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Discharge summary
|
report
|
Admission Date: [**2176-10-29**] Discharge Date: [**2176-11-5**]
Date of Birth: [**2136-3-10**] Sex: F
Service: SURGERY
Allergies:
nsaids
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Morbid obesity
Major Surgical or Invasive Procedure:
1. Laparoscopic repair of paraesophageal hernia.
2. Placement of laparoscopic adjustable band and port device.
History of Present Illness:
[**Known firstname 45779**] has class III morbid obesity with weight of 276.2
pounds as of [**2176-9-10**] (her initial screen weight on [**2176-8-8**] was
280 pounds), height of 64 inches and BMI of 47.4. Her previous
weight loss efforts have included Weight Watchers, the Salad
Diet, the South Beach diet, the [**Doctor Last Name 1729**] diet, over-the-counter
ephedra-containing Ma [**Doctor Last Name **], Slim-Fast, prescription weight loss
medication and pancreatic lipase inhibitor orlistat (Xenical),
and [**First Name8 (NamePattern2) 1446**] [**Last Name (NamePattern1) **]. Her weight and age 21 was 140-145 pounds with
her lowest adult weight 130 pounds at age 20 and her highest
weight 281.7 pounds on [**2176-8-19**]. She weighed 140-145 pounds 10
years ago and 165 pounds 5 years ago. She states she developed
significant [**Last Name 4977**] problem in childhood and cites as factors
contributing to her excess weight genetics, large portions,
grazing, late night eating, too many carbohydrates in saturated
fats, stress, compulsive eating and emotional eating as well as
lack of exercise regimen. Her current activity includes
swimming 30 minutes 2-3 times per week and walking 10-15 minutes
twice per week. She denied anorexia, bulimia, diuretic or
laxative abuse but stated she does have binge eating without
purging. She has significant psychological history of
depression/bipolar disorder/anxiety and suicide attempts
admitted to [**Hospital 1191**] Hospital in [**Location (un) 10059**] x 2 in [**2171**] for drug
overdose and lithium toxicity with auditory hallucinations,
followed by psychiatrist and a therapist and is currently on
psychotropic medications (paroxetine, Abilify and lorazepam).
Past Medical History:
PMH: COPD, Fatty liver, HTN, HL, hypothyroidism,GERD, bipolar
disorder, iron deficiency anemia, renal insufficiency,
nephrogenic diabetes insipidus
PSH: wisdom teeth, breast implants, precervical cancer surgery
Social History:
She smoked one pack per day of cigarettes for 25 years quit
[**2176-7-29**], no
recreational drugs, no alcohol and does drink both carbonated
and caffeinated beverages. Two daughters age 20 and age 21 who
had been in DSS group homes and in [**Doctor Last Name **] homes. She is
divorced and is on disability, used to work in cosmetic sales,
lives alone but does have supportive friends.
Family History:
Her family history is noted for both parents living father with
history of stroke, mother with heart disease, hyperlipidemia,
asthma, thyroid disorder; sister living with heart disease and
thyroid disorder; multiple family members with mental illness
Physical Exam:
VS: T 98 HR 80 BP 120/78 RR 20 O2 99%RA
Constitutional: NAD
Neuro: Alert and oriented to person, place and time; affect flat
Cardiac: RRR, NL S1,S2, No MRG
Lungs: CTA B
Abdomen: Soft, non-tender, non-distended, no rebound tenderness
or guarding
Wounds: Abdominal lap sites with steri-strips, no periwound
erythema/ induration, mild periwound ecchymosis
Ext: 2+ DP pulses
Pertinent Results:
LABS:
[**2176-11-5**] 10:09AM BLOOD WBC-8.4 RBC-3.77* Hgb-9.7* Hct-30.8*
MCV-82 MCH-25.7* MCHC-31.5 RDW-16.0* Plt Ct-207
[**2176-11-5**] 06:27AM BLOOD Glucose-90 UreaN-24* Creat-1.5* Na-146*
K-3.7 Cl-108 HCO3-26 AnGap-16
[**2176-11-5**] 10:09AM BLOOD Glucose-124* UreaN-22* Creat-1.5* Na-143
K-4.1 Cl-106 HCO3-27 AnGap-14
[**2176-11-5**] 10:09AM BLOOD Calcium-9.7 Phos-3.3 Mg-2.2
[**2176-11-4**] 02:05AM BLOOD Glucose-100 UreaN-21* Creat-1.4* Na-143
K-4.0 Cl-107 HCO3-23 AnGap-17
[**2176-11-4**] 04:05PM BLOOD Na-139 K-3.9 Cl-103
[**2176-11-4**] 08:39PM BLOOD Na-141 K-3.7 Cl-105
[**2176-11-3**] 04:04AM BLOOD Glucose-102* UreaN-19 Creat-1.6* Na-149*
K-3.9 Cl-112* HCO3-26 AnGap-15
[**2176-11-2**] 12:31AM BLOOD Glucose-102* UreaN-15 Creat-1.7* Na-155*
K-4.1 Cl-119* HCO3-23 AnGap-17
[**2176-11-2**] 04:44AM BLOOD Na-158* K-4.0 Cl-121*
[**2176-11-2**] 12:31AM BLOOD Glucose-102* UreaN-15 Creat-1.7* Na-155*
K-4.1 Cl-119* HCO3-23 AnGap-17
[**2176-11-2**] 04:44AM BLOOD Na-158* K-4.0 Cl-121*
[**2176-11-2**] 07:58AM BLOOD Glucose-147* UreaN-17 Creat-1.8* Na-159*
K-4.4 Cl-122* HCO3-28 AnGap-13
[**2176-11-2**] 12:28PM BLOOD Glucose-95 UreaN-19 Creat-1.8* Na-154*
K-4.5 Cl-117* HCO3-26 AnGap-16
[**2176-11-2**] 04:15PM BLOOD Glucose-101* UreaN-18 Creat-1.6* Na-149*
K-4.0 Cl-113* HCO3-25 AnGap-15
[**2176-11-2**] 08:25PM BLOOD Glucose-105* UreaN-19 Creat-1.6* Na-150*
K-4.2 Cl-114* HCO3-26 AnGap-14
[**2176-11-1**] 09:27AM BLOOD Na-159* Cl-122*
[**2176-11-1**] 09:48AM BLOOD Glucose-139* UreaN-15 Creat-2.0* Na-159*
K-3.9 Cl-123* HCO3-26 AnGap-14
[**2176-11-1**] 12:05PM BLOOD Na-156* K-3.5 Cl-120*
[**2176-11-1**] 02:10PM BLOOD Na-154* K-3.9 Cl-120*
[**2176-11-1**] 10:10PM BLOOD Na-152* K-3.5 Cl-116*
[**2176-11-1**] 01:25AM BLOOD Glucose-128* UreaN-15 Creat-2.1* Na-168*
K-3.9 Cl-131* HCO3-26 AnGap-15
[**2176-10-31**] 08:50AM BLOOD Glucose-136* UreaN-15 Creat-1.9* Na-167*
K-3.7 Cl-129* HCO3-27 AnGap-15
[**2176-10-31**] 10:50AM BLOOD Glucose-100 UreaN-15 Creat-1.9* Na-167*
K-4.5 Cl-132* HCO3-23 AnGap-17
[**2176-10-31**] 04:02PM BLOOD Na-164* K-3.6 Cl-128*
[**2176-10-31**] 08:50AM BLOOD Calcium-10.7* Phos-2.5*# Mg-2.6
[**2176-10-31**] 10:50AM BLOOD Osmolal-346*
[**2176-11-4**] 02:05AM BLOOD Osmolal-304
[**2176-10-31**] 10:50AM BLOOD TSH-0.71
[**2176-10-31**] 10:50AM BLOOD T4-13.1*
[**2176-10-31**] 05:31PM BLOOD Na-163*
[**2176-10-31**] 08:36PM BLOOD Na-159*
[**2176-10-31**] 11:32PM BLOOD Na-163*
[**2176-11-1**] 04:50AM BLOOD Na-163*
[**2176-11-1**] 04:12PM BLOOD Na-154*
[**2176-11-1**] 06:40PM BLOOD Na-154*
[**2176-11-1**] 08:48PM BLOOD Na-153*
[**2176-11-3**] 12:29AM BLOOD Na-148*
[**2176-11-3**] 09:08AM BLOOD Na-145
[**2176-11-3**] 12:32PM BLOOD Na-146*
[**2176-11-3**] 04:38PM BLOOD Na-143 K-4.4
[**2176-11-3**] 08:36PM BLOOD Na-144
[**2176-11-4**] 06:33AM BLOOD Na-144
[**2176-11-4**] 11:58AM BLOOD Na-144
Imaging:
[**2176-10-30**]: UGI SGL CONTRAST W/ KUB:
IMPRESSION: Appropriate lap band position, patent stoma, no
evidence of leak.
[**2176-10-31**] ECG:
Sinus tachycardia. Low precordial lead voltage. ST-T wave
changes in the
anterolateral leads which raise the question of active
anterolateral ischemic process. Followup and clinical
correlation are suggested. No previous tracing available for
comparison
[**2176-11-1**]: CHEST (PORTABLE AP):
IMPRESSION: No pneumothorax, hematoma, or other sequela of
procedural
complication identified. Bibasilar atelectasis.
[**2176-11-1**]:
CHEST PORT. LINE PLACEMENT:
IMPRESSION: New right PICC terminating within the right atrium,
4.5-5.0 cm
beyond the cavoatrial junction.
Brief Hospital Course:
The patient presented to pre-op on [**2175-10-30**]. Pt was
evaluated by anaesthesia and taken to the operating room for
laparoscopic adjustable gastric band placement. There were no
adverse events in the operating room; please see the operative
note for details. Pt was extubated, taken to the PACU until
stable, then transferred to the [**Hospital1 **] for observation.
Neuro: The patient became intermittently agitated beginning on
POD1, pulling at her NGT, IV lines and threatening to leave
against medical advice and complaining of thirst. Psychiatry
was consulted, however, the patient declined visitation; the
patient's home psychiatric medication regimen was resumed at
this time. Overnight on POD2, the pt became progressively
disoriented, again attempting to leave against medical advice
and lacked insight into all aspects of her hospitalization and
expected post-operative recovery. Psychiatry was re-consulted
as the patient appeared to lack any capacity for decision
making. At this time, electrolytes had been checked and the
serum sodium was noted to be 167 making a metabolic cause for
the patient's disorientation more likely; upon reviewing the
sodium level, psychiatry felt her mental status changes were
more likely the result hypernatremia induced delerium related to
diabetes insipidus. After normalization of serum sodium levels,
the patient remained alert and oriented x 3 without any further
issues regarding agitation or insight into her care.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. Of note, the
patient's InnoPran XL was changed to regular release propranolol
as all medications must be crushed.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: She was initially on bariatric stage 1 diet, which
was well tolerated despite patient consuming more liquid than
ordered. An upper GI study was performed on POD 1 which
revealed appropriate band position without evidence of
obstruction. Her diet was further advanced to stage 2 and then
3 due to the patient's extreme thirst and dietary
non-compliance; the patient tolerated this level of intake well.
Additionally, on POD2, the patient was noted to be
hypernatremic with a serum sodium level of 167. Renal was
consulted and felt this was due to diabetes insipidus related to
prior lithium use; [**Name8 (MD) **] RN at the patient's PCP's office confirmed
this was a known diagnosis. The patient was identified as
having a free water deficit of approximately 10 liters; LR was
discontinued, D5W initiated, fluid intake liberalized and the
patient was transferred to the TSICU for q 3-4 hour serum sodium
monitoring. While in the TSICU, the patient's hypernatremia
gradually resolved over the course of 4 days with resolution of
her delerium; she was transferred back to the general surgical
[**Hospital1 **] on POD6. Her serum sodium remained between 141-146; Renal
felt it was safe for discharge to home with liberal fluid
intake, a stage 3 diet and a repeat serum sodium level within 1
week. Both the patient's PCP and nephrologist were contact[**Name (NI) **]
and follow-up appointments were made for the patient.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and [**Last Name (un) **]
dyne boots were used during this stay; she 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
liberalized stage 3 diet, ambulating, voiding without
assistance, and pain was well controlled. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan including
follow-up with her PCP tomorrow and her nephrologist on [**11-25**], [**2175**].
Medications on Admission:
Aripiprazole 15 mg daily
Paroxetine 10 mg daily
Perphenazine 32 mg q HS
Propranolol XL 160 mg daily
Levothyroxine 88 mcg daily
Zolpidem 10 mg daily
Omeprazole 40 mg [**Hospital1 **]
Lorazepam 1 mg QID
Diphenhydramine 25 mg daily
Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice a
day as needed for constipation.
Disp:*250 ml* Refills:*0*
2. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for Pain.
Disp:*100 ML(s)* Refills:*0*
3. aripiprazole 15 mg Tablet Sig: One (1) Tablet PO once a day:
Please crush.
4. paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO once a
day: Please crush.
5. perphenazine 8 mg Tablet Sig: Four (4) Tablet PO QHS (once a
day (at bedtime)).
6. propranolol 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*0*
7. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime):
Please crush.
9. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day: Open capsule,
sprinkle contents onto applesauce, swallow whole. Do not chew
beads.
10. lorazepam 1 mg Tablet Sig: One (1) Tablet PO four times a
day: Please crush.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Gastroesophageal reflux with paraesophageal hernia.
2. Obesity.
3. Fatty liver.
4. Diabetes Insipidus
5. Hypernatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions: Please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, nausea or vomiting,
difficulty drinking fluids, severe abdominal bloating, inability
to eat or drink, foul smelling or colorful drainage from your
incisions, redness or swelling around your incisions, confusion,
headache, weakness, increased thirst or any other symptoms which
are concerning to you.
Diet: Stay on Stage III diet until your follow up appointment.
Do not self advance diet, do not drink out of a straw or chew
gum. Please drink fluids freely and contact Dr. [**Last Name (STitle) 15645**] office
or report to the Emergency Department immediately if you are
unable to tolerate liquids.
Medication Instructions:
Resume your home medications except for the following changes:
1. Please stop InnoPran XL (propranolol) as this medication
CANNOT be crushed. A new prescription for propranolol (regular
release) has been provided to you as you may crush this
medication. Please notify your primary care provider of this
change.
2. Please stop amiloride per our Nephrologist.
CRUSH ALL PILLS.
You will be starting some new medications:
1. You are being discharged on medications to treat the pain
from your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
2. You should begin taking a chewable complete multivitamin with
minerals. No gummy vitamins.
3. You should take a stool softener, Colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
4. You must not use NSAIDS (non-steroidal anti-inflammatory
drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and
Naproxen. These agents will cause bleeding and ulcers in your
digestive system.
Activity:
No heavy lifting of items [**10-12**] pounds for 6 weeks. You may
resume moderate exercise at your discretion, no abdominal
exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Completed by:[**2176-11-5**]
|
[
"553.3",
"293.0",
"530.81",
"296.80",
"272.4",
"V85.42",
"280.9",
"244.9",
"253.5",
"585.4",
"496",
"278.01",
"403.90",
"571.8",
"E939.8",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.95",
"53.71"
] |
icd9pcs
|
[
[
[]
]
] |
12444, 12450
|
7035, 11112
|
281, 394
|
12616, 12616
|
3467, 7012
|
2808, 3060
|
11391, 12421
|
12471, 12595
|
11138, 11368
|
12791, 13597
|
3075, 3448
|
227, 243
|
14893, 15256
|
422, 2149
|
13622, 14881
|
12631, 12743
|
2171, 2386
|
2402, 2792
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,619
| 167,551
|
30791
|
Discharge summary
|
report
|
Admission Date: [**2176-7-14**] Discharge Date: [**2176-8-4**]
Date of Birth: [**2098-11-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
Chest Tube Placement
History of Present Illness:
77M found down at the bottom of 4 stairs. Cannot recall event.
Patient was hypoxic to 85% and intubated in the ED.
Past Medical History:
Seizure Disorder
HTN
s/p bilat cataract extraction
Telangiectasias
B/L Dupytren's
LBBB, Pacemaker
Afib with LBBB
Basal Cell Carcinoma
CHF
Pleural Effusion
Social History:
Patient lives alone - has children help with errands
Family History:
Non-contrib
Physical Exam:
(on admission)
95.7 74 153/86 20 86RA 87nonRB
GEN: intubated/sedated
HEENT: large contusion in back of head
Pupils: R 1.5-1 L 2-1.5
Corneal reflexes trace b/l
Positive cough reflex
Moving all 4 ext. spontaneously, no posturing, no withdrawl
Pertinent Results:
[**2176-7-14**] 10:40PM TYPE-ART PO2-196* PCO2-50* PH-7.37 TOTAL
CO2-30 BASE XS-2
[**2176-7-14**] 10:40PM LACTATE-1.2
[**2176-7-14**] 08:31PM GLUCOSE-125* UREA N-30* CREAT-1.2 SODIUM-142
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-32 ANION GAP-12
[**2176-7-14**] 08:31PM CALCIUM-8.6 PHOSPHATE-2.9 MAGNESIUM-2.4
[**2176-7-14**] 08:31PM WBC-7.1 RBC-4.40* HGB-12.0* HCT-38.1* MCV-87
MCH-27.3 MCHC-31.5 RDW-19.6*
[**2176-7-14**] 08:31PM PLT COUNT-163
[**2176-7-14**] 08:31PM PT-24.3* PTT-36.0* INR(PT)-2.4*
[**2176-7-14**] 08:31PM FIBRINOGE-337
[**2176-7-14**] 06:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2176-7-14**] 06:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2176-7-14**] 05:00PM PT-22.8* PTT-36.4* INR(PT)-2.3*
[**2176-7-14**] 04:35PM GLUCOSE-110* UREA N-31* CREAT-1.1 SODIUM-142
POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-30 ANION GAP-16
[**2176-7-14**] 04:35PM estGFR-Using this
[**2176-7-14**] 04:35PM ALT(SGPT)-18 AST(SGOT)-32 CK(CPK)-129 ALK
PHOS-119* AMYLASE-79 TOT BILI-0.4
[**2176-7-14**] 04:35PM LIPASE-43
[**2176-7-14**] 04:35PM cTropnT-0.04*
[**2176-7-14**] 04:35PM CK-MB-6
[**2176-7-14**] 04:35PM ALBUMIN-3.7 CALCIUM-9.0
[**2176-7-14**] 04:35PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-POS tricyclic-NEG
[**2176-7-14**] 04:35PM WBC-6.0 RBC-4.70 HGB-13.0* HCT-39.9* MCV-85
MCH-27.7 MCHC-32.6 RDW-19.4*
[**2176-7-14**] 04:35PM NEUTS-79* BANDS-0 LYMPHS-12* MONOS-7 EOS-1
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2176-7-14**] 04:35PM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-1+ OVALOCYT-1+
SCHISTOCY-OCCASIONAL
[**2176-7-14**] 04:35PM PLT SMR-LOW PLT COUNT-138*
CT Head [**7-14**]
1. Small focus of blood in the posterior right frontal lobe
likely represents cortical and subarachnoid hemorrhage.
2. Marked brain atrophy, with ventricular and sulcal prominence,
and numerous coarse calcifications throughout both [**Doctor Last Name 352**] and
white matter, which may represent tuberous sclerosis, perinatal
cytomegalovirus infection, or sequela of other prior infectious
processes
Brief Hospital Course:
<B>A/P:</B> 77 y/o M with a PMHx of CHB s/p PPM, CAD s/p MI,
HTN, LBBB at baseline, blindness, HOH, who initially presented
to [**Hospital1 **] on [**2176-7-14**] s/p fall and had VF arrest on [**7-22**] now
intubated.
<B>1. Respiratory Failure </B>
Initially intubated on arrival to the ED given his SAH and MS
changes. He was extubated on [**7-15**], and was re-intubated
peri-code for airway protection. Had no known parenchymal lung
disease to prevent safe extubation. However, appears to have
had peri-code aspiration and was initially not responsive.
Received treatment for aspiration PNA with Vanco/Zosyn and
diuresed aggressively. Had attempted SBT on [**7-26**] which failed
due to persistant tachypnea and low tidal volumes. In
discussion
with family, trach would not be his wish, so on [**8-3**], pt. was
extubated with plans for CMO if he would not breath
spontaneously. He was quickly transitioned to comfort measures
with ativan and morphine to treat shortness of breath and passed
away with family at bedside.
<B>2. s/p VF arrest</B>
Was on floor when had spontaneous VF arrest. Appears to have
devolved from Afib with aberrancy as initial cause. EP
following. Interrogation of PPM otherwise unrevealing.
.
<B>3. SAH s/p fall </B>
On coumadin with hx of falls; admitted initially with
SAH/subcortical hemorrhage. Admitted to trauma service;
followed by neurosurgery/neurology. It was decided not to
proceed with operative management and to watch his interval
progression. He was given a dilantin load and completed a 10
day course of dilantin for sz ppx. Prior to admission he was
communicative and functional, but post-SAH was not communicative
per his nephew. Was not able to recognize people or hold
conversation although was able to utter words but steadily
improved in the few days after his VF arrest.
.
<B>4. Fever</B>
Developed fever post-VF arrest; likely aspiration pneumonia
given his code and unresponsiveness. Also had enterococcal UTI
.
<B>5.R pleural effusion now resolved </B>
Had exudative effusion previously s/p chest tube drainage
(placed for PTX but had 2L of exudative drainage). Cytology
negative. No further reaccumulation occured during his
hospitalization.
.
<B>6. Anemia </B>
Likely AOCD, but no iron studies.
- will add on iron studies
.
<B>6. Atrial Fibrillation</B>
Off anticoagulation given multiple falls and SAH. Is not
candidate for future anticoagulation
- will start ASA once cleared by neurosurgery in the future
.
<B>6. LUE DVT</B>
Diagnosed on [**7-25**], unable to treat given recent SAH. No further
treatment at this time.
.
<B>7. PTX</B>
Had iatrogenic right PTX after R subclavian line placement. A
chest tube was placed on [**7-15**] which removed 2L of serosanguinous
drainage. CT placed to water seal on [**7-16**] and subsequently
removed prior to his transfer on the floor.
.
Medications on Admission:
Medications prior to admission:
Coumadin
Digoxin 0.125
ASA 325
Lasix 80/160 alternating
Lisinopril 40 qD
Lopressor 50 [**Hospital1 **]
Mysoline 250 [**Hospital1 **]
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Subarachnoid hemmorhage
Pleural Effusion
s/p Vfib arrest
Multifactorial respiratory failure
anoxic brain injury
aspiration PNA
nosocomial UTI
atrial fibrillation
Deep Vein Thrombosis
Discharge Condition:
deceased
Discharge Instructions:
none
Followup Instructions:
none
|
[
"E880.9",
"599.0",
"401.9",
"453.8",
"511.8",
"427.31",
"V45.02",
"852.01",
"428.0",
"459.89",
"348.1",
"285.29",
"V66.7",
"784.5",
"507.0",
"518.81",
"389.9",
"512.1",
"427.41",
"V10.83",
"427.5",
"412",
"369.4",
"780.39"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.62",
"38.93",
"96.04",
"99.07",
"96.71",
"96.6",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
6362, 6371
|
3250, 6117
|
323, 346
|
6598, 6608
|
1049, 3227
|
6661, 6668
|
755, 768
|
6333, 6339
|
6392, 6577
|
6143, 6143
|
6632, 6638
|
783, 1030
|
6175, 6310
|
275, 285
|
374, 491
|
513, 669
|
685, 739
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,190
| 145,260
|
2067+55353
|
Discharge summary
|
report+addendum
|
Admission Date: [**2138-8-14**] Discharge Date: [**2138-8-19**]
Date of Birth: [**2085-1-5**] Sex: F
Service: Thoracic Surgery
PAST MEDICAL HISTORY:
1. Hodgkin's lymphoma treated with radiation in [**2110**]
2. Congestive heart failure
3. Pulmonary fibrosis
4. Pericarditis
PAST SURGICAL HISTORY:
1. Tracheostomy placement, [**2138-6-20**]
2. Gastrostomy placement [**2138-7-4**], removed
3. Splenectomy
4. Total abdominal hysterectomy with bilateral
salpingo-oophorectomy
5. Status post pericardiectomy
6. Status post decortication
ALLERGIES: INTRAVENOUS DYE
INPATIENT MEDICATIONS:
1. Albuterol 1 to 2 puffs po q6h prn
2. Ipratropium inhaler 1 to 2 puffs q6h prn
3. Lasix 60 mg po qd
4. Lopressor 12.5 mg po bid
5. Lansoprazole 30 mg po qd
6. Docusate 100 mg po bid
7. Reglan 10 mg qid
8. Levothyroxine 100 mcg qd
9. Sertraline 50 mg qd
10. Iron 325 mg qd
11. Epogen 2 40,000 units subcutaneous every Friday
12. Ambien 10 mg q hs
13. Clindamycin 450 mg q6h for two weeks
14. Bactrim 1 tablet po bid for two weeks
HISTORY OF PRESENT ILLNESS: A 54-year-old female well known
to the thoracic service, status post radiation therapy for
Hodgkin's lymphoma in [**2110**], status post pericardiectomy in
[**2127**] with severe pulmonary fibrosis. The patient had problem
with shortness of breath and bilateral effusions for the past
three years. She underwent decortication in the recent past.
She was discharged on [**8-8**] following a brief admission
for increased secretions and difficulty breathing. In the
interim, the patient's respirations got worse. She had more
trouble breathing increased secretions. The patient was
taking clindamycin and Bactrim which did not seem to improve
her symptoms.
PHYSICAL EXAM:
GENERAL: Ill appearing female, shallow breaths.
LUNGS: Decreased breath sounds bilaterally. Rales
throughout.
CARDIOVASCULAR: Regular rate and rhythm, no murmurs.
ABDOMEN: Soft, nontender, nondistended.
IMAGING: Chest x-ray - improved expansion of left lower
lobe.
LABS: White blood cells 12.1, hematocrit 36.4, platelets
359. Sodium 137, potassium 5.1, chloride 90, bicarbonate 42,
BUN 11, creatinine 0.4, glucose 126.
HOSPITAL COURSE: The patient was admitted to the thoracic
service. She was started on vancomycin and intermittent
suctioning through her trach tube. Along with her home
medication and albuterol and ipratropium nebulizers, through
her hospitalization she remained afebrile. Her respiratory
status slowly improved until on day #5 she required only 1
liter of oxygen which has been the case for the past couple
of years. She had a decreased amount of secretion. The
patient reports feeling significantly better. The patient
ambulates well with oxygen. We are continuing intravenous
antibiotics. A central line will be placed on [**2138-8-18**]. Trach tube removed on the same day.
DISCHARGE CONDITION: Good
DISCHARGE STATUS: The patient is discharged home with VNA.
The patient should continue intravenous vancomycin for nine
days to complete the course of 14 days. The patient should
follow up with Dr. [**Last Name (STitle) 952**] in one week.
DISCHARGE MEDICATIONS:
1. Lopressor 12.5 mg [**Hospital1 **]
2. Albuterol 1 to 2 puffs q6h prn
3. Ipratropium 1 to 2 puffs q6h prn
4. Zolpidem 10 mg po q hs
5. Lansoprazole 30 mg po qd
6. Ferrous sulfate 325 mg qd
7. Docusate 100 mg po bid
8. Levothyroxine 100 mcg po qd
9. Metoclopramide 10 mg po qid ac hs
10. Vancomycin 1000 mg intravenous q 12 hours x9 days
11. Ibuprofen 400 mg po q8h prn
12. Tylenol 1 to 2 tablets po q6h prn
13. Lasix 60 mg po bid
14. Epogen 2 40,000 units subcutaneous q Friday
15. Sertraline 50 mg po qd
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Last Name (STitle) 7487**]
MEDQUIST36
D: [**2138-8-18**] 11:14
T: [**2138-8-18**] 11:23
JOB#: [**Job Number 11238**]
Name: [**Known lastname 1364**], [**Known firstname 1365**] Unit No: [**Numeric Identifier 1366**]
Admission Date: [**2138-8-14**] Discharge Date: [**2138-9-2**]
Date of Birth: [**2085-1-5**] Sex: F
Service: [**Last Name (un) 1613**]. [**Doctor First Name 1379**]
ADDENDUM IS FOR TIME PERIOD FROM [**2138-8-19**], DATE OF EXPECTED
DISCHARGE, TO DATE OF ACTUAL DISCHARGE, [**2138-9-2**].
PAST MEDICAL HISTORY, PAST SURGICAL HISTORY, ALLERGIES,
INPATIENT MEDICATIONS AND HISTORY OF PRESENT ILLNESS AS
PREVIOUSLY DICTATED.
HOSPITAL COURSE FROM [**2138-8-19**] TO [**2138-9-2**]: The patient was
scheduled to go home on [**2138-8-19**], however, developed
respiratory distress and increased sputum secretions and was
transferred to the Intensive Care Unit. A Pulmonary consult
by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1614**] was obtained and, after thorough
evaluation, Dr. [**Last Name (STitle) 1614**] and Dr. [**Last Name (STitle) 384**] felt that [**Known firstname **]
[**Known lastname **] had aspirated and was continuing to aspirate.
Therefore, we placed a tracheostomy tube and percutaneous
endoscopic gastrostomy tube and made her strict NPO taking
all alimentation and medications via the feeding tube. With
aggressive pulmonary toilet, physiotherapy, intravenous
antibiotics, we eventually cleared her infection and improved
her pulmonary status to the point where she was on two liters
of oxygen. She was discharged to home on [**9-2**] in
reasonable condition on two liters of home oxygen and home
tube feeds.
DISCHARGE STATUS: To home with Visiting Nurses Association
services, home feedings and home oxygen.
FOLLOW UP: The patient will follow up with Dr. [**Last Name (STitle) 384**] in two
weeks.
DISCHARGE MEDICATIONS: As per previous Discharge Summary.
[**First Name11 (Name Pattern1) 904**] [**Last Name (NamePattern4) 1369**], M.D. [**MD Number(1) 1370**]
Dictated By:[**Last Name (NamePattern4) 1615**]
MEDQUIST36
D: [**2139-3-23**] 14:11
T: [**2139-3-23**] 13:21
JOB#: [**Job Number 1616**]
|
[
"V44.1",
"428.0",
"515",
"507.0",
"201.90",
"V44.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93",
"33.24",
"97.23",
"97.02"
] |
icd9pcs
|
[
[
[]
]
] |
2906, 3154
|
5782, 6098
|
2213, 2884
|
323, 1059
|
1764, 2195
|
5678, 5758
|
1088, 1749
|
170, 300
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,476
| 119,840
|
50457
|
Discharge summary
|
report
|
Admission Date: [**2104-11-30**] Discharge Date: [**2104-12-5**]
Date of Birth: [**2028-12-15**] Sex: F
Service: MEDICINE
Allergies:
Percocet / Ciprofloxacin / Penicillins
Attending:[**First Name3 (LF) 8684**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
central line placement
Colonoscopy
Transfusion of 1units of packed red blood cells
History of Present Illness:
75 yoF w/ h/o PVD, htn who is brought in from her [**Hospital 4382**] facility for BRBPR. By report, this morning at ~6am
patient was being changed by the nursing staff at Foley House
when she was found to have bright red blood and clots in her
Depends. She was otherwise asymptomatic but was transferred to
[**Hospital1 18**] for further evaluation.
