against tube. Sats 100% with 40% fio2.
- PTX resolved and CT d/c
- subsequent sputum cx grew out MRSA, patient tx w/ course of
vancomycin and was again ready for extubation
- d/w patient and family led to decision to change code status
to DNR/DNI
- following extubation, patient again began to fail, presumably
due to CHF and likely aspiration
- d/w family and patient led to decision to change plan of care
to CMO
- patient started on morphine gtt and was stable o/n off lasix
gtt w/ permissive po's
- in the AM, family requested d/c 100% NRB and patient expired
w/in approximately 15 minutes from respiratory arrest
.
# Humeral fracture: Humeral head shattered, rods floating freely
in rotator cuff. Ortho consulted. Plan was for OR repair [**2-4**]
weeks following pulmonary recovery.
.
# Diarrhea: C diff neg x 3. Toxin B pending. Possibly related to
antibx or catharsis from gib. Continue to follow.
.
# CV:
a) ischemia: no clear h/o ischemic disease. On aspirin 81mg,
will continue this / hold beta-blocker given relative
bradycardia. Not on statin, will need better records
.
b) pump: unclear history, otherwise initially appeared euvolemic
to dry, chf possible contribution to hypoxia, ground glass
opacities and positive proBNP. Developed fluid overload in
setting of possible ARF.
- on norvasc, holding for hypotension.
.
c) rhythm: h/o paroxysmal AF, not currenly on anti-coag given
recent guiac positive stools with HCT drop at OSH. Will hold
anti-coag now.
.
# Anemia:
- OSH EGD [**10-1**] showed esophagitis
- PPI increased to [**Hospital1 **] when patient developed black stools
- colonoscopy deferred given respiratory status and relatively
stable hct
- patient continued to have guiac positive and occasionally
black stools and was supported w/ transfusions until made CMO
.
# transaminitis: mild, possibly med related, resolved.
.
# depression/anxiety: continue paxil (dose decreased while on
linezolid to decrease r/o serotonin syndrome)
# h/o breast cancer: continue tamoxifen
# hypothyrodism: continue synthroid.
.
# Thrombotic prophylaxis: Patient should be on coumadin for
afib, lovenox for fracture but given concern for GI bleeding,
unstable crits at OSH, thus, these medications were held. SQ
heparin was administered.
.
# Code:full -> DNR/DNI -> CMO
# Access: right subclavian TLC ([**10-18**]), right DP a-line
([**2033-10-16**]), right fem a-line [**10-25**] (could not place in either arm
or left foot)
.
# Comm: spokesperson [**Name (NI) 16883**] (daughter), In addition, family
discussions included all 3 of patient's daughters
Medications on Admission:
Medications: on transfer: prednisone 40, atrovent nebs, levaquin
250, zofran protonix40,, colace, senna, caltrate, vitamin D,
aspirin 81, vicodin, mvi, levoxyl, paxil 20, norvasc 5,
tamoxifen 20.
--On amio until [**10-11**]
--on vanc/zosyn until [**10-11**]
--on lovenox until [**10-10**]
Discharge Medications:
none, patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
MRSA pneumonia
aspiration pneumonitis
GI bleed
left humeral fracture
Discharge Condition:
patient expired
Discharge Instructions:
none, patient expired
Followup Instructions:
none, patient expired
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
|
[
"812.21",
"427.31",
"E932.0",
"512.8",
"584.9",
"V09.0",
"458.29",
"401.9",
"578.9",
"311",
"507.0",
"518.81",
"515",
"428.0",
"482.41",
"996.40",
"V66.7",
"244.9",
"E888.9",
"999.9",
"599.0",
"V10.3",
"280.0",
"288.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"99.04",
"96.72",
"33.24",
"96.04",
"97.41",
"34.04",
"96.6",
"38.93",
"33.22",
"00.14"
] |
icd9pcs
|
[
[
[]
]
] |
11853, 11862
|
6592, 11467
|
316, 332
|
11974, 11991
|
3703, 6569
|
12061, 12176
|
2631, 2649
|
11807, 11830
|
11883, 11953
|
11493, 11784
|
12015, 12038
|
2664, 3684
|
224, 278
|
360, 2200
|
2222, 2410
|
2426, 2615
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,885
| 100,074
|
1608
|
Discharge summary
|
report
|
Admission Date: [**2176-4-9**] Discharge Date: [**2176-4-12**]
Date of Birth: [**2121-4-8**] Sex: F
Service: SURGERY
Allergies:
Ovral-21 / Codeine / Sulfonamides
Attending:[**Doctor First Name 5188**]
Chief Complaint:
bruising and some mild abdominal pain
Major Surgical or Invasive Procedure:
Exploratory laparotomy, debridement of abdominal
wall, small and large bowel resection, and closure over a
[**Location (un) 5701**] bag.
Exploratory laparotomy.
History of Present Illness:
INDICATIONS FOR SURGERY: This is a 55-year-old woman who
noted some bruising and some mild abdominal pain over a large
incisional hernia site. She came to the emergency room where
she developed profound sepsis and a CT scan which showed
intraperitoneal air. She also was found to have crepitance
and expanding hematoma or bruising over her incisional
hernia.
The patient was taken emergently to the operating room.
Past Medical History:
s/p MVC ('[**61**]), s/p R AKA, ventral hernia repair w/ component
seperation ('[**66**]), anxiety
Social History:
Mother and son are the patient's support system
Family History:
noncontributory
Physical Exam:
gen: Intubated, secated
CV: +s1s2
Pulm: coarse BS diffusely
Abd: large [**Location (un) 5701**] bag in place
Ext: + edema
Pertinent Results:
[**4-9**] CT: 1. Large ventral abdominal wall hernia with two discrete
defects. The more inferior hernia defect (smaller defect)
contains several loops of necrotic- appearing bowel with
evidence of pneumatosis and possible perforation, suggesting
strangulated ventral hernia. Large amount of subcutaneous free
air within the ventral hernia sac inferiorly which tracks
retroperitoneally and into the mesentery, for which necrotizing
fascitis should be considered.
2. Likely aspiration at the lung bases, worse on the right side.
[**4-10**] Pathology: I) Ventral hernial sac (A-B):
Hernial sac with acute inflammation and serositis.
II) Abdominal wall (C-D):
Skin and subcutaneous tissue with extensive necrosis and abscess
formation.
III: Distal ileum and ascending colon, resection (E-L):
Extensive hemorrhagic necrosis and transmural infarction of the
small and large intestine:
a. Transmural necrosis is present at the proximal (ileal)
resection margin.
b. Viable distal (colonic) resection margin with serositis;
acute inflammation focally extends into the subserosa and
muscularis.
[**2176-4-9**] 06:00PM BLOOD WBC-19.2* RBC-3.46* Hgb-11.0*# Hct-33.3*
MCV-96 MCH-31.6 MCHC-32.9 RDW-13.5 Plt Ct-163
[**2176-4-11**] 02:39AM BLOOD WBC-63.3*# RBC-2.66* Hgb-8.0* Hct-25.5*
MCV-96 MCH-30.2 MCHC-31.4 RDW-17.1* Plt Ct-47*#
[**2176-4-11**] 08:09PM BLOOD WBC-50.3* RBC-3.14* Hgb-9.5* Hct-27.5*
MCV-88 MCH-30.1 MCHC-34.4 RDW-18.5* Plt Ct-25*
[**2176-4-9**] 06:00PM BLOOD Neuts-65 Bands-12* Lymphs-6* Monos-10
Eos-1 Baso-1 Atyps-0 Metas-2* Myelos-3*
[**2176-4-10**] 01:40AM BLOOD Neuts-79* Bands-3 Lymphs-11* Monos-0
Eos-0 Baso-0 Atyps-0 Metas-6* Myelos-1*
[**2176-4-9**] 06:00PM BLOOD ALT-62* AST-212* LD(LDH)-359*
AlkPhos-139* Amylase-17 TotBili-3.8*
[**2176-4-10**] 09:50AM BLOOD ALT-33 AST-98* LD(LDH)-245 AlkPhos-94
Amylase-42 TotBili-6.4*
[**2176-4-11**] 08:12AM BLOOD ALT-88* AST-406* AlkPhos-158* Amylase-27
TotBili-7.4*
[**2176-4-12**] 03:09AM BLOOD ALT-160* AST-576* AlkPhos-297*
TotBili-8.1*
[**2176-4-9**] 06:00PM BLOOD Lipase-22
[**2176-4-10**] 09:50AM BLOOD Lipase-63*
[**2176-4-11**] 08:12AM BLOOD Lipase-17
[**2176-4-11**] 03:54PM BLOOD Cortsol-30.6*
[**2176-4-11**] 03:54PM BLOOD Cortsol-34.2*
[**2176-4-9**] 06:06PM BLOOD Lactate-3.2* K-3.6
[**2176-4-10**] 10:03AM BLOOD Glucose-78 Lactate-4.3* Na-126* K-3.9
Cl-102
[**2176-4-11**] 02:51AM BLOOD Glucose-93 Lactate-5.9* Na-124* K-4.3
Cl-109
[**2176-4-11**] 11:46AM BLOOD Lactate-7.7*
[**2176-4-12**] 06:11AM BLOOD Glucose-146* Lactate-5.1* K-3.7
Brief Hospital Course:
The patient was admitted, and underwent the aforementioned
surgical procedures; for details, please see operative notes.