.
Upon arrival to [**Hospital1 18**] ED, vitals T 95.9, BP 107/54, HR 110, RR
18, O2 98% RA. She denied any chest pain, shortness of breath,
abdominal pain, fevers, chills, nausea, or vomiting. She was NG
lavaged which was negative for coffee grounds or gross blood.
Hct was found to be at her baseline at 33.5. However, repeat
calculated Hct was 29. She was type and crossed for 6 units
PRBCs. She had poor access so an R IJ CVL was placed. She
received ~750 cc of NS w/ stable SBPs in 110s and HR decrease
from 110s->80s. In the ED, U/A also suggestive of UTI although
patient asymptomatic and no leukocytosis or left shift.
.
Upon arrival to the MICU, patient continues to be
hemodynamically stable. Patient noted a history of normal bowel
movements but does note diarrhea starting this morning mixed
with blood. Denies any fevers, chills, CP, SOB, N/V/abd pain,
orthopnea, PND. Does note chronic dry cough. Patient denies any
prior h/o GIB. Pt has had multiple EGDs at [**Hospital6 **]
showing ulcers. Her last was in [**2095**].
Past Medical History:
# peripheral vascular disease
# htn
# chronic venous stasis c/b LLE ulcer
# s/p tracheostomy in [**4-/2096**] s/p incarcerated hernia repair and
failure to wean. Decannulated in 12/99.
# Depression: bipolar in nature
# degenerative joint disease
# obesity
# h/o CVA
# incontinence
Social History:
Divorced. Lives in [**Hospital3 **] facility, Foley House. No h/o
tobacco use. Social EtOH.
Family History:
mother died of MI at age 63. Father died of cancer of unclear
type. No h/o colon cancer per patient.
Physical Exam:
T: 97.5 BP: 118/63 HR: 74 RR: 21 O2 98% 2LNC
Gen: Pleasant, elderly appearing female in NAD
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Supple, No LAD, No JVD. R IJ CDI. s/p tracheostomy.
CV: RRR. nl S1, S2. [**2-5**] <> murmur at LLSB
LUNGS: CTAB
ABD: Obese. NABS. Soft, NT. No HSM
EXT: Large lower extremite with significant edema symmetric
bilat. WWP, Bilat LE wrapped with compression wraps. Dopplerable
DP pulses bilat.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Moving all
extremities.
Pertinent Results:
[**2104-11-30**] 10:55AM BLOOD WBC-5.8 RBC-4.10* Hgb-10.7* Hct-33.5*
MCV-82 MCH-26.0* MCHC-31.9 RDW-16.2* Plt Ct-239
[**2104-12-1**] 04:26AM BLOOD WBC-6.0 RBC-3.71* Hgb-9.8* Hct-30.5*
MCV-82 MCH-26.3* MCHC-32.0 RDW-16.2* Plt Ct-201
[**2104-12-1**] 02:20PM BLOOD Hct-30.9*
[**2104-12-1**] 10:28PM BLOOD Hct-28.4*
[**2104-12-2**] 04:18AM BLOOD WBC-6.8 RBC-3.46* Hgb-9.2* Hct-28.6*
MCV-83 MCH-26.6* MCHC-32.1 RDW-16.3* Plt Ct-182
[**2104-11-30**] 10:55AM BLOOD Glucose-103 UreaN-33* Creat-0.8 Na-141
K-4.0 Cl-103 HCO3-33* AnGap-9
[**2104-12-1**] 04:26AM BLOOD Glucose-460* UreaN-22* Creat-0.6 Na-144
K-3.2* Cl-111* HCO3-28 AnGap-8
[**2104-12-2**] 04:18AM BLOOD Glucose-68* UreaN-9 Creat-0.5 Na-144
K-3.7 Cl-109* HCO3-29 AnGap-10
CXR: AP UPRIGHT CHEST: There is a central venous line via right
internal jugular access with the tip in the lower SVC. No
pneumothorax. An opacity in the right lower lung may represent
an effusion and/or atelectasis. Lungs are otherwise clear. The
cardiomediastinal contours are within normal limits.
IMPRESSION:
1. Status post right IJ line placement with tip in lower SVC. No
pneumothorax.
2. Possible right pleural effusion.
.
colonoscopy [**2104-12-3**]:
Multiple diverticula were seen in the sigmoid colon and
descending colon.Diverticulosis appeared to be of moderate
severity.There was no active bleeding noted.
Impression: Diverticulosis of the sigmoid colon and descending
colon
Otherwise normal colonoscopy to cecum and terminal ileum
Recommendations: 1. No active bleeding noted.
2. Follow serial Hct
Brief Hospital Course:
75 yoF w/ h/o PVD, htn, chronic venous stasis who p/w
hematochezia.
.
# GIB:
- NG lavage was negative in ED.
- No history of prior GIBs per patient report.
- She had a R IJ triple lumen place for access in the ED.
- Her hematocrit remained stable upon admission to the ICU.
- She required no blood transfusions.
- Her aspirin and blood pressure meds were held.
- She remained hemodynamically stable.
- She was prepped with GoLytely overnight but failed to clear so
received another GoLytely prep the following day.
- She was brought down to the GI suite on [**12-2**] but became
tachycardic into the 130s and so the procedure was cancelled and
she was brought back up to the ICU.
- Tachycardia resolved with IVFs
- Was kept NPO and had colonoscopy the following morning
revealing diverticular disease but otherwise normal.
Diverticular disease likely cause of the LGIB.
.
# UTI:
- evidence of UTI on U/A w/ positive nitrites and many bacteria
but on [**3-3**] WBCs on micro. She had no leukocytosis, left shift,
fever, or leukocytosis and so she was not treated intially.
- However, in the setting of tachycardia and some subjective
chills, as well as E. coli growing from the urine, she was
started on Bactrim.
- tachycardia resolved on bactrim, and with restarting CCB as
well as fluids so likely tachycardia was due to combination of
all of the above
.
# venous stasis: chronic nonhealing ulcers. Well known to
podiatry service. Podiatry was consulted and left
recommendations for wound treatment. Also seen by wound care.
Their recommendations included the following:
- Cleanse both legs daily with wound cleanser
- remove any dry/thick skin that easily is removed
- pat dry
- For left leg:
apply aloe vesta moisturizer to intact skin
apply aquacel ag to large ulcer on medial aspect
apply Adaptic to posterior calf
cover with softsorb, wrap with Kerlix
change daily
- For right leg:
apply lac-hytrin 2% lotion to dry skin daily
cover with soft sorb dressings
wrap with Kerlix
change daily
-wrap both legs with ace wrap from above toes to below knees
-float heels off bed surface with pillows
-Wound care also recommended pt be seen by vscular surgery for
evaluation. An appointment for this was scheduled to take place
as an outpt as there were no acute issues in the hospital.
.
# htn: She remained normotensive throughout hospitalization.
Her BP meds were held in the setting of her GI bleed as above
and restarted prior to discharge.
.
# depression: no active issues during admission. She was
continued on her home dose depakote and risperidone.
.
# PPx: Heparin sc TID. No need for PPI given negative NG
lavage.
- holding asa
- fexofenadine in place of loratadine was used in hosp since
loratidine not in formulary but on discharge switched back to
loratidine 10mg daily.
Medications on Admission:
aspirin 81 mg Qday
diltiazem HR 180 mg Qday
Divalproex 250 mg [**Hospital1 **]
risperidone 0.5 mg [**Hospital1 **]
lasix 20 mg qam, 40 mg qpm
loratadine 10 mg Qday
loperamide 2mg [**Hospital1 **] prn loose stool
tylenol prn
multivitamin
Discharge Medications:
1. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
2. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
3. Risperidone 0.25 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
4. loratidine Sig: Ten (10) mg once a day.
5. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
6. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): continue while not ambulatory.
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO qam.
9. Lasix 20 mg Tablet Sig: Two (2) Tablet PO qpm.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) **]
Discharge Diagnosis:
Primary:
# Hematochezia, lowest hct of 28
# Diverticular disease
.
Secondary:
# peripheral vascular disease
# htn
# chronic venous stasis c/b LLE ulcer
# s/p tracheostomy in [**4-/2096**] s/p incarcerated hernia repair and
failure to wean. Decannulated in 12/99.
# Depression: bipolar in nature
# degenerative joint disease
# obesity
# h/o CVA
# incontinence
Discharge Condition:
Stable
Discharge Instructions:
You were admitted and treated for bright red blood in your stool
likely due to diverticuli or small outpouchings seen in your
large intestine during the colonosopy.
.
If you develop recurrent bleeding in your stool, black stools,
fever greater than 101F, chest pain, shortness of breath, or if
you at any time become concerned about your health please
contact your PCP, [**Name10 (NameIs) 18**] at [**Telephone/Fax (3) **] or present to the nearest
ED.
.
Please take your medications as prescribed. No changes were
made to your medications.
.
Please go to your scheduled appointments listed below.
Followup Instructions:
- [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] is aware of your admission and hospital
course and will see you within 1-2 weeks of discharge. If she
has not been in touch with you within that time frame please
call her office at ([**Telephone/Fax (1) 8417**]
- Podiatric medicine: Provider: [**Name10 (NameIs) **] [**Doctor Last Name **], DPM
Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2104-12-18**] 9:40
- Vascular surgery: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2105-1-2**] 9:30
|
[
"707.19",
"296.80",
"518.0",
"585.9",
"041.11",
"V44.0",
"041.4",
"511.9",
"V09.0",
"459.81",
"278.00",
"715.90",
"443.9",
"403.90",
"788.30",
"599.0",
"V12.54",
"562.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.23",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8344, 8414
|
4471, 7262
|
307, 392
|
8817, 8826
|
2907, 4448
|
9473, 10078
|
2246, 2350
|
7549, 8321
|
8435, 8796
|
7288, 7526
|
8850, 9450
|
2365, 2888
|
262, 269
|
420, 1815
|
1837, 2120
|
2136, 2230
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,910
| 182,652
|
6197
|
Discharge summary
|
report
|
Admission Date: [**2109-1-14**] Discharge Date: [**2109-1-31**]
Date of Birth: [**2029-10-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 663**]
Chief Complaint:
Malaise, fever, chills, and L wrist pain
Major Surgical or Invasive Procedure:
Left wrist washout
History of Present Illness:
The patient is a 79 year old gentleman with a history of septic
arthritis of R elbow from S. Aureus, atrial fibrillation, and
spinal stenosis who presented with three days of malaise, fever,
and chills along with L wrist pain. On [**1-12**], the patient had
been in his usual state of health when he experienced chills and
fatigue. Over the next few days he started to experience L wrist
pain that he attributed to arthritis. His malaise worsened and,
on [**1-15**], he had a fever to 103. He presented to his PCP, [**Last Name (NamePattern4) **].
[**First Name (STitle) **]. In the office BP 90/60, the patient also vomited there.
He was noted to have swollen L wrist. Given concern for possible
sepsis he was urgently referred to ED where aspiration of L
wrist was performed and revealed frankly purulent fluid. Seen by
ID and, after blood cultures drawn, given vancomycin and
ceftazidime. SBP 95-105 range. Lactate returned at 5.3, WBC 17.3
with 31 bands-- sepsis protocol started. Pt given 2 L NS and R
IJ was placed. Pt was briefly dyspneic and CVP was 18, thus
further fluids were held Pt subsequently admitted to ICU.
On presentation to ICU pt stated he felt better. He did admit
his appetite had been poor and that he had hardly eaten anything
for three days. He said dyspnea had resolved.
Past Medical History:
1. Paroxsymal atrial fibrillation on amiodarone.
2. Question amiodarone related lung toxicity.
2. Spinal stenosis and sciatica
3. Low back pain - hx of disc herniation at age 35 with surgery
in recent past.
4. Hx of melanoma on R chest s/p extensive right axillary node
dissection in [**2061**]
5. Glaucoma
6. Detached retina
Social History:
Former Chief of Anesthesia for over 20 years at the [**Hospital **]
hospital. His wife died of PBC. He currently lives by himself
and is able to live independently. He gets some support from his
son and daughter who live in the area. The patient has
previously admitted to drinking 0.5 bottles of wine/day almost
daily. Now he says he drinks "occasionally". He quit smoking
over 40 years ago (15 pack years) and denies every using illicit
drugs.
Family History:
-Father - died at age 70 of DM, CVA
-Mother - died at age 85 of CVA
-both son and daughter are healthy
Physical Exam:
VS: T: 101.3 ; BP: 103/48 ; HR: 85 ; RR: 18 ; SaO2: 93% on 2L
Gen: elderly well nourished male with alcohol on his breath
lying on gurney in the ED at a 30 degree angle with NAD.
Eyes: Pupils are equal at 3-4mm, no scleral icterus, no
nystagmus.
Mouth: Oropharynx dry, no lesions.
Neck: Supple, full ROM, JVP flat.
Cor: RR, nl S1S2, sinus on telemetry no murmurs.
Chest: Dry rales at R base, otherwise CTA.
Abd: Soft, NT, ND, minimal bowel sounds.
Ext: No edema, DP +2
Neuro: A+O x3, CN II-XII grossly intact.
MSK: L wrist diffusely swollen and tender. No erythema. Distal
sensation preserved with normal capillary refill. Pain with L
wrist movement, unable to flex or extend fingers from pain.
Pertinent Results:
101
17.3 > 16.0 < 243
49.1
N:65 Band:31 L:2 M:2 E:0 Bas:0
139 101 35
--------------< 152
4.5 21 1.5
Ca: 9.5 Mg: 1.8 P: 3.2
CXR:
Single bedside AP examination labeled "upright at 1725 hours"
with patient lordotically positioned and leaning toward his
right. In comparison with the study dated [**2108-10-2**], the lung
volumes are lower with further progression of the diffuse,
bilateral fine and coarse interstitial opacities. However, there
are now patchy airspace opacities at the medial aspect of both
lung bases, with left basilar subsegmental atelectasis. Allowing
for the factors above, the heart size is not grossly changed,
though there is some prominence of the central pulmonary vessels
with probable small bilateral pleural effusions, and coarsely
calcified pleural plaques are redemonstrated. The left-sided
dual-chamber cardiac pacemaker with lead tips projected over the
RA and RV apex is unchanged, with interval placement of a right
IJ double- lumen central venous catheter reaching the distal
SVC, and no evident pneumothorax (in this position).
Incidentally noted is gaseous distention of the stomach.
IMPRESSION: Complex appearance, likely representing some degree
of pulmonary edema, superimposed on underlying interstitial lung
disease, conceivably related to the patient's presumed
asbestos-exposure, or to drug toxicity. More confluent bibasilar
airspace opacities may relate to be the above (with lower lung
volumes), or represent new pneumonic infiltrates.
XRAY LEFT WRIST:
There are no signs of acute fractures or dislocations. The
patient has abnormal widening of the scapholunate interval
measuring 5 mm consistent with SL ligament injury. There are
degenerative changes seen at the first MCP, first CMC, and
triscaphe joint. A well-corticated density is seen adjacent to
the ulnar styloid likely sequela of prior old trauma or an
accessory ossicle. There is some faint chondrocalcinosis seen in
the radiocarpal joint. The metacarpal head and joint spaces are
preserved.
IMPRESSION:
1. Chondrocalcinosis with abnormal widening of the scapholunate
interval. Findings can be seen with CPPD arthropathy.
2. Degenerative changes most prominent within the first ray.
Brief Hospital Course:
79 yo male pAfib admitted for strep pneumo bacteremia and
infected left wrist now with elevating leukocytosis despite abx
and progressive SOB.
# Septic arthritis: Arthocentesis of the left wrist consistent
with septic joint. Culture later grew out strep pneumo. He was
taken for surgical washout. He was treated with Cetriaxone for
two weeks (last day [**2109-1-29**]) and then follow up with 1 week of
oral Levofloxacin.
# Strep pneumo sepsis: He presented with fever to 103 and was
hypotensive. He was admitted to the ICU because he met SIRS
criteria. He did not need pressors. He was initially put on
Cetazidime and Vancomycin. When the blood grew out strep
pneumococcus, this was changed to Ceftriaxone and treated as
above.
# Atrial fibrillation: He has history of atrial fibrillation and
was maintaining sinus rhythm with amiodarone as outpatient.
During this admission, he went into afib and cardioversion was
successful in keeping him in sinus less than one day. He was
rate controlled with metoprolol and diltiazem and anticoagulated
with Lovenox with bridge to warfarin with a goal INR of [**3-3**].
Amiodarone was later stopped after CT chest demonstrated
progression of his known pulmonary fibrosis presumably secondary
to amiodarone.
#Leukocytosis: After the patient became stabilized from his
initial infection, he developed a persistent leukocytosis with
out fever or other signs of infection. This was temporaly
related to PICC placement, which was subsequently removed.
Shortly thereafter his leukocytosis began to resolve.
Additionally he was begun on oral vancomycin for presumed
c.difficile infection although he has had 3 negative stool
samples. However, he should continue this medication for an
additional 2 weeks.
# Pulmonary fibrosis: During this hospital course, he grew
progressively more short of breath and required supplemental
oxygen. CT chest showed progressive worsening of his pulmonary
fibrosis but no signs of edema or pneumonia. Dr. [**Last Name (STitle) **] from
Pulmonary who follows him as an outpatient was consulted and
felt that this was consistent with progression of his pulmonary
fibrosis due to amiodarone. He will likely need continued home
oxygen therapy. His amiodarone was stopped on [**1-24**].
#Dysphagia: Patient was noted to have worsening coughing during
eating and a video swallow confirmed moderate to severe
aspiration. As the patient was unable to safely consume enough
calories orally, a PEG tube was placed on [**1-27**] in IR with no
complications. Tube feedings were begun with no complications.
He will need continued therapy and follow up to assess if his
dysphagia improves.
# Pseudogout: On joint aspiration the patient was found to have
positive birefringent crystals concerning for pseudogout. He
will need outpatient follow up with rheumatology.
# ETOH abuse: Patient has a known history of ETOH abuse and
there was concern that part of his atrial fibrillation may be
due to an element of mild etoh withdrawal. He was started on a
CIWA scale but did not require any treatment. In addition, after
discussion with his PCP, [**Name10 (NameIs) **] valium was begun for a few
days in hopes that this might better control his rate. This was
subsequently discontinued as it was making the patient more
sedated and his rate was under better control.
.
# Macrocytosis: Pt found to have an elevated MCV, a B12, TSH and
folate were wnl. No further intervention taken and this can be
worked up as an outpatient.
# Glaucoma: Pt was continued on home timolol drops.
Medications on Admission:
1) Amiodarone 100 daily
2) Metoprolol 50 [**Hospital1 **]
3) Aspirin 81 daily
4) Timolol 0.25% one drop both eyes [**Hospital1 **]
Discharge Medications:
1. Ocuvite Tablet Sig: One (1) Tablet PO daily ().
2. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day).
3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Hold for diarrhea.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days: Until [**2109-2-7**].
10. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
11. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Apply
for only 12 hours of the day.
13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
14. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
15. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
16. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
17. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 14 days.
18. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once
Daily at 16).
19. Enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous Q12H
(every 12 hours): Until INR>2.
20. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours): Hold for RR<12 or sedation.
21. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
22. Ultram 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
23. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-30**] Sprays Nasal
TID (3 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
Septic Arthritis
Strep Pneumo Bacteremia
Atrial Fibrillation
.
Secondary
Spinal Stenosis
Discharge Condition:
Hemodynamically stable; afebrile
Discharge Instructions:
You were admitted to the hospital for wrist pain, fever and
chills. You were found to have an infection in your wrist that
also spread to your blood. You were treated with antibiotics and
had the wrist cleaned out in the operating room. You will need
to continue the 1 week course of Levofloxacin.
You were also found to be back in atrial fibrillation. You were
started on heparin and underwent a procedure called
cardioversion to get you back into sinus rhythm, however, you
converted back into atrial fibrillation. You heart rate was then
controlled with medications as you were anticoagulated with
Lovenox (a form of heparin) with a bridge to coumadin which you
will take long term. Your coumadin levels will need to be
monitored.
You wer also found to have an elevated white blood cell count.
You were treated with antibiotics and this returned to [**Location 213**]
levels. You will need to continue these antibiotics while at
rehab.
.
You will need to follow up with
Cardiology: Dr [**Last Name (STitle) 1911**] [**1-31**] at 1:40pm
PCP Dr [**First Name8 (NamePattern2) **] [**2-25**] at 10am
Rheumatology Dr [**Last Name (STitle) 1667**] [**2-21**] at 9:30am
Followup Instructions:
Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 902**]
Date/Time:[**2109-1-31**] 1:40
PCP Dr [**First Name8 (NamePattern2) **] [**2-25**] at 10am
Rheumatology Dr [**Last Name (STitle) 1667**] [**2-21**] at 9:30am
Dr. [**Last Name (STitle) **] [**2-15**] (infectious diseases)
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2109-2-6**] 9:00
Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4506**] NP/DR [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2109-2-6**] 10:00
|
[
"289.89",
"584.9",
"995.92",
"365.9",
"711.03",
"727.05",
"275.49",
"724.00",
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"008.45",
"712.13",
"427.31",
"V10.82",
"515",
"038.0",
"288.60",
"276.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"81.91",
"80.13",
"83.42",
"99.62",
"88.72",
"44.32",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
11448, 11491
|
5616, 9163
|
357, 377
|
11624, 11659
|
3386, 5593
|
12878, 13488
|
2538, 2643
|
9345, 11425
|
11512, 11603
|
9189, 9322
|
11683, 12855
|
2658, 3355
|
276, 319
|
405, 1705
|
1727, 2056
|
2072, 2522
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,188
| 190,512
|
41340
|
Discharge summary
|
report
|
Admission Date: [**2149-5-10**] Discharge Date: [**2149-5-22**]
Date of Birth: [**2080-12-10**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
respiratory arrest, acute COPD exacerbation
Major Surgical or Invasive Procedure:
Intubation and extubation
Central line placement and removal
History of Present Illness:
Ms. [**Known lastname **] is a 68yo F with history of COPD who reportedly had
cough and runny nose and called EMS. She developed dyspnea
while in the ambulance and required LMA for respiratory support.
She became pulseless and CPR was initiated for approximately 30
seconds before she regained spontaneous circulation. No shocks
or medications were administered.
In the ED, patient was emergently intubated with etomidate and
succinylcholine. She was moving all 4 extremities prior to
sedation. She then became hypotensive and was started on
levophed through a R IJ central line. Patient was given
fentanyl/versed for sedation and started on vanc/zosyn. Her EKG
showed sinus rhythm at 77 with cor pulmonale but no ST changes.
The post-arrest team was consulted and recommended against
cooling given short period of pulselessness. Blood cultures
were drawn after initiation of antibiotics, and she received 5
liters of IVF. Vitals on transfer were 74, 141/56 on
0.05mcg/kg/min, 20, AC 450x20, 100%, 5 PEEP.
In the ICU, she was intubated and sedated. Her ICU course was
significant for subsequent extubation, steroids and completion
of antibiotic course. She had no significant delirium following
extubation, but did note persistent dyspnea and hypoxia.
Past Medical History:
COPD
Raynaud's phenomena
Tobacco dependence
Social History:
Lives with husband, they own and run a grocery store/deli.
Patient worked until admission. Known tobacco use long-standing,
current. Denies regular alcohol or illicit drug use.
Family History:
Daughter healthy, lives in area, no lung disease.
Physical Exam:
Admission to ICU
Vitals: T: 98.4 BP: 107/41 P: 80 R: 13 O2: 95% AC
General: Intubated, sedated, not following commands but
withdraws to pain
HEENT: NC/AT, PERRL, sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: Bilateral coarse breath sounds on vent without clear
wheezing or rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: Bilateral hands and feet cool and dusky (history of
Raynaud's), bilateral DP pulses dopplerable, no clubbing or
edema
Discharge examination: (pertinent findings)
Patient 90-92% in 1L NC at rest, 2L with ambulation. Mild
dyspnea with extended conversation.
AxOx3 without agitation, no JVD
Lungs with diffuse scattered rhonchi without wheezes, distant
lung sounds.
CV: regular, normal S1S2
Abdomen benign, positive BS
Ext: No pitting edema.
Pertinent Results:
.
STUDIES:
CXR [**2149-5-10**]:
FINDINGS: Single supine AP portable view of the chest was
obtained.
Endotracheal tube is seen, terminating approximately 4 cm above
the level of the carina. Nasogastric tube is seen, coursing
below the level of the
diaphragm, terminating in the expected location of the stomach.
The lungs are clear relatively hyperinflated, with relative
lucency in the upper lobes, suggesting chronic obstructive
pulmonary disease. No focal consolidation, pleural effusion, or
definite pneumothorax is seen. Two curvilinear opacities
projecting over the left upper lobe and right lung apex are not
present on subsequent imaging at 20:20 the same day. Cardiac and
mediastinal silhouettes are unremarkable.
.
CT [**2149-5-10**]:
IMPRESSION:
1. No acute intrathoracic process.
2. Severe pulmonary emphysema, with multiple nodules and
extensive scarring. Recommend correlation to prior imaging; if
unavailable, followup CT in [**7-6**] months is recommended.
3. Nasogastric tube terminates at the GE junction; recommend
advancement so that it is well within the stomach.
3. Severe atheromatous disease, with probable chronic mesenteric
ischemia.
.
CT HEAD W/O [**2149-5-10**]:
IMPRESSION:
1. No acute intracranial process.
2. Mild paranasal sinus disease.
.
CXR [**2149-5-12**]:
FINDINGS:
There is an endotracheal tube in situ, the tip of which is
approximately 3.5 cm proximal to the carina. The heart and
mediastinal contours are within normal limits. There is no acute
consolidation. No pleural effusion is seen. Coarse lung markings
are seen in addition to hyperinflation suggesting COPD. A
nasogastric tube is noted, the tip of which is below the
diaphragm. There is a right internal jugular central venous
catheter, the tip of which projects over the SVC.
IMPRESSION: No acute consolidation. Support hardware is as
outlined above.
.
CXR [**2149-5-13**]: IMPRESSION: No evidence of pneumonia. Little
interval change.
.
CXR [**2149-5-14**]:
FINDINGS: In comparison with the study of [**5-13**], the endotracheal
tube has
been pulled back to approximately 4 cm above the carina.
Continued
hyperexpansion of the lungs consistent with chronic pulmonary
disease.
Indistinctness of pulmonary vessels suggests some superimposed
elevation of pulmonary venous pressure.
.
MICRO:
BCX [**2149-5-10**]: PENDING
UCX [**2149-5-10**]: NEGATIVE
URINE CULTURE (Final [**2149-5-14**]): NO GROWTH.
.
Legionella Urinary Antigen (Final [**2149-5-11**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
.
SPUTUM CX:
**FINAL REPORT [**2149-5-13**]**
GRAM STAIN (Final [**2149-5-11**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2149-5-13**]):
RARE GROWTH Commensal Respiratory Flora.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE. SPARSE
GROWTH.
Beta-lactamse negative: presumptively sensitive to
ampicillin.
Confirmation should be requested in cases of treatment
failure in
life-threatening infections..
.
**FINAL REPORT [**2149-5-13**]**
Respiratory Viral Culture (Final [**2149-5-13**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final [**2149-5-11**]):
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further
information.
.
SPUTUM CX [**2149-5-12**]:
**FINAL REPORT [**2149-5-15**]**
GRAM STAIN (Final [**2149-5-12**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2149-5-15**]):
RARE GROWTH Commensal Respiratory Flora.
ADMISSION LABS:
[**2149-5-10**] 08:20PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.0
LEUK-NEG
[**2149-5-10**] 08:20PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.014
.
DISCHARGE LABS:
Brief Hospital Course:
HOSPITAL COURSE:
Ms. [**Known lastname **] is a 68yo F with history of COPD here after cardiac
arrest likely in setting of respiratory failure and acidosis. Pt
was cared for in the MICU where she was intubated. Her HD status
was monitored, and she required brief pressors. She was treated
initially with broad spectrum abx given hypotension and concern
for PNA on top of COPD exacerbation. Pt was initially extubated
on HOD#2, but had increasing agitation and did not tolerate
BIPAP and was reintubated. Reintubation was complicated by
hypotension likely [**2-26**] propofol induction, requiring pressors.
Abx were tailored to CTX for haemophilus in the sputum for
planned 10 day course. She was continued on steroids with a
taper. She was re-extubated on HOD#5.
# Post cardiac arrest: She likely had a PEA arrest in setting of
respiratory failure. The post-arrest team was already consulted
in the ER and recommended against cooling given short period of
pulselessness. She was started on levophed for hypotension in
setting of intubation and had dusky extremities but this was in
setting of known Raynaud's and reportedly common for patient.
Patient was started on broad spectrum antibiotic coverage for
possible sepsis. PE was unlikely given her lack of findings on
CTA. MI was unlikely given her reassuring EKG and her elevated
troponin is likely related to myocardial leak from CPR. Serum
and urine tox were remarkable for positive urine benzos but
otherwise negative which suggested against ingestion. Her
lactate and LDH elevations were likely in the setting of
ischemia from arrest. Troponins were negative times three. Her
HD status improved and she was weaned off pressors.
# Respiratory failure/COPD: Her respiratory thought to be
related to underlying infection causing her URI symptoms of
cough and runny nose or COPD exacerbation. Her chest xray and CT
do not show any clear consolidation but her RLL opacity could be
a developing pneumonia or related to aspiration during CPR. She
was extubated the morning following admission and tolerated
bipap for most of the day, however later that evening there was
concern she was not tolerating BIPAP well and was reintubated,
became hypotensive [**2-26**] to propofol required brief levophed, got
more IVF's, bronch showed thick secretions at carina. Added
tobramycin for double pseudomonal coverage. CTX grew out H flu
and her ABX were peeled back to ceftriaxone and CAP. She
completed a course of Azithromycin for COPD exacerbation.
On HOD#5, pt was re-extubated and tolerated this well, and was
able to be weaned to nasal cannula. She was placed on standing
nebs, and transferred to the medicine floors.
On the floor she was started on spirvia daily and continued on
albuterol nebs prn. She was continued on ceftriaxone and
cefpodoxime to complete her 10 day course. She was placed on a
slow prednisone taper. PT evaluated her and felt that she
should go to rehab. She was initially resistant but after doing
poorly with physical therapy, agreed to go to rehab.
Of note her CTA on admission showed sequelae of pulmonary
hypertension and was concerning for severe COPD. The patient
was set up with a pulmonary appointment at [**Hospital1 18**] and will need
formal PFTs. She also should likely have a TTE given concern
for pulmonary hypertension.
# Acute haemophilus pneumonia: Pt with thick secretions from
bronch as above. Sputum Cx prior to reintubation grew
Haemophilus. He was treated with ceftriaxone and discharged home
to complete a 10 day course with cefpodoxime.
# Hypotension: Pt had hypotension with reintubation, thought to
be most likely [**2-26**] propofol. She required brief pressors, which
were weaned off. This resolved completely on HOD#4.
# Atrial flutter with RVR: Pt had runs of aflutter, likely [**2-26**]
COPD, with rates in 150s, requiring Dilt while on CPAP. Once pt
reintubated, this resolved. Pt was in sinus rhythm prior to
transfer to medicine floors. She was started on ASA 325 mg
daily for CHADS2 score of 2 and started on diltiazem for BP and
rate control (patient likely to go back into a.fib at some point
in the future given right heart strain on CT/plumonary
hypertension).
# Transaminitis: Most likely [**2-26**] shock liver in setting of PEA
arrest. LFT's were trended, and improved prior to transfer to
medicine floor.
# HTN: Pt became quite hypertensinve in ICU to SBP 180s in the
MICU. Captopril was initially started and transitioned to
lisinopril 40 mg daily. Diltiazem was started and uptitrated to
diltiazem 360 mg daily. Chlorthalidone 25 mg daily was started.
She has PCP follow up early next week for blood pressure check.
# Severe atheromatous disease seen on CTA: Concerning for
vascular disease. Lipids were checked and were not very
elevated, however she was started on simvastatin 40 mg daily due
to the findings on CT. HgbA1c was checked and was 6.2%.
Transitions of care:
- Patient will need repeat chest CT in [**7-6**] months due to
multiple nodules seen on chest CT here.
- Check labs in 2 weeks for monitoring of
creatinine/electrolytes on new BP meds.
- Check LFTs in 6 weeks on new statin.
- Follow BP and uptitrate/add more antihypertensives as
necessary
- The patient noted that she had not sought regular preventive
care in quite some time, and was aware of the importance of
follow-up with a new provider following her rehabilitation stay.
Medications on Admission:
albuterol prn
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*1*
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*1 Cap(s)* Refills:*2*
4. diltiazem HCl 360 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO once a day.
Disp:*30 Capsule, Extended Release(s)* Refills:*2*
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. prednisone 10 mg Tablet Sig: see taper below Tablet PO once a
day for 7 days: take 20 mg (2 tablets) for 2 days. Then take 10
mg (1 tablet) for 2 days. Then take 5 mg ([**1-26**] tablet) for 2
days.
.
Disp:*7 Tablet(s)* Refills:*0*
7. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One (1)
Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
8. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. chlorthalidone 15 mg Tablet Sig: One (1) Tablet PO once a
day.
10. Lab work
Please check chemistries, BUN, and Creatinine on [**2149-5-23**] and one
week afterward to assess tolerance of anti-hypertensive
medications.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] Center
Discharge Diagnosis:
Primary:
H. flu pneumonia
Hypercarbic respiratory failure
COPD exacerbation
Atrial fibrillation with rapid ventricular response
Hypertension
Diabetes Type II
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital due to difficulty breathing
from a pneumnia and an exacerbation of your chronic obstructive
pulmonary disease (COPD). While you were being transferred to
the hospital there was concern your heart was not able to pump
blood effectively to the rest of your body for a very short
period of time. When you arrived in the ED you were intubated
(a breathing tube was placed).
While in the ICU you were extubated, but then reintubated due to
difficulty with your breathing. Your pneumonia and COPD
exacerbation were treated and you were able to be extubated.
You will need pulmonary function tests and an echo of your heart
as an outpatient.
You were diagnosed with high blood pressure (hypertension) and
started on multiple medications to control your pressure.
On the chest CT on admission you were seen to have multiple
nodules of unknown significance. It is recommended that you
undergo a repeat CT scan of the chest in [**7-6**] months to check
for change in the nodules.
You will need labs checked within a couple of days after you are
discharged. It is also important that you acapella device to
help your breathing.
Medication changes:
START prednisone taper:
- take 20 mg (2 tablets) for 2 days.
- Then take 10 mg (1 tablet) for 2 days.
- Then take 5 mg ([**1-26**] tablet) for 2 days.
START spiriva daily (this treats your COPD)
START aspirin 325 mg daily
START lisinopril 20 mg daily (this treats your high blood
pressure)
START dilitiazem 360 mg daily (this treats your high blood
pressure)
START chlorthalidone 15 mg daily (this treats your high blood
pressure)
START simvastatin 40 mg daily (this treats your cholesterol)
Continue using albuterol 2 puffs every 4 hours as needed for
shortness of breath.
Followup Instructions:
You will need to establish care with a primary doctor and see a
pulmonary specialist in follow up. It is important that you
keep th following appointments:
Name: [**Location (un) **],[**Last Name (un) **] K.
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **]
Address: [**Location (un) **], [**Apartment Address(1) 6850**], [**Location (un) **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 3329**]
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2149-6-4**] at 3:40 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2149-6-4**] at 4:00 PM
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
Completed by:[**2149-5-23**]
|
[
"427.5",
"427.32",
"487.0",
"276.4",
"305.1",
"443.0",
"401.9",
"491.21",
"458.9",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.91",
"96.04",
"38.97",
"33.24",
"99.60"
] |
icd9pcs
|
[
[
[]
]
] |
14207, 14257
|
7431, 7431
|
349, 411
|
14459, 14459
|
3017, 7151
|
16389, 17407
|
1977, 2028
|
12885, 14184
|
14278, 14438
|
12847, 12862
|
7448, 12321
|
14610, 15771
|
7408, 7408
|
2043, 2998
|
15791, 16366
|
266, 311
|
439, 1700
|
7167, 7390
|
14474, 14586
|
12342, 12821
|
1722, 1767
|
1783, 1961
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,683
| 175,941
|
49312
|
Discharge summary
|
report
|
Admission Date: [**2129-3-5**] Discharge Date: [**2129-3-11**]
Date of Birth: [**2046-10-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1171**]
Chief Complaint:
transfer from [**Hospital1 1516**] service for diuresis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an 82 year-old gentleman with a history of CAD s/p CABG,
systolic HF, and PVD s/p numerous revascularizations who
presented with worsening edema, SOB and LLE cellulitis. Patient
is a poor historian, but per report from wife, he recently
completed an outpatient course of antibiotics (name unknown) and
was noted to have pain and darkening of the L 1st toe over the
last week. No c/o fevers or chills. He has had weight gain over
the past week and has felt SOB at rest and on exertion, with
ankle edema, orthopnea and PND, but no CP. Of note, he was
admitted for CHF exacerbation and similar toe complaints
12/[**2127**].
.
In ED, VS T 96.7, BP 100/39, HR 98, 18, 100%RA. Pt was noted to
be somnolent. Pt received vanco and pip-tazo for dry
gangrene/osteo after two sets of blood cultures were obtained.
He was noted to have an elevated BNP and troponin and admitted
to cardiology for further eval and mgmt. He additionally
received 200cc NS bolus prior to transfer to the floor.
.
On the floor, he was to be started on a lasix gtt for diuresis,
but given SBP in the 80s, he was transferred to the CCU for
closer monitoring for diuresis.
.
On arrival to the CCU, patient is drowsy, but in no acute
distress and denies current foot pain. He currently feels SOB
and has a dry cough. He notes having intermittent palpitations
and lightheadedness in the past, but denies these sx currently.
Also denies abd pain.
Past Medical History:
# CAD: IMI [**2097**] s/p 2V CABG, s/p redo 5V CABG
# Chronic systolic HF: ischemic cardiomyopathy, LVEF 30%
# Atrial fibrillation on coumadin
# DM type 2: c/b peripheral neuropathy
# CKD: baseline creatinine 1.5-2.5
# hyperlipidemia
# HTN
# Anemia: baseline HCT mid 20s
# COPD: no PFTs recently
# PVD: s/p redo fem-fem right to AK-popliteal with 8-mm PFT and
right 2nd toe amputation on [**2123-7-30**]; s/p right femoral
BK-popliteal bypass with PTFE on [**2125-5-30**]. L Fem-[**Doctor Last Name **] w/ PTFE
and 3rd L toe amputation [**9-5**]
# s/p Aortobifemoral bypass graft for abdominal aortic
aneurysm [**2118**]
# colon polyps s/p polypectomy
# internal hemorrhoids
Social History:
Was an officeworker (accountant) for International Harvester.
Lives with his wife in [**Name (NI) 577**]. He denies current tobacco use.
He quit smoking at age 51. He smoked for 40yrs (since age 11),
about three packs per day (120 pack/yr hx). He reports social
drinking, perhaps two cocktails per week when out for dinner. He
denies illegal drug use or prescription drug abuse.
.
Family History:
No significant family hx of cancer or heart disease. Father died
in 70s from MI, had [**Name (NI) 2320**]. One brother had [**Name (NI) 2320**], died in 50s.
Sister died at age 12 of rheumatic fever.
Physical Exam:
VS: T 97.0 BP 119/53 P 92 RR 18 SpO2 100% 2L
GEN: Drowsy, oriented to hospital, year "19..." (best response).
HEENT: NCAT, PERRL, no icterus, MM dry.
NECK: Supple, JVP 15-20cm
CV: Irregular rate and rhythm, nl S1 and S2, no m/r/g
LUNGS: Decreased BS B/L, bibasilar crackles, expiratory wheezes
b/l
ABD: NABS. Soft, distended, NT.
EXT: 3+ pitting edema b/l with erythema of BLE (L >R). Left 1st
toe with dark hematoma & gangrenous skin with blister on dorsum
of toe. Open wound at distal tip is dry and without drainage.
Multiple toe amputations.
PULSES: 1+ DP pulses bilat, PT pulses dopplerable.
Pertinent Results:
[**2129-3-5**] 07:20PM CK(CPK)-44
[**2129-3-5**] 07:20PM CK-MB-NotDone cTropnT-0.21*
[**2129-3-5**] 04:32PM TYPE-ART PO2-73* PCO2-42 PH-7.50* TOTAL
CO2-34* BASE XS-7 INTUBATED-NOT INTUBA
[**2129-3-5**] 04:32PM LACTATE-0.9
[**2129-3-5**] 11:08AM COMMENTS-GREEN TOP
[**2129-3-5**] 11:08AM LACTATE-1.3
[**2129-3-5**] 11:00AM GLUCOSE-80 UREA N-71* CREAT-1.4* SODIUM-135
POTASSIUM-3.8 CHLORIDE-94* TOTAL CO2-32 ANION GAP-13
[**2129-3-5**] 11:00AM estGFR-Using this
[**2129-3-5**] 11:00AM CK(CPK)-45
[**2129-3-5**] 11:00AM cTropnT-0.23*
[**2129-3-5**] 11:00AM CK-MB-NotDone proBNP-8569*
[**2129-3-5**] 11:00AM WBC-10.4 RBC-3.27* HGB-8.7*# HCT-26.0*
MCV-80* MCH-26.6* MCHC-33.4 RDW-18.3*
[**2129-3-5**] 11:00AM NEUTS-78.2* LYMPHS-10.4* MONOS-6.3 EOS-4.4*
BASOS-0.7
[**2129-3-5**] 11:00AM PLT COUNT-408
[**3-5**] CXR: 1. Retrocardiac opacity is concerning for pneumonia.
Probable small left pleural effusion.
2. Moderate cardiomegaly with no definite pulmonary edema.
[**3-5**] Foot Xray 1. Interval amputation of the left first digit
with irregularity of the amputation site and overlying soft
tissue ulcer. Osteomyelitis cannot be excluded in this location.
2. Increasingly poor visualization of the left fifth MTP joint,
which may be due to disuse osteopenia; however, again
osteomyelitis cannot be excluded.
3. Interval amputation of the right third digit.
Given the severe diffuse background osteopenia, if there is
continued clinical concern for osteomyelitis and it will change
clinical management, an MRI of is recommended.
[**3-7**] Echo: The left and right atrium are moderately dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is mildly dilated. There is severe regional left
ventricular systolic dysfunction with inferior and inferolateral
thinning/akinesis and hypokinesis of the anterior septum and
anterior wall. The apex and remaining segments contract well
(LVEF = 25%).The right ventricular cavity is moderately dilated
with mild free wall hypokinesis. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
IMPRESSION: Symmetric left ventricular hypertrophy with cavity
dilation and extensive regional systolic dysfunction c/w
multivessel CAD. Moderate pulmonary arteyr systolic
hypertension. Moderate tricuspid regurgitation. Mildly dilated
ascending aorta.
Compared with the prior study (images reviewed) of [**2128-11-17**],
the left ventricular cavity is slighly larger and anterior and
anteroseptal dysfunction is new c/w interim ischemia.Overall
systolic function is more depressed.
Brief Hospital Course:
A&P: 82 yo male with a hx of CAD s/p CABG, systolic HF, and PVD
presents with acute decompensated HF with LLE cellulitis and
infection of wound in distal forefoot.
.
# Acute on chronic systolic HF, EF 20-30%: Patient presented
with significant volume overload on exam and had a positive
heart failure ROS. BNP elevated to 8569. Unclear precipitant,
but possible etiologies include Na intake, hypertension,
ischemia, or worsening valvular dysfunction. [**Name (NI) 103331**] pt with
120mg IV furosemide and started gtt at 10mg/hr. He diuresed 1-2L
net negative daily and was continued on PO metolazone. Echo was
consistent with worsening EF and interim ischemia. His
lisinopril and carvedilol were continued with careful
observation of BPs. Patient's lasix gtt was uptitrated to
20mg/hr with continued improvement in urine output, hypoxia and
symptoms. His blood pressures improved with diuresis and were
stable.
.
# LLE ulcers and celllulitis: Started on empiric vanc and
pip-tazo per vascular recs. Vascular opted not to intervene
surgically. He remained afebrile with blood cultures negative to
date. At discharge, he was transitioned to TMP-SMX for an
additional 14 days.
.
# Pulmonary opacity: Retrocardiac opacity on CXR concerning for
PNA. Patient had a nonproductive cough, but no fevers. This was
felt to be well covered by his concurrent 7d course of
vancomycin and pip-tazo as mentioned above.
.
# CAD: S/p CABG [**10-5**]. Trop-T currently .23 -> .21 (baseline
troponin .16-.23). MB negative. No new ischemic changes noted on
EKG. Continued on ASA, rosuvastatin, carvedilol.
.
# Atrial Fibrillation: Remained in afib with rate well
controlled. Patient not on warfarin anticoagulation due to
history of bilateral psoas hematomas [**1-6**]. Continued carvedilol
and ASA. Monitored on tele without events.
.
# CKD: Creatinine initially 1.4 (baseline 1.5-2.5). Creatinine
trended up with diuresis but with good urine output however he
was still at his baseline and likely it was falsely low on
admission bc of hypervolemia.
.
# Anemia: Hct 26, with baseline mid 20s. Continue erythopoeitin.
Hct monitored daily.
Medications on Admission:
1. Fluticasone-Salmeterol 250-50 mcg inh [**Hospital1 **]
2. Aspirin 325 mg daily
3. Rosuvastatin 10 mg DAILY
4. Senna 8.6 mg [**Hospital1 **] PRN
5. Docusate Sodium 100 mg [**Hospital1 **]
6. Multivitamin DAILY
7. Insulin Glargine 8 units SC QHS
8. Oxycodone-Acetaminophen 5-325 mg Q8H PRN
9. Carvedilol 3.125 mg [**Hospital1 **]
10. Metolazone 5 mg [**Hospital1 **]
11. Lisinopril 2.5 mg DAILY
12. Trazodone 25 mg QHS PRN
13. Torsemide 80 mg [**Hospital1 **]
14. Epoetin Alfa 4,000 unit SC QMOWEFR
15. Hydroxyzine HCl 25 mg [**Hospital1 **] PRN itching
16. Humalog sliding scale
Discharge Medications:
1. Rosuvastatin 5 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.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
9. Insulin Glargine 100 unit/mL Cartridge Sig: Eight (8) units
Subcutaneous at bedtime.
10. Insulin Lispro 100 unit/mL Cartridge Sig: as directed per
sliding scale Subcutaneous four times a day.
11. Metolazone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) unit
Injection QMOWEFR (Monday -Wednesday-Friday).
13. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every eight (8) hours as needed for pain.
16. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1)
Recon Soln Intravenous once for 1 doses: Administer 6hrs after
last dose received at [**Hospital1 18**].
17. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO twice a day for 14 days.
18. Torsemide 20 mg Tablet Sig: Four (4) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] of [**Location (un) 583**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Acute on Chronic Systolic Congestive Heart Failure
2. Peripheral Vascular Disease
3. Hypotension
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted to the hospital for treatment of your heart
failure. You were given medications to help remove fluid. Upon
your discharge from the hospital, your symptoms were much
improved.
.
We have made the following changes to your medications:
Started bactrim, an antibiotic for your foot infection.
You will receive one more dose of zosyn, an antibiotic for
pneumonia.
Lowered your aspirin dose to 81mg daily due to some mild
bleeding.
.
Please follow-up with your primary cardiologist Dr.[**Name (NI) 17483**]
on [**2129-4-1**] at 9:00am on [**Hospital Ward Name 23**] [**Location (un) 436**].
.
Please follow up with Dr. [**Last Name (STitle) 1391**] as needed for your leg
ulcers.
.
If you develop any of the following, chest pain, shortness of
breath, cough, fever, chills, lightheadness, nausea, vomiting,
or decrease in urine output, please call your doctor or go to
your local emergency room.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2L/day
Followup Instructions:
Please follow-up with your primary cardiologist Dr.[**Name (NI) 17483**]
on [**2129-4-1**] at 9:00am on [**Hospital Ward Name 23**] [**Location (un) 436**].
.
Please follow up with Dr. [**Last Name (STitle) 1391**] as needed for your leg
ulcers.
Completed by:[**2129-3-11**]
|
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21,202
| 100,711
|
30387
|
Discharge summary
|
report
|
Admission Date: [**2147-1-27**] [**Year/Month/Day **] Date: [**2147-2-12**]
Date of Birth: [**2090-7-16**] Sex: M
Service: MEDICINE
Allergies:
Cefepime / Cipro Cystitis
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Cough, malaise, hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
56 year old man with a h/o AML s/p allo SCT in [**2143-6-16**] c/b
chronic skin and pulmonary GVHD treated with prednisone 10mg
daily. He reports 5-6 days of URI symptoms, myalgias, cough
productive of yellow sputum, decreased appetite, and poor PO
intake. No fevers, though he has been taking tylenol. He
presented to heme/onc clinic today and reported headache and
nausea with improved after 1L NS. He was afebrile but hypoxic to
90% on RA, which improved to 94% on 2L. Nasal swab and blood
cultures were sent. CXR was negative. He was given
vancomycin/aztreonam (due to cefepime allergy) and admitted for
further workup.
.
O2 sats were in the mid-80s on RA so he was placed on nasal
cannula and then shovel mask. 6pm ABG was: 7.46/37/69. Lactate
1.1.
.
Overnight pt became more hypoxic and tachypnic. Febrile to
101.8. Azithro was added to his abx. Chest CT [**First Name9 (NamePattern2) 5692**] [**Last Name (un) 22975**] tree
[**Male First Name (un) 239**] opacities and concern for brochiolitis/pneuonitis. BMT
wanted to give IVIG due to low IgG, but pt was too hypoxic.
Eventually 86% on NRB. [**Hospital Unit Name 153**] was called. Pt given albuterol x 1,
and CXR taken. Pt c/o resp fatigue. Transfered to ICU.
.
ROS:
(+) As noted above.
(-) No current chest pain, palpitations, SOB, abdominal pain,
N/V/D.
Past Medical History:
# Pulmonary embolism x2 ([**2143**] and dx [**5-/2146**] in RML and RLL): on
warfarin
# Acute myeloid leukemia:
- [**3-/2143**]: diagnosed
- [**6-/2143**]: underwent a matched unrelated allogeneic stem cell
transplant.
- post-transplant course c/b bx-proven GVHD of the liver and an
intermittent skin rash, s/p management with cyclosporine,
mycophenolate, rituximab, and currently, steroids.
# type 2 DM: steroid-induced
# hyperlipidemia
# bilateral hip AVN
# HTN
# nephrolithiasis: s/p lithotripsy and previous nephrostomy tube
and emergent surgery to repair ureteral damage
# BCC s/p excision
# SCC left cheek, s/p Mohs' [**5-/2144**]
# multiple back surgeries: L5-S1 surgery x 3, and cervical spine
fusion (bone graft, no hardware)
# anterior cervical diskectomy and instrument arthrodesis at
C5-C6 and C6-C7 for degenerative cervical spondylitic disease
with spinal cord compression and foraminal stenosis at C5-C6 and
C6-C7 [**2-/2144**]
# chronic numbness, neuropathic pain in left upper extremity
# multilevel compression fractures T11, T12, L1 and mild
compression L3 and L4
# OSA: refused biPAP at home
Social History:
Lives with his wife, and son. [**Name (NI) **] is retired, worked as a [**Company 22957**]
technician
Tobacco - 40 pk year hx, quit 5 yrs ago.
EtOH - denies
Drug use - denies.
Family History:
Mother died suddenly in her 70s.
Father died of unknown cancer.
One sister has thyroid cancer.
One brother has diabetes.
One sister has [**Name (NI) 5895**].
Physical Exam:
Admission physical exam
Vitals: 101.8 132/88 109 24 91% NRB FS 127
General: A&Ox3 but appears SOB, speaking full sentences
HEENT: dry MMM, clear OP, no scleral icterus
Neck: Supple, no masses
Lungs: Coarse breath sounds througout, no wheezes.
CV: Regular, nml S1/S2, no murmurs.
Abdomen: Soft, NT, ND, +BS
Extrem: Hands and feet warm and well perfused, no cyanosis, 2+
pedal pulses, no edema.
Neuro: CN grossly intact, strength and sensation grossly intact.
[**Name (NI) **] physical Exam:
Please refer to daily progress note.
Pertinent Results:
ICU Admission Labs:
pH 7.45, pCO2 38, pO2 50 HCO3 27 from clotted sample
pH 7.42 pCO2 40 pO2 75 HCO3 27, on face mask 100%
Lactate:1.4
Ca: 8.7 Mg: 2.0 P: 2.7
ALT: 22 AP: 94 Tbili: 0.3
AST: 25 LDH: 292
MCV 108
wbc 3.1
plts 158
hct 41.9
N:79 Band:3 L:9 M:8 E:0 Bas:1
MB: 2 Trop-T: <0.01
================================================================
Pertinent Labs:
[**2147-1-27**] 11:15AM BLOOD IgG-61* IgA-19* IgM-15*
[**2147-1-27**] 11:15AM BLOOD CK-MB-2 cTropnT-<0.01
[**2147-1-27**] 09:57PM BLOOD CK-MB-2 cTropnT-<0.01
[**2147-1-28**] 06:00AM BLOOD CK-MB-2 cTropnT-<0.01
[**2147-1-28**] 11:30AM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-223*
[**2147-1-28**] 10:50AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN- 0.1
[**2147-1-28**] 10:50AM BLOOD B-GLUCAN- <31 pg/mL
[**2147-1-29**] 04:30AM BLOOD PT-37.8* PTT-40.1* INR(PT)-3.9*
[**2147-1-30**] 04:04AM BLOOD PT-44.7* PTT-39.4* INR(PT)-4.8*
[**2147-2-5**] 02:58AM BLOOD IgG-523*
[**2147-2-9**] 05:54AM BLOOD Gran Ct-5040
[**2147-2-10**] 06:30AM BLOOD LD(LDH)-240
================================================================
Labs on [**Month/Day/Year **]:
[**2147-2-12**] 06:00AM BLOOD WBC-6.0 RBC-2.76* Hgb-10.0* Hct-29.4*
MCV-106* MCH-36.3* MCHC-34.1 RDW-16.5* Plt Ct-215
[**2147-2-12**] 06:00AM BLOOD PT-19.6* PTT-25.7 INR(PT)-1.8*
[**2147-2-12**] 06:00AM BLOOD Glucose-167* UreaN-14 Creat-1.0 Na-140
K-3.8 Cl-99 HCO3-34* AnGap-11
[**2147-2-12**] 06:00AM BLOOD Calcium-8.4 Phos-3.2 Mg-1.9
================================================================
Microbiology:
[**2147-1-27**] 12:00 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT [**2147-1-30**]**
Respiratory Viral Culture (Final [**2147-1-30**]):
TEST CANCELLED, PATIENT CREDITED.
Refer to respiratory viral antigen screen and respiratory
virus
identification test results for further information.
Respiratory Viral Antigen Screen (Final [**2147-1-30**]):
THIS IS A CORRECTED REPORT.
Positive for Respiratory viral antigens.
PREVIOUSLY REPORTED AS.
Negative for Respiratory Viral Antigen [**2147-1-28**].
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
REPORTED BY PHONE TO [**Doctor Last Name **] FOREST AT 1135 [**2147-1-30**].
Respiratory Virus Identification (Final [**2147-1-30**]):
REPORTED BY PHONE TO S. FOREST 11.35A [**2147-1-30**].
POSITIVE FOR INFLUENZA A VIRAL ANTIGEN.
Viral antigen identified by immunofluorescence
[**2147-1-28**] 11:17 am CMV Viral Load (Final [**2147-1-31**]): CMV DNA not
detected.
[**2147-2-3**] 4:07 am URINE Legionella Urinary Antigen (Final
[**2147-2-3**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
[**2147-2-5**] 6:10 pm SPUTUM Source: Induced.
GRAM STAIN (Final [**2147-2-5**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN CLUSTERS.
RESPIRATORY CULTURE (Final [**2147-2-7**]):
HEAVY GROWTH Commensal Respiratory Flora.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2147-2-6**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Preliminary):
YEAST.
[**2147-2-6**] 8:21 am Influenza A/B by DFA
Source: Nasopharyngeal swab.
**FINAL REPORT [**2147-2-6**]**
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2147-2-6**]):
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2147-2-6**]):
Negative for Influenza B.
================================================================
Imaging
CTA chest [**1-28**] 1. Bibasilar bronchiectasis, unchanged compared
with yesterdays examination with mulktilobar peribronchovascular
ground-glass opacity with a tree-in-[**Male First Name (un) 239**] configuration. This
pattern is nonspecific infectious or inflammatory, and
consistent with small airways infection, atypical infections
including fungal infection such as aspergillosis. 2. There is
no pulmonary embolism.
Echocardiography [**1-30**]: Poor image quality. The left atrium is
normal in size. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. There is no ventricular septal defect.
The right ventricular cavity is mildly dilated with normal free
wall contractility. The ascending aorta is mildly dilated. The
aortic valve is not well seen. There is no aortic valve
stenosis. No aortic regurgitation is seen. No mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
Brief Hospital Course:
56M with h/o AML s/p allo SCT c/b chronic skin/pulmonary GVHD,
who presented to clinic with URI symptoms, myalgias, and
decreased PO intake and was found to be hypoxic, admitted on
[**2147-1-27**] and discharged on [**2147-2-12**].
# Hypoxia: On admission was hypoxic to 90% on RA, febrile and
w/o leukocytosis then rapidly developed more profound hypoxia on
the floor. On transfer to the ICU required 100% non rebreather
mask. Underwent CTA which demonstrated multifocal tree-[**Male First Name (un) 239**]
opacities consistent with bronchiolitis and ruled out PE. Nasal
swab DFA Was positive for influenza. His high oxygen demand was
thought to be multifactorial with viral
bronchiolitis/pneumonitis and possibly exacerbation of
underlying chronic pulmonary GVH. Other contributing mechanisms
were atelectasis, under-recruitment and sleep apnea as evidenced
by his improved oxygenation with non-invasive positive pressure
ventilation. Significant Heart Failure was ruled out per [**Male First Name (un) 72257**] and
normal echocardiography. Patient was treated with Tamiflu 150mg
[**Hospital1 **] and will complete 10 days of treatment on day of ICU
[**Hospital1 **] (this increased dose and prolonged dose is as per
recent guidelines for Flu treatment in BMT patients). D/t to his
high risk of superinfection as well as possible LLL infiltrate
he was also covered with Abx: Vanco+Aztereonem+Azithro were
started on [**1-27**], on [**2-2**] aztreonem was changed to meropenem for
more wide spectrum coverage. Azithromycine was intially given
[**Date range (1) 72263**] and then restarted on [**2-2**] and continued untill
[**2-5**] when urine legionella returned neg. On day of ICU
[**Month/Year (2) **] patient is thus on day 11 of Vanco and day 5 of
Meropenem. Patient's home prednsione dose of 10mg daily was
increased to 40mg daily for suspected Acute on chronic pulmonary
GVHD, this was reduced back to home dose a day prior to ICU
[**Month/Year (2) **]. IVIG was given on [**1-30**] for hypogammaglobulinemia and
influenza infection without complications. Acyclovir and Bactrim
prophylaxis were continued. Patient continued to require 60-80%
of Oxygen throughout most of his ICU stay which we were able to
wean to 50% on non-invasive ventilation, but patient did not
tolerated this due to discomfort from the mask. Over the final
24h of his ICU stay his oxygemnation improved remarkably and on
ICU discharged O2 requirement is down to 4L through nasal canula
with Saturations >92%. He was then transferred to the floor
with gradual improvement of his oxygenation as he completed the
antiviral ([**2-9**], 10 day course) and antibiotics ([**2-11**], 10 day
course). He declined CPAP on the floor. His O2Sat remained
stable and he was discharged with home oxygen. He was
instructed to have follow up appointment with his doctor to
determine further need for oxygen requirement as his pneumonia
improves.
# AML: s/p SCT ([**6-/2143**]), c/b chronic GVHD of skin/lungs.
Patient was on higher dose of prednisone while in the ICU which
was tapered back to home dose of 10 mg by the time of transfer
from ICU to floor. He remained on home prednisone and ID
prophylaxis with acyclovir and Bactrim.
# Hypogammaglobulinemia. He received 0.4g/kg of IVIG on [**1-30**].
IgG on [**2-5**] improved to 523. No additional IVIG was given. His
level can be monitored in the outpatient setting.
# H/o PE: Patient was intially supertheraputic d/t azithromycin
therapy, recieved vitamin K and warfarine was held. He then
became undertheraputic and was bridged with Lovenox. Warfarin
was restarted on [**2-3**] at 5mg daily, INR is 2.1 on day of ICU
[**Month/Year (2) **] and Lovenox was discontinued. He continued with 5 mg
warfarin with INR beteween 2.0-2.3 until [**2147-2-11**] when INR
level dropped to 1.8 and he received a total of 7 mg warfarin on
the evening of [**2147-2-11**] with INR still at 1.8. He was
instructed to take 7.5 mg of warfarin on Sunday and 5 mg of
warfarin on [**Year (4 digits) 766**] with lab on Tuesday in the outpatient
setting, so that his INR can be followed up by his doctor.
Adjustment of his warfarin is likely given recent
discontinuation of antibiotics.
# Type 2 DM. Because of his poor po intake initially, NPH was
held. As his appetite improved, his insulin was readjusted to
10 unit NPH [**Hospital1 **] and then to 12 unit NPH [**Hospital1 **] with insulin sliding
scale. Patient reports that his home dose insulin is 12 units
and not 10 units [**Hospital1 **]. He was discharged on home dose NPH.
# Hypertension. He continued with home metoprolol tartrate 12.5
mg [**Hospital1 **] as at home.
# Hyperlipidemia. He continued with home atorvastatin 20 mg
daily.
# Previous EKG changes: Early in ICU course patient noted to
have transient lateral/posterior ST depressions in V4-V6, I and
AvL. With CE x 3 neg. and No CP. This was likely demand ischemia
in this patient with multiple coronary risk factors but no known
CAD. He continued statin and beta blocker. Consider outpatient
stress test.
# FEN. Patient refused a diabetic diet and preferred regular
diet while on the floor.