The patient returned to the SICU intubated and sedated for
further care. On [**4-12**], her family decided to make the patient CMO
after two exploratory laparotomies.
Neuro: The patient was sedated and received paralytics at times
to keep her comfortable while ventilated. She received pain
medications IV when appropriate.
CV: The patient's vital signs were routinely monitored, and was
put on vasopressin, norepinephrine and epinephrine during her
stay to maintain appropriate hemodynamics.
Pulmonary: Vital signs were routinely monitored. She was
intubated and sedated throughout her admission, and her
ventilation settings were adjusted based on ABG values. Serial
chest x-rays were performed.
A bronchoscopy was performed on [**4-10**], with aspiration of feculant
material from the right bronchus intermedius, blood clot
adherent to left main bronchus.
GI/GU/FEN:
Post operatively, the patient was made NPO with IVF. She was
unable to be extubated and did not receive any nutrition. On
[**4-12**], the patient was made CMO.
The patient's intake and output were closely monitored, and IVF
were adjusted when necessary. The patient's electrolytes were
routinely followed during this hospitalization, and repleted
when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. Her white blood count
continued to rise throughout her admission; for trends, please
see results section. The patient was in septic shock with
multiorgan failure. She was on vancomycin, fluconazole and
Zosyn during her stay, and culture data was routinely monitored.
Endocrine: The patient's blood sugar was monitored throughout
this stay; insulin dosing was adjusted accordingly, and she was
put on a drip when necessary.
She received cosyntropin for a cortisol stimulation test.
Hematology: The patient's complete blood count was examined
routinely; multiple (over 6 units) transfusions were required
during this stay.
Prophylaxis: The patient received subcutaneous heparin during
this stay.
The patient was made CMO on [**4-12**], after which she passed away.
Medications on Admission:
serax 15''', amitryptiline
Discharge Disposition:
Expired
Discharge Diagnosis:
Perforated viscus, dead bowel, and
deep tissue infection.
Discharge Condition:
deceased
Discharge Instructions:
none
Followup Instructions:
none
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**]
|
[
"557.0",
"995.92",
"799.89",
"785.52",
"571.5",
"038.9",
"518.81",
"070.54",
"552.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.12",
"33.24",
"45.62",
"45.79",
"38.93",
"54.3"
] |
icd9pcs
|
[
[
[]
]
] |
6197, 6206
|
3869, 6119
|
330, 494
|
6308, 6318
|
1317, 3846
|
6371, 6485
|
1143, 1160
|
6227, 6287
|
6146, 6174
|
6342, 6348
|
1175, 1298
|
253, 292
|
522, 940
|
962, 1062
|
1078, 1127
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,853
| 104,495
|
34539
|
Discharge summary
|
report
|
Admission Date: [**2187-8-7**] Discharge Date: [**2187-8-14**]
Date of Birth: [**2121-6-12**] Sex: F
Service: NEUROSURGERY
Allergies:
Latex
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
Evacuation of a postoperative wound hematoma.
History of Present Illness:
66 yo female who presents with a deterioration of function
since a recent discharge from [**Hospital1 18**]. Patient was admitted from
[**2187-7-22**] to [**2187-7-31**] for new onset numbness from breast level to
feet, urinary retention, and fecal incontinence. Patient has a
longstanding history of metastatic melanoma and imaging showed a
lesion at T4-T5. Palliative surgery was conducted to decompress
these lesions. Postop course included some improvement of
function. On discharge, the patient continued to have left lower
extremity paralysis but had sensation and her right leg was 4 to
4/5 strength. Since that time, she was able to bend her right
leg
at the knee, and to wiggle her left foot on her bed. About a
week ago, she experienced some changes in pain in her middle
back.
In rehab, it was determined that the patient had a elevated WBC
to the 42, and a positive UA. She was started on PO vancomycin,
and levoquin. She was transferred to [**Hospital1 18**].
Past Medical History:
1. Spina bifida
2. melanoma (left forearm) - with metastatic involvement in [**5-3**] - refused treatment initially
3. Chronic tinnitis
Social History:
Lives with husband, retired translator. Non smoker.
Family History:
Non-contributory
Physical Exam:
O: T: 97.2 BP: 141/64/ HR: 94 R 16 O2Sats 99%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 4-2mm EOMs intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T FE FF IP Q AT [**Last Name (un) 938**] G
R 5 5 5 wiggles foot
L 5 5 5 uable to move foot
Sensation: Not intact to light touch on legs, no propioception
of
bilateral great toes, vibration bilaterally.
Reflexes: B T Br Pa Ac
Right 2+ -
Left 2+ -
Toes upgoing bilaterally
CT/MRI:
Pertinent Results:
[**2187-8-13**] 05:45AM BLOOD WBC-13.5* RBC-3.96* Hgb-11.8* Hct-35.1*
MCV-89 MCH-29.7 MCHC-33.5 RDW-14.8 Plt Ct-223
[**2187-8-7**] 05:20PM BLOOD Neuts-92* Bands-1 Lymphs-3* Monos-4 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2187-8-7**] 05:20PM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
[**2187-8-13**] 05:45AM BLOOD Plt Ct-223
[**2187-8-8**] 01:34PM BLOOD Fibrino-281
[**2187-8-8**] 07:47PM BLOOD FacVIII-214*
[**2187-8-8**] 07:47PM BLOOD VWF AG-185* VWF CoF-276*
[**2187-8-13**] 05:45AM BLOOD UreaN-18 Creat-0.6 Na-130* K-3.8 Cl-97
HCO3-26 AnGap-11
[**2187-8-13**] 05:45AM BLOOD Calcium-8.3* Phos-2.7 Mg-2.0
Brief Hospital Course:
Mrs [**Known lastname **] is a 66 yo woman with a h/o cutaneous melanoma on
forearm (excised [**12-2**]) and spina bifida who initially
presented 3 weeks ago ([**7-22**]) with a complaint of 4 days of
increasing lower extremity weakness and numbness and fecal and
urinary
incontinence. She initially presented to an OSH and MRI was
performed, showing an intermedullary cord lesion. She was
transferred to the [**Hospital1 **], and CT demonstrated diffuse metastatic
disease from malignant melanoma including lungs, mediastinum,
gallbladder, liver, left ureter with moderate
hydronephrosis,cervix with uterine obstruction and ischiorectal
fossa. A thoracic MRI done at [**Hospital1 18**] demonstrated 2 enhancing
spinal masses most likely metastasis with leptomeningeal
involvement- 1
intramedullary mass posterior to the T3-T4 disc space measuring
2
cm, and a second small possible intradural metastasis just
posterior to L2. There was associated spinal cord edema. On
[**7-25**] whe underwent laminectomy at T3-T4 and resection of an
intradural intramedullary tumor to improve her neurological
symptoms. She was discharged to rehabilation [**7-31**]. In rehab, on
[**8-4**], she began to feel a very painful 'a lump' in her upper
back at the site of her surgical excision. The pain was diffuse
throughout her upper back, but did not radiate elsewhere.
It was significantly worse with pressure, almost unbearable. It
continued to worsen, and on [**8-5**] she states that she was 'in and
out of consciousness'. Labs from the rehab facililty indicated
that she had an elevated WBC to 42, and a positive UA. She was
started on PO vancomycin 125 mg q6h and levoquin 500 mg qday.
She was transferred to [**Hospital1 18**]. On admission, her hct was 18.9 and
CT chest showed a large hematoma the right posterior back
measuring 18 cm x 4.9 cm x 25 cm, and a new R pleural effusion.
She was transfused five units PRBC and two units FFP, and Hct
increased to 29%. She was taken to the OR on [**8-8**] and the
hematoma was evacuated and washed out, using the old incision.
She remained in the ICU for 2 days she had some slow improvement
of her right leg and no change (plegic in left leg)A hematology
consult was obtained for cause of her hematoma and bleeding
during surgery they felt it would be unlikely for her to have a
primary factor deficiency or [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) 4516**] disease and not to
have had prior
bleeding problems. [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) 4516**] disease and more rarely
FXIII deficiciency, however, can occur in the setting of normal
coagulation studies. She may have acquired platelet dysfunction,
and vancomycin is known to cause platelet dysfuction. Regarding
her systemic disease they felt her malignant melanoma was so
advanced that she unfornately she did not qualify for any type
of treatment.
From an ID perspective she was only treated for 7 days with
Cipro other antibiotic were dc'd. She developed anal ulcers from
diahrrea. The left aspect has a full thickness ulcer approx. 2 x
3 cm, right aspect has a full thickness ulcer approx. 1.5 x 1
cm-each site has yellow brown tissue with irregular wound edges.
The periwound tissue is erythemic extending posteriorly along
the intergluteal cleft where the epidermis is denuded. Our wound
care specialist recommended: Keep perianal tissue clean and dry.
Check patient every 1-2 hours for fecal incontinence.
Cleanse perianal tissue with Foam cleanser and disposable
washcloths wet with warm water. Pat the tissue dry (Please no
facecloths or towels and no
rubbing of the tissue) Apply a thin layer of Critic Aid Clear
Moisture Barrier Ointment to the perianal tissue, covering the
ulcers and extending posteriorly along the intergluteal tissue
daily and prn or every 3rd cleansing.
Neurologically she has some antigravity movement on her right
leg 3-4/5 strength. She has no movement of her left leg. She has
normal strength in his arms. Her incision is dry and clean. She
is eating a regular diet. A foley is in place due to the anal
ulcers. She will go to rehab and return to the brain tumor
clinic for radiation planning on [**9-3**].
Medications on Admission:
Bisacodyl 10 mg PO/PR DAILY:PRN
Senna 1 TAB PO BID:PRN
Docusate Sodium (Liquid) 100 mg PO BID
Pantoprazole 40 mg PO Q24H
Multivitamins 1 TAB PO DAILY
Oxycodone SR (OxyconTIN) 20 mg PO Q12H
Acetaminophen 500 mg PO Q6H:PRN
Oxycodone (Immediate Release) 15 mg PO Q3H:PRN
Lorazepam 1 mg PO Q4H:PRN
Lactulose 15 mL PO BID
Zolpidem Tartrate 5 mg PO HS
Insulin SC (per Insulin Flowsheet)
Hydromorphone (Dilaudid) 0.5 mg IV Q2H:PRN postop pain
Dexamethasone 4 mg PO Q8H
Ciprofloxacin HCl 500 mg PO Q12H
Heparin 5000 UNIT SC TID
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
7. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
8. Oxycodone 5 mg Tablet Sig: Three (3) Tablet PO Q3H (every 3
hours) as needed.
9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
10. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO BID (2
times a day).
11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
12. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
14. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 2 days.
15. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO twice a
day: Start after 4mg dose-Continue on this dose until follow up
at brain tumor clinic.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Malignant Melanoma
Wound Hematoma
Discharge Condition:
Neurologically stable with left leg paralysis and right leg
weakness
Discharge 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.
?????? 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.
?????? Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by pain
medicine.
?????? Any weakness, numbness, tingling in your extremities.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
?????? Fever greater than or equal to 101?????? F.
?????? Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Followup Instructions:
Dr [**Last Name (STitle) 548**] on [**9-3**] at 9:30 am (this will be confirmed)
2. with Dr [**Last Name (STitle) **] [**Last Name (NamePattern4) 724**] (Neuro-Onc) and Dr [**First Name (STitle) 13014**] (Rad-Onc) on [**9-3**]
at 10:30 am [**Hospital Ward Name 23**] [**Location (un) **]
3. with Dr [**Last Name (STitle) **] on [**9-3**] at 1 pm for the [**Hospital 11884**] clinic
[**Hospital Ward Name 23**] 9 reception area A
Have your sutures removed next Monday at your rehab facility
Completed by:[**2187-8-14**]
|
[
"599.0",
"199.0",
"569.41",
"V10.82",
"E878.8",
"197.7",
"998.12",
"198.3",
"198.82",
"276.1",
"591",
"787.6",
"198.1",
"197.0",
"741.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"03.02",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
9047, 9094
|
2879, 7064
|
278, 326
|
9172, 9243
|
2196, 2856
|
10735, 11256
|
1579, 1597
|
7635, 9024
|
9115, 9151
|
7090, 7612
|
9267, 10712
|
1612, 1760
|
230, 240
|
354, 1334
|
1775, 2177
|
1356, 1493
|
1509, 1563
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,770
| 169,897
|
47533
|
Discharge summary
|
report
|
Admission Date: [**2105-12-17**] Discharge Date: [**2105-12-23**]
Service: CARDIOTHORACIC
Allergies:
Sulfasalazine
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
[**2105-12-17**] - Flexible Bronchoscopy; AVR(19mm CE Magne Pericardial
Valve)
History of Present Illness:
The patient is an 85-year-old woman who presented with
congestive heart failure. Cardiac echo showed critical aortic
stenosis with fairly normal left ventricular function with
moderate mitral regurgitation. Cardiac cath
demonstrated confirmed presence of critical aortic stenosis with
clean coronaries. The patient was, therefore, referred for
aortic valve replacement by [**Doctor Last Name **].
Past Medical History:
Aortic stenosis
Congestive heart failure with preserved EF
Hypertension
CVA
Hypothyroidism
Rheumatoid arthritis
Glaucoma
Ulnar neuropathy
Social History:
Smoked 1ppd for about 20yrs, quit 50yrs ago. No etoh. Lives
with husband. [**Name (NI) 8588**] independent in ADLs.
Family History:
Mother died at 70 from complications of htn, father died age 55
from brain tumor.
Physical Exam:
71 Regular 118/60 67" 146
GEN: NAD
HEENT: Unremarkable
NECK: Supple, slightly decrease range of motion.
LUNGS: Clear
HEART: RRR, III/VI systolic murmur
ABD: Soft, nontender, nondistended, NABS
EXT: [**1-12**]+ Pulses, no edema, no varicosities
NEURO: Nonfocal
Discharge
A/O x3 nonfocal
Pulm CTAB
Cardiac RRR
Sternal inc: no drainage, no erythema
Abd soft, NT, ND
Ext warm, trace edema
Pertinent Results:
CXR [**12-21**]: The patient is status post median sternotomy, the
AVR. There has been interval removal of a right-sided Swan-Ganz
catheter. Thecardiomediastinal silhouette is stable. There has
been interval improvement in left retrocardiac opacification.
Small bilateral pleural effusions, left greater than right are
unchanged. Pulmonary vascular markings are normal.
Echo [**12-17**]: Prebypass: The left atrial appendage emptying
velocity is depressed (<0.2m/s). There is mild symmetric left
ventricular hypertrophy with normal cavity size. Overall left
ventricular systolic function is normal (LVEF>55%). There are
complex (>4mm) atheroma in the ascending aorta. There are
complex (>4mm) atheroma in the aortic arch. There are complex
(>4mm) atheroma in the descending thoracic aorta. The aortic
valve leaflets are severely thickened/deformed. There is severe
aortic valve stenosis (area <0.8cm2). Moderate (2+) aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. Moderate to severe (3+)mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. The main pulmonary artery is
dilated. Postbypass: Biventricular systolic function is
preserved. Bioprosthetic valve seen in the aortic position.
Leaflets move well and the valve appears well seated. Trace
aoric insufficiency seen that resolved with protamine. Mean
gradient across the aortic valve is 7-9 mm Hg. Moderate to
severe mitral regurgitation persists.
[**2105-12-17**] 11:46AM BLOOD WBC-11.2*# RBC-3.34* Hgb-9.6* Hct-28.4*
MCV-85 MCH-28.8 MCHC-34.0 RDW-16.3* Plt Ct-76*#
[**2105-12-22**] 10:40AM BLOOD WBC-11.4* RBC-3.60* Hgb-10.3* Hct-31.0*
MCV-86 MCH-28.7 MCHC-33.4 RDW-15.5 Plt Ct-188
[**2105-12-17**] 11:46AM BLOOD PT-20.3* PTT-63.1* INR(PT)-1.9*
[**2105-12-22**] 08:45AM BLOOD PT-14.2* PTT-30.7 INR(PT)-1.3*
[**2105-12-22**] 10:40AM BLOOD PT-15.3* PTT-34.7 INR(PT)-1.4*
[**2105-12-17**] 12:47PM BLOOD UreaN-27* Creat-1.0 Cl-115* HCO3-22
[**2105-12-22**] 08:45AM BLOOD Na-142 K-4.3 Cl-108
[**2105-12-20**] 03:00AM BLOOD Calcium-8.6 Phos-3.9 Mg-2.3
Brief Hospital Course:
Ms. [**Known lastname 100486**] was amditted to the [**Hospital1 18**] on [**2105-12-17**] for surgical
management of her aortic stenosis. She was taken directly to the
operating room where she underwent an aortic valve replacement
using a 19mm CE Magna Pericardial valve. Given the abnormailties
seen on her most recent CT scan, the thoracic surgical service
performed a flexible bronchoscopy during her operation. Please
see separate operative notes for details. Postoperatively she
was taken to the cardiac surgical intensive care unit for
monitoring. She developed atrial fibrillation which responded to
beta blockade. On postoperative day one, Ms. [**Known lastname 100486**] [**Last Name (Titles) 5058**]
neurologically intact and was extubated. Coumadin was started
for paroxysmal atrial fibrillation. On postoperative day three,
Ms. [**Known lastname 100486**] was transferred to the step down unit for further
recovery. She was gently diuresed towards her preoperative
weight. The physical therapy service was consulted for
assistance with her postoperative strength and mobility. Ms.