# Access: PICC while in the hospital.
# Code status: Full Code, ICU consent done with wife/HCP [**Name (NI) 4457**], h
[**Telephone/Fax (1) 72264**], c-[**Telephone/Fax (1) 72265**]
Medications on Admission:
MEDICATIONS:
- Acyclovir 400mg PO TID
- Atorvastatin 20mg daily
- Budesonide 3mg TID
- Folic acid 1mg daily
- Gabapentin 300mg QHS
- Oxycodone ER 40mg Q8h
- Hydromorphone 4mg; 0.5-1 tablet daily prn
- NPH 10units [**Hospital1 **]
- Humalog SS
- Metoprolol tartrate 12.5mg [**Hospital1 **]
- Pantoprazole 40mg [**Hospital1 **]
- Prednisone 10mg daily
- Bactrim 400mg-80mg Tablet daily
- Warfarin 2.5mg alternating with 5mg daily
- Calcium carbonate 648mg TID
- Cholecalciferol 1000unit daily
.
ALLERGIES:
- Cefepime
- Cipro
[**Hospital1 **] Medications:
1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
5. acyclovir 400 mg Tablet Sig: One (1) Tablet PO twice a day.
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. warfarin 5 mg Tablet Sig: 0.5-1 Tablet PO Once Daily at 4 PM:
Please take 1.5 tablets (7.5 mg) on Sunday and then take 1
tablet (5 mg) daily until your INR is above 2. Further dosage
adjustment per your healthcare provider.
10. calcium carbonate 648 mg Tablet Sig: One (1) Tablet PO three
times a day.
11. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
12. budesonide 3 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO three times a day.
13. Insulin Sliding Scale
Use Humalog insulin sliding scale as you have been at home.
Dosage per your healthcare [**Provider Number 72266**]. oxycodone 40 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q8H (every 8 hours).
15. hydromorphone 4 mg Tablet Sig: 0.5-1 Tablet PO once a day as
needed for pain.
16. vitamin B12
Injection per month, dosage per your healthcare [**Provider Number 72267**]. Insulin NPH
10-12 units twice a day.
Dosage adjustment per your healthcare [**Provider Number 72268**]. Home Oxygen
Continuous oxygen 2-3L flow per minute via nasal cannula.
Pulse dose for portability.
For pnuemonia.
19. Outpatient Lab Work
Please have a PT and INR checked on Tuesday, [**2147-2-14**], and have
the results faxed or called in to your PCP's office (Dr. [**Last Name (STitle) 1683**].
Phone [**Telephone/Fax (1) 22609**], Fax [**Telephone/Fax (1) 22611**].
[**Telephone/Fax (1) **] Disposition:
Home With Service
Facility:
[**Location (un) **] oxygen
[**Location (un) **] Diagnosis:
Primary diagnosis:
- Influenza A pneumonia
Secondary diagnoses:
- Chronic graft versus host disease- Lung and Skin
- Type 2 Diabetes
- History of pulmonary embolism
[**Location (un) **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
[**Location (un) **] Instructions:
Dear Mr. [**Known lastname 47367**],
It was a pleasure to take care of you at [**Hospital1 827**].
You were admitted to the hospital for cough and increased
trouble with breathing. In the hospital, it was found that you
have influenza pneumonia. Because of your increased oxygen use,
you were transferred to the intensive care unit for close
monitoring. You were treated with an antiviral for the flu as
well as antibiotics for possible bacterial pneumonia as well.
You completed the course of the antiviral and antibiotics while
in the hospital.
Please note the following changes in your medications:
- Please START supplemental oxygen at 2-3L/min, continuously,
until your pneumonia and shortness of breath have resolved. Your
doctors [**Name5 (PTitle) **] [**Name5 (PTitle) **] [**Name5 (PTitle) **] when you can stop using oxygen.
You will need to have your INR level checked on Tuesday, [**2147-2-14**],
and have the results faxed to your PCP who manages your
coumadin.
It will be important for you to follow up with your doctors [**First Name (Titles) 3**] [**Name5 (PTitle) 57228**] below.
Followup Instructions:
Department: HEMATOLOGY/BMT
When: THURSDAY [**2147-2-16**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/BMT
When: THURSDAY [**2147-2-16**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9574**], NP [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: DERMATOLOGY
When: [**Hospital Ward Name **] [**2147-4-14**] at 3:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2722**], MD [**Telephone/Fax (1) 1971**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2147-2-12**]
|
[
"249.00",
"782.1",
"488.01",
"996.85",
"V58.61",
"V12.51",
"279.52",
"724.5",
"E932.0",
"279.00",
"595.9",
"518.81",
"327.23",
"272.4",
"E879.8",
"205.00",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.14",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
8630, 13952
|
326, 332
|
3747, 3751
|
18174, 19187
|
3025, 3184
|
13978, 14503
|
3690, 3728
|
16748, 16851
|
7051, 8607
|
16683, 16683
|
259, 288
|
16883, 16883
|
14533, 16651
|
17045, 18151
|
360, 1678
|
3767, 4098
|
16702, 16727
|
16898, 17010
|
4114, 7015
|
1700, 2816
|
2832, 3009
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,386
| 150,628
|
20158
|
Discharge summary
|
report
|
Admission Date: [**2157-12-3**] Discharge Date: [**2158-1-9**]
Date of Birth: [**2101-12-25**] Sex: M
Service: MEDICINE
Allergies:
Lipitor
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
bloody stools
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
55 year old male with ETOH cirrhosis c/b esophageal varices
requiring multiple banding attempts who presented to OSH with
severe fatigue/weakness x 1 week. He describes feeling himself
until earlier this week when he had 2 days of epistaxis which
stopped on its own. He also noted maroon colored stools, [**1-18**]
BMs per day for past week, and a small amount of blood in his
urine. At OSH, platelets were 5,000, INR 2.0, Hct 20, and T.
bili of 10. He was given 4U platelets, 3 units FFP and 3 units
PRBCs and transferred to [**Hospital1 18**] where he is followed by Dr.
[**Last Name (STitle) 497**]. He also has a history of hepatopulmonary syndrome on
oxygen (2-4L), followed by Dr. [**Last Name (STitle) 2168**].
.
NG tube placed at OSH, 1g ceftriaxone, octreitide drip initiated
and transferred here for further w/u. In ED, hct 22, plt 14,
INR 1.7, Tbili 13. He received additional 2U pRBCs, 2 FFP,
hepatology was consulted with plans for EGD this AM.
.
His last EGD in [**Month (only) 596**] showed scarred esophageal varices but
development of gastric varices. He has had no recent
colonoscopy in [**Hospital1 **] system.
.
ROS: + nausea, some loose maroon stools. Fever to 100 on
wednesday, no pulmonary sx, dysuria. Denies NSAIDs, but did
take [**2-19**] tylenol on wednesday. Steadfastly denies ETOH
consumption since may.
Past Medical History:
1. Cirrhosis due to ETOH, known esophageal varices last banded
in [**2155**]. last EGD in [**2157-6-17**] with no esophageal varices
noted, evidence of past banding with scarring was noted, and
varices at the fundus.
2. Alcohol abuse.
3. COPD.
4. Pulmonary sarcoidosis dx in [**2131**] but no treatment
5. Osteomyelitis
6. Hepatopulmonary syndrome on 2-4L
7. PUD
Social History:
Married, retired prison guard. He smoked [**1-18**] PPD x 17 years ago
and quit 17 years ago. He denies any history of exposure to
asbestos or other inhaled toxins. Stopped drinking in [**Month (only) 116**], as
above.
Family History:
notable for early heart disease - his father suffered an MI at
age 51 and died at age 59. There is no other history of
pulmonary or oncological disease in the family.
Physical Exam:
Physical Exam on Admission:
Vitals: temp 97.1 , bp 92/70 HR 69, RR 18, SaO2 98% on 4L
General: tired-appearing, jaundiced man in NAD
HEENT: icteric sclera, NG tube in place with clotted blood
around nares, PERRL, EOMI
CV: RRR, nls1s2, loud holosystolic murmur throughout, JVP flat
Pulm: CTAB, no wheezes
Abdomen: soft, mildly distended, no TTP, + HSM. no fluid wave
Ext: clubbing bilaterally, trace edema, 2+ DPs
Neuro: AA&Ox3, FS all 4 ext, nl strength, no asterixis
Skin: no caput. spiders over chest/back
Pertinent Results:
IMAGING:
CXR ([**12-3**])
1. Interval improvement of left lung base opacities.
2. Persistent bilateral hilar lymphadenopathy consistent with
known history of sarcoidosis.
3. NG tube with sideport at the level of the GE junction.
Advancement is recommended.
.
Abdominal U/S ([**12-3**]):
IMPRESSION:
1. Cirrhosis is without evidence of focal lesion.
2. Cholelithiasis without evidence of cholecystitis.
3. Marked splenomegaly.
4. No evidence of ascites.
Brief Hospital Course:
55yo with ETOH cirrhosis, hepatopulmonary syndrome with UGIB,
coagulopathy.
.
MICU COURSE: Pt admitted to MICU and underwent EGD, showing
portal hypertensive gastropathy with diffuse bleed. He received
total of 4uPRBC, 4uFFP, and 3 bag of PLT. His bleeding slowed,
though still some dark stools & small amount of BRB on toilet
paper post-procedure. He was weaned off the octreotide per liver
team recs.
Fever to 102.1 on [**2157-12-5**]. Blood cx's from [**12-5**] (2/2 bottles)
growing enterococcus. Pt started on vancomycin and transferred
out of MICU given HD stability & hct stability.
.
FLOOR COURSE:
.
# GI bleed
Patient underwent EGD which showed portal hypertensive
gastropathy with diffuse bleed (as above). On the floor his
blood pressure and hematocrit had stabilized. After > 1 week on
the medical floor his hematocrit slowly declined but remained >
22. He was continued on nadolol until he became progressively
more hypotensive (see below).
.
# Enterococcus Bacteremia
Patient was found to have two enterococcus species in his blood.
The source of this infection was sought; TTE / TEE were
negative for endocarditis, but CT abdomen did show thickened
colon consistent with colitis. Flexible sigmoidoscopy was
performed which showed diverticula but no colitis. He was
treated w/ ampicillin for the enterococcus and flagyl for
colitis, which may have been low grade diverticuliits. Serial
blood cultures remained negative after the initial enterococcus
isolate.
.
# E Coli UTI
Patient grew E coli from his urine, although UA was negative for
inflammation. Treatment was deferred and UA / UCx was repeated.
Then sent to the MICU.
.
# ETOH induced cirrhosis / ESLD
On the medical floor the patient's MELD score and liver
dysfunction worsened daily. His bilirubin, INR, and creatinine
all increased. He was listed as first on the transplant list.
He was continued on lactulose / rifaximin as well as
spironalactone / lasix. The diuretics were d/c'd on [**12-16**] given
his worsened renal function. As part of pre-transplant workup
he underwent R heart catheterization (which showed moderately
elevated left sided pressures but no PA hypertension). He also
had several infectious studies sent to ensure lack of infection
/ evaluate baseline before transplant (CMV, Blastomycosis, HSV 1
+2, EBV).
.
# Pulmonary: Sarcoidosis/hepatopulmonary/COPD:
Patient has previously diagnosed hepatopulmonary syndrome. At
baseline he was using 2L of NC, however as time progressed he
was requiring 4 L NC on [**12-20**].
.
# ARF
Patient on the floor developed ARF in the setting of worsened
liver dysfunction. Initially creatinine was stable, however
after 2 days of doubled lasix dose, his creatine climbed. This
was also in the setting of IV contrast for a CT scan. His
diuretics were withheld, however creatinine kept climbing.
Albumin and IVFs trial did not improve creatinine. Urine
eosinophils were negative. Renal was consulted; hepatorenal was
not considered the most likely diagnosis. He was then
transferred for further evaluation in the MICU.
.
# Volume overload
Given low albumin and cirrhosis patient had increasing LE edema.
He was initially on lasix / aldactone. The lasix dose was
increased to 80 mg daily x 2 days. Her creatinine then
increased and diuretics were witheld. Stockings were applied to
LE's bilaterally to assist in reduction of edema.
.
MICU COURSE:
The patient was readmitted to the MICU on [**2157-12-20**] for worsening
hypotension, renal failure and hepatic failure. He required
pressor support to maintain his BP and mechamical ventilation
for hypoxia and respiratory distress. The pt's renal failure
worsened and he was treated with CVVH and a Lasix gtt
intermittently. On [**2157-12-25**], the patient complained of chest
discomfort and an ECG revealed 2-[**Street Address(2) 2051**] depressions V4-V6,
isolated ST elevation V2, TWI II, III, AVF. No therapy beyond
pain control could be provided for this given the patient's
underlying coagulopathy and hypotension. Over the coming two
weeks, the patient's condition failed to improve. On [**2158-1-4**],
in consultation with the patient's family and the liver service,
it was decided to change the goals of his care to comfort only,
as it was felt the patient was highly unlikely to ever receive a
liver transplant. Pressor and ventilatory support were
withdrawn, and on the [**1-9**] the patient expired.
Medications on Admission:
Advair 250/50 [**Hospital1 **]
thiamine 100 mg qd
MVI
folate 1 mg qd
nadolol 20 mg qd
Protonix 40 mg q12h
Aldactone 50 mg qd
Lactulose 30 mL
Combivent 2 puffs q6h prn
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Cirrhosis due to ETOH
COPD
Pulmonary sarcoidosis
Hepatopulmonary syndrome
Myocardial ischemia
UGIB
Coagulopathy
Pancolitis
C Diff
Acute Renal Failure
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"041.4",
"456.8",
"428.30",
"V15.82",
"578.9",
"574.20",
"571.2",
"280.0",
"V17.49",
"518.82",
"303.91",
"286.9",
"401.9",
"995.92",
"411.89",
"572.8",
"584.5",
"041.04",
"496",
"560.1",
"599.0",
"038.9",
"517.8",
"135",
"537.89",
"562.11",
"572.3",
"428.0",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"48.23",
"45.23",
"99.04",
"99.05",
"45.13",
"99.07",
"37.21",
"88.72",
"39.95",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
8189, 8198
|
3525, 7939
|
289, 301
|
8391, 8400
|
3040, 3502
|
8456, 8602
|
2325, 2494
|
8157, 8166
|
8219, 8370
|
7965, 8134
|
8424, 8433
|
2509, 2523
|
236, 251
|
329, 1676
|
2537, 3021
|
1698, 2070
|
2086, 2309
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,170
| 155,231
|
4313
|
Discharge summary
|
report
|
Admission Date: [**2109-12-11**] Discharge Date: [**2109-12-28**]
Date of Birth: [**2038-2-24**] Sex: F
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 10593**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
71 year-old Female with h/o AFib (on coumadin), diastolic CHF,
HTN, DVT/PE, and stage III CKD who was recently admitted from
[**Hospital1 18**] on [**2108-11-24**] for multifocal pneumonia, now transferred
back to [**Hospital1 18**] from rehab with acutely worsening dyspnea
withdesaturation to 80's on room air and marked bilateral leg
swelling.
.
Patient was admitted to [**Hospital1 18**] on [**2109-11-24**] with dyspnea and found
to have multifocal healthcare-associated pneumonia. She was
treated with IV Vancomycin, and discharged on [**2109-12-2**] to rehab
to complete a 14-day course. She was also noted to have an acute
on chronic diastolic CHF exacerbation which responded to gentle
diuresis, as well as an E. coli UTI which was treated with IV
cefipime (completed 10-day course). Per patient report and last
discharge summary, she was discharged from hospital off her
usual daily Lasix 20mg po daily prescription. At rehab on [**12-11**],
she was noted to be acutely dyspneic with desaturation to the
80s on room air, which improved to 100% on a non-rebreather. She
denied fevers, chills or chest pain. She was transferred to
[**Hospital1 18**] ED.
.
In the ED, initial VS 97.0 (102 rectal) 70 168/73 20 100% NRB.
Patient was noted to be somnolent, and her CXR showed hazy
densities in the bilateral hila with moderate pulmonary edema
and small pleural effusions. She had some hypoglycemia after
receiving insulin in the ED and was placed on D50, and also
received a CT head which was unremarkable. She was started on
BiPAP because of acute hypoxic respiratory distress. She was
given Nitroglycerin 0.4 mg SL x 1 for afterload reduction. ABG
(on BiPAP) 7.42/39/219. She was subsequently admitted to the
MICU for respiratory distress.
.
On arrival in the MICU, pt was initially found to be somnolent
but arousable. Patient was given Lasix 20mg IV x 2 with some
response. Creatinine subsequently bumped from 1.9 to 2.1. She
received 500 cc D10W for her hypoglycemia with good response to
blood sugars 200s.
.
On the floor, patient states that she is not currently dyspneic.
She reports no fevers or chills. There is no chest pain noted.
She does note some increased swelling of her legs. She does
report a dry [**Hospital1 **].
.
ROS: Denies headaches or vision changes. Denies chest pain,
dizziness or lightheadedness; no palpitations. No nausea or
vomiting, denies abdominal pain. No dysuria or hematuria. Denies
muscle weakness, myalgias or neurologic complaints.
Past Medical History:
-Type 2 diabetes mellitus x > 20 years, last Hgb A1c 7.2 [**7-/2109**]
-Chronic kidney disease stage 3 (baseline creatinine ~ 1.6-1.8)
-Gout
-History of left leg DVT ([**2099**])
-History pulmonary embolism X 2 ([**2099**])
-History of right ACA stroke ([**2099**]), involving right
thalamus/internal capsule and significant small vessel ischemic
disease; with residual deficits
-Atrial fibrillation, on Coumadin
-Hypertension
-Hyperlipidemia
-Multifocal PNA in [**11/2109**]
-Ecoli UTI's with complicated resistance pattern
-Osteoarthritis
-S/p tubal ligation
Social History:
Originally from [**Location (un) 11084**] [**State 9512**] but has been [**Location (un) 86**] for
decades. She is widowed but has one son and a grand-daughter in
college. Lives alone at home. Uses a walker and has PT,
housekeeper visits. Never used ETOH, tobacco or illicits
Family History:
Maternal: Diabetes Mellitus
Physical Exam:
ADMISSION PHYSICAL EXAM:
.
Vitals: T:33.8 BP:129/61 P:65 R:14 O2: 100% 2 L NC
General: shivering, NAD
HEENT: unable to assess due to pt somnolence
Neck: obese, unable to assess JVP
Lungs: poor inspiratory effort, rhonchorous throughout
CV: Distant heart sounds, 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+ bilat pitting edema, no calf
tenderness
Neuro: A&Ox2, somnolent, unable to assess further due to
somnolence
.
DISCHARGE PHYSICAL EXAM:
.
Vitals: T: 97.8 BP 153/67 P 67 RR 18 SaO2 98% RA
Weight: 85.3 -> 85.1 -> 86.0 -> 84.5 -> 85.1 -> 79.9 -> 86.3 ->
85.5
-> 87.1 -> 90.1 [baseline wt = 185-190 lbs]
General: pleasant, smiling elderly AAF seated upright in chair
in NAD, talking comfortably
HEENT: PERRL, MMM, no lesions noted in oropharynx
Neck: obese, unable to assess JVP
Lungs: CTAB, no crackles/wheezes/rhonchi
CV: Distant heart sounds, RRR, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: large (4inchx4inch) compressible ventral hernia
superior to umbilicus, medium (1inchx1inch) compressible
umbilical hernia. Normoactive bowel sounds. Abdomen soft,
nontender, nondistended, no rebound/guarding. No inguinal
hernia.
Ext: warm and well perfused BL. 1+ pitting edema in BL legs, 2+
pitting edema in BL feet. Pulses nonpalpable [**3-6**] pedal edema.
Neuro: nonfocal, fluent speech
Pertinent Results:
ADMISSION LABS:
WBC-9.4 RBC-3.02* Hgb-9.0* Hct-27.9* MCV-93 MCH-29.9 MCHC-32.3
RDW-19.2* Plt Ct-264
Neuts-78.1* Lymphs-11.3* Monos-5.3 Eos-5.0* Baso-0.3
PT-18.7* PTT-28.5 INR(PT)-1.7*
Glucose-27* UreaN-35* Creat-1.9* Na-146* K-4.1 Cl-113* HCO3-25
AnGap-12
Calcium-9.0 Phos-4.1 Mg-1.9
ALT-21 AST-19 TotBili-0.6
ProBNP-4941*
ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
ABG = Temp-39.2 pO2-219* pCO2-39 pH-7.42 calTCO2-26 Base XS-1
Glucose-102 Lactate-0.8 Na-144 K-4.3 Cl-111*
.
DISCHARGE LABS:
WBC-12.3* RBC-2.60* Hgb-7.4* Hct-24.2* MCV-93 MCH-28.4
MCHC-30.5* RDW-20.0* Plt Ct-468*
Glucose-91 UreaN-82* Creat-2.6* Na-143 K-4.7 Cl-109* HCO3-23
AnGap-16
Calcium-9.3 Phos-3.5 Mg-2.2
.
JOINT FLUID ANALYSIS (RIGHT KNEE), [**12-16**]:
WBC-9800* RBC-800* Polys-94* Lymphs-0 Monos-6
Moderate needle-shaped negatively birefringent monosodium urate
crystals.
Culture = 2+ PMNs, no bacteria.
.
ELECTROLYTES:
[**2109-12-11**]: UreaN-35* Creat-1.9*
[**2109-12-12**]: UreaN-37* Creat-1.9*
[**2109-12-12**]: UreaN-37* Creat-2.1*
[**2109-12-13**]: UreaN-40* Creat-2.2*
[**2109-12-14**]: UreaN-43* Creat-2.3*
[**2109-12-15**]: UreaN-46* Creat-2.4*
[**2109-12-16**]: UreaN-46* Creat-2.2*
[**2109-12-17**]: UreaN-44* Creat-2.1*
[**2109-12-18**]: UreaN-46* Creat-2.3*
[**2109-12-19**]: UreaN-63* Creat-2.7*
[**2109-12-20**]: UreaN-49* Creat-2.6*
[**2109-12-20**]: UreaN-54* Creat-2.5*
[**2109-12-20**]: UreaN-56* Creat-2.6*
[**2109-12-21**]: UreaN-60* Creat-2.6*
[**2109-12-21**]: UreaN-59* Creat-2.6*
[**2109-12-21**]: UreaN-67* Creat-2.8*
[**2109-12-22**]: UreaN-68* Creat-2.8*
[**2109-12-23**]: UreaN-72* Creat-2.6*
[**2109-12-23**]: UreaN-73* Creat-2.7*
[**2109-12-24**]: UreaN-80* Creat-2.6*
[**2109-12-25**]: UreaN-81* Creat-2.6*
[**2109-12-25**]: UreaN-85* Creat-2.6*
[**2109-12-26**]: UreaN-89* Creat-2.6*
[**2109-12-27**]: UreaN-86* Creat-2.4*
[**2109-12-28**]: UreaN-82* Creat-2.6*
.
URINE:
[**2109-12-11**] 08:40PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008
[**2109-12-11**] 08:40PM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2109-12-11**] 08:40PM URINE RBC-1 WBC-3 Bacteri-FEW Yeast-OCC Epi-0
TransE-2
.
MICRO:
Blood Cx ([**12-11**], final): NEGATIVE
Urine Cx ([**12-11**], final): yeast (10,000-100,000 organisms)
Urine Cx ([**12-22**], final): yeast (>100,000 organisms)
MRSA screen ([**12-11**] nasal swab, final): NEGATIVE
.
STUDIES:
PA PORTABLE CHEST X-RAY ([**2109-12-11**]): As similar to multiple prior
exams, there is a relative hazy density in the bilateral hilar
regions with pulmonary vascular indistinctness. The
hemidiaphragms are not well defined. The cardiomediastinal
silhouette is markedly enlarged with widening superiorly and an
enlarged cardiac silhouette
inferiorly. The patient's chin overlies the lung apices,
limiting the
evaluation. No gross pneumothorax is seen.
IMPRESSION: Limited study due to body habitus. There are low
lung volumes which result in bronchovascular crowding, but
beyond that there is likely moderate pulmonary edema presumably
cardiogenic in etiology. There may also be small bilateral
pleural effusions.
.
CT HEAD WITHOUT CONTRAST ([**2109-12-11**]): There is no evidence of
hemorrhage, edema, shift of normally midline structures,
hydrocephalus, or recent infarction. Marked prominence of the
ventricles and sulci are consistent with age-related
involutional change. Periventricular and subcortical white
matter hypodensities are consistent with chronic small vessel
ischemic disease. A tiny lacune in the right thalamus was better
seen on prior CT from [**2109-7-28**]. Calcification of the
bilateral cavernous carotid and vertebral arteries is noted. The
visualized portions of the paranasal sinuses and mastoid air
cells are well aerated. The imaged osseous structures are
intact.
IMPRESSION: No acute intracranial process.
.
TRANSTHORACIC ECHO ([**2109-12-11**]): The left atrium is mildly dilated.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
IMPRESSION: Normal global and regional biventricular systolic
function. Siastolic dysfunction. Mild mitral
regurgitation.Compared with the prior study (images reviewed) of
[**2106-5-25**], mild symmetric LVH is not seen on the current study.
The other findings are similar.
.
IMPRESSION: 71 yo female with h/o AFib on Coumadin, type II
IDDM, CKD stage III, DVT/PE, s/p recent admission for multifocal
PNA, now transferred to [**Hospital1 18**] from rehab for worsening hypoxia,
volume overload and patchy opacities on CXR concerning for CHF
vs recurrent PNA; now improving after IV diuresis.
.
PA AND LATERAL CHEST X-RAY ([**2109-12-13**], wet read): pulmonary edema
markedly improved since last x-ray on [**12-11**]. Small perihilar
effusion. Persistent small bilateral pleural effusions. Severe
cardiomegaly.
Brief Hospital Course:
71 yo female with h/o AFib on Coumadin, type II IDDM, CKD stage
III, DVT/PE, s/p recent admission for multifocal PNA, now
transferred to [**Hospital1 18**] from rehab for worsening hypoxia, leg
swelling and patchy opacities on CXR, found to have diastolic
CHF exacerbation, with hospitalization complicated by gout flare
and recurrent pneumonia, hyperglycemia [**3-6**] prednisone and [**Last Name (un) **].
.
# CHF EXACERBATION: Pt with recent hospitalization for PNA
returning with recurrent hypoxia and CXR showing persistent
bilateral patchy opacities initially concerning for pulmonary
edema vs. recurrent PNA or resistant organisms after treatment
for last episode of PNA. Suspicion for CHF exacerbation from
underlying diastolic dysfunction, especially considering
discontinuation of diuretics; BNP 4941 on admission also
supported this. Her clinical presentation with dyspnea and leg
swelling also supported the diagnosis of CHF. Patient also has
AFib, which was felt to be potentially worsening her cardiac
output in the setting of her other issues. She was hypertensive
to 140s-160s on transfer to the floor, and it was felt that her
hypertension could be addiing to her diastolic dysfunction by
increasing afterload. Patient was afebrile starting on HD#1,
with no leukocytosis or productive [**Last Name (LF) **], [**First Name3 (LF) **] recurrent pneumonia
was found to be unlikely. Her antibiotics were discontinued on
transfer to the floor. Pulmonary embolism was also found to be
unlikely given pt is anticoagulated. TTE with no evidence of
valvular dysfunction. Troponins 0.05 and 0.04 with flat CK-MB in
the setting of CKD; myocardial ischemia unlikely. For her CHF,
patient was initially diuresed with Lasix 20 mg IV daily. For
afterload reduction, her amlodipine was uptitrated to 10mg
daily. Repeat chest x-ray on HD#3 showed vast improvement in her
pulmonary edema, with persistent small bilateral pleural
effusions. However, creatinine rose to 2.7 on HD #9 up from
baseline of 2.2 (pt was close to her dry weight of 185-190 lbs).
She still had 2+ pitting pedal edema. Considered intravascular
depletion with interstitial fluid overload, so discontinued
lasix and gave gentle IV hydration. See below for more on renal
issues. Creatinine was 2.6 on discharge; patient discharged on
home dose of Lasix 20mg PO daily. She will follow up on her CHF
and volume status with cardiologist [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] on [**12-31**]. Will
also need chest CT in [**2110-1-2**] to follow up resolution of
her pneumonia.
.
# GOUT FLARE: patient has history of frequent gout flares. She
was on home dose of prednisone 10mg daily for suppressive
therapy. Because it was unclear why she was on chronic
prednisone, this was discontinued on HD# 5. On HD#7, patient
developed severe right knee pain and fever. Right knee
arthrocentesis was performed and showed needle-shaped negatively
birefringent crystals consistent with monosodium urate crystals.
Fluid cultures were negative. Her gout flare was found likely
[**3-6**] discontinuing home prednisone as well as her decreased PO
intake during hospitalization. Patient was given burst steroid
therapy for her gout flare with prednisone 60mg daily for 5
days, then taping back to home dose of 10mg daily after that.
She could not receive NSAIDs or colchicine for her gout flare
secondary to her CKD and [**Last Name (un) **]. Patient discharged on prednisone
10mg daily, with scheduled outpatient followup with her
rheumatologist [**First Name5 (NamePattern1) 9619**] [**Last Name (NamePattern1) 9620**].
.
# [**Last Name (un) **] ON CKD: patient has h/o CKD stage III with baseline
creatinine 2.2. Her creatinine trended up during
hospitalization, peaking at 2.7 on HD #7. Hypotheses for cause
included decreased solute delivery [**3-6**] poor perfusion from CHF,
intravascular volume depletion with interstitial edema (had 2+
peripheral edema throughout), and intrinsic renal failure from
ATN/AIN. She had normal urine sediment numerous times, and no
urine eosinophils. FEurea found to be 27% on HD#20, indicating
prerenal insufficiency. Patient's volume status was very
difficult to evaluate during hospitalization, as she had pedal
edema despite normal weights. Nephrology was consulted and felt
that she was most likely intravascularly depleted. Therefore
diuretics were held for three days. Her creatinine remained
stable around 2.4-2.6. It may be that she has established new
baseline renal function. She was discharged on home dose of 20mg
Lasix daily, with instructions for fluid restriction and low
sodium diet.
.
# HYPERGLYCEMIA: while she was on prednisone, patient was
frequently hyperglycemic to the mid 300's. She had a small anion
gap acidosis at times (no ketonuria). Her insulin sliding scale
was titrated up and PM lantus was added. As prednisone was
tapered back to 10mg daily, her blood sugars improved. She will
be discharged on her current hospital sliding scale and
long-acting insulin regimen: 12 units lantus qPM, and sliding
scale. At rehab, she should be transitioned back to her home
insulin regimen, which is sliding scale plus humalog mix 75/25
solution 6 units qAM and 6 units qPM.
.
# UMBILICAL/VENTRAL HERNIAS: patient has h/o chronic umbilical
and ventral hernia. At the time of her gout flare, there was
also concern for hernia incarceration as ventral hernia did not
feel compressible. KUB showed no evidence of obstruction.
Patient was evaluated by surgery, who felt that hernia was not
entrapped. She is scheduled for outpatient surgical followup for
potential repair of umbilical and ventral hernias once she is
medically stable. Would need to have prednisone and coumadin
discontinued prior to surgery.
.
# AFIB WITH RVR: patient has h/o AFib, on coumadin. She had two
episodes of self-terminating AFib with RVR to the 130's during
hospitalization. She remained hemodynamically stable throughout.
No treatment was instituted as this appears to be paroxysmal
afib and pt asymptomatic. Has low baseline HR so cannot add beta
blocker.
.