[**Known lastname 100486**] continued to make steady progress and was discharged
to rehab on postoperative day 6. She will follow-up with Dr.
[**Last Name (STitle) 914**], her cardiologist and her primary care physician. [**Last Name (NamePattern4) **].
[**Last Name (STitle) **]. [**Doctor Last Name **] will manage her coumadin dosing for a target INR
of 2.0-2.5 after discharge from rehab.
Medications on Admission:
Verapamil 240mg QD, Sythroid 50mcg QD, Lasix 80mg [**Hospital1 **],
Lisinopril 10mg QD, Naproxen, Aspirin 325mg QD, Lopressor
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
4. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic EVERY OTHER DAY (Every Other Day): left eye only-
every other day.
5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime): each eye.
6. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO ONCE (Once) for 1
doses: Please titrate for a goal INR 2-2.5.
9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 1
weeks.
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 1
weeks.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] at [**Location (un) 701**]
Discharge Diagnosis:
Aortic stenosis s/p Aortic Valve Replacement
Post-operative Atrial Fibrillation
PMH: Rheumatoid arthritis, Glaucoma, Ulnar neuropathy,
Hypertension, Paroxysmal Atrial Fibrillation, Hypothyroid,
Multinodular goiter, h/o Stroke
Discharge Condition:
Good
Discharge Instructions:
[**Month (only) 116**] shower, no baths or swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns
Coumadin for atrial fibrillation. Goal INR is 2.0-2.5. Your
coumadin will be dosed by Dr. [**Last Name (STitle) **] after discharge from
Rehab.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 914**] (Surgeon) in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with cardiologist Dr. [**Last Name (STitle) 100487**] in 2 weeks. [**Telephone/Fax (1) 4022**]
Follow-up with Dr. [**Last Name (STitle) **] PCP [**Last Name (NamePattern4) **] 1 week. [**Telephone/Fax (1) 250**]
Please call all providers for appointments.
Scheduled Appointemnts:
- CAT SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2106-3-11**] 10:00
- Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**]
Date/Time:[**2106-3-11**] 10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD Phone:[**Telephone/Fax (1) 4022**]
Date/Time:[**2106-3-8**] 2:00
Completed by:[**2105-12-23**]
|
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icd9cm
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,213
| 174,250
|
34345
|
Discharge summary
|
report
|
Admission Date: [**2104-9-24**] Discharge Date: [**2104-10-7**]
Service: MEDICINE
Allergies:
Penicillins / Celebrex / Plaquenil / Sulfa (Sulfonamides)
Attending:[**Last Name (NamePattern1) 1171**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**Hospital1 **]-ventricular pacemaker upgrade
Trans-esophageal Echocardiogram
Cardioversion
EGD (Esophago-gastro-duodenoscopy)
Colonoscopy
History of Present Illness:
83yo M with h/o HTN, DLP, CHF, A fib s/p permanent pacemaker
(4/'[**04**]), anterior MI s/p CABG ([**2084**]), AAA with multiple repairs,
CVA presents with shortness of breath.
.
Patient's cardiac history dates back to [**2084**] when he developed
chest pain and was found to have an anterior MI. He received a
CABG in [**2084**] and has been chest pain free since then.
.
Patient first experienced shortness of breath on exertion about
five years ago, when he was placed on Lasix with adequate
management of his symptoms until recently. Patient's EF as
reported by echo in [**2102**] and in [**2104-7-6**] was stable at 30-35%.
.
Patient's most recent symptoms became apparent beginning in
[**2104-5-6**] when he began to experience progressive episodes of
shortness of breath and fatigue. Symptoms began following a
stroke which occurred in [**2104-4-5**], which resulted in left arm
hemiparesis that resolved with physical therapy. Workup for the
stroke revealed that the patient was in atrial fibrillation, and
patient was placed on Coumadin. He began experiencing worsening
dyspnea on exertion and
had multiple medication adjustments of his HF regimen with
suboptimal response. As a result, an ICD was placed [**2104-6-5**] for
what was believed to be symptomatic a fib. Patient was also
subsequently cardioverted in [**2104-6-5**] for continued dyspnea on
exertion.
.
Patient reported worsening of dyspnea following placement of
ICD, with PND, orthopnea which was minimally relieved when
sitting up in a chair at night, inability to sleep due to
shortness of breath. Patient's activity tolerance also
decompensated from being able to walk and play golf without
shortness of breath in [**2104-5-6**] to his current state, where he
becomes dyspneic at rest. Patient also reports that he began to
experience hemoptysis of dark red sputum in the past two weeks.
He has noticed a bloated abdomen with nausea and feelings of
fullness for the past 4 months as well. Patient denies chest
pain, but reports that he experienced a mild tightness in his
chest with the episodes of dyspnea.
.
Patient was recently found by his cardiologist to have a low BP
in the upper 70's and upper 80's, and his Lisinopril was
discontinued and Lasix was stopped. Lasix was reinitiated and
stopped several times in an attempt to prevent hypotension while
treating symptoms of dyspnea.
.
Patient presented and was admitted to Upper [**Hospital 2748**] [**Hospital **]
Hospital [**9-21**] for continued worsening symptoms, and was believed
to be "profoundly azotemic." He was given IV fluids without any
improvement of dyspnea, and was re-initiated on Lasix briefly.
During his hospital stay at the OSH 2 days prior to presentation
at [**Hospital1 18**], per family, patient developed hypothermia of 90
degrees F. Family reports that patient was wrapped in multiple
blankets at the hospital, and his temperature increased to 92
degrees F.
.
CXR was obtained at OSH on [**9-23**] which showed cardiomegaly with
fine bibasilar markings. An echo obtained [**9-23**] at OSH showed
worsened MR (3+) with worsened EF ~15%. CT chest with IV
contrast was obtained at the OSH as well, which resulted in
elevation of patient's Cr from baseline of 0.9-1.5 to 3.4.
.
The plan at the OSH was to transfer the patient to [**Hospital **]
[**Hospital3 26522**] Center, but patient's family decided to seek
care at [**Hospital1 18**] and drove patient to [**Location (un) 86**]. On presentation, he
was mildly dyspneic on 3L O2 NC with sats in the low 90's.
However, patient reported that he felt his breathing was
improved. He has remained asymptomatic of chest pain since
admission, and had one episode of dyspnea and drops of sats into
80's following bedside TTE, which resolved following elevation
of the head of the bed and increase of oxygen to 4L. He is
currently breathing comfortably on 4L NC without use of
accessory muscles.
.
Past Medical History:
Cardiac Risk Factors:
- Hypertension
- Dyslipidemia
- s/p Prior anterior MI [**2084**]
.
Cardiac History: CABG ([**2084**]), anatomy as follows:
- LIMA to LAD, SVG to RCA
.
No PCI (most recent cardiac catheterization [**2084**])
.
ICD placed [**2104-6-5**] for symptoms attributed to atrial
fibrillation.
.
Other Past History:
- CHF, most recent Echo [**2104-9-23**] with EF ~15%, severe MR (Echo
[**2104-5-5**] and [**2104-7-14**] with EF 30%)
- Atrial fibrillation, diagnosed [**5-/2104**]
- CVA [**5-/2104**] with UE hemiparesis x1 week
- Abdominal Aortic Aneurysm [**2095**] with multiple endograft repairs
- [**Hospital1 **]-fem bypass several years prior
- Bilateral inguinal hernias
- h/o Rectal bleed [**2100**]
.
Social History:
Social history is significant for the absence of current tobacco
use, 120 pk-yr history of prior tobacco use (x60 years, quit
[**2084**]). There is no history of alcohol abuse.
.