# PNEUMONIA: pt initially admitted with concern for CHF
exacerbation vs recurrent pneumonia. Did not receive antibiotics
as afebrile and no [**Month/Day (2) **]. However when she developed fever and
gout flare, also had repeat chest x-ray which showed possible
recurrence of pneumonia in the same distribution of her prior
pneumonia. Out of concern for recurrence of inadequately treated
pneumonia, as well as fevers, patient was treated with full
course of vancomycin and cefipime for hospital-acquired
pneumonia. She remained afebrile and asymptomatic after this.
.
# HTN, BENIGN: Patient was hypertensive during hospitalization,
with BP ranging from 140s-160s systolic. To greater reduce pt's
afterload and improve her diastolic CHF, patient's home
amlodipine was uptitrated to 10mg daily. Her home doses of
clonidine and labetolol were continued.
.
# GERD: home omeprazole continued. Inactive during
hospitalization.
.
# H/O DVT AND PE: continued warfarin.
.
# NORMOCYTIC ANEMIA: patient has a chronic, stable anemia which
is most likely secondary to her CKD. She is on darbapoeitin for
this. Inactive during hospitalization.
.
TRANSITION OF CARE:
- will need chest CT in [**2110-1-2**] to follow up on resolution
of pneumonia
- please transition patient back to home insulin regimen
(insulin sliding scale, plus humalog mix 75/25 6 units qAM and 6
units qPM) during rehab as tolerated.
- please follow up urine culture from [**2109-12-28**] (initial nursing
concern for urinary frequency overnight, but turned out to be
chronic; UA/UCx already sent).
- If no contraindications, recommend starting aspirin 81 mg
daily in future.
- Recommend follow-up with Nephrology for chronic kidney
disease.
- Has appointment in Surgery Clinic on [**2110-1-9**] at 1pm regarding
possible hernia repair.
Medications on Admission:
1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
4. darbepoetin alfa in polysorbat 40 mcg/0.4 mL Syringe
Injection
5. Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig: One (1)
injection Subcutaneous twice a day: 6u in the am and 6u in the
pm.
6. Humalog 100 unit/mL Solution Sig: One (1) injection
Subcutaneous before meals: Continue taking this as you were
before admission.
7. labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
11. bisacodyl Oral
12. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
14. vancomycin 1,000 mg Recon Soln Sig: One (1) injection
Intravenous q 48 hrs for 4 doses: To end on [**2109-12-8**] for total
14 days course. .
15. cefepime in D5W 1 gram/50 mL Piggyback Sig: 500 mg
Intravenous once a day for 9 days: 500 mg every day, last dose
on [**2109-12-8**].
16. Lab Check Sig: One (1) check Q3 days: Please check
creatinine Q3 days for the first 9 days.
17. Combivent 18-103 mcg/Actuation Aerosol Sig: 1-2 puffs
Inhalation four times a day for 7 days. Disp:*1 inhaler*
Refills:*3*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
1. Heart failure
2. Hypothermia
3. Hypoglycemia (low blood sugar)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure participating in your care at [**Hospital1 771**]. You were admitted to the hospital with
shortness of breath. You were sent to the ICU, where your
breathing improved after getting IV Lasix (a diuretic, or "water
pill") which took the extra fluid off your lungs. You then were
transferred to the regular medical floor, where your breathing
and leg swelling continued to improve with more Lasix.
Please attend the appointment listed below with cardiologist
[**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] (see below) on [**12-30**] to follow up on your
fluid overload and difficulty breathing. You also have an
outpatient appointment with surgery to evaluate your stomach
hernia, and an appointment with rheumatology to follow up on
your gout.
Please weigh yourself every morning. Call your doctor if your
weight goes up more than 3 lbs.
We made the following changes to your medications:
1. RESTARTED Lasix 20mg by mouth daily
2. INCREASED Amlodipine from 5mg by mouth daily to 10mg by mouth
daily
Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2109-12-30**] at 11:00 AM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8428**], MD
Specialty: Internal Medicine
Location: [**Hospital1 **] HEALTHCARE - [**State 3753**]GROUP
Address: [**State **], [**Apartment Address(1) 3745**], [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**Telephone/Fax (1) 2205**]
Please discuss with the staff at the facility the need for a
follow up appointment with Dr. [**Last Name (STitle) 2903**]. The facility can call the
number above to make the appointment.
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: THURSDAY [**2110-1-9**] at 1 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: RHEUMATOLOGY
When: THURSDAY [**2110-2-13**] at 2:30 PM
With: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
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"V49.86",
"428.0",
"285.21",
"530.81",
"250.00",
"274.01",
"403.10",
"553.20",
"553.1",
"799.02",
"276.2",
"584.5",
"427.31",
"585.3",
"416.2",
"486",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.91"
] |
icd9pcs
|
[
[
[]
]
] |
20201, 20291
|
10680, 18548
|
286, 293
|
20401, 20401
|
5229, 5229
|
21683, 23146
|
3701, 3730
|
20312, 20380
|
18574, 20178
|
20584, 21520
|
5733, 10657
|
3770, 4328
|
21549, 21660
|
239, 248
|
321, 2806
|
5245, 5717
|
20416, 20560
|
2828, 3392
|
3408, 3685
|
4353, 5210
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,585
| 129,790
|
33781
|
Discharge summary
|
report
|
Admission Date: [**2169-4-23**] Discharge Date: [**2169-4-26**]
Date of Birth: [**2086-4-18**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
intracerebral hemorrhage
Major Surgical or Invasive Procedure:
Endotracheal intubation, radial arterial line
History of Present Illness:
Ms. [**Name14 (STitle) 78124**] is an 83 year old woman with HTN and advanced
dementia who awoke at 9:30 this morning with difficulty speaking
and right sided weakness. Pt walked to the bathroom, but was
unable to hold her toothbrush, her speech was unintelligeable to
her husband. She went back to bed. She did not complain of
headache. She awoke and was still unable to communicate, but
suddenly started vomiting intractably and she was unable to move
her right side. EMS was called, brought to [**Hospital1 **] where CT
revealed large L hemisphere hemorrhage.
At [**Hospital1 **] SBP's noted to be 178-203, She was given etomidate,
succ, dilantin 1g IV, ativan 2mg IV, Zofran 4mg IV, intubated
for airway protection and transferred to [**Hospital1 18**] for evaluation.
Pt was hypotensive to SBP 60 on arrival, given fluid bolus with
return to 100's.
ROS: (per husband), no recent illnesses, wt loss, cough, SOB,
CP, urinary sx, diarrhea. Recently had her birthday party on
[**4-19**]. Pt at times does not recognize her sons or [**Name2 (NI) 78125**].
Past Medical History:
1) Hypertension
2) [**Name (NI) 78126**] pt requires assistance with all ADL's by her very
attentive husband for the last 6 years, she is still able to
feed
herself, she would wander from the house if doors were not kept
locked.
Social History:
lives with husband, homebound d/t dementia, never smoker, no
ETOH or illicits.
Family History:
NC
Physical Exam:
Vitals: T98.3, BP 106/54, HR 56, R 19, 99% RA
Gen- intubated and sedated, critically ill
HEENT: NCAT, intubated, OP clear
Neck: no carotid bruit
CV: RRR, no MRG
Chest: CTA B
Abd: soft, nt, nd, BS+
Extrem: no CCE
Neurologic Exam:
MS- unresponsive to voice, reaches with left arm to pull away
hand from sternal rub.
CN: PERRL 3-->2mm bilaterally, intermittent tonic, conjugate
left
gaze deviation, no blink to threat, +corneals, no papilledema,
exudates or hemorrhages. face symmetric, intact gag, intact
oculocephalic reflex.
Motor: markedly increased tone in bilateral lower extremities.
No
adventitious movements. internal rotation with R arm to noxious,
dorsiflexes R foot to nailbed pressure, withdraws L leg to
nailbed in plane of the bed, withdraws L hand to nailbed
pressure.
Sensory- intact in all 4 extrem to noxious.
Reflexes- Right- 3+ patellar, [**Hospital1 **], tri, Left 2+ patellar, [**Hospital1 **], tri
Gait- unable to test
Pertinent Results:
Admission Labs:
145 113 16 AGap=15
-------------<166
3.3 20 0.7
MCV 88
WBC 8.9, Hgb 10.8, Hct 32.6, Plate 202
N:86.9 L:9.3 M:3.6 E:0.1 Bas:0.1
PT: 13.0 PTT: 22.2 INR: 1.1
IMAGING:
OSH CT- large L lobar hemorrhage in fronto-parietal regions.
midline shift with intraventriculr spread to lateral vents and
3rd.
CT at [**Hospital1 18**]-
Large left frontoparietal intraparenchymal hemorrhage with
intraventricular and subarachnoid extension, early
hydrocephalus,
and signs of impending uncal herniation. There is also 6 mm of
midline shift and significant surrounding edema and mass effect.
Brief Hospital Course:
Ms. [**Name14 (STitle) 78124**] is and 83 year old woman with hypertension and
advanced dementia who presents with large left hemispheric
hemorrhage. Her examination at present is limited due to
multiple sedating medications given prior to transfer to this
hospital. She localized noxious stimuli with her left arm and
has evidence
of R sided hemiparesis. She has intact brainstem reflexes. Her
hemorrhage is likely related to hypertension in setting of
underlying amyloid angiopathy associated with her chronic
dementing illness. Given the size and location of the hemorrhage
her prognosis for a meaningful neurologic recovery is very poor
with the substrate of advanced dementia. At present there early
evidence of mass effect, and she would require neurosurgical
intervention to prevent obstruction of CSF flow. The patient's
prognosis and her prior expressed wishes were discussed in
detail with her husband and sons. She had expressed that she
would "not want to be on life support." Her husband has been her
sole caretaker for the last 6 years. She recently turned 83 last
week with a large family celebration. Her family decided to make
the patient DNR, and for comfort measures only, with the
exception of continued ventilatory support until family arrived
from [**Location (un) **].
The patient was admitted to the Neurology ICU and given Morpine
PRN for comfort. The patient's sister arrived from [**Name (NI) **] two days
later and the patient was extubated and transferred to the floor
as full CMO status. She passed away shortly thereafter.
Medications on Admission:
ISMN 30mg daily
Lisinopril 20mg daily
Paxil 20mg daily
Aspirin daily
Seroquel 50mg QHS
Namenda 5mg QAM, 10mg QPM
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
NA
Discharge Condition:
NA
Discharge Instructions:
NA
Followup Instructions:
NA
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"348.4",
"331.4",
"294.8",
"401.9",
"277.30",
"431"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5204, 5213
|
3456, 5013
|
341, 388
|
5259, 5263
|
2829, 2829
|
5314, 5411
|
1843, 1847
|
5177, 5181
|
5234, 5238
|
5039, 5154
|
5287, 5291
|
1862, 2075
|
276, 303
|
416, 1477
|
2845, 3433
|
2092, 2810
|
1499, 1730
|
1746, 1827
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,962
| 101,113
|
28130
|
Discharge summary
|
report
|
Admission Date: [**2142-7-28**] Discharge Date: [**2142-8-11**]
Date of Birth: [**2084-9-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lipitor
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Coronary Artery Bypass Graft x 3(LIMA-LAD,SVG-RI,SVG-OM) [**2142-8-6**]
Aorto-left leg arteriogram ,balloon angioplasty proximal
peroneal artery [**2142-7-31**]
History of Present Illness:
This 57 year old male wastransferred from [**Hospital3 1280**] after
cardiac catherization revealed double vessel disease. He
initially presented there on [**7-22**] with a nonhealing infection of
a left toe. During his hospitalization he underwent amputation
of the left middle toe on [**2142-7-25**]. He developed two episodes of
new rest chest pain with EKG changes of transient ST elevations
in AVR, V1, V2. Chest pain resolved on its own and enzymes were
negative. These episodes occurred on [**7-22**] and [**7-25**], with no
chest pain in the past 3 days. Cardiac catheterization was
performed on[**7-27**] and he was transferred to [**Hospital1 18**] today for
cardiac surgical evaluation.
Past Medical History:
Paroxysmal Atrial Fibrillation
Diabetes Mellitus on insulin pump
Congestive heart failure
Dyslipidemia
Peripheral Vascular Disease
h/o Cellulitis
History of C. diff colitis
Hypothroidism
Hypertension
Right below knee amputation [**5-7**]
Left middle toe amputation [**2142-7-25**]
Cataract surgeries
multiple vascular surgical procedures
Social History:
Race:Caucasian
Last Dental Exam: Several years ago - poor denition
Lives with: Widowed, lives with dtr and granddaughter
Occupation: Retired x 7 years
Tobacco: None
ETOH:None
Family History:
noncontributory
Physical Exam:
admission:
Pulse:AF 69 Resp:13 O2 sat:100% RA
B/P Right:145/66 Left:
Height:5'9" Weight:170#
General:
Skin: Dry [] intact [] Multiple pinpoint lesions LLE
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 Varicosities:
None [] Right BKA, Left 3rd toe wound packed, tissue pink, no
purulent drainage
Neuro: Grossly intact
xPulses:
Femoral Right:2+ Left:2+
DP Right:NA Left:0
PT [**Name (NI) 167**]:NA Left:0
Radial Right:2+ Left:2+
Carotid Bruit Right:none Left:none
Pertinent Results:
[**2142-7-30**] Vein mapping: Patent left greater and short saphenous
vein with diameters amenable for bypass conduit
[**2142-7-30**] Carotid U/S: Right ICA <40% stenosis. Left ICA <40%
stenosis.
[**2142-8-6**] Echo: PRE-BYPASS: The left atrium is moderately dilated.
No spontaneous echo contrast is seen in the body of the left
atrium. No spontaneous echo contrast is seen in the left atrial
appendage. The left atrial appendage emptying velocity is
depressed (<0.2m/s). The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets are moderately thickened. There is no
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is mild
mitral annular calcification as well as calcification of both
subvalvular apparati. There is non-flow restricting chordal [**Male First Name (un) **]
but no valvular [**Male First Name (un) **]. Trivial mitral regurgitation is seen. There
is a very small pericardial effusion. POSTBYPASS: The patient is
A-paced and is on a phenylephrine infusion. Left ventricular
function remains normal. Mild aortic regurgitation persists.
Trivial mitral regurgitation persists. Aortic contours are
normal.
[**2142-8-10**] 04:30AM BLOOD WBC-8.9 RBC-2.92* Hgb-8.7* Hct-26.2*
MCV-90 MCH-29.8 MCHC-33.1 RDW-15.7* Plt Ct-259
[**2142-7-28**] 04:50PM BLOOD WBC-7.9 RBC-3.41* Hgb-10.0* Hct-29.4*
MCV-86 MCH-29.3 MCHC-34.0 RDW-13.6 Plt Ct-358
[**2142-8-10**] 04:30AM BLOOD Glucose-162* UreaN-28* Creat-1.7* Na-135
K-4.1 Cl-104 HCO3-24 AnGap-11
[**2142-7-28**] 04:50PM BLOOD Glucose-408* UreaN-26* Creat-1.5* Na-131*
K-5.2* Cl-98 HCO3-25 AnGap-13
Brief Hospital Course:
He received medical management while undergoing extensive
pre-operative work-up, including lab work, carotid ultrasound,
vein mapping and a vascular surgical consult. On [**7-31**] he was
brought to Operating Room by vascular surgery for serial
arteriogram of the left lower extremity and balloon angioplasty
of the proximal peroneal artery. Please see operative note for
details. Following the case he was transferred back to floor for
further medical care.
On [**8-6**] he was brought to the Operating Room where he underwent
coronary artery bypass graft x 3 was undertaken. Please see
operative report for surgical details. He tolerated the
procedure well and was extubated easily. The wound vac remained
on the left toe amputation site. He was begun on beta blockers
and then Cardizem was initiated after Amiodarone failed to
control his atrial fibrillation. He converted to sinus rhythm
and Coumadin was resumed for the paroxysmal fibrillation and his
peripheral vascular disease.
He was below his properative weight at discharge but there
remained a moderate asmount of right stump edema which precluded
the prosthesis from fitting. A stump shrinker was therfor
utilized. The toe amputaion site was clean with a wound vac in
place. he will be followed by his vascular surgeon Dr.[**Last Name (STitle) **]
after discharge.
He was stable and ready for discharge to rehabilitaion on POD 5.
medicationsd were as listed as was follow up.
Medications on Admission:
Avapro 300 mg daily
Diltiazem 180 q PM
IV Vanco 1 gm daily
Florastor 250 [**Hospital1 **]
Levothyroxine 50 daily
Metoprolol 100 TID
ASA 325 daily
Crestor 5 daily
Novolog pump
Coumadin 5 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
6. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
three times a day.
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever, pain.
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
11. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
12. Sodium Chloride 0.9 % 0.9 % Syringe Sig: One (1) ML
Injection PRN (as needed) as needed for line flush.
13. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours).
14. Metoclopramide 5 mg/mL Solution Sig: Two (2) ml Injection
Q6H (every 6 hours) as needed for gastroparesis.
15. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
16. Insulin Pump Reservoir 3 mL Misc Sig: as directed- self
administered Miscellaneous continuous: self administration.
17. Coumadin 2.5 mg Tablet Sig: as directed Tablet PO once a
day: INR [**1-31**] goal.
18. Outpatient Lab Work
INR [**8-12**] then M-W-F for 2 weeks then prn
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary artery bypass graft x
Past medical history:
Paroxysmal Atrial Fibrillation
Diabetes Mellitus on insulin pump
Congestive heart failure
Dyslipidemia
Peripheral Vascular Disease
Cellulitis
History of C diff 1 year ago
Hypothroidism
Hypertension
Past Surgical History:
Right BKA [**5-7**]
Left middle toe amputation [**2142-7-25**]
Cataract surgeries
> 30 surgeries on bilateral LE d/t PVD - vascular surgeon is Dr.
[**Last Name (STitle) **]
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet and Ultram
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right - healing well, no erythema or drainage.
Wound Vac left toe
Edema right stump
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
Surgeon: Dr. [**Last Name (STitle) **] at [**Hospital3 1280**] in 2 weeks([**Telephone/Fax (1) 6256**])
office will call with appointment
Please call to schedule appointments with:
Primary Care: Dr. [**First Name (STitle) **] [**Name (STitle) **] ([**Telephone/Fax (1) 20261**]in [**12-30**] weeks
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 31888**] in [**12-30**] weeks
Vascular Surgery: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in 2 weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? for paroxysmal atrial
fibrillation/peripheral vascular disease
Goal INR 2-2.5
First draw day after discharge
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directedby [**Hospital1 **] staff
Completed by:[**2142-8-11**]
|
[
"401.9",
"250.03",
"414.01",
"411.1",
"V49.75",
"440.23",
"427.31",
"428.0",
"V02.54",
"244.9",
"707.15",
"272.4",
"V49.72",
"V45.85"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"00.40",
"36.12",
"39.50",
"88.42",
"38.93",
"86.28",
"88.48"
] |
icd9pcs
|
[
[
[]
]
] |
7859, 7933
|
4412, 5860
|
284, 447
|
8451, 8710
|
2521, 4389
|
9464, 10468
|
1743, 1761
|
6105, 7836
|
7954, 8013
|
5886, 6082
|
8734, 9441
|
8256, 8430
|
1776, 2502
|
234, 246
|
475, 1174
|
8035, 8233
|
1551, 1727
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,642
| 118,655
|
55157
|
Discharge summary
|
report
|
Admission Date: [**2116-7-23**] Discharge Date: [**2116-7-27**]
Date of Birth: [**2064-9-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Excision of intracardiac left atrial tumor (? myxoma)
History of Present Illness:
51 year old male from [**State 9896**]
has been found to have a left atrial mass measuring 5.2 x 3.0
cm.
This was discovered after he underwent workup for some
musculoskeletal chest pain and had an abnormal EKG in [**Country 532**]. He
describes that the chest pain was occurring for about a month in
[**Month (only) 956**] but has now totally resolved. He was referred to Dr.
[**Last Name (STitle) 171**] who has recommended TEE followed by cardiac
catheterization via left radial access to further evaluate. He
is
now being referred to cadiac surgery for removal of left atrial
mxyoma.
Past Medical History:
s/p atrial mass excision- final pathology pending
PMH:
Hemorrhoids, Gastritis, Benign colon polyps, appendectomy,
removal of benign colon polyps
Social History:
Lives with:in [**Country 532**] with wife, but will be staying in [**Name (NI) 86**]
for
procedure
Contact:[**Name (NI) 112515**] (wife) Phone #[**Telephone/Fax (1) 112516**]
Occupation:Former Wold bank employee. Works as an economist for
British Petroleum
Cigarettes: Smoked no [x] yes []
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**2-18**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
father had CAD,
died of MI at age 72. Mother had CABG this year at age 75
Physical Exam:
Pulse:70 Resp:18 O2 sat:100/RA
B/P Right:125/73 Left:124/77
Height:6' Weight:180 lbs
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 [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x]
Extremities: Warm [x], well-perfused [x] Edema; none
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: +2 Left:+2
DP Right:+2 Left:+2
PT [**Name (NI) 167**]:+2 Left:+2
Radial Right:+2 Left:cath site
Carotid Bruit none Right: Left:
Pertinent Results:
[**2116-7-26**] 06:20AM BLOOD Hct-38.6*
[**2116-7-25**] 06:25AM BLOOD WBC-10.8 RBC-4.13* Hgb-12.7* Hct-37.4*
MCV-91 MCH-30.7 MCHC-33.9 RDW-12.4 Plt Ct-185
[**2116-7-24**] 02:25AM BLOOD WBC-13.5* RBC-4.26* Hgb-13.1* Hct-38.4*
MCV-90 MCH-30.8 MCHC-34.1 RDW-12.5 Plt Ct-208
[**2116-7-23**] 11:09AM BLOOD PT-13.4* PTT-30.2 INR(PT)-1.2*
[**2116-7-26**] 06:20AM BLOOD UreaN-13 Creat-0.8 Na-137 K-4.1 Cl-100
[**2116-7-25**] 06:25AM BLOOD Glucose-96 UreaN-16 Creat-1.0 Na-136
K-4.3 Cl-99 HCO3-30 AnGap-11
.
[**2116-7-23**] Intra-op TEE:
Conclusions
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast is seen
in the body of the left atrium. No spontaneous echo contrast is
seen in the body of the left atrium or left atrial appendage. A
mass 5cm x 3.5 cm consistent with a myxoma or tumor is seen in
the body of the left atrium. The mass was attached to the fossa
ovalis portion of the interatrial septum with a broad base of
2cm. No other attachments were seen. It was seen prolapsing into
the left ventricle in diastole with no flow compromise.
No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal.
The ascending, transverse and descending thoracic aorta are
normal in diameter and free of atherosclerotic plaque to 40cm
from the incisors.
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. No mitral regurgitation is seen. There is
no pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results before surgical
incision.
POST-BYPASS:
Normal biventricular systolic funciton.
Mitral valve anatomy and function normal.
Interatrial septum post patc h closure is intact.
Intact thoracic aorta.
No other new findings.
Brief Hospital Course:
The patient was brought to the Operating Room on [**2116-7-23**] where
the patient underwent removal of left atrial mass with Dr.
[**Last Name (STitle) **]. Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD 4 the patient was ambulating freely, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged home in good condition with
appropriate follow up instructions. Final pathology is pending
at the time of discharge.
Medications on Admission:
none
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
RX *Adult Low Dose Aspirin 81 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2
2. Metoprolol Tartrate 25 mg PO TID
Hold for HR < 55 or SBP < 90 and call medical provider.
[**Last Name (NamePattern4) 9641**] *metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*0
3. Oxycodone-Acetaminophen (5mg-325mg) [**1-13**] TAB PO Q4H:PRN pain
RX *Endocet 5 mg-325 mg [**1-13**] tablet(s) by mouth every four (4)
hours Disp #*40 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
s/p atrial mass excision
PMH:
Hemorrhoids, Gastritis, Benign colon polyps, appendectomy,
removal of benign colon polyps
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: 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 one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Recommended Follow-up:
The Cardiac Surgery Office will call you with the following
appointments:
Surgeon: Dr. [**Last Name (STitle) **], [**Telephone/Fax (1) 170**] in the [**Hospital **] medical office
building, [**Last Name (NamePattern1) **], Suite2A
Wound check: [**Telephone/Fax (1) 170**] in the [**Hospital **] medical office building,
[**Last Name (NamePattern1) **], Suite2A
ECHOCARDIOGRAM Phone:[**Telephone/Fax (1) 62**], [**2116-8-3**] 11:00, [**Hospital Ward Name 22747**]
[**Location 2104**] 4
Cardiologist:[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2116-8-3**] 12:40
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] in [**4-16**] 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:[**2116-7-27**]
|
[
"212.7",
"535.50",
"V12.72",
"V17.3",
"455.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.33",
"35.61",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
6072, 6130
|
4345, 5480
|
289, 344
|
6294, 6471
|
2332, 4322
|
7111, 8096
|
1573, 1649
|
5535, 6049
|
6151, 6273
|
5506, 5512
|
6495, 7088
|
1664, 2313
|
239, 251
|
372, 962
|
984, 1130
|
1146, 1557
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,855
| 158,506
|
10024
|
Discharge summary
|
report
|
Admission Date: [**2190-9-10**] Discharge Date: [**2190-9-18**]
Date of Birth: [**2113-2-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
diarrhea, abdominal pain
Major Surgical or Invasive Procedure:
EGD
gastric mass biopsy
History of Present Illness:
Mr. [**Known lastname **] is a 77 y.o. male with 4.9 x 4.4 cm AAA and h/o PUD
s/p Billroth II years ago who presented with abdominal pain and
dropping hematocrit. In the work-up for the anemia, he was found
to have a large gastric mass on EGD [**9-11**], which was not biopsied
at the time of the inital study because the lesion was friable
and his Hct was unstable. He has also been found to have
multiple hypoechoic hepatic lesions (likely cysts) and a
multiple renal cysts (the largest in the right upper pole) on
abd CT, as well as free fluid in the pelvis and nodular scarring
of the right lung base as noted on CTA.
.
He was previously in the CSRU for hemodynamic stablization
(including RBC transfusion x 5 units) and then transferred to
the surgical floor on [**9-13**]. He was transferred to the medical
service for further workup of his gastric mass and multiple
medical comorbidities. He subsequently developed acute onset of
shortness of breath for which he was transferred to the MICU on
[**9-16**].
Past Medical History:
CAD
RAS
HTN
AAA (4.5 cm)
Billroth II in [**2172**]
PUD
Gastritis
CRI
R common iliac angioplasty
L renal aa angio w/ stent
colon polpectomy in [**2182**]
R - > L fem-[**Doctor Last Name **] bypass
Gastric cancer, not staged yet
Social History:
No ETOH, 65 pky smoking history, no illicit drugs, married, has
close support from wife per patient.
Family History:
Non-contributory
Physical Exam:
T 98.0 / 143/74 / 28 / 117 / 100% on 100% NRB, then 2L nc after
15 min, then RA
GENERAL: In respiratory distress, can speak in complete
sentences, using accessory muscles
HEENT: PERRL, OP clear, no swelling of lips or neck, neck soft
nonswollen, no thyromegaly or masses
LUNGS: Mild expiratory wheezing, expiratory phase is not
prolonged
HEART: 3/6 SEM, no r/g, irregular
ABDOMEN: Distended, firm, nontender to palpation throughout,
normal BS
EXTR: No cyanosis, edema. +clubbing
NEURO: Normal gait, [**5-1**] motor throughout, CN 2-12 normal as
tested
SKIN: No lesions
BACK: No tenderness to palpation over spine
Pertinent Results:
[**2190-9-10**] 12:00PM BLOOD WBC-10.6 RBC-1.97*# Hgb-5.5*# Hct-18.2*#
MCV-93 MCH-27.8# MCHC-30.0*# RDW-22.1* Plt Ct-105*
[**2190-9-11**] 06:00AM BLOOD WBC-18.3* RBC-3.18*# Hgb-9.6* Hct-27.3*
MCV-86 MCH-30.2 MCHC-35.2*# RDW-18.3* Plt Ct-56*
[**2190-9-12**] 02:58AM BLOOD WBC-17.5* RBC-3.59* Hgb-10.9* Hct-31.6*
MCV-88 MCH-30.5 MCHC-34.7 RDW-18.9* Plt Ct-62*
[**2190-9-13**] 02:44AM BLOOD WBC-20.0* RBC-3.79* Hgb-11.3* Hct-33.9*
MCV-90 MCH-30.0 MCHC-33.4 RDW-18.6* Plt Ct-81*
[**2190-9-15**] 09:26AM BLOOD WBC-19.8* RBC-4.16* Hgb-12.4* Hct-37.6*
MCV-91 MCH-29.9 MCHC-33.1 RDW-17.9* Plt Ct-100*
[**2190-9-16**] 06:28PM BLOOD WBC-26.6* RBC-4.21* Hgb-12.6* Hct-38.0*
MCV-90 MCH-30.0 MCHC-33.2 RDW-17.1* Plt Ct-127*
[**2190-9-18**] 06:14AM BLOOD WBC-14.6* RBC-3.38* Hgb-9.9* Hct-30.7*
MCV-91 MCH-29.2 MCHC-32.2 RDW-17.2* Plt Ct-159
[**2190-9-10**] 03:05PM BLOOD PT-12.2 PTT-24.7 INR(PT)-1.0
[**2190-9-14**] 04:00AM BLOOD PT-13.8* PTT-32.4 INR(PT)-1.2*
[**2190-9-18**] 06:14AM BLOOD PT-12.8 PTT-27.5 INR(PT)-1.1
[**2190-9-10**] 12:00PM BLOOD Glucose-101 UreaN-29* Creat-1.7* Na-139
K-7.8* Cl-110* HCO3-20* AnGap-17
[**2190-9-11**] 03:09AM BLOOD Glucose-174* UreaN-25* Creat-1.6* Na-139
K-4.3 Cl-109* HCO3-22 AnGap-12
[**2190-9-14**] 04:00AM BLOOD Glucose-87 UreaN-18 Creat-1.2 Na-142
K-4.2 Cl-114* HCO3-20* AnGap-12
[**2190-9-17**] 04:59AM BLOOD Glucose-113* UreaN-26* Creat-1.3* Na-138
K-4.6 Cl-108 HCO3-20* AnGap-15
[**2190-9-18**] 06:14AM BLOOD Glucose-70 UreaN-33* Creat-1.4* Na-138
K-4.7 Cl-107 HCO3-23 AnGap-13
[**2190-9-10**] 12:00PM BLOOD ALT-40 AST-138* CK(CPK)-343* AlkPhos-72
Amylase-100 TotBili-0.2
[**2190-9-16**] 06:28PM BLOOD ALT-16 AST-21 LD(LDH)-410* CK(CPK)-103
AlkPhos-82 Amylase-76 TotBili-0.3
[**2190-9-10**] 12:00PM BLOOD CK-MB-10 MB Indx-2.9 cTropnT-0.09*
[**2190-9-16**] 06:28PM BLOOD CK-MB-6 cTropnT-0.12*
[**2190-9-17**] 07:32AM BLOOD CK-MB-NotDone cTropnT-0.11*
[**2190-9-10**] 03:05PM BLOOD proBNP-1217*
[**2190-9-16**] 06:28PM BLOOD TSH-4.4*
[**2190-9-14**] 04:00AM BLOOD CEA-3.8
[**2190-9-16**] 03:37PM BLOOD Lactate-0.9
[**2190-9-16**] 06:37PM BLOOD Lactate-2.8*
[**2190-9-10**] 06:24PM BLOOD Type-ART pO2-237* pCO2-45 pH-7.27*
calTCO2-22 Base XS--5 Intubat-NOT INTUBA
[**2190-9-10**] 06:41PM BLOOD Type-ART pO2-99 pCO2-34* pH-7.38
calTCO2-21 Base XS--3 Intubat-NOT INTUBA
[**2190-9-10**] 08:29PM BLOOD Type-ART Temp-36.9 pO2-138* pCO2-29*
pH-7.48* calTCO2-22 Base XS-0 Intubat-NOT INTUBA Comment-CORE
[**2190-9-12**] 02:28PM BLOOD Type-ART pO2-86 pCO2-27* pH-7.47*
calTCO2-20* Base XS--1
[**2190-9-13**] 09:36AM BLOOD Type-ART pO2-101 pCO2-25* pH-7.45
calTCO2-18* Base XS--4
[**2190-9-16**] 03:37PM BLOOD Type-ART Temp-37.0 Rates-/40 O2 Flow-2
pO2-153* pCO2-30* pH-7.43 calTCO2-21 Base XS--2 Intubat-NOT
INTUBA Comment-NASAL [**Last Name (un) 154**]
[**2190-9-16**] 06:37PM BLOOD Type-ART Temp-37.0 Rates-/40 Tidal V-10
O2 Flow-10 pO2-64* pCO2-39 pH-7.31* calTCO2-21 Base XS--6
Intubat-NOT INTUBA Comment-NEBULIZER
.