Patient previously employed as mechanical contractor, plumber,
handyman repairing heating and air conditioning units.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Mother had a heart condition of uncertain
nature, died at [**Age over 90 **]yo. Father had h/o lung cancer.
Physical Exam:
VS - T 98.0 P 78 BP 98/64 R 20 94% RA
Gen: Alert, interactive, WDWN male in mild respiratory distress.
Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Pale conjunctiva. No
pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP ~14cm to earlobes. No carotid bruits.
CV: PMI located in 5th intercostal space, midclavicular line.
RRR, normal S1, S2. Grade I systolic murmer at RUSB, Grade II
systolic murmer at apex. No thrills, lifts. Occasional S4.
Chest: Mild pectus excavatum. Resp were minimally labored but
without accessory muscle use. Fine crackles to mid-lung on
right, fine crackles in lower lobes on left. Minimal
end-expiratory wheezes in upper lobes b/l.
Abd: Soft, NT, mildly distended. +BS. No HSM or tenderness. No
abdominial bruits.
Ext: No c/c/e. Cool LE's.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Non-suppurative, non-tender, non-erythematous scaly brown
lesions on mid-plantar surface of left foot.
Neuro exam: Alert, oriented. PERRL, EOMI, CNs symmetric and
intact. Strength 5/5 bilaterally in upper extremities, 4+/5
bilaterally in legs. Gait not assessed secondary to dyspnea.
Rapid alternating movements of fingers intact.
Pulses:
Right: Carotid 2+ DP 1+ PT 1+
Left: Carotid 2+ DP 1+ PT 1+
.
Pertinent Results:
[**2104-9-24**] URINE HOURS-RANDOM UREA N-500 CREAT-94 SODIUM-LESS
THAN POTASSIUM-48 CHLORIDE-LESS THAN
[**2104-9-24**] 03:05PM GLUCOSE-132* UREA N-123* CREAT-4.1*
SODIUM-125* POTASSIUM-4.6 CHLORIDE-80* TOTAL CO2-27 ANION
GAP-23*
[**2104-9-24**] 03:05PM ALT(SGPT)-22 AST(SGOT)-22 LD(LDH)-282*
CK(CPK)-69 ALK PHOS-69 TOT BILI-0.8
[**2104-9-24**] 03:05PM CK-MB-6 cTropnT-0.14* proBNP-GREATER TH
[**2104-9-24**] 03:05PM ALBUMIN-4.1 CALCIUM-8.9 PHOSPHATE-6.2*
MAGNESIUM-3.5*
[**2104-9-24**] 03:05PM DIGOXIN-1.0
[**2104-9-24**] 03:05PM WBC-8.6 RBC-3.50* HGB-10.9* HCT-32.1* MCV-92
MCH-31.1 MCHC-33.9 RDW-15.9*
[**2104-9-24**] 03:05PM NEUTS-83.1* LYMPHS-11.1* MONOS-5.0 EOS-0.6
BASOS-0.2
[**2104-9-24**] 03:05PM PT-32.7* PTT-40.4* INR(PT)-3.4*
.
CXR on Admission [**2104-9-24**]: There is no comparison available.
[**Month/Day/Year **] enlargement of the cardiac silhouette, pacemaker in
situ. [**Month/Day/Year **] aortic tortuosity of the thoracic aorta. The lung
volumes are low and show bilateral blunting of costophrenic
sinus and increase in interstitial structures that have fibrotic
appearance. There are no signs of additional pneumonia and no
signs suggestive of overhydration. Clips of the bypass surgery,
abdominal aortic stent graft in situ.
.
Echocardiogram ([**2104-9-24**]): The left atrial volume is markedly
increased (>32ml/m2). Color-flow imaging of the interatrial
septum raises the suspicion of an atrial septal defect, but this
could not be confirmed on the basis of this study. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is moderately dilated. There is severe global left
ventricular hypokinesis (LVEF = 15-20 %). [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] The right ventricular
cavity is dilated with severe global free wall hypokinesis. The
aortic valve leaflets are moderately thickened. There is no
aortic valve stenosis. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. [**Month/Day/Year **] to severe
(3+) mitral regurgitation is seen. [**Month/Day/Year **] [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. Severe pulmonic regurgitation is seen. There is no
pericardial effusion. IMPRESSION: Severe global biventricular
systolic dysfunction. The anterior wall and septum are akinetic.
The LV and RV are dilated. Severe mitral regurgitation, [**Month/Day/Year 1192**]
tricuspipd regurgitation. Possible atrial septal defect.
.
CHEST CT WITHOUT CONTRAST IMPRESSION ([**2104-9-29**]):
1. Findings consistent with pulmonary fibrosis, which can be due
to chronic hypersensitivity pneumonitis. Superimposed
ground-glass opacities can be seen in the setting of pulmonary
hemorrhage, which would be consistent with given history of
hemoptysis. Pulmonary infection cannot be excluded. The findings
are not typical for asbestosis. Amiodarone toxicity can present
with similar imaging findings and can be considered if patient
was treated with amiodarone. 2. Several noncalcified pulmonary
nodules, largest measuring 10 mm, three- month followup chest CT
is recommended. FDG-PET can be non-conclusive in the setting of
surrounding ground-glass opacities. 3. Dense atherosclerotic
coronary artery calcifications, status post bypass graft
procedure. 4. Basal bronchiectasis, which can be seen in the
setting of chronic aspiration. 5. No evidence of CHF.
.
CXR on discharge [**2104-10-5**]: Comparison with the previous study
done [**2104-10-2**]. Evidence for mild interstitial edema persists.
Heart appears enlarged as before. The patient is status post
median sternotomy. Mediastinal structures are unchanged. A
pacemaker remains in place.
Brief Hospital Course:
Patient is an 83 year old male with history of ischemic
cardiomyopathy with newly further depressed ejection fraction,
severe mitral regurgitation, atrial fibrillation status post
failed cardioversion in [**2104-6-5**], status-post ICD/pace-maker,
who was transferred to [**Hospital1 18**] for further management of dypsnea
and his cardiac problems.
Patient arrived on the floor and was very dyspneic with minimal
exertion. His laboratories were remarkable for creatinine of
4.1, sodium of 132, and INR of 3.4. He was also noted to have
mild hemoptysis.
Hospital course is as followed by system:
#) Congestive heart failure, history of ischemic cardiomyopathy:
Per report from patient's outside hospital, an echocardiogram
was completed prior to transfer that demonstrated a worsened
ejection fraction of 15%, with severe mitral regurgitation (as
compared to echocardiogram from [**2104-6-5**] where his EF was
approximately 30% and MR [**First Name (Titles) **] [**Last Name (Titles) 1192**]). On exam, he appeared
fluid overloaded with rales bilaterally and elevated JVP. A
chest x-ray was completed at admission as well as a bedside
echocardiogram, which confirmed the above findings. Patient was
started on a lasix drip after he failed to diuresis to lasix
boluses on night of admission; a goal urine output of 60cc/hr
was maintained. Hydralazine was added for afterload reduction as
well given his severe mitral regurgitation.
The next day, patient was transferred to the cardiac intensive
care unit for further monitoring and possible Swanz placment
given that he was still very dyspneic with minimal exertion (eg
moving in bed) and possible ionotropic support for diuresis. He
received Diuril in addition to his lasix drip, and continued to
have good diuresis. He was transferred back to the cardiology
floor the next day.
Given that the the patient's symptoms appeared to have worsened
around the time of his pacermaker placement, and he had failed
cardioversion, it was felt that he may have some benefit from a
[**Hospital1 **]-ventricular pacemaker. An electrophysiology (EP) consult was
obtained, and plans were made for placement of a biventricular
pacemaker to help his cardiac output, as he was being paced
approximately 90% of the time. It was also felt that a
tranesophageal echocardiogram (TEE), followed by cardioversion
if no clot was seen, would also be of benefit to give the
patient better cardiac output with "atrial kick."
Patient underwent an upgrade of his pacemaker to a
[**Hospital1 **]-ventricular pacemaker on [**2104-10-1**] and reported improvement in
his symptoms.
He underwent a TEE with subsequent cardioversion on [**2104-10-3**] and
again reported improvement in his symptoms.
He continued to diurese well on the lasix drip, which was
transitioned to intravenous lasix doses and then an oral regimen
(120mg PO daily). At time of discharge, his weight was down over
4 kilograms.
Because of some low blood pressures in hospital his Toprol XL
was restarted at half his dose (25mg [**2-6**] tab daily) His
hydralazine was restarted. An ace-inhibitor or [**Last Name (un) **] was not
started due to his renal function, which improved but continued
to be variable. His digoxin was stopped given his variable renal
function and decompensated failure at time of admission.
He has an ICD in place for primary prevention given his low
ejection fraction. He is on anticoagulation for that as well as
his atrial fibrillation and history of CVA.