STUDIES:
EKG: Sinus 110 with frequent APCs, pseudonormalization of T
waves, nonpathogenic Q waves anteriorly and laterally
.
CT chest [**9-14**]:
IMPRESSION:
1. New bilateral moderate pleural effusions obscure evaluation
of previously identified right lower lobe opacity and further
characterization is not possible at this time.
2. Unchanged descending aortic aneurysm.
3. Hypodense hepatic, renal and adrenal lesions better evaluated
on the recent dedicated abdominal CT.
.
CTA Abdomen [**9-10**]:
IMPRESSION:
1. Stable abdominal aortic aneurysm without evidence of rupture
or
dissection.
2. New ascites. The possibility of hemoperitoneum cannot be
excluded in this patient who is severely anemic.
3. Foley catheter with balloon inflated in the urethra.
4. Unchanged multiple hypodense lesions in the liver and kidney,
and dilated intrahepatic duct post-cholecystectomy and mild
prominence of the pancreatic duct.
5. Bilateral hypodense adrenal lesions, stable from 4/[**2189**].
Brief Hospital Course:
A/P: Mr. [**Known lastname **] is a 77 y.o. male with AAA, anemia and large
gastric [**Hospital **] transferred to the MICU [**9-16**] for acute onset SOB,
felt likely [**1-29**] vocal cord spasm.
.
#) Gastric Mass / Liver Lesions / Pulmonary Lesion: pt underwent
biopsy of GI mas on [**9-14**] while on surgical service, diagnostic
for gastric cancer, which showed poorly differentiated
adenocarcinoma with signet ring features. Plan was for staging
laparoscopy when he developed SOB resulting in MICU transfer.
CT C/A/P with hypodensities in liver, kidney, and adrenals,
though not reported as metastasis at this time. post biopsy
course complicated by bleeding requring 5U PRBC on [**2098-9-9**].
Given episode of SOB, plan for staging laparoscopy deferred
until after pt meets with his outpt PCP to discuss further goals
of care. his aspirin and plavix were discontinued. he was
started on PPI [**Hospital1 **].
.
.
#) Liver Findings: nodular liver, low platelets, ascites,
splenic varices all c/w cirrhosis; etiology unclear, given new
malignancy diagnosis, will need to discuss further w/u with
primary PCP as above.
.
.
#) Anemia: baseline hct ~30, some chronic component most likely
2/2 blood losses from the gastric mass; pt with acute bleeding
after biopsy of gastric mass (hct down to 18) requiring 5U PRBC
on [**9-10**] while in CSRU, stable Hct and vitals after transfusion
s/p biopsy. HCT remained stable for remainder of hospital
course without additional transfusion with HCT ~30 again.
.
#) AAA: stable; on aggressive BP control, pt continued on BB.
.
.
#) Leukocytosis: unclear etiology; pateint was c/o diarrhea
prior to admission and for the first few days of hospital
course; no prior antibiotic exposure; rising count after
admission but afebrile; ? response to recent EGD instrumentation
vs. traumatic foley insertion vs. reaction to blood transfusion
(saw in note that there was some question of reaction on [**9-10**]
and blood bank w/u initiated) vs. C. diff colitis vs. viral
gastroenteritis vs. GI upset from unknown source. Pt was on
Flagyl/cipro earlier this admission, but unclear to why; cdfiff
remained negative, pt afebrile, attributed to tumor.
.
..
#) HTN: pt switched to IV metoprolol 5mg Q6 hours while NPO, his
home regimen was restarted upon discharge.
.
#) Traumatic foley insertion: pt with h/o penile prosthesis.
patient had balloon inflated while in urethra (per notes); foley
was left in place to tamponade the bleed. urology was
consulted, and following. foley was removed without
complication, though pt had mild ongoing bleeding. pt was
discharged with instructions provided (to wife via phone) to
followup with urology in 4 weeks time.
.
.
# acute SOB: no history of lung disease, no CHF history, 65 pky
smoking history with emphysema on imaging, was transferred from
medicine floor to MICU on [**9-16**] for acute episodes of SOB and
hypoxemia x2. First SOB episode was at 3 pm earlier [**9-16**], SBP
170s, 100% 2L nc was switched to 100% NRB, patient was using
accessory muscles with labored breathing, but could clearly
state that he was having a hard time breathing. He was given
lasix 20, hydral 10, combivent nebs, but his SOB resolved before
he started diuresing. He eventually diuresed 1L from the lasix
over the next hour. At 6 pm, he had a second SOB episode, BP
176/111, HR 118, 100% 2L nc was switched to 100% NRB with ABG
7.31/39/64. He was again given lasix, hydral, combivent nebs,
with no resolution after 30 min. He was transferred to the MICU
on 100% NRB after a 50 min SOB episode.
.
In the MICU, his SOB spontaneously and suddenly resolved from
extreme SOB on 100% NRB to a normal breathing pattern on RA over
10 minutes, with no further intervention or medication. Upon
questioning, he states that he has never had any similar
episodes before in his life. He describes these episodes as
"being able to breathe in, but not being able to breathe out"
and "it's as though someone is trying to prevent you from
breathing". The episodes both started when he started thinking
about his ex lap tomorrow for staging of his gastric cancer. He
states that "anxiety" is the right word to describe how he was
feeling when his thoughts started coming too fast and he felt
overwhelmed and started breathing too fast. He said when he
calmed down upon arriving in the MICU, he could breathe normally
again.
.
He sleeps flat in bed, has never been told he has emphysema or
CHF, uses no oxygen or inhalers on a daily basis at home, can
walk a few blocks before having to stop from SOB, can go up and
down 1 flight of stairs, on no lasix or water pills at home (was
written for lasix here to start on [**9-17**]). He has never had
psychiatric issues, depression, anxiety, panic disorder, but
feels overwhelmed by recent cancer diagnosis.
.
etiology was ultimately attributed to vocal cord spasm as no
abnormalities on physical exam, though ABGs were markedly
abnormal. ENT scoped patient and found completely normal exam
throughout. Steroids had been started 1 hour before ENT
investigation, so unlikely that edema had resolved. Appears that
patient had 2 anxiety/panic attacks over surgery that was to be
for tomorrow, now cancelled. cardiac enzymes mildly elevated
felt [**1-29**] mild elevation in creatinine. TTE ordered but canceled
per PCP who is cardiologist as cardiac etiology felt unlikely.
pt treated with Ativan prn for anxiety and discharged home with
recomendation for further w/u if episodes recurred.
.
.
ACCESS: LSC central line placed on [**9-10**].
.
COMM: Wife [**Name (NI) 33518**]: [**Telephone/Fax (1) 33519**]
Medications on Admission:
Ipratropium Bromide Neb 1 NEB IH Q6H:PRN
Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN
Lorazepam 0.5-1 mg PO Q8H:PRN anxiety
Amlodipine 5 mg PO DAILY
Metoprolol 37.5 mg PO TID
Doxazosin 8 mg PO HS
Furosemide 40 mg PO DAILY
Pantoprazole 40 mg IV Q12H
Haloperidol 2 mg IV Q2H:PRN agitation
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Doxazosin 4 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
5. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: Three (3)
Tablet Sustained Release 24 hr PO once a day.
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
6. Zestril 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Outpatient Lab Work
please have your CBC drawn when you are seen by Dr. [**Last Name (STitle) **] to
ensure that it is stable (HCT=30 upon discharge)
Discharge Disposition:
Home
Discharge Diagnosis:
Gastric adenocarcinoma
Respiratory distress
Thrombocytopenia
AAA
Hypertension
Blood loss anemia
Emphysema
Discharge Condition:
Stable. tolerating PO diet, ambulating without difficulty,
HCT=30.
Discharge Instructions:
Please take all medications as prescribed.
.
you were started on pantoprazole to be taken twice daily given
your GI bleeding.
.
your metoprolol was titrated up for better blood pressure
control given your aortic aneurysm to toprol 150mg po qdaily.
.
your aspirin and plavix were discontinued during this admission
given your recent GI bleeding, and in anticipation of your
staging laparoscopy.
.
.
you were noted to have blood in your urine during this
admission, this was felt due to a traumatic foley insertion, you
were seen by urology. please follow-up with your primary care
physician if you continue to have blood in your urine.
.
.
If you develop any black or bright red stools, lightheadedness,
dizziness, shortness of breath, abdominal pain or any other
concerning symptom please call your doctor or come to the
emergency room.
Followup Instructions:
You should follow up with Dr. [**Last Name (STitle) **] on [**2190-9-20**], please call him at
[**Telephone/Fax (1) **] to arrange this. You should specifically discuss
when to restart aspirin and plavix with him. You should have
your hematocrit drawn when you are seen by him to ensure that it
is stable.
.
.
You should follow up with your primary care physician [**Name Initial (PRE) 176**] [**1-30**]
weeks regarding blood in your urine, this was felt due to a
traumatic foley insertion during this admission.
.
.
You will also need to coordinate with the surgical oncology team
for an exploratory laparotomy as an outpatient to further workup
your gastric malignancy. Their phone number is [**Telephone/Fax (1) 7508**].
|
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48,872
| 171,109
|
43767
|
Discharge summary
|
report
|
Admission Date: [**2184-2-25**] Discharge Date: [**2184-3-1**]
Date of Birth: [**2131-7-16**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Percocet / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Cough/Dyspnea
Major Surgical or Invasive Procedure:
Rigid Bronchoscopy and Y Stent Removal
History of Present Illness:
52 yo M 52 year-old man with a history of diabetes, kidney
transplant in [**2162**] and [**10/2182**], pancreas transplant in [**2167**],
colon cancer, and tracheobronchomalacia status post Y stent
placement [**2183-11-27**] presenting to the MICU for NIPPV s/p Y stent
removal. Initially after stent placement, pt states that his
symptoms improved greatly, but in the time since, his cough
became progressively worse. On bronchoscopy, increasing
granulation tissue was noted in left mainstem. For this reason,
IP took him to the OR [**2184-1-27**] for stent removal. He was extubated
after OR and was recovering in the PACU, when he developed cough
and respiratory distress. He was placed on BiPAP, with
improvement in his respiratory status. BiPAP was then weaned; pt
felt weak while satting 96% on 6L NC, getting nebs. VS were HR
88 155/52 21. Pt was transferred to MICU with plan to put pt on
BiPAP overnight for pt comfort and monitoring.
.
On arrival to the MICU, initial VS were:
T 98 BP 160/65 HR 85 RR 23 O2 92% NRB
He was in NAD, speaking in short sentences on NRB, but indicated
that he was concerned that he was having a very hard time
breathing. For this, he was placed back on BiPAP, with
improvement.
Past Medical History:
# Diabetes mellitus type I, now Diabetes mellitus type II post
pancreas transplant (failed)
# Status post renal ([**2162**]), pancreas transplants ([**2167**]), kidney
transplant [**2182-11-12**]
# Tracheobronchomalacia, severe. medical optimization since
[**5-/2183**]
# CKD Baseline Cr 1.1-1.5 this year
# Hypertension
# GERD
# HLD
# Peptic ulcer disease
# [**Female First Name (un) 564**] esophagitis
# Right lower extremity cellulitis
# Left fifth toe amputation for Gangrene
# Charcot Arthropathy- Septic left subtalar joint
# Urinary tract infections
# Retinopathy, status post vitrectomy
# Esophageal achalasia
# Post-strep GN
# h/o stage 1 colon ca s/p resection in [**2178**]
# s/p venous graft surgery
Social History:
-Tobacco history: None
-ETOH: None
-Illicit drugs: None
-Home: Lives with Wife [**Name (NI) **] ([**Telephone/Fax (1) 94038**], [**Telephone/Fax (1) 94039**])
-Work: disabled, former business owner
Family History:
No lung cancer or congenital lung disease.
Mother had frequent bronchitis
Physical Exam:
Admission Exam:
T 98 BP 145/65 HR 85 RR 23 O2 95% BiPAP
General Appearance: On BiPAP, comfortable
Chest: Rhonchi at the bases, mild expiratory wheeze, transmitted
upper airway sounds, no increased WOB
Cardiovascular: reg rate, nl S1/S2
Abdomen: soft, NT/ND, NABS, no HSM
Extremities: BLE, chronic skin changes w/ pretibial erythema,
L>L, right ankle, pre-tibial area with numerous surgical scars
from "charcot joint" s/p repair
Neurological: A&O x3, CN II-XII intact, non focal
.
Discharge Exam:
T 98 BP 110/80 HR 80 RR 18 O2 Sat 93% NC
GEN: On BiPAP, NAD
CV: RRR, normal s1/s2, no s3/s4, no m/r/g
PULM: Bibasilar crackles, on BiPAP, no increased WOB
Abdominal: Soft, Non-tender, Bowel sounds present, Distended
Extremities: Right lower extremity edema: 1+, Left lower
extremity edema: 1+, pedal edema markedly improved since
admission
Neurologic: A/Ox3, CN II-XII intact, non focal
Pertinent Results:
Admission Labs:
[**2184-2-24**] 11:00AM BLOOD WBC-6.9 RBC-4.13* Hgb-11.6* Hct-36.7*
MCV-89 MCH-28.1 MCHC-31.6 RDW-14.3 Plt Ct-403
[**2184-2-24**] 11:00AM BLOOD UreaN-30* Creat-1.4* Na-144 K-5.2* Cl-104
HCO3-30 AnGap-15
[**2184-2-24**] 11:00AM BLOOD Albumin-3.9 Calcium-10.2 Phos-3.1
[**2184-2-24**] 11:00AM BLOOD tacroFK-5.2
[**2184-2-25**] 04:10PM BLOOD Type-[**Last Name (un) **] pO2-38* pCO2-48* pH-7.42
calTCO2-32* Base XS-5 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**]
[**2184-2-25**] 04:10PM BLOOD Glucose-131* Lactate-0.9 Na-141 K-4.3
Cl-100
[**2184-2-25**] 04:10PM BLOOD Hgb-11.6* calcHCT-35
[**2184-2-25**] 04:10PM BLOOD freeCa-1.28
.
Discharge Labs:
[**2184-3-1**] 06:01AM BLOOD WBC-4.5 RBC-3.53* Hgb-10.5* Hct-31.7*
MCV-90 MCH-29.6 MCHC-33.0 RDW-13.6 Plt Ct-376
[**2184-3-1**] 06:01AM BLOOD Glucose-221* UreaN-46* Creat-1.6* Na-142
K-4.0 Cl-99 HCO3-33* AnGap-14
[**2184-3-1**] 06:01AM BLOOD Calcium-10.1 Phos-4.0 Mg-2.3
.
CXR ([**2184-2-25**]):
No acute intrathoracic process.
.
CXR ([**2184-2-26**]):
Both lungs are well expanded and clear without any opacities
concerning for consolidation or pulmonary edema. There is no
pneumothorax or pleural
effusion. Mild widening of the upper mediastinal silhouette
which has been
stable since at least [**2183-5-21**] is likely from prominent
mediastinal fat.
.
TTE ([**2184-2-27**]):
The left atrium is mildly dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is a
trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2183-1-15**], no
change.
.
CXR ([**2184-2-28**]):
The heart size is upper limits of normal but stable. There has
been
development of a right-sided pleural effusion with blunting of
the CP angle. There is some atelectasis at the lung bases. There
are no signs for overt pulmonary edema. No pneumothoraces are
identified.
Brief Hospital Course:
Primary Reason for Admission: 52 y/o man with kidney transplant
x2 (last [**2181**]) and pancrease transplant ([**2167**]) s/p Y stent
placement ([**11/2183**]) for tracheobronchial malacia admitted to the
MICU s/p Y stent removal for NIPPV.
.
Active Problems:
.
# Respiratory Distress: Given his acute decompensation s/p Y
stent removal and rapid improvement with NIPPV, likely related
to tracheobronchial malacia +/- an element of pulmonary edema.
His PFTs have shown a restrictive pattern previously, which
raises concern for a second process that may be contributing to
his severe respiratory distress, though this is not likely
related to his acute decompensation. CXR showed no e/o pneumonia
or pneumothroax, though was c/w mild pulmonary edema on
admission. For this he was given 40mg IV Lasix on MICU days 1
and 2; his Cr remained stable and he was diuresed ~4L during his
MICU course. MIP was -80, MEP was +80, indicating his poor
pulmonary function is not likely to be a primary MSK/Neuro
issue. Unfortunately, his respiratory status only improved
mildly with dirusis and he continued to require 6L O2 during the
day and NIPPV at night for hypoxia. He was offered inpatient
pulmonary rehab, which he declined. Interventional Pulm
continued to follow throughout his course and had no additional
recommendations. He will go home with O2 and BiPAP. He will
require aggressive pulmonary rehab and will f/u with thoracics
for possible tracheal reconstruction.
.
# Kidney/Pancreas Transplant: His Cr remained stable and near
his baseline throughout his course. His home Prednisone,
Cellcept and Tacrolimus were contuinued throughout. Renal
Transplant was consulted and was actively involved in his care
for the duration of his hospital stay. His home NaHCO3 was
decreased and his Bactrim was restarted per Transplant.
.
# Chronic Problems:
.
# DM: BG was elevated in the 200-300s. For this his home Lantus
was increased to 19qAM and 15 qPM. His home ISS was continued.
.
# HTN: On admission to the MICU, pt was severely hypertensive
with SBP 220s. His home Amlodipine/Losartan were restarted, but
he continued to be persistently hypertensive. For this,
Labetalol 200mg PO TID was started with marked improvement in
his BP.
.
Transitional Issues: Pt was d/c'ed home with O2 and BiPAP. He
will follow up with his PCP and Nephrology. His caretakers were
notified of his admission and discharge plan.
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
puffs inh every six (6) hours as needed for cough or wheezing.
ALENDRONATE - 70 mg Tablet - 1 Tablet(s) by mouth qweek
AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily)
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily)
FUROSEMIDE - (Dose adjustment - no new Rx) - 20 mg Tablet - 1
Tablet(s) by mouth twice a day as needed for edema
INSULIN GLARGINE [LANTUS] - (Dose adjustment - no new Rx) - 100
unit/mL Solution - 14 units qam 10 in the pm twice daily
INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - Inject TID on
a
sliding scale as directed.
LOSARTAN - 25 mg Tablet - 1 (One) Tablet(s) by mouth once a day
MYCOPHENOLATE MOFETIL - 500 mg Tablet - 2 Tablet(s) by mouth
twice a day
PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 40 mg
Tablet(s) by mouth once a day
PREDNISONE - 5 mg Tablet - 1 Tablet(s) by mouth once a day
TACROLIMUS - (Dose adjustment - no new Rx) - 1 mg Capsule - 3
Capsule(s) by mouth twice a day
TAMSULOSIN - 0.4 mg Capsule, Ext Release 24 hr - 1 Capsule(s) by
mouth daily
TRAZODONE - 50 mg Tablet - 1 (One) Tablet(s) by mouth at bedtime
as needed
SODIUM BICARBONATE - 650 mg Tablet - 4 Tablet(s) by mouth twice
a
day
.
Medications - OTC
ASPIRIN [ASPIRIN [**Hospital1 **]] - (Prescribed by Other Provider) -
81 mg Tablet, Chewable - 1 Tablet(s) by mouth once a day, 3
times
a week
GUAIFENESIN [MUCINEX] - 1,200 mg Tablet, ER Multiphase 12 hr - 1
Tablet(s) by mouth twice a day
Discharge Medications:
1. BiPAP
BiPAP ST [**11-27**] with backup rate 10, Oxygen 4-6 L continuous
2. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every 4-6 hours as needed for cough.
3. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
4. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO qAM.
Disp:*30 Tablet(s)* Refills:*2*
7. Lasix 20 mg Tablet Sig: One (1) Tablet PO qPM.
Disp:*30 Tablet(s)* Refills:*2*
8. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. tacrolimus 1 mg Capsule Sig: 3.5 Capsules PO Q12H (every 12
hours).
10. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
14. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
15. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
16. sodium bicarbonate 650 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
17. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
18. guaifenesin 600 mg Tablet Extended Release Sig: Two (2)
Tablet Extended Release PO BID (2 times a day).
19. labetalol 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
20. insulin glargine 100 unit/mL Solution Sig: Nineteen (19)
units Subcutaneous qAM: inject 19 units subcutaneous every
morning.
21. insulin glargine 100 unit/mL Solution Sig: Fifteen (15)
units Subcutaneous qHS: inject 15 units subcutaneous every
evening.
22. insulin lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous three times a day: inject three times as day per
sliding scale as directed.
23. Supplemental Oxygen
please provide home oxygen, titrate to O2 sat >92% for
tracheobronchial malacia
Discharge Disposition:
Home With Service
Facility:
[**Hospital 6549**] Medical Company
Discharge Diagnosis:
Primary Diagnosis:
Tracheobronchial Malacia
Secondary Diagnosis:
Restrictive Lung Disease
Pulmonary Edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr [**Known lastname 410**],
It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted to have your pulmonary stent
removed. After the stent was removed, you were having some
difficult breathing adn were admitted to the ICU. We gave you
diuretics and your breathing improved. You will need pulmonary
rehab as an outpatient and should continue to use the
supplemental oxygen and the BiPAP machine as directed.
Please note the following changes to your medications:
STARTED Labetalol 200mg by mouth three times a day
INCREASED Lasix to 40mg by mouth in the morning and 20mg by
mouth in the afternoon
INCREASED Lantus to 19 units in the morning and 15 units in the
evening
RESTARTED Bactrim 1 tab by mouth daily
DECREASED Sodium Bicarb to 975mg by mouth twice a day
Followup Instructions:
Please call Dr.[**Name (NI) 9920**] office ([**Telephone/Fax (1) 721**]) to schedule a
follow up appointment in mid [**Month (only) 547**]. He is expecting your phone
call.
Please call Dr[**Name (NI) 5070**] office ([**Telephone/Fax (1) 7769**]) to schedule a
follow up appointment.
Department: [**Hospital **] HEALTHCARE OF [**Location (un) **]
When: MONDAY [**2184-3-8**] at 12:00 PM
With: [**First Name11 (Name Pattern1) 20**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3070**]
Building: [**Street Address(2) 8172**] ([**Location (un) 620**], MA) Ground
Campus: OFF CAMPUS Best Parking: Parking on Site
Department: PAT-PREADMISSION TESTING
When: WEDNESDAY [**2184-3-17**] at 11:15 AM
With: PAT-PREADMISSION TESTING [**Telephone/Fax (1) 2289**]
Building: CC [**Location (un) 591**] [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2184-3-17**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15553**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2184-6-15**] at 4:00 PM
With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
|
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icd9cm
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[
[
[]
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[
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[
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13225, 13525
|
273, 288
|
396, 1614
|
12518, 12561
|
3596, 4237
|
12472, 12497
|
12597, 12709
|
1636, 2351
|
2367, 2569
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,299
| 183,566
|
17573
|
Discharge summary
|
report
|
Admission Date: [**2180-10-21**] Discharge Date: [**2180-10-25**]
Date of Birth: [**2118-5-2**] Sex: M
Service: MEDICINE
Allergies:
Vioxx / Dilaudid
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
ERCP attempted, unable to cannulate major papilla
History of Present Illness:
Mr. [**Known lastname **] is a 62 yo male with a history of CAD s/p CABG, CHF
s/p ICD placement, afib on coumadin, chronic alcoholic
pancreatitis, and s/p whipple procedure (Puestow procedure) who
presents with fevers, chills, nausea, vomiting, and abdominal
pain. Reports that he had non-radiating periumbilical abdominal
pain that started 4 days PTA and was associated with nausea.
Pain was dissimilar from prior pancreatitis or SBO pain or other
pain he has had in past. Pain resolved by the following day. On
day PTA, pain recurred and was more severe and associated with
N/V/D, fevers, and chills. Denies melena, hematochezia, LH,
dizziness, chest pain, SOB, cough. Emesis was dry heaves,
non-bloody. He initially presented to an OSH where due to
eleavted LFTs and bilirubin, RUQ ultrasound was performed and
was reportedly unremarkable. He was given a dose of zosyn and
transferred for possible ERCP. Of note, he reports ETOH intake
on Tues and Thursday of this week. Also c/o pruritus which is
stable from baseline.
In the ED, initial vs were: pain 8, T 97.5, HR 90, BP 110/80, RR
16, O2 sat 93%. Patient was repeatedly hypotensive with SBPs
70s-80s and required multiple 250cc boluses of IVF which were
given gently due to history of CHF. Right IJ CVL was placed.
Labs were notable for WBC count 22.4K with 5 bands, K 3.2,
creatinine 1.1 (up from 0.7), ALT 95, AST 112, Tbili 3.9, INR
3.4, lactate 2.2, and a positive UA. CT abdomen and pelvis with
contrast showed no acute pathology. He was evaluated by surgery
and ERCP team. He received vancomycin 1g IV, dilaudid 1 mg IV,
and diphenhydramine 50 mg IV. Vital signs on sign-out were T
97.6, HR 83, BP 107/66, RR 16, O2 sat 95% on RA with improvement
in abdominal pain.
On arrival to the ICU, he reported abdominal pain was much
improved compared with yesterday, currently [**2-16**]. Denies nausea
but reports his usual back pain is more severe due to bed
positioning.
On arrival to the floor, he reported his abdominal pain to be
resolved. He also denied nausea and vomitting.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
cough, change in usual shortness of breath, or wheezing. Denies
chest pain, chest pressure, palpitations, or weakness. Denies
nausea, vomiting, diarrhea, constipation, or changes in bowel
habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes. All
other systems negative.
Past Medical History:
Atrial fibrillation.
-Chronic alcoholic pancreatitis s/p partial resection with
Whipple.
-Pancreatic pseudocyst diagnosed in 3/[**2173**].
-Coronary artery disease status post percutaneous transluminal
angioplasty with stent x 5 vessels in 6/[**2167**]. EF 40%
-Psoriasis with severe arthritis requiring hand surgery.
-Hyperlipidemia.
-Gout.
-COPD
-Hyperlipidemia
-Chronic abdominal pain on narcotics
-h/o polysubstance absue
-ETOH abuse
-Mild chronic thrombocytopenia
-GERD
-s/p ICD placement L c/b abscess and shange to R
-Chronic AF
-BPH
-SBO [**2180-6-6**]
Past Surgical History:
-Puestow procedure, open cholecystectomy, feeding jejunostomy
tube [**2-/2175**]
-Appendectomy
-Cervical fusion for C4-5 compression fx after assault on the
job
-Laminectomy [**1-/2173**]
-CABG
Social History:
Smokes 1-2 packs daily for decades, consumes EtOH [**12-20**] drinks
per week, drank [**3-9**] drinks (Highballs, scotch and water) on
Thursday as well as Monday. Denies recreational drug use. No
h/o withdrawal (gives up ETOH every year for Lent). Retired
police officer. Lives alone. Son is HCP
Family History:
Denies family history of gastrointestinal disorders and cancers,
including pancreatic disease. Father expired of bronchial
cancer.
Physical Exam:
VS: T 97.6, HR 83, BP 107/66, RR 16, O2 sat 95% on RA
General: Alert, oriented, no apparent distress
HEENT: Sclera icteric, MM slightly dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Coarse breaths sounds bilaterally with exp wheezes
CV: Irregular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, not tender to palpation, no rebound or guarding.
Bowel sounds present, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Diffuse erythematous silvery scaly patches with cream
applied
Pertinent Results:
[**2180-10-21**] 03:20AM BLOOD WBC-22.4*# RBC-4.28* Hgb-14.2# Hct-43.4#
MCV-102*# MCH-33.2*# MCHC-32.7 RDW-14.4 Plt Ct-177#
[**2180-10-24**] 03:24AM BLOOD WBC-6.0 RBC-3.76* Hgb-12.4* Hct-40.0
MCV-107* MCH-33.0* MCHC-31.0 RDW-13.9 Plt Ct-138*
[**2180-10-21**] 03:20AM BLOOD PT-33.8* PTT-33.7 INR(PT)-3.4* (warfarin
held for procedure)
[**2180-10-22**] 04:00PM BLOOD PT-27.4* PTT-34.4 INR(PT)-2.7* (warfarin
held for procedure)
[**2180-10-23**] 06:05AM BLOOD PT-21.7* PTT-35.6* INR(PT)-2.0*(warfarin
held for procedure)
[**2180-10-24**] 03:24AM BLOOD PT-20.2* INR(PT)-1.9* - Received
Warfarin 2 mg
[**2180-10-24**] 03:24AM BLOOD Glucose-84 UreaN-8 Creat-0.7 Na-139 K-4.1
Cl-106 HCO3-28 AnGap-9
[**2180-10-21**] 03:20AM BLOOD Albumin-3.3* Calcium-8.0* Phos-3.4
Mg-1.1*
[**2180-10-24**] 03:24AM BLOOD Calcium-8.4 Phos-3.0 Mg-1.6
[**2180-10-21**] 03:20AM BLOOD ALT-95* AST-112* LD(LDH)-205 AlkPhos-329*
TotBili-3.9* DirBili-3.1* IndBili-0.8
[**2180-10-23**] 06:05AM BLOOD ALT-70* AST-67* LD(LDH)-184 AlkPhos-254*
TotBili-1.3
[**2180-10-24**] 03:24AM BLOOD ALT-53* AST-49* AlkPhos-219* TotBili-1.1
[**2180-10-21**] 03:20AM BLOOD Lipase-27
[**2180-10-21**] 03:20AM BLOOD cTropnT-<0.01
[**2180-10-21**] 12:29PM BLOOD CK-MB-5 cTropnT-<0.01
[**2180-10-21**] 07:39PM BLOOD VitB12-546 Folate-14.8
[**2180-10-21**] 06:24AM URINE Color-Amber Appear-Hazy Sp [**Last Name (un) **]-1.021
[**2180-10-21**] 06:24AM URINE Blood-SM Nitrite-NEG Protein-75
Glucose-NEG Ketone-TR Bilirub-MOD Urobiln-1 pH-5.0 Leuks-TR
[**2180-10-21**] 06:24AM URINE RBC-[**3-10**]* WBC-[**11-25**]* Bacteri-MOD
Yeast-NONE Epi-0-2
[**2180-10-21**] URINE CULTURE-FINAL NO GROWTH.