If patient continues to have further symptoms from his mitral
regurgitation, mitral valve replacement might be a
consideration, however that was no pursued during this admission
given the improvement in his symptoms with medical therapy and
his multiple other co-morbidities.
#) Gastrointestinal bleed:
On [**2104-9-28**] the patient developed three episodes of bloody stools
which were maroon in color mixed with a significant quantity of
stool. He did not have any subsequent bowel movements or
hematochezia, and was asymptomatic apart from minimal dizziness
following the bowel movements. Given concern for acute
gastrointestinal bleeding from either an upper or lower source,
patient's anti-coagulation was held (he had been on a heparin
drip after his INR was <2.0); his diuresis and beta-blocker were
temporarily stopped. He was started on an intravenous proton
pump inhibitor and maintained on clears. The gastroenterology
team was consulted for further evaluation, and on [**2104-10-2**], the
patient underwent upper endoscopy and colonoscopy. Records were
obtained from the patient's prior colonoscopy, which was from
[**2099**], demonstrating no significant findings. There was some
erosion and friability of the gastric mucosa, however no
bleeding was located. Biopsies of the gastric mucosa and h.
pylori serologies were pending at time of discharge and should
be followed up. It was felt that it was safe to resume
anticoagulation. The prior bleeding was felt to likely be due to
gastritis or an ulcer, which had resolved. He should continue
twice daily proton pump inhibitor until follow up with his
primary care provider or [**Name Initial (PRE) **] gastroenterologist. He had no further
episodes of bleeding and his hematocrit remained stable.
#) Coronary artery disease: Patient has ischemic cardiomyopathy
as evidenced by echocardiogram, and is status post CABG for a
myocardial infarction in [**2084**]. During his stay, he had no
symptoms concerning for acute coronary syndrone. He was
continued on his aspirin once he had no evidence of bleeding, as
well as metoprolol and his statin.
#) Rhythm: Patient has a Pacemaker/ICD in place for history of
atrial fibrillation and for primary prevention given his low
ejection fraction. He had a few episodes of NSVT (less than 10
beats) at the time of his prep for his colonoscopy, with
accompanying electrolyte distrubances, which were felt to be the
cause. He had no further episodes once his electrolyte
abnormalities resolved.
Patient underwent upgrade of his biventricular pacemaker as well
as a TEE with cardioversion as described above. He was started
on an amiodarone load to prevent recurrance of atrial
fibrillation. He will ultimately take 200 mg daily for
maintenance.
His anticoagulation was continued for his history of atrial
fibrillation. His coumadin dose was lowered due to the fact that
he was started on amiodarone.
#) Acute on Chronic Renal Failure: Based on records accompanying
patient, his baseline creatinine appears to range between 0.9 -
1.4 until [**2104-6-5**], at which time it was in the mid 2's. At time
of transfer, his creatinine had risen to over 3, and upon
arrival it was over 4. It was felt that he likely had acute
tubular necrosis from the contrast given to the patient for a
CTA done prior to his transfer, coupled with his low flow state
due to his decompensated congestive heart failure. His
creatinine peaked at 4.4, and then stabalized in the 1.7 to 2.3
range.
#) Hemoptysis: Patient has been experiencing hemoptysis for 2
weeks prior to arrival, which has been dark about half a
spoonful of dark red blood mixed with sputum. It was felt that
was likely secondary to pulmonary edema and subsequent pulmonary
vascular dilation in the setting of supratherapeutic INR. A
pulmonary consult was obtained for further evaluation and
recommendations regarding anticoagulation. His hemoptysis
improved and resolved as his INR normalized. His outside
imaging, including the CTA of this chest was reviewed, and a
repeat CAT scan without contrast was obtained after diuresis to
rule out any signs of malignancy, given his long tobacco use
history and asbestosis exposure. No large lesions were seen,
however "several noncalcified pulmonary nodules, largest
measuring 10 mm" were reported. Patient should have a repeat
chest CT in three months to follow up. The radiology report
notes that a FDG-PET can be non-conclusive in the setting of
surrounding ground-glass opacities.
#) Interstitial Pulmonary Fibrosis: No acute issues. Patient was
weaned off of oxygen. Repeat CAT scan as noted in results.
#) Elevated INR: Patient's Coumadin was held beginning [**9-21**],
however his INR was still 3.4 at admission. He was given vitamin
K to further lower his INR in the event that he needed any
procedures. He was maintained on a heparin drip after his
gastrointestinal work-up and bridged back to coumadin. His INR
was 1.9 on the day of discharge.
#) Anemia: Patient has anemia, which may be due to combination
of renal insufficiency and heart failure. His work up for
gastrointestinal bleeding is as noted above. Iron studies were
obtained and revealed an iron of 26, TIBC of 286, ferritn 260,
and transferritin of 220. He should continue to follow up with
his primary provider for further management of his anemia. He
did not receive any blood transfusions, and his hematocrit
remained stable in the 28-32 range.
.
#) HTN: Patient's blood pressure has been in low 100's and high
90's since admission, likely due to his heart failure. He had no
problems with hypertension during his stay, and his blood
pressure actually remained on the low side, without symptoms.
.
#) Dyslipidemia: Continued home statin dose.
.
#) Possible Sleep Apnea: Consider assessment after patient's
acute cardiac issues have resolved.
.
#) Urinary tract infection: Patient was noted to have an urine
analysis consistent with infection. He had had a foley in place
to monitor diuresis and due to his severe dyspnea with any
exertion. The foley was removed and he completed a course of
treatment with vancomycin given his pencillin allergy.
.
#) Code: Full code.
.
#) Discharge: Patient was evaluated by physical therapy and felt
to be safe for discharge home without services. He had a very
supportive family that was involved in his care. He will follow
up closely with his local cardiologist for a device check and
cardiology appointment.
Medications on Admission:
- Toprol XL 25mg daily
- Lasix 80mg tid (recently discontinued)
- Lisinopril 5mg (discontinued 7/'[**04**])
- Metolazone 2.5mg 3x per week (M, W, F)
- ASA 81mg daily
- Coumadin 5mg daily (initiated 4/'[**04**], held since [**2104-9-21**])
- Simvastatin 10mg daily
- Protonix 20mg daily (initiated 1 month ago)
- PRN Nitroglycerin patch
- Tylenol prn arthritic pain
.
ALLERGIES: PCN (hives), Celebrex, Plaquenil (unknown reaction)
Discharge Disposition:
Home With Service
Facility:
Upper [**Hospital 2748**] Hospital Home Health Agency
Discharge Diagnosis:
Primary Diagnosis:
- Decompensated Heart Failure
Secondary Diagnosis:
- Chronic atrial fibrillation
- Acute renal failure
- Spontaneous GI bleed
- Severe mitral regurgitation
Discharge Condition:
Stable, ambulating without difficulty, cleared by physical
therapy for discharge. On room air.
Discharge Instructions:
You were admitted for further management of your heart failure,
respiratory distress, and atrial fibrillation. You were treated
with several medications. You underwent an upgrade of your
pacemaker as well as cardioversion after transesophageal
echocardiogram. You also underwent an upper endoscopy and
colonoscopy to ensure you had no active gastrointestinal
bleeding.
Please contact your primary care physician, [**Name10 (NameIs) 2085**], or go
to the emergency room if you experience any shortness of breath,
chest pain, headaches, dizziness, bleeding, or other concerning
symptoms.
A number of medication changes have been made, so please review
the changes closely.
You will need to have your coumadin level (INR) followed closely
(once a week until your amiodarone dose is stable) because of
the effect amiodarone has on coumadin levels. You will also need
to have pulmonary function tests completed and have an eye exam
when you return to your home town while on amiodarone.
Please weigh yourself every morning, and call your physician if
your weight increases more than 3 lbs. Please adhere to 2 gram
sodium diet, and limit your fluid intake to 1500 mL daily.
A follow-up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**] was scheduled on
[**10-14**] at 11:30am. Dr.[**Name (NI) 79032**] phone number is
[**Telephone/Fax (1) 79033**]. In addition to general cardiac follow-up, your
[**Hospital1 **]-ventricular pacemaker will be checked at this appointment. A
copy of your medical information from this hospital stay will be
faxed to Dr. [**Last Name (STitle) 9404**] at [**Telephone/Fax (1) 79034**]. You should have your INR
(coumadin level) checked regularly (weekly at first given
changes in your medications).
.
A follow-up appointment was also made with your primary care
physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 79035**] for [**10-27**] at 3:45pm.
His phone number is [**Telephone/Fax (1) 79036**].
Followup Instructions:
A follow-up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**] was scheduled on
[**10-14**] at 11:30am. Dr.[**Name (NI) 79032**] phone number is
[**Telephone/Fax (1) 79033**]. In addition to general cardiac follow-up, your
[**Hospital1 **]-ventricular pacemaker will be checked at this appointment. A
copy of your medical information from this hospital stay will be
faxed to Dr. [**Last Name (STitle) 9404**] at [**Telephone/Fax (1) 79034**]. You should have your INR
(coumadin level) checked regularly (weekly at first given
changes in your medications).
.
A follow-up appointment was also made with your primary care
physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 79035**] for [**10-27**] at 3:45pm.
His phone number is [**Telephone/Fax (1) 79036**].
|
[
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"584.9",
"996.64",
"276.1",
"E879.6",
"285.9",
"786.3",
"428.23",
"403.90",
"515",
"428.0",
"578.9",
"438.20",
"585.9",
"414.8",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.51",
"88.72",
"45.23",
"99.61",
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
21128, 21212
|
10743, 20647
|
293, 435
|
21437, 21534
|
6953, 10720
|
23610, 24468
|
5439, 5630
|
21233, 21233
|
20673, 21105
|
21558, 23587
|
5645, 6934
|
234, 255
|
463, 4363
|
21306, 21416
|
21253, 21284
|
4385, 5109
|
5125, 5423
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,853
| 127,587
|
9703
|
Discharge summary
|
report
|
Admission Date: [**2142-5-9**] Discharge Date: [**2142-5-14**]
Date of Birth: [**2115-9-7**] Sex: M
Service: MEDICINE
Allergies:
Gadolinium-Containing Agents
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
headache, myalgias, chills
Major Surgical or Invasive Procedure:
Lumbar Puncture
History of Present Illness:
HPI: 26 year old male with chronic low back pain presents with
one and a half days of diffuse myalgias, chills, congestion and
a headache. The chills began abruptly the night before last and
persisted with sweating throughout the night and were
accompanied by myalgias and head pain. He reports that his whole
body was sore, and he awoke in the morning with a stiff neck so
severe that he could not turn his head, although he does admit
that his entire body felt stiff as well. His headache began in
the front and progressed down the left portion of his face and
lasted throughout the day yesterday. At maximum upon arrival to
the ED yesterday, he says the pain was 8.5/10, but improved
throughout the day to a [**4-19**]. He says that the pain was so bad
that he couldn't open his eyes, although he denies photophobia.
He also reports severe weakness/fatigue throughout his entire
body to the point that he could not stand by the time he got the
ED. ROS is significant for a sore throat and nasal congestion
for the past few days. He denies nausea, vomiting, and vision
changes. Denies sick contacts or recent travel.
In the ED, patient was noted to have a temperature of 100.3 and
vitals were otherwise within normal limits. He was given motrin,
vancomycin, ceftriaxone, and morphine.
.
Overnight, he had an episode of shaking and severe back pain
requiring morphine and dilaudid. This morning he says that his
headaches, myalgias, and stiffness have improved, but the back
pain has persisted and is so severe it limits movement. He also
still has some nasal congestion, but no sore throat.
Past Medical History:
Low back pain
Headaches
Social History:
SH: Denies smoking, alcohol, drugs. Lives alone. Works at [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] in annuities. Has had unprotected intercourse after
being tested at his yearly exam for HIV and other STDs. Lifts
weights (upper extremities) regularly.
Family History:
FH: Father died suddenly of brain aneurysm at age 41. Paternal
grandparent with colon cancer.
Physical Exam:
VS: t97.5, 120/64, p61, rr18, 99%RA, wt 97 kg
Gen: lying in bed, NAD
HEENT: clear OP, no photophobia
Neck: some stiffness
CVS: rrr, nl s1 s2, no m/g/r
Lungs: CTAB, no c/w/r
Abd: soft, NT, ND, nl BS
Ext: no edema
Neuro: CN 2-12 intact, [**4-14**] motor strength throughout
MSK: Pt c/o muscle pain and stiffness with movement
Back: Pain on palp around LP site
Pertinent Results:
[**2142-5-9**] 07:14PM CEREBROSPINAL FLUID (CSF) PROTEIN-31
GLUCOSE-61
[**2142-5-9**] 07:14PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-2*
POLYS-17 LYMPHS-67 MONOS-17
[**2142-5-9**] 10:59AM LACTATE-0.9 K+-3.9
[**2142-5-9**] 10:45AM GLUCOSE-95 UREA N-11 CREAT-1.1 SODIUM-138
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-28 ANION GAP-12
[**2142-5-9**] 10:45AM WBC-21.4*# RBC-5.02 HGB-14.5 HCT-41.5 MCV-83
MCH-28.9 MCHC-35.0 RDW-14.6
[**2142-5-9**] 10:45AM ALT(SGPT)-14 AST(SGOT)-26 CK(CPK)-424* ALK
PHOS-91 TOT BILI-0.4
Imaging:
CXR: No acute cardiopulmonary abnormality identified.
.
Head CT: No acute intracranial hemorrhage or mass effect.
.
MR spine: No evidence of inflammation or abscess although study
limited because anaphylactic reaction to gadolinium.
.
Micro:
Blood culture: negative to date
CSF: Negative gram stain. 1 WBC, protein 31, glucose 61. Polys
17, lymph 67, Mono 17.
CSF culture: Negative to date
Mono spot: pending
U cx: Negative to date
Brief Hospital Course:
26 year old male with history of chronic low back presents with
headache, weakness, myalgias, chills for one and a half days.
In the ED, he was found to have a [**Month/Day/Year **] to 100.3 and a
leukocytosis of 21,000. He was started on vancomycin and
ceftriaxone for concern of meningitis. In the ED, a lumbar
puncture was performed that was unremarkable. After the LP,
patient began to complain of lower back pain in the general LP
site. He was admitted for weakness, leukocytosis, and concern
for meningitis. The night of admission, he began to complain of
severe lower back pain and was given dilaudid and morphine. The
following morning the myalgias, headache, and chills had
resolved, however his back pain persisted and was more severe
than prior.
1. Viral sydrome: Unclear etiology of leukocytosis and chills.
CXR, Ua, and CSF were negative. The myalgias resolved shortly
after admission. Blood cultures, urine cultures and CSF
cultures were negative. There was concern for paraspinal
abscess given leukocytosis and acute on chronic back pain but an
MRI spine showed no evidence of abscess although the imaging was
imperfect due to removal from machine secondary to reaction to
gadolinium. After discussion with radiology attending, given
young patient with good tissue planes, further imaging unlikely
to be more revealing. He felt convinced there was no evidence of
abscess.
2. Back pain: Likely musculoskeletal etiology secondary to
irritation by viral syndrome or lumbar puncture. Physical exam
showed evidence of paraspinal tightness and tenderness, left
greater than right. MR spine was unremarkable. Back pain
improved dramatically on tizanidine and ibuprofen. Patient
discharged on evening tizanidine and ibuprofen with follow up in
primary care. He was advised not drive after taking tizanidine.
3. Anaphylactic reaction to gadolinium: While in the hospital,
the patient experienced an anaphylactic reaction to gadolinium
with hypotension, severe itch, and tongue swelling. A code blue
was called. He improved with epinephrine, solumedrol, benadryl,
and famotidine. He was sent to the ICU for observation for 36
hours. In the MICU his vital signs remained stable and he was
quickly weaned off of the epinephrine with stable BPs. He was
further maintained on IV solumedrol, benadryl, and famotidine
for 72 hours. He was transferred out of the ICU after 36 hours
and remained stable. He was discharged with a steroid taper and
a week of qhs benadryl and [**Hospital1 **] famotidine as well as an
epinephrine pen and instruction to avoid gadolinium in the
future.
4. Leukocytosis/Abnormal diff: His leukocytosis improved from
21.4 to 11.7 in three days. He remained afebrile after the day
of admission. On discharge he had an elevated white count
(25.2) thought to be due to steroids and possibly reaction to
anaphylaxis. However, also noted on the day of discharge was an
abnormal diff with 74.7% Neutrophils, 2 bands, 9.1 % lymphs, 2
metamyelocytes and 5.1 myelocytes. However, patient was
otherwise asymptomatic and felt well. He was therefore
discharged with instructions to follow up with his primary care
provider. [**Name Initial (NameIs) **] CBC with diff should be drawn at his follow up
appointment next week.
Medications on Admission:
Ibuprofen/motrin prn for back pain
Claritin prn for seasonal allergies
Discharge Medications:
1. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
2. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*7 Tablet(s)* Refills:*0*
3. Prednisone 10 mg Tablet Sig: Four (4) Tablet PO once a day:
Take 4 tablets once a day for 2 days ([**5-15**], [**5-16**]), take 2 tablets
once a day for 2 days ([**5-17**], [**5-18**]), take 1 tablet once a day for 2
days ([**5-19**], [**5-20**]), then discontinue. .