[**2180-10-21**] MRSA SCREEN MRSA SCREEN-FINAL No MRSA
isolated.
[**2180-10-21**] Blood Culture, Routine-PENDING INPATIENT
[**2180-10-21**] Blood Culture, Routine-PENDING INPATIENT
CT ABD/PELVIS W/CONTRAST10/16:
1. Prior Puestow procedure with minimal surrounding stranding,
nonspecific.
2. Decrease in size of cystic lesions in the region of the
proximal pancreas are likely residual pseudocysts.
3. Lymphadenopathy, as above.
4. Progression of lower lumbar spine degenerative changes, as
above.
CXR [**10-21**] IMPRESSION:
Broken sternal wires. Small bilateral pleural effusions and
underyling
collapse/consolidation. Mild assymetric upper zone
redistribution.
ERCP [**10-23**] Impression: Cannulation of suspected minor papilla
superficially with a sphincterotome using a free-hand technique.
Contrast medium was injected resulting in partial opacification
of thin, irregular pancreatic duct.
Due to altered anatomy, redundant folds and edema, the major
papilla was unable to be located for cannulation.
Otherwise normal ercp to third part of the duodenum
Recommendations: Return to floor
Continue with current antibiotic therapy for [**10-19**] day course
Consider pancreatic protocol CT scan to further delineate the
pancreatic/biliary anatomy as patient is unable to get MRCP due
to defibrillator.
Pending resolution of current inflammation, would consider
repeat ERCP in [**1-8**] weeks if clinically indicated.
Brief Hospital Course:
62 year old male with a history of CAD s/p CABG, AF on coumadin,
COPD, CHF, chronic pancreatitis s/p Puestow procedure and
cholecystectomy, admitted with cholestatic LFTs and abdominal
pain with hypotension on admission c/w biliary
obstruction/cholangitis with sepsis.
.
.
# Sepsis d/t biliary obstruction/cholangitis: Patient presented
with hypotension, fever, leukocytosis and abdominal pain
consistent with sepsis. BP initially 70s-80s in ED but was fluid
responsive. Now hemodynamically stable, doing well on
antibiotics, see below.
.
# Biliary obstruction/Cholangitis -
Pt was initially managed in the ICU and was treated aggressively
with Vancomycin and Pip/Tazo. ERCP and Surgery were consulted.
He clinically stabilized, with improvement in blood pressure
after bolusing IVF, and providing antibiotics. He underwent
ERCP attempt [**10-23**], but they were unable to cannulate the major
papilla. He was continued on antibiotics and his LFT's were
closely followed. Despite inability to complete the ERCP, his
LFT's continued to downtrend, and the patient symptomatically
improved, with resolution of abdominal pain. He remained
hemodynamically stable, and his blood pressure medications were
able to be resumed prior to discharge. He will complete a 10 day
course of Cipro/Flagyl for his cholangitis (7 days remain).
Considering his clinical improvements, the pt will pursue
further [**Month/Year (2) 2742**] and management as an outpt, which will likely
include CT Pancreas, and repeat ERCP once the inflammation has
decreased. Pt should have LFT's/CBC drawn at a follow up PCP
[**Name Initial (PRE) **].
.
# Urinary tract infection - Patient had a positive UA, but Ucx
from [**10-21**] had no growth. Thus, it is unlikely that it was the
source of his infection or reflective of bacteremia.
.
# ETOH abuse: Pt denies h/o withdrawal although drinks on a
fairly regular basis. Counseled at length the need for him to
quit.
He was monitored on the CIWA scale, but did not score. There was
no evidence of withdrawl.
.
# CAD: He denies CP during this hospitalization although he
reported CP in the ambulance and at the OSH ED. He stated that
this was dissimilar from "cardiac" pain. Cardiac enzymes were
checked and were negative. He was provided aspirin 81 mg PO
daily. His blood pressure medications were initially held due
to his sepsis, but these were resumed prior to discharge and
were tolerated well.
His Crestor was held, and will be held on discharge until PCP
follow up, considering his elevated LFT's from his biliary
obstruction. Please follow up and resume when appropriate.
.
# Atrial Fibillation: Pt currently in afib, rate controlled.
Pt's metoprolol was resumed on [**10-25**], which he tolerated without
difficulty. Pt's warfarin was initially held for ERCP, but this
was resumed prior to discharge. Please see results section for
recent INR's and warfarin dosing.
His warfarin was resumed on [**10-24**]; please note the interaction
with the antibiotics. His INR will need close following.
Discussed with patient the need for close INR monitoring,
especially while on antibiotics. Pt agrees to go to his coumadin
clinic [**10-26**] for INR check.
.
# COPD: pt reports being on Combivent at home, although this was
not on his medication list from the PCP [**Name Initial (PRE) 3726**]. He denied any
respiratory symptoms.
He was discharged on his home regimen.
.
# BPH: resumed flomax
.
# Gout: continued allopurinol
.
# GERD: Continued PPI
.
# Psoriasis/Arthritis:
His methotrexate was held considering infection. He was
continued on folic acid. He was provided Clobetasol Propionate
0.05% Cream 1 Appl TP [**Hospital1 **] for 2 Days and Calcipotriene 0.005%
Cream 1 Appl TP [**Hospital1 **] for 2 Days, with reported benefit.
He was requested to f/u with his PCP for management of his
psoriasis medications after the hospitalization.
.
Prophylaxis: Subcutaneous heparin
Code: Full (discussed with patient)
Medications on Admission:
Protonix 40 mg daily
Folic acid 1 mg daily
Aspirin 81 mg daily
Methotrexate 7.5 mg daily vs weekly
Allopurinol 100 mg daily
Motrin 800 mg TID for years
Coumadin 2mg PO daily
Flomax 0.4mg PO daily
Demerol 100mg PO q6 prn
Imdur 180mg PO daily
Metoprolol tartrae 2tabs PO BID (unsure of dose)
Folic acid 1mg PO daily
Combivent 2puffs q 4 prn
Reglan 5mg PO qhs prn
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. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. isosorbide mononitrate 120 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia: prescribed by other provider.
6. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tab
Sublingual as DIR as needed for chest pain.
7. Flovent HFA 110 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation twice a day.
8. warfarin 1 mg Tablet Sig: One (1) Tablet PO q 4 pm: Please
follow closely with [**Hospital 197**] clinic and titrate dose as needed.
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. metoprolol tartrate 100 mg Tablet Sig: Two (2) Tablet PO
twice a day.
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
13. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
14. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puff
Inhalation twice a day.
15. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
# Sepsis due to cholangitis
# Biliary obstruction
# Urinary tract infection
# Coronary artery disease
# Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with abdominal pain and low blood pressure,
and you were found to have a significant infection in your bile
ducts due to an obstruction. You were treated with antibiotics,
and we attempted to evaluate and treat this obstruction with a
procedure called ERCP, but this was unsuccessful. You will
complete a 2 week course of antibiotics, and you will follow up
with the ERCP doctors for further [**Name5 (PTitle) 2742**]. Please complete
your antibiotics as prescribed.
It is extremely important that you follow closely with your
[**Hospital 197**] Clinic while you are on antibiotics, as this will
increase the effects of your coumadin, and your dosing will need
to be adjusted.
New Medications:
Ciprofloxacin
Flagyl (metronidazole)
Holding:
Methotrexate
Crestor
Followup Instructions:
Please go to your [**Hospital 197**] Clinic on Thursday, [**2180-10-26**] for
an INR check.
Name: CHAKRABORTY,AUROBINDO
Location: SUBURBAN CARDIOLOGY & INTERNAL MEDICINE
Address: [**Location (un) 8056**], [**Location (un) **],[**Numeric Identifier 45328**]
Phone: [**Telephone/Fax (1) 8058**]
Appointment: Monday, [**10-30**] at 11:30AM
Please check CBC and LFT's at this appointment.
Department: DIV. OF GASTROENTEROLOGY
When: THURSDAY [**2180-11-9**] at 1:15 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
|
[
"V45.82",
"576.1",
"425.4",
"274.9",
"V45.4",
"576.2",
"288.60",
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"303.91",
"599.0",
"305.1",
"V45.81",
"995.91",
"272.4",
"577.1",
"038.9",
"287.5",
"696.0",
"571.3",
"427.31",
"414.01",
"496",
"V58.61",
"V45.89",
"600.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.11",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
13734, 13793
|
7884, 11826
|
293, 345
|
13962, 13962
|
4789, 7861
|
14953, 15675
|
4040, 4174
|
12237, 13711
|
13814, 13941
|
11852, 12214
|
14145, 14930
|
3513, 3709
|
4189, 4770
|
2443, 2906
|
239, 255
|
373, 2423
|
13977, 14121
|
2928, 3490
|
3725, 4024
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,380
| 102,438
|
29673
|
Discharge summary
|
report
|
Admission Date: [**2150-12-29**] Discharge Date: [**2151-2-13**]
Date of Birth: Sex:
Service:
PREOPERATIVE DIAGNOSIS: Esophageal perforation.
POSTOPERATIVE DIAGNOSIS: Esophageal perforation.
OPERATIONS:
1. Left thoracotomy, repair of esophagus with intercostal
muscle flap [**2150-12-29**].
2. Thoracentesis, right chest, [**2151-1-7**].
3. Bronchoscopy [**2151-1-12**].
4. Tracheostomy, bronchoalveolar lavage, open jejunostomy
tube placement [**2151-1-13**].
HISTORY OF PRESENT ILLNESS: The patient is an 87-year-old
female who presented to an outside hospital with fever and
abdominal pain. On CT scan, the patient was found to have
evidence of esophageal perforation. She was transferred to
our hospital for care.
HOSPITAL COURSE: The patient, upon arrival to the hospital,
had a left thoracotomy and repair of her esophagus. There was
seen to be a large size hole in the distal aspect of her
esophagus. Given the amount of necrosis and the amount of
fibrinous exudate and debris in the left chest, it was felt
that the perforation had occurred some time ago. The patient
had some debridement and buttressing of the esophageal repair
site with intercostal muscle flap.
The patient was sent to the intensive care unit. She had a
prolonged and difficult postoperative course. Attempts at
extubation were made several times; however, the patient was
unable to remain extubated for prolonged periods and required
reintubation each time.
X-rays and CT scans of the chest showed that the patient had
developing pleural effusions, especially on the right side.
The left side seemed to be fairly well evacuated with the
chest tubes which were in place. She needed a right
thoracentesis performed on [**2151-1-7**] under ultrasound
guidance. This returned a fair amount of serosanguineous
fluid. A bronchoscopy performed approximately 5 days later
showed that the patient had significant copious secretions,
and it was thought that she would not be a good candidate for
extubation. Given the copious secretions and the numerous
failed extubations previously, the patient underwent a
tracheostomy and open jejunostomy tube on [**2151-1-13**].
The patient's pleural fluid on several occasions grew out
Enterococcus. Eventually, the speciation came back as
vancomycin resistant enterococcus. The patient's white count
had risen to 34,000 and remained elevated for several days.
Upon beginning linezolid, however, the patient's white count
began to decrease. Approximately 10 days after the linezolid
was begun, the white count went down to normal.
The patient had a continued difficult postoperative course.
She continued to have copious secretions from her
tracheostomy site and required suctioning several times a
day. Her cultures intermittently grew enterococcus but her
white count did stay down with the antibiotic regimen that
she was on.
Eventually, the patient had all other systems resolved except
for her kidneys. She stopped making any urine and had
increasingly rising creatinine. The patient had been on
intermittent and continuous hemodialysis. After discussion
with the family, it was thought that the patient would need
lifetime dialysis for supplementation of her kidneys. Given
the fact that the patient had requested not to be on chronic
support such as chronic dialysis, and after discussion with
the family, it was decided to withdraw support. Support was
withdrawn, and the patient expired approximately 48 hours
thereafter. The family was present at the bedside for this.
[**Name6 (MD) 4667**] [**Name8 (MD) **], M.D. [**MD Number(2) 39921**]
Dictated By:[**Name8 (MD) 67551**]
MEDQUIST36
D: [**2151-10-18**] 15:56:43
T: [**2151-10-18**] 22:56:17
Job#: [**Job Number 71100**]
|
[
"276.1",
"997.4",
"511.9",
"995.92",
"518.1",
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"518.81",
"510.9",
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"428.0",
"530.4",
"584.5",
"038.9",
"293.0",
"403.91",
"682.2",
"578.1"
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icd9cm
|
[
[
[]
]
] |
[
"39.95",
"31.1",
"99.07",
"96.04",
"33.24",
"45.13",
"99.15",
"46.32",
"34.3",
"96.72",
"38.93",
"99.04",
"34.51",
"34.91",
"96.6",
"00.14",
"38.95",
"42.89"
] |
icd9pcs
|
[
[
[]
]
] |
781, 3774
|
533, 763
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,670
| 193,406
|
11645
|
Discharge summary
|
report
|
Admission Date: [**2172-12-7**] Discharge Date: [**2172-12-14**]
Date of Birth: [**2099-3-7**] Sex: M
Service: CARDIOTHOR
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 73 year-old
male with known history of aortic stenosis had progressive
exertional dyspnea over the last two years now accompanied by
chest pain. Echo in [**2168**] and [**2169**] had showed an aortic
stenosis greater than approximately 70 mm of mercury with a
cross sectional valvular area of 0.8 cm squared.
Catheterization done in [**2170-10-29**] as well showing mild
to moderate aortic stenosis at a gradient of only 20 mm of
mercury. Echo re-performed on [**2172-10-17**] showed a gradient
of 72 mm of mercury followed a [**2172-11-6**]
catheterization showing severe as well as right coronary
artery to be 78% diseased. There was LAD irregularities and a
circumflex lesion of 60%. There was also a cross section
valvular area of the area involved measured 0.6 cm squared.
The patient was therefore evaluated for aortic valve
replacement and coronary artery bypass graft.
PAST MEDICAL HISTORY: Otherwise negative.
SOCIAL HISTORY: Negative for tobacco, rare ethanol ingestion.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs blood pressure
133/70, heart rate of 60, no acute distress. Trachea is
midline. There was no carotid bruit. Heart had a III/VI
systolic murmur heard at the right sternal border. The point
of maximal impulse was displaced laterally in the fifth
intercostal space. Lungs were clear to auscultation
bilaterally. Lower extremities were non-edematous and
palpable pulses to dorsalis pedis and posterior tibialis.
LABORATORIES ON ADMISSION: Hematocrit initially was 39, BUN
and creatinine 26 and 1.4 with BUN at baseline with normal
sufficiency.
EKG sinus rhythm with left ventricular hypertrophy.
Chest x-ray showed no acute cardiopulmonary disease.
HOSPITAL COURSE: The patient went to the operating room and
underwent coronary artery bypass graft times four LIMA to LAD
saphenous vein graft diagonal saphenous and then sequential
to the obtuse marginal as well as saphenous vein graft to the
posterior descending artery as well as tissue valve aortic
valve repair.
He went to the ICU where postoperative day one he was
extubated. His pressures were already weaned. Lasix and
aspirin were started due to some hypotension he was
transfused a unit of packed cells for a crit of 25. His
Lopressor was held. He was ultimately transferred to the
floor and started on a regular diet.
Postoperative day one once he arrived on the floor he was
complaining of significant substernal chest pain. EKG showed
ST elevations diffusely across the anterior leads as well as
PR depressions. Bedside echocardiogram showed no evidence of
wall motion abnormalities but he did have a rub on
auscultation. It was felt that he was suffering from
pericarditis and was therefore started on hydrous ibuprofen
around the clock which subsequently palliated his pain.
Postoperative day two his creatinine was noted to be 2.7. It
should also be noted on the evening of postoperative day one
going into postoperative day two he did have hypotension to
the 60s and 70s which was asymptomatic. A combination of the
hypotension which was ultimately resuscitated fluid and blood
and the setting with the pericarditis being treated by
nonsteroidals it was felt that this was the etiology for his
acute renal failure. A nephrology consultation was obtained.
They recommended to check the normal urine studies including
urine fenas and urine urinarias, stop the Ansaid, stop the
diuresis, transfuse blood as needed as well as stop anything
like Zantac or other interstitial nephritis inciting agents.
His renal function began to improve.
The following day after a transfusion on postoperative day
three his crit was 25. His BUN and creatinine were down to 51
and 1.5. He was ambulating at this point although only at a
level two. He was having issues of shortness of breath. His
chest x-ray at this time post chest tube removal just showed
markedly hypo-expanded lung fields. He was therefore given
more aggressive pulmonary toilet. He had bursts of SVT with
atrial fibrillation. Therefore Amiodarone was started and he
had a load of beta blockers started back once his pressure
was over 100 systolic.
On postoperative day four he was in sinus rhythm. He was on
his Amiodarone and beta blockade. His pressures were
climbing into the 120s. His labs at this time showed a crit
of 26 and BUN and creatinine of 56 and 1.5. His was
ambulating a level four at this time. He was therefore felt
appropriate for discharge and was being screened as such.
He had a temperature of 98.0 F, heart rate of 55, blood
pressure 178/77, respiratory rate of 20 and a room air
saturation of 93%. His heart is without any click, no
murmur, regular rhythm. Lungs were decreased at the bases
bilaterally, no crackles. Lower extremities were trace
edema, warm and well perfused with palpable pulses distally.
His discharge labs were as mentioned.
DISCHARGE STATUS: To rehab.
DISCHARGE DIAGNOSIS:
1. Status post coronary artery bypass graft times four
including the LIMA to the LAD as well as saphenous vein graft
diagonal and in the oblique marginal sequentially in the
saphenous vein graft to the PDA with aortic tissue valve
repair not requiring anticoagulation. The patient has a
history of coronary artery disease and unstable angina.
Additionally the patient has suffered postoperative acute
renal failure that has now improved and resolving. This was
non-oliguric and additional postoperative supraventricular
tachycardia as well as atrial fibrillation currently in sinus
rhythm and on Amiodarone therapy.
DISCHARGE MEDICATIONS: Include
1. Hydralazine 10 milligrams po q six.
2. Lasix 20 milligrams po q day.
3. Protonix 40 milligrams po q day.
4. Amiodarone 400 mg po tid times seven days then change to
400 milligrams po bid times seven days then change to 400
milligrams po q day times 14 days and then stop.
5. Percocet 5 325 one to two tablets po four to six prn.
6. Synthroid 75 micrograms po q day.
7. Lopressor 12.5 milligrams po bid.
8. KCL 20 milliequivalents q day.
9. Aspirin 325 milligrams po q day.
10. Lipitor 20 milligrams po q day.
DI[**Last Name (STitle) 408**]E INSTRUCTIONS: The patient will have follow up with
Dr. [**Last Name (Prefixes) **] in 30 days from discharge. Wound check in
seven days from discharge. See his cardiologist or PCP in
three weeks from time of discharge. No heavy lifting greater
than 10 lbs. times 30 days. No driving times 30 days. [**Month (only) 116**]
shower. Steri Strips stay intact will fall off on their own.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36
D: [**2172-12-14**] 11:21
T: [**2172-12-14**] 11:26
JOB#: [**Job Number 36922**]
|
[
"458.2",
"997.1",
"423.9",
"427.31",
"244.9",
"285.9",
"424.1",
"584.9",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.13",
"35.21",
"39.61"
] |
icd9pcs
|
[
[
[]
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5741, 6956
|
5099, 5717
|
1908, 5078
|
172, 1083
|
1677, 1890
|
1106, 1127
|
1143, 1211
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,935
| 198,756
|
51949
|
Discharge summary
|
report
|
Admission Date: [**2121-6-5**] Discharge Date: [**2121-6-7**]
Date of Birth: [**2062-2-8**] Sex: M
Service: [**Year (4 digits) 662**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 18794**]
Chief Complaint:
Malaise
Major Surgical or Invasive Procedure:
Internal Jugular central line placement [**2121-6-5**]
History of Present Illness:
Pt is a 59 yo M with PMHx type 1 DM complicated by b/l BKA (left
[**2113**] and right [**2118**]), neuropathy, retinopathy and nephropathy,
HTN, and COPD with extensive smoking history, OSA on BiPAP, who
presented to the ED with complainsts of acute onset
fatigue/malaise, weakness, and diarrhea. He woke up today
feeling unwell. He endorses a [**3-6**] day hx of loose non-bloody
diarrhea. He has not had any fevers, chills, nausea, vomiting,
or abdominal pain. No recent antibiotic use. He has had a
decreased appetite with decreased po recently. He denies any
dysuria, freuqency, or hematuria. He does note a worsening of a
chronic cough recently, with more SOB. He also states that he
has been unable to lie flat in his new bed due to SOB, and this
has been ongoign since his most recent hospital d/c in [**Month (only) 547**]
[**2121**]. By report, his PCA noted him to be less responsive at
home, and so they preented to the ED.
In ED, intial VS were 98.1 68 120/82 16 97, but in room was
noted to be 83% RA, with 2L bumped to 90-93%. Exam showed a
sleepy, disheveled, but alert and oriented male. Cellulitis and
yeast were noted under his pannus, so he was given vancomycin.
Stumps looked chroncially erythematous, not acutely infected.
Lungs were rhonchorous. No evidence of PNA on CXR and U/A was
clean but had "many bacteria" so he was also given levofloxacin
750mg. His left arm was thought to be more swollen, so an
ultrasound was performed, which was negative for DVT. Labs were
notable for leukocytosis to 14.8 with 90% polys (no bands),
hyperkalemia to 6.1 (verified), and acute on chronic renal
failure (2.4 from 1.7). CE's showed elevated toponin but at his
basline given renal failure. EKG showed NSR 66, no peaked Ts, no
ischemic changes. Received 30g kayexylate for hyperkalemia. His
BPs dropped to as low as 70/30, so a RIJ was placed. He received
5L NS, getting his 6th now. Levophed was started. Most recent
vital signs afebrile BP 119/82 60-70 16 92%4L. Sats were as low
as 85% (positionally), ABG drawn which was 7.27/50/61, and
patient was put on home BiPAP with improvement in O2 sats.
Of note the patient has had 3 admissions in [**2121**]. The first was
[**Date range (1) **], which started with a MICU stay for hypoxia,
hypercarbia and resultant lethargy. BiPap was used
intermittently with improvement in mental status and ventilation
at that time. He was readmitted 1 day after d/c ([**2036-3-20**]) for
dyspnea felt to be mutifactorial (PNA vs COP vs volume
overload), treated with levoflox x 10days, as well as an
Enterococcal UTI. He left AMA from that admission. He was most
recently admitted [**Date range (1) 92895**] for cellulitis of bilateral stumps,
treated initially with vancomycin but switched to bactrim on
discharge. That admission also featured an ICU stay for BiPAP to
treat hypoxia and hypercarbia felt due to chronic
hypoventilation from morbid obesity, COPD, and methadone use.
Past Medical History:
#. Diabetes, insulin dependent, with neuropathy, retinopathy,
nephropathy, and diabetic foot ulcers. s/p bilateral BKAs due to
nonhealing ulcers. LBKA [**2113**], RBKA [**2118**]
#. h/o IVDU/morphine addiction: On methadone.
#. COPD: 1 ppd / 40 years. No PFTs on file
# OSA - recent sleep study suggesting BiPAP auto SV
EPAPmin=EPAPmax= 6, Pressure support min 3 and Pressure support
max 6 with back up rate 8. Was discharged from from [**4-12**]
admission with BiPAP.
#. Chronic renal insufficiency: Recent baseline 1.5-1.7.
Multiple
hospitalizations with bumps into the 2s.
#. HTN
#. PVD: h/o recurrent leg ulcers, cellulitis
#. ? Hepatitis C
#. GERD
#. h/o MRSA and VRE infection
#. h/o decubitus ulcer, now healed
Social History:
Lives with his girlfriend, [**Name (NI) **], in [**Name (NI) 3146**], who helps him with
ADLs. Has VNA care who he says helps wash him, give him
medications and prepare his meals. He has spoked 1ppd x 40
years. Denies Etoh use. Denies recreational drug use currently.
Family History:
NC
Physical Exam:
Admission Physical Exam
97.7 147/75 68 18 94% 4L
Gen: morbidly obese/ unkept/ A+Ox3
HEENT: AT/NC, PERRLA, EOMI, anicteric, no conjuctival pallor
NECK: supple, trachea midline, no LAD, JVD difficult to assess.
RIJ in place.
LUNG: Moderate air movement with insp/exp wheezes and scattered
rhonchi, no accessory muscle use
CV: S1&S2, RRR, no R/G/M
ABD: morbidly obese, Soft/+BS/ NT/ ND/no rebound/ no guarding
BACK: Sacral area not examined
[**Name (NI) **]:
b/l stumps are erythematous but not warm to touch, with
granulation tissue no purulence. decub ulcer. In the
intertrigious regions, there is contact erythema most c/w fungal
rash, with tenderness to palpation. there is no frank skin
breakdown or purulence.
GU: Foley in place.
Pertinent Results:
Admission Exam
[**2121-6-5**] 07:56AM BLOOD WBC-14.8*# RBC-4.50* Hgb-13.1* Hct-42.3
MCV-94 MCH-29.1 MCHC-30.9* RDW-16.5* Plt Ct-260
[**2121-6-5**] 07:56AM BLOOD Neuts-89.7* Lymphs-5.0* Monos-4.6 Eos-0.6
Baso-0.2
[**2121-6-5**] 07:56AM BLOOD Glucose-305* UreaN-33* Creat-2.4* Na-137
K-6.1* Cl-99 HCO3-28 AnGap-16
[**2121-6-5**] 07:56AM BLOOD ALT-8 AST-16 LD(LDH)-170 CK(CPK)-379*
AlkPhos-71 TotBili-0.2
[**2121-6-5**] 07:56AM BLOOD TotProt-6.5 Albumin-3.0* Globuln-3.5
Brief Hospital Course:
59 yo M with PMHx IDDM complicated by b/l BKA (left [**2113**] and
right [**2118**]), neuropathy, retinopathy and nephropathy, HTN, COPD
admitted with pannicular cellulitis and hypotension.
.
#. Hypotension - Likely secondary to recent diarrheal illness
and associated hypovolemia. Patient's blood pressure improved
with 5L of IV NS fluid resuscitation. There was no obvious
cellulitis of the pannicular region but rather a fungal/yeast
infection was noted. This was treated with miconazole and wound
care. CXR was without focal infiltrate and U/A was clean despite
"many bacteria" which likely was colonization. Stumps did not
look acutely infected. The patient was easily weaned off of
levophed on arrival to ICU. He was initially covered with IV
vancomcyin from ED for any gram positive infection (does have a
hx of MRSA. Antibiotics were not continued upon admission to ICU
and the patient remained afebrile and HD stable. His blood and
urine cultures were monitored and his blood pressure medication
was held initially. He was called out to the [**Year (4 digits) **] [**Hospital1 **] on
[**2121-6-6**] and monitored overnight prior to discharge. Cultures were
negative at time of discharge. His home amlodipine was restarted
at discharge as his hypotension completely resolved (he was a
bit hypertensive to SBP 150s prior to reinitiation of
amlodipine).
# Hypoxia: Pt with known pulmonary comorbidities including OSA,
hypoventilation and COPD. He is a chronic retainer with baseline
pCO2 likely around high 40s, and he is slightly above this on
presentation per ED ABG. He is a methadone user and this may
also decrease his respiratory drive. No evidence of PNA. Admits
to not using BiPAP freuqently. Stated he would try BiPAP while
in the hospital but refused this treatment daily. Once clearly
improved, home dose of Methadone were restarted. His oxygen
saturation was 96% on RA on day of admission.
#. Acute on Chronic CKD: Pt with Cr 2.4 and at his baseline
1.8-2.0. Improved status-post volume resuscitation. Urine
lytes with FeNa 0.8 consistent with prerenal etiology. This
improved to 2.0 at the time of discharge.
# Orthopnea. Patient complains of new orthopnea since recent
hospitalization. BNP > 9000 on admission. Echo obtained on
[**2121-6-6**] which showed overall low normal left ventricular systolic
function (LVEF 50%). Right ventricular chamber size and free
wall motion were normal, and no valvular disease was seen.
#. COPD: Pt with extensive smoking history. No wheezing on exam,
was not being treated for exacerbation. No evidence of this
currently. He was continued on home Tiotropium and Advair and
given Albuterol nebs prn with improvement in his symptoms. He
was discharged on his home COPD regimen.
#. IDDM: Pt last documented A1C was 8.6% in 4/[**2121**]. Continued
on home insulin 70/30 and ISS with ASA and statin.
#. Chronic Pain: Initially written for lower dose Methadone but
resumed home dose once clinical picture more clear.
# CODE: DNR/I confirmed with patient upon admission.
Primary communication was with his friend [**Name (NI) **] [**Name (NI) 44865**]
[**Telephone/Fax (1) 107541**] and [**Telephone/Fax (1) 107542**]. The patient was deemed medically
stable for discharge to home. He will have wound care and
medication reconciliation provided by VNA at home. He has close
follow-up scheduled with his PCP.
Medications on Admission:
1. Aspirin 81 mg PO DAILY (Daily).
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
3. Ranitidine HCl 150 mg PO DAILY
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID
5. Docusate Sodium 100 mg Capsule PO BID
6. Fluticasone-Salmeterol 250-50 mcg Inhalation [**Hospital1 **]
7. Amlodipine 5 mg Tablet PO once a day.
8. Miconazole Nitrate 2 % Cream Topical [**Hospital1 **] apply to affected
areas.
9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation DAILY
10. Ferrous Sulfate 300 mg (60 mg Iron) PO DAILY.
11. Nicotine 14 mg/24 hr Patch 24 hr Transdermal once a day.
12. Insulin NPH & Regular Human 100 unit/mL (70-30) Sig: 20
units of 70/30 in the morning, and 10 units of 70/30 in the
evening
13. Methadone 10 mg Tablet Sig: Nine (9) Tablet PO twice a day.
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for fungal rash.
8. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily): DO NOT SMOKE CIGARETTES WHILE WEARING
THE NICOTINE PATCH.
10. Ranitidine HCl 15 mg/mL Syrup Sig: One [**Age over 90 1230**]y (150)
mg PO DAILY (Daily).
11. Methadone 10 mg Tablet Sig: Nine (9) Tablet PO BID (2 times
a day).
12. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
13. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: Twenty (20) units Subcutaneous QAM.
14. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: Ten (10) units Subcutaneous q evening.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Hypovolemic hypotension
Morbid obesity
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. [**Known lastname 50416**], you were admitted to the hospital because of low
blood pressure and dehydration associated with a recent
diarrheal illness. You were given fluids and your condition
improved. You are now deemed medically stable for discharge to
home.
.
There have been no changes to your home medications.
.
It was a pleasure to care for you during this hospital stay.