Disp:*14 Tablet(s)* Refills:*0*
4. Epinephrine 0.15 mg/0.3 mL Pen Injector Sig: One (1)
Intramuscular once: If you need to use this pen, please contact
emergency services for further evaluation and treatment.
Disp:*1 * Refills:*0*
5. Pepcid 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
6. Benadryl 25 mg Capsule Sig: One (1) Capsule PO at bedtime for
7 days.
Disp:*7 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
1. Viral syndrome
2. Acute on chronic low back pain
3. Anaphylactic reaction to gadolinium
Discharge Condition:
Stable, afebrile, ambulatory
Discharge Instructions:
While you were here, you were diagnosed with a viral syndrome.
During your admission you developed worsening low back pain
likely musculoskeletal in nature that improved with tizanidine
and ibuprofen. While receiving an MRI for your back pain, you
experienced an anaphylactic reaction to gadolinium, a type of
contrast. You should NOT receive gadolinium in the future- you
are allergic. If you experience a similar event please call
emergency services and use the epinephrine pen as prescribed.
At your follow up appointment scheduled on [**2142-5-23**] you should
have a CBC drawn to ensure your white count has improved and
that the abnormalities noted during your stay have improved.
Please call your doctor [**First Name (Titles) **] [**Last Name (Titles) **] greater than 100.4, night
sweats, numbness and tingling, worsening weakness or any other
symptoms that may concern you.
Take the tizanidine as needed for pain at night. Do not drive
after taking tizinidine or benadryl, you will be drowsy. You
may also take ibuprofren as needed for pain. Please continue to
take famotidine, benadryl, and prednisone over the next week as
prescribed. If you continue to experience severe pain, please
make an appointment to follow up with your primary care doctor
earlier than is already scheduled.
Followup Instructions:
Please follow up in [**Hospital6 733**] as indicated below
([**Telephone/Fax (1) 250**]):
Provider: [**Name10 (NameIs) **] FERN, RNC Date/Time:[**2142-5-23**] 10:40
Provider: [**Name10 (NameIs) **] FERN, RNC Date/Time:[**2142-5-31**] 10:00
|
[
"724.2",
"338.29",
"079.99",
"995.0",
"338.19",
"285.9",
"E947.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
8124, 8130
|
3787, 7055
|
314, 331
|
8286, 8317
|
2806, 3386
|
9670, 9915
|
2316, 2412
|
7176, 8101
|
8151, 8265
|
7081, 7153
|
8341, 9647
|
2427, 2787
|
248, 276
|
359, 1957
|
3395, 3764
|
1979, 2005
|
2021, 2299
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,657
| 148,669
|
46309
|
Discharge summary
|
report
|
Admission Date: [**2182-2-25**] Discharge Date: [**2182-2-26**]
Date of Birth: [**2119-4-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa (Sulfonamides) / Codeine / Prednisone
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This 62 year old female is s/p redo sternotomy for redo
tricuspid valve replacement and coronary revascularization. She
had a prolonged postoperative course due to the need for
pulmonary toilet and agitation. She was discharged to a
rehabilitation facility on [**2-22**], but signed herself out on
the 3rd. She presented to the ED on the 5th complaining of
dyspnea. CXR demonstrates no change from prior films.
Past Medical History:
Hypertension
Hypercholesterolemia
coronary artery disease
s/p 4 stents at [**Hospital1 112**] in [**2161**]
gastroesophageal reflux
Depression/Anxiety
Uterine cancer in her 20s
h/o pulmonary embolism
h/o strokes with residual dysarthria and voice hoarseness
chronic obstructive pulmonary disease
Social History:
Lives in [**Location **]. Retired hair dresser and real estate [**Doctor Last Name 360**].
Tobacco - Active tobacco, 3 per day for the last 5 years.
Reports only starting
smoking at age 56.
ETOH - 1 to 2 glasses wine per night.
Drugs - stopped smoking marijuana three weeks ago. Denies IVDA,
heroin, and cocaine.
Family History:
No premature coronary artery disease.
Physical Exam:
admission:
BP: 124/92 Pulse: 94 Resp: 18 O2 sat: 99/2L
General: Alert and oriented x 3. Non-toxic.
Skin: Dry[x] intact[x]
HEENT: PERRLA [] EOMI[x]
Neck: Supple [] Full ROM[x]
Chest: Lungs clear bilaterally[x]
Heart: RRR [x] Irregular [] Murmur: III/VI @LLSB in diastole
Abdomen: Soft, non-distended, non-tender[x]
Extremities: Warm, well-perfused[x] Edema Varicosities: None []
Neuro: Grossly intact
Pulses:
Femoral Right: nd Left: nd
DP Right: palp Left: palp
PT [**Name (NI) 167**]: palp Left: palp
Radial Right: palp Left: palp
Pertinent Results:
[**2182-2-26**] 04:05AM BLOOD WBC-6.5# RBC-3.27* Hgb-9.8* Hct-31.5*
MCV-97 MCH-29.9 MCHC-31.0 RDW-18.0* Plt Ct-243
[**2182-2-25**] 10:00AM BLOOD WBC-7.4 RBC-3.49* Hgb-10.8* Hct-33.3*
MCV-95 MCH-30.8 MCHC-32.3 RDW-18.0* Plt Ct-257
[**2182-2-26**] 04:05AM BLOOD Glucose-93 UreaN-25* Creat-1.2* Na-142
K-4.0 Cl-108 HCO3-27 AnGap-11
[**2182-2-25**] 12:47PM BLOOD ALT-11 AST-20 LD(LDH)-536* CK(CPK)-32
AlkPhos-111* TotBili-1.5
Brief Hospital Course:
Follwoing admission an echcardioghram was performed which was
unremarkable and revealed no pericardail effusion. Cultures
were negative and labs unremarkable.
She remained stable and felt well when her meds were resumed
(she was not taking any aftyer signing out AMA).
She was discharged home from the ICU on meds listed, with the
same precautions and restrictions and follow up as before.
Medications on Admission:
Aspirin 325 mg Tablet, Delayed Release (E.C.) [**Year/Month/Day **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Duloxetine 30 mg Capsule, Delayed Release(E.C.) [**Year/Month/Day **]: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Simvastatin 10 mg Tablet [**Year/Month/Day **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Ropinirole 0.25 mg Tablet [**Year/Month/Day **]: One (1) Tablet PO QPM (once
a day (in the evening)).
Disp:*30 Tablet(s)* Refills:*2*
Lorazepam 0.5 mg Tablet [**Year/Month/Day **]: 0.5 Tablet PO BID (2 times a
day).
Disp:*30 Tablet(s)* Refills:*2*
Tramadol 50 mg Tablet [**Year/Month/Day **]: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
Oxycodone-Acetaminophen 5-325 mg Tablet [**Year/Month/Day **]: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
Amiodarone 200 mg Tablet [**Year/Month/Day **]: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
Metoprolol Tartrate 50 mg Tablet [**Year/Month/Day **]: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
Cipro 500mg [**Hospital1 **]
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Duloxetine 30 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
3. Simvastatin 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Ropinirole 0.25 mg Tablet [**Hospital1 **]: One (1) Tablet PO QPM (once a
day (in the evening)).
Disp:*30 Tablet(s)* Refills:*2*
5. Lorazepam 0.5 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID (2 times a
day).
Disp:*30 Tablet(s)* Refills:*2*
6. Tramadol 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. Oxycodone-Acetaminophen 5-325 mg Tablet [**Hospital1 **]: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
8. Amiodarone 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
Hypertension
Hypercholesterolemia
coronary artery disease
s/p 4 stents at [**Hospital1 112**] in [**2161**]
gastroesophageal reflux
Depression/Anxiety
Uterine cancer in her 20s
h/o pulmonary embolism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Pain controlled with oral agents
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**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2182-3-18**]
1:20
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2182-3-18**] 2:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2182-3-19**] 10:15
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2182-2-26**]
|
[
"438.13",
"272.0",
"423.9",
"414.01",
"E930.8",
"995.1",
"401.9",
"E849.3",
"V10.42",
"530.81",
"V45.82",
"496",
"300.4",
"V12.51"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5560, 5619
|
2563, 2956
|
343, 350
|
5864, 5864
|
2117, 2540
|
6649, 7204
|
1467, 1506
|
4324, 5537
|
5640, 5843
|
2982, 4301
|
6048, 6626
|
1521, 2098
|
284, 305
|
378, 795
|
5879, 6024
|
817, 1116
|
1132, 1451
|
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