Followup Instructions:
Department: [**Hospital3 249**]
When: THURSDAY [**2121-6-12**] at 1:40 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**], South [**Hospital **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2121-6-7**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
11191, 11248
|
5666, 9044
|
338, 394
|
11336, 11336
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5171, 5643
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4418, 5152
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291, 300
|
422, 3355
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11351, 11488
|
3377, 4097
|
4113, 4383
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,817
| 119,060
|
53560
|
Discharge summary
|
report
|
Admission Date: [**2128-5-7**] Discharge Date: [**2128-5-8**]
Date of Birth: [**2045-12-20**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Fevers, hypotension, tachycardia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
82 M w DM, CHF, CRF, recent AKA who was transferred from
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] after he was noted to be unresponsive to verbal
stimuli with the following vital signs:
100.9 120s 90-92% on 2L NC.
.
In the ambulance the patient was placed on a NRB with sat 100%.
He was given 650 mg APAP.
Vital signs in the ED: 102.3 132 81/54 93% on RA (98-99% on 3L)
.
He was noted to have minimal purulent drainage from staples of
AKA which was sent for culture. Pt was awake but nonverbal and
unresponsive to verbal stimuli. A rigt hip wound/opening 4 cm in
length was noted; culture was sent. His skin was noted to be hot
to touch.
.
In the ED, a CXR was performed that was negative for acute
cardiopulmonary process. Medications and interventions in the
ED:
- Empiric levaquin
- Vancomycin to cover for likely SSI
- 2 L NS
- Blood cultures x2
- EKG: ST at 120s, inferior Q waves, TWI & STD anteriorly
- SC CVL placed (confirmed by CXR)
.
Initially labwork revaled lactate of 4.0. He remained
hypotensive approx 70/40 despite 2 L NS. Levophed started at
0455. Repeat lactate at 0502 was 3.1.
.
REVIEW OF SYSTEMS: Unable to obtain.
Past Medical History:
- DM
- CHF (EF unknown)
- CRF
- Recent AKA roughly 2 weeks ago at [**Hospital1 112**]
- s/p sternotomy
- CAD s/p MI, CABG
- Depression
- Aspiration
- CVA [**2120**]
Social History:
- Lives at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] for the past 5 years
- Has 8 children
- Married
Family History:
non contributory
Physical Exam:
Admission Physical:
GEN: lethargic, confused, NAD
HEENT: Poor dentition.
NECK: NO JVD
COR: +S1S2 tachycardic
PULM: CTAB no c/w.r
[**Last Name (un) **]: Distended, hypoactive bowel sounds. NT
EXT: s/p L AKA. Sutures with minimal edema, no exudate.
NEURO: Moves LE equally. L upper extremity contracture
.
Discharge Physical:
GEN: NAD
HEENT: supple, MMM, no LAD
NECK: NO JVD
COR: +S1S2 tachycardic, no m,r,g
PULM: CTAB no c/w.r
[**Last Name (un) **]: Distended, hypoactive bowel sounds. NT
EXT: s/p L AKA. staples in place with minimal edema, no exudate.
NEURO: Moves LE equally. L upper extremity contracture
Pertinent Results:
Pertinent Labs:
[**2128-5-7**] 03:15AM BLOOD WBC-3.2* RBC-3.11* Hgb-10.0* Hct-33.0*
MCV-106* MCH-32.0 MCHC-30.2* RDW-18.2* Plt Ct-320
[**2128-5-7**] 03:15AM BLOOD Neuts-43* Bands-8* Lymphs-40 Monos-7
Eos-1 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2128-5-7**] 12:08PM BLOOD WBC-4.5 RBC-2.27*# Hgb-7.3*# Hct-23.7*#
MCV-105* MCH-32.2* MCHC-30.8* RDW-17.8* Plt Ct-264
[**2128-5-7**] 02:15PM BLOOD WBC-4.8 RBC-2.33* Hgb-7.5* Hct-24.3*
MCV-104* MCH-32.0 MCHC-30.7* RDW-17.9* Plt Ct-270
[**2128-5-8**] 02:50AM BLOOD WBC-4.8 RBC-2.10* Hgb-6.7* Hct-21.6*
MCV-103* MCH-31.9 MCHC-31.0 RDW-17.9* Plt Ct-213
[**2128-5-7**] 03:15AM BLOOD PT-12.6* PTT-24.7* INR(PT)-1.2*
[**2128-5-8**] 02:50AM BLOOD Ret Aut-2.9
[**2128-5-7**] 03:15AM BLOOD Glucose-237* UreaN-35* Creat-1.0 Na-137
K-7.5* Cl-104 HCO3-20* AnGap-21*
[**2128-5-7**] 12:08PM BLOOD Glucose-159* UreaN-19 Creat-0.6 Na-141
K-4.5 Cl-114* HCO3-18* AnGap-14
[**2128-5-8**] 02:50AM BLOOD Glucose-132* UreaN-12 Creat-0.5 Na-138
K-4.1 Cl-112* HCO3-17* AnGap-13
[**2128-5-7**] 03:15AM BLOOD ALT-26 AST-57* AlkPhos-122 TotBili-0.6
[**2128-5-8**] 02:50AM BLOOD LD(LDH)-200 TotBili-0.3 DirBili-0.1
IndBili-0.2
[**2128-5-7**] 03:15AM BLOOD proBNP-958*
[**2128-5-7**] 03:15AM BLOOD cTropnT-0.03*
[**2128-5-7**] 12:08PM BLOOD CK-MB-3 cTropnT-0.02*
[**2128-5-7**] 03:15AM BLOOD Albumin-2.7* Mg-2.5
[**2128-5-8**] 02:50AM BLOOD Hapto-408*
[**2128-5-8**] 02:50AM BLOOD Calcium-7.5* Phos-2.5* Mg-1.6
[**2128-5-8**] 01:27PM BLOOD Mg-1.9
[**2128-5-8**] 05:52AM BLOOD Vanco-14.1
[**2128-5-7**] 03:40AM BLOOD Lactate-4.0*
[**2128-5-8**] 09:32AM BLOOD Lactate-1.3
Micro:
[**2128-5-7**] 03:45AM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.025
[**2128-5-7**] 03:45AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-5.5 Leuks-MOD
[**2128-5-7**] 03:45AM URINE RBC-2 WBC-16* Bacteri-NONE Yeast-NONE
Epi-0
[**2128-5-7**] 3:15 am BLOOD CULTURE
Blood Culture, Routine (Pending):
[**2128-5-7**] 3:30 am BLOOD CULTURE
Blood Culture, Routine (Pending):
[**2128-5-7**] 3:46 am SWAB Source: Right AKA site.
WOUND CULTURE (Preliminary):
STAPH AUREUS COAG +. MODERATE GROWTH
[**2128-5-7**] 3:51 am SWAB Source: Right groin wound.
WOUND CULTURE (Preliminary):
STAPH AUREUS COAG +. MODERATE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 110082**] FROM
[**2128-5-7**]
[**2128-5-7**] 9:18 am MRSA SCREEN Source: Nasal swab.
MRSA SCREEN (Pending):
[**2128-5-7**] 3:45 am URINE Site: NOT SPECIFIED CHEM# [**Serial Number 110083**]
[**5-7**].
URINE CULTURE (Pending):
Imaging:
TTE:
The left atrium is elongated. Left ventricular wall thicknesses
are normal. Left ventricular cavity size could not be determined
(no parasternal views available) but was visually normal.
Overall left ventricular systolic function is moderately
depressed secondary to hypo to akinesis of the distal segments
of the LV, akinesis of the apex, and dyskinesis of the basal
inferior and infero-lateral walls. The remaining segments are
hyperdynamic (LVEF= 35-40 %). A small (0.6 cm) sessile,
pedunculated, mobile structure is seen in the apex of the left
ventricle most likely c/w a thrombus, although a prominenent
trabeculation cannot be excluded . Right ventricular chamber
size and free wall motion are normal. The number of aortic valve
leaflets cannot be determined. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Poor image quality. No pericardial effusion.
Moderate regional and global left ventricular systolic
dysfunction c/w multivessel CAD. Possible small left ventricular
apical thrombus. No significant valvular disease.
CHEST (PORTABLE AP) Study Date of [**2128-5-7**] 3:26 AM
IMPRESSION: Low lung volumes. Retrocardiac opacity likely
represents
atelectasis rather than focal consolidation.
CHEST (PORTABLE AP) Study Date of [**2128-5-7**] 4:53 AM
Left subclavian catheter tip is in the upper SVC. There is no
evident
pneumothorax. There are persistent low lung volumes with
bilateral
atelectasis, larger on the left side. Cardiomediastinal contours
are
unchanged. The stomach is very distended. There is no pleural
effusion.
Sternal wires are aligned.
CT ABD & PELVIS WITH CONTRAST Study Date of [**2128-5-7**] 5:16 AM
FINDINGS: There is minimal dependent atelectasis at the lung
bases. Diffuse
multivessel coronary artery disease is present. The liver
enhances
homogeneously. No focal liver lesions are identified. The portal
veins are
patent. The gallbladder is decompressed. The pancreas is mildly
atrophic.
The spleen and adrenal glands are unremarkable. Several cysts
are seen in
both kidneys, the largest have simple fluid attenuation. The
kidneys enhance
symmetrically and excrete contrast promptly. There is no
ascites. No
abdominal or retroperitoneal adenopathy is present. The stomach
is distended
with air. The small and large bowel are of normal caliber and
appearance.
PELVIS: There is a large amount of formed stool in the distal
sigmoid colon
and rectum, the wall of which is mildly thickened. A normal
air-filled
appendix is seen in the right lower quadrant. There is no free
pelvic fluid.
There is no inguinal or abdominal adenopathy. There are no
concerning lytic
or sclerotic bone lesions. Several bilateral gluteal granulomas
are noted.
Subcutaneous soft tissue nodules are noted in the left abdomen.
Correlate
with subcutaneous drug injection.
IMPRESSION: No source of intra-abdominal infection.
CHEST (PORTABLE AP) Study Date of [**2128-5-7**] 6:06 AM
There are no acute interval changes. There are persistent low
lung volumes. Bibasilar atelectasis is larger on the left side.
There is no pneumothorax or pleural effusion. Left subclavian
catheter tip is in the proximal SVC. The stomach is very
distended.
CT HEAD W/O CONTRAST Study Date of [**2128-5-7**] 1:55 PM
IMPRESSION: No hemorrhage or mass effect. Extensive
encephalomalacia of
right MCA territory, compatible with chronic infarction. In the
setting of
extensive background hypodensity, acute infarction cannot be
completely
excluded
CT LOW WXT W/C RIGHT:
FINDINGS: Within the visualized pelvis, there is mild rectal
wall thickening,
which is nonspecific in the setting of free pelvic
nonhemorrhagic fluid, but
given a small amount of mesorectal fat stranding, this may
represent a mild
proctitis. A Foley catheter is within the decompressed bladder.
Within the
left prostate, there is a 1.8 x 2.0 x 1.9 cm hypodense lesion
with rim
enhancement(3:51, 701B:39), previously 1.4 x 1.5cm on [**2128-5-7**] on
which it is
not well seen, concerning for abscess, less likely hematoma, but
malignancy is
not excluded. A small amount of fluid is seen in the right
inguinal canal.
There is a large right hydrocele and probably a left hydrocele,
incompletely
imaged on this study. Edema is seen in the anterior pelvic wall
soft tissues.
Atherosclerotic calcifications are seen in the visualized
portions of the
iliac arteries. A surgical clip is seen in the prostate.
The right external iliac artery is occluded with thrombus
extending into the
right common femoral artery. Atherosclerotic calcifications are
seen in the
superficial femoral artery. The SFA patency is not well
evaluated.
Expansion of the right common femoral vein with adjacent
stranding (6:61) with
possible filling defect in the distal superficial femoral vein
(3:202) could
represent DVT.
Within the right thigh, there is edema in the subcutaneous
tissues. At the
amputation site there is a small amount of fluid and edema
tracking into the
fascial planes. No drainable fluid collection is seen. Low
attenuation within
vastus medialis is noted. Small hyperdense foci adjacent to the
amputed femur
in the distal thigh do not change on the initial and delayed
images (3:235,
6:237-246, 701B:22) and while they may represent blood products
are higher in
attenuation than the adjacent vessels.
BONE WINDOWS: Status post right above-knee amputation. No
periosteal reaction
or cortical destruction suspicious for osteomyelitis. Smooth
amputed margins.
IMPRESSION:
1. Status post above-knee amputation with soft tissue edema and
fluid in the
right thigh. No drainable fluid collection. No CT evidence of
osteomyelitis.
2. Hyperdense foci at the resection site are hyperdense compared
to adjacent
vasculature and do not diffuse on initial and delayed image.
Blood products
are not excluded. If there is concern for active extravasation
CTA could be
performed. Correlate with operative note to determine whether
this represents
surgical material.
3. Hypodense rim-enhancing fluid collection in the left prostate
is increased
in size from [**2128-5-7**], concerning for prostatic abscess, less
likely hematoma.
Malignancy is not excluded.
4. Possible DVT in the superficial femoral vein. Ultrasound is
recommended
for further evaluation.
5. Circumferential rectal wall thickening with adjacent
stranding is
nonspecific, but may represent proctitis.
6. Hydroceles.
7. Low attenuation in the vastus medialis may represent
myositis. Edema
about the superficial and deep fascial planes of the posterior
compartment
could represent fasciitis, but is not adequately characterized.
Brief Hospital Course:
82 M w CHF, DM, CKD (baseline creatinine unknown), recent AKA
presenting with SIRS/SEPSIS in setting of likely SSI.
.
# SEPTIC SHOCK/HYPOTENSION: On admission several SIRS criteria
(hypotension, tachycardia, tachypnea, leukopenia, fever) with a
suspected surgical site of infection. In the ED they were able
to express purulent fluid from the surgical site. The pt also
had a productive cough on admission as well. Unclear how long
this has persisted for. In the ED he was placed on Levophed as
well as bolused several IVF. In the ICU we continued to fluid
resuscitate and we able to wean off Levophed and maintain
hemodynamic stability. We continued Vancomycin and Cefepime
covering his potential surgical site source and a potential
respiratory source as well. Vascular surgery evaluated the
surgical site and were not certain it was infected. They
recommended obtaining a CT of the leg looking for evidence of
infection. This imaging study was obtained prior to transfer. At
the time of transfer blood and urine cultures were pending and a
wound cx from surgical site grew coag + staph aureus.
.
# Anemia- Hct on admission 33 trended down with fluid
resuscitation. Most likely initial value was hemoconcentrated
due to distributive shock. OSH records show a baseline of
24-27. He received 1U PRBCs prior to transfer for a HCT of 21.
His stool was guaiac negative x2 and a CT abdomen and pelvis was
negative for RP bleed. His lab data was not concerning for
hemolysis.
.
# Troponin Elevation: Troponin noted to be 0.03 in the ED, which
may reflect demand ischemia in the setting of sepsis with
hypotension & tachycardia. EKG not concerning for acute ischemic
event. Repeat troponin trended down.
.
# CKD: Creatinine on admission 1.0. Baseline creatinine 0.4. A
calculated FeNa was 0.55% suggesting pre-renal etiology.
Creatine trended down with fluid resuscitation.
.
# DM2: He was placed on an insulin sliding scale
# Transitional- We were planning on continuing antibiotic
coverage for a total of 8 days to cover for HCAP although a
definitive source has not been indentified. Two blood cultures
and a urine culture is pending at time of discharge. Prior to
discharge the final read on the CT of his RLE was obtained which
showed multiple new findings. Please see attached report for
further details.
Medications on Admission:
- simvastatin 40 mg
- divalproex 250 mg [**Hospital1 **]
- Docusate [**Hospital1 **]
- ASA 325
- MVI
- NPH 5 units [**Hospital1 **]
- APAP prn
- oxy 2.5 Q4H PRN
- dulcolax suppository QOD
- cymbalta 30 QD
- glipizide 5 mg QAM
- senna 2 tabs QHS
- trazodone 25 mg QHS
- bisacodyl 1 supp QD PRN
- Metoprolol 75 mg [**Hospital1 **]
Discharge Medications:
1. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO QHS (once a day (at bedtime)).
2. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
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. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
7. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram
Intravenous Q 12H (Every 12 Hours).
8. cefepime 2 gram Recon Soln Sig: Two (2) gram Injection Q12H
(every 12 hours).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Sepsis
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:
Mr. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital with a severe
infection and a low blood pressure. We have started you on
antibiotic medications and gave you IV fluids which has improved
your blood pressure. We are transfering you to [**Hospital1 3372**] for further treatment considering this is where
your surgery took place.
Followup Instructions:
Per your family request, we are transferring your care to
[**Hospital1 3487**] Hospital.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
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"890.1",
"585.9",
"414.01",
"438.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
15499, 15514
|
11964, 14274
|
336, 342
|
15565, 15565
|
2554, 2554
|
16168, 16386
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1892, 1910
|
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15535, 15544
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15743, 16145
|
1925, 2535
|
4580, 4641
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1520, 1540
|
264, 298
|
4816, 11941
|
370, 1501
|
15580, 15719
|
2570, 4469
|
1562, 1729
|
1745, 1876
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,286
| 187,490
|
41497
|
Discharge summary
|
report
|
Admission Date: [**2165-8-28**] Discharge Date: [**2165-8-29**]
Date of Birth: [**2104-1-13**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
A fib with RVR
Major Surgical or Invasive Procedure:
Pleurex tube insertion [**8-28**]
History of Present Illness:
61yo with history of a-fib, stage IV lung CA s/p chemo and
radiation therapy who presented today for placement of a pleurex
catheter. After pleurex placement he drained 2.5L and pleurex
placed. He was in the PACU and was noted to have a narrow
complex tachycardia with rates from the 130-180s. His SBP
ranged from 75-120, RR 30-50's. He had some nausea and received
zofran 4mg IV. Also given ativan 0.25mg ativan. Denied any
light headedness, dizziness, Palpitations, chest pain, Dyspnea.
He was given lopressor 2.5 mg IV and lopressor 50mg with no
change ([**12-23**] home dose), as well as a 500cc NS bolus. His heart
rate and pressures did not respond. They discussed starting an
esmolol drip, but anesthesia was wary given his low SBP. It was
decided to transfer him to the MICU for further management of
his A-fib with RVR.
.
On the floor, He is tachypneic and HR in the 150s - 180s, but
asymptomatic.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies vomiting, diarrhea, constipation, abdominal pain, or
changes in bowel habits. Denies dysuria, frequency, or urgency.
Denies arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
Stage IV squamous cell lung CA s/p chemo and XR with chronic R
effusion
AFib (? atrial tachycardia)
s/p CCY 25 years ago
PUD
IBS
Glaucoma
Social History:
Lives with his wife and son. [**Name (NI) **] 2 kids and 2 grandkids. He is
a retired painter. Painted houses his whole like. Smoked 2 PPD
for 40 years, just quit over the last few months. Denies
current alcohol use, but used to drink intermittently. No
ilicit drug use or narcotic abuse. Currently lives at home and
limited in ADL by fatigue. Finds it difficult to walk up flight
of stairs without becoming extremely dyspneic.
Family History:
Father [**Name (NI) 4278**] lymphoma at age 56. One paternal uncle had
[**Name (NI) 4278**] lymphoma at age 29. One paternal aunt had cancer at
30s. Paternal grandmother had uterine cancer at age 45.
Another grandmother with lung cancer. His father had 7
siblings. He has 4 sisters.
- father had a-fib and CAD.
- No HTN, HLD or DM in the family
Physical Exam:
Admission Physical Exam:
Vitals: T: 100.6, BP: 93/23 P: 169, R:42 O2: 96% Face tent FIO2
100%
General: Lying in bed, tachypneic, Alert, oriented
HEENT: PERRL, EOMI, Sclera anicteric, MMM, oropharynx clear, no
teeth
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, with expiratory
tubular sounds in the left upper posterior lung fields
CV: tachycardic, hard to hear heart sounds over tachypnea,
normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, bandage in
place in left mid axillary line
GU: no foley
Ext: Upper extremities warm to touch, distal lower extremities
cool, 1+ pulses, no clubbing, cyanosis with 2+ posterial tibial
pitting edema
Neuro: CN II-XII intact, sensation intact, strength 5/5 in all
extremities.
Discharge Physical Exam:
Vitals: Afebrile BP 90/40 HR 120 RR 20 O2 94%
General: Lying in bed, alert, oriented
Lungs: Clear to auscultation bilaterally, with expiratory
tubular sounds in the left upper posterior lung fields
CV: Tachycardic but improved, distant heart sounds, normal S1 +
S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, bandage in
place in left mid axillary line
Pertinent Results:
Admission Labs:
[**2165-8-28**] 08:56PM WBC-14.7*# RBC-2.74* HGB-8.8* HCT-25.3*
MCV-93 MCH-32.1* MCHC-34.7 RDW-17.0*
[**2165-8-28**] 08:56PM NEUTS-91* BANDS-0 LYMPHS-5* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2165-8-28**] 08:56PM PLT SMR-NORMAL PLT COUNT-234
[**2165-8-28**] 08:56PM PT-15.2* PTT-32.1 INR(PT)-1.3*
[**2165-8-28**] 08:56PM CORTISOL-42.1*
[**2165-8-28**] 08:56PM ALBUMIN-2.1* CALCIUM-7.5* PHOSPHATE-3.7
MAGNESIUM-1.4*
[**2165-8-28**] 08:56PM ALT(SGPT)-22 AST(SGOT)-26 LD(LDH)-141 ALK
PHOS-114 TOT BILI-1.4
[**2165-8-28**] 08:56PM GLUCOSE-91 UREA N-21* CREAT-1.1 SODIUM-131*
POTASSIUM-4.3 CHLORIDE-96 TOTAL CO2-28 ANION GAP-11
[**2165-8-28**] 09:16PM freeCa-1.02*
[**2165-8-28**] 09:16PM LACTATE-2.0
Studies:
ECG [**2165-8-28**]: Marked baseline artifact. Atrial fibrillation with a
ventricular rate of 125. Low voltage throughout the tracing.
Non-specific T wave flattening. Compared to the previous tracing
of [**2165-3-18**] the rhythm has gone from atrial flutter to atrial
fibrillation. The non-specific T wave changes were also present
at that time. There is no diagnostic interval change other than
the change in rhythm.
CXR [**2165-8-28**]: Compared to the prior chest radiograph, there is
slightly improved aeration of the right hemithorax with a
moderate loculated pleural effusion. A Pleurx catheter enters at
the lateral right hemithorax and terminate in the mid medial
right hemithorax. Right perihilar air space opacification may be
related to known malignancy, but developing infection or
re-expansion edema is possible. It is uncertain whether an
apparent lucency in the re-expanded lung could represent a
cavitary process or an area of aerated lung surrounded by fluid.
The left lung is clear. There is no left-sided pleural effusion.
There is no pneumothorax. An SVC stent is in unchanged position.
Cardiac silhouette appears enlarged but probably unchanged from
prior.
TTE [**2165-8-29**]: The left atrium is mildly dilated. The right atrium
is moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. The estimated right atrial pressure is 0-5 mmHg.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is mildly dilated. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
severely depressed (LVEF= 20 %). The right ventricular cavity is
dilated with mild global free wall hypokinesis. There is
abnormal septal motion/position. The aortic valve leaflets are
mildly thickened (?#). There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. An eccentric, posterioly directed jet of mild
to moderate ([**12-23**]+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is a small
to moderate sized pericardial effusion, measuring from 0.6
centimeters to 2.0 centimeters at greatest dimension. The
effusion appears circumferential, with preferential fluid
collection near the right atrium. There is brief right atrial
diastolic collapse. There is right ventricular diastolic
collapse, consistent with impaired fillling/tamponade physiology
(clips 76 and 77). IMPRESSION: Biatrial enlargement. Dilated
left ventricle with normal wall thickness and severe global left
ventricular systolic dysfunction. Mild to moderate mitral
regurgtitation. Normal pulmonary artery systolic pressure. Small
to moderate sized circumferential pericardial effusion with
echocardiographic evidence of tamponade.
CXR [**2165-8-29**]: Moderate right loculated hydropneumothorax is
unchanged allowing for the difference in position of the
patient. Left lower lobe retrocardiac opacities have increased.
This could be due to atelectasis, but aspiration is also a
consideration. Right lower lobe opacities probably reexpansion
pulmonary edema are stable. There is no left pneumothorax. Right
chest tube is in place in standard position.
Brief Hospital Course:
61 yo man with hx of ?a-fib (narrow complex tachycardia) and
rate controlled as well as stage IV squamous cell lung Ca who
was admitted to the ICU s/p pluerex catheter placement in A-fib
with RVR and hypotension.
#. Hypotension: He presented with hypotension in the setting of
Afib with RVR after pleurex catheter placement. He was felt to
be initially volume depleted and was given 5L normal saline. He
was also initially placed on vancomycin/cefepime due to recent
instrumentation and potential concern for sepsis. His heart
rate was controlled to his baseline HR of 120's and his
hypotension did not improve. He was also given stress dose
steroids. Initial bedside echo did not reveal significant
pericardial effusion but formal echo in the AM revealed a mild
to moderate posterior pericardial effusion with evidence of RV
diastolic collapse consistent with tamponade. Cardiology
evaluated the patient and felt that he did not have significant
LV dysfunction on TTE to fully explain his continued
hypotension. The cardiology team felt that while
pericardiocentesis could possibly help his short term
hemodynamics, he could have a longstanding effusive-constrictive
physiology that may require pericardial window. Risks and
benefits of drainage vs pericardial window were discussed with
the patient, who expressed a desire to go home and focus on
comfort measures. Therefore, he was discharged home with VNA
bridge to hospice.
#. Tachycardia: He presented to the MICU in Afib with RVR
similar to prior episodes. His rates responded to IV and po
metoprolol although dosing was limited due to hypotension. His
HR improved to the 120's prior to discharge. It was felt that
his tachycardia was driven by hypovolemia and hypotension. He
also had some post-procedure hypoxia that may have contributed
to his tachycardia. His home metoprolol dose was decreased due
to hypotension but may be able to be uptitrated as an outpatient
if tachycardia remains an issue and BPs are stable.
#. Hypoxia: He had a new oxygen requirement after his procedure
in the setting of Afib with RVR and hypotension. There was some
concern for mild reexpansion pulmonary edema but his oxygen
requirement improved prior to discharge.
#. Low grade fevers: He had a low grade fever on admission and
was initially treated with vancomycin and cefepime. These were
stopped prior to discharge due to low likelihood for infection.
#. Back Pain: Continued home oxycodone
#. SIADH: He has a histroy of SIADH and sodium levels remained
stable
#. Stage IV lung Ca: He is s/p multiple rounds of radiation
therapy and 2 rounds of chemo, getting vinorelbine when able as
an outpatient. He expressed a desire for a comfort-focused
treatment and was discharged with VNA bridge to hospice.
#. Pleural effusions: He is s/p pleurex catheter placement and
developed the hypotension and tachycardia after the procedure.
He was set up with VNA to drain his Pleurex after discharge.
#. Code status: DNR/DNI, discharged with VNA bridge to hospice
Medications on Admission:
LORAZEPAM - 0.5 mg Tablet Q6H:PRN nausea;vomiting;anxiety
METOPROLOL SUCCINATE - 100 mg PO Daily
OMEPRAZOLE - 20 mg Daily
Aspirin 81mg PO Daily
Vitamin B12 1,000mcg PO Daily
Colace 100mg PO Daily
Senna [**12-23**] tab PO BID:PRN
Discharge Medications:
1. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for anxiety, nausea, vomiting.
2. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: 0.5 Tablet Extended Release 24 hr PO once a day.
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
5. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a
day.
6. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day.
7. senna 8.6 mg Tablet Sig: 1-2 Tablets PO once a day as needed
for constipation.
Discharge Disposition:
Home With Service
Facility:
Discharge Diagnosis:
Stage IV lung cancer
Pericardial effusion
Atrial fibrillation with RVR
Hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Last Name (Titles) **],
You were admitted to [**Hospital1 18**] for placement of a pleurex catheter
to drain fluid from your lung. Following the procedure, you
developed very fast heart rates and low blood pressures,
requiring admission to the ICU. We did an ultrasound of your
heart that showed fluid around the heart, which may have been
contributing to your low blood pressure. We wanted to try to
drain this fluid, but have opted to go home where you can be
comfortable instead. There is a chance that this fluid will
continue to accumulate and may continue to make your blood
pressure low. You have verbalized understanding of this and
have stated that you would prefer to be treated at home and kept
comfortable rather than coming back to the hospital.
Medication changes:
Please take only a half dose of your metoprolol (50 mg instead
of 100 mg). The VNAs can check you blood pressure at home and
decide if you should stop taking this medication altogether or
go back up to your regular dose
Followup Instructions:
Please keep your regularly scheduled appt Dr. [**Last Name (STitle) **]
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2165-9-10**] at 1:30 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"276.50",
"427.31",
"V49.86",
"162.8",
"423.9",
"253.6",
"423.3",
"511.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
12069, 12099
|
8088, 11111
|
317, 353
|
12225, 12225
|
4058, 4058
|
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2337, 2689
|
11390, 12046
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12120, 12204
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11137, 11367
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12376, 13153
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2729, 3562
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1317, 1706
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13173, 13395
|
263, 279
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381, 1298
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4074, 8065
|
12240, 12352
|
1728, 1868
|
1884, 2321
|
3587, 4039
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,777
| 134,801
|
50562
|
Discharge summary
|
report
|
Admission Date: [**2151-6-24**] Discharge Date: [**2151-7-15**]
Date of Birth: [**2082-11-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 922**]
Chief Complaint:
sudden onset shortness or breath
Major Surgical or Invasive Procedure:
Cardiac catheterization [**2151-6-25**]
Coronary artery bypass graft x 4 [**2151-6-29**] (Left internal mammary
artery to Left anterior descending, Saphenous vein graft to
Diagonal, Saphenous vein graft to Obtuse marginal "Y" graft,
Saphenous vein graft to Posterior lateral branch)
History of Present Illness:
Mr. [**Known lastname 105259**] is a 68 year-old man with ESRD on HD, CAD, COPD.
He was in his usual state of health on [**6-21**] when he was seated
in a chair and he had sudden onset shortness of breath without
chest pain or palpitations. He was admitted to [**Hospital 4199**] Hospital
on [**6-21**]. There he was intubated for hypoxic respiratory failure.
He was briefly hypotensive in the peri-intubation period,
thought to be secondary to propofol vs. sepsis. For the latter
he was treated briefly with vancomycin and Zosyn. Also under
consideration was that he may have aspirated secondary to
benzodiazepine overdose. He was also treated for a COPD
exacerbation with steroids and nebulizers. He was subsequently
thought to have had flash pulmonary edema secondary to a primary
cardiac event, as below.
.
On his initial EKG, he had precordial ST elevations and T-wave
inversions inferiorly that were thought to be rate related. He
was hypotensive and having an upper GI bleed, so treatment of
acute MI including [**Month/Year (2) **], beta [**Month/Year (2) 7005**], statin, ACEI were
with-held. He was transferred to the ICU wihere EKG showed
resolution of the ST elevation; however, troponin rose to 4.8.
Cardiology was consulted and agreed that no treatment options
for ACS were available as he was not stable for catheterization,
anticoagulation was contraindicated (GI bleed), beta [**Month/Year (2) 7005**]
could not be given because of hypotension, and his ESRD
precluded ACEI.
.
On the second hospital day, the patient became tachycardic to
the 130s and desatruated to 88% on 2L. EKG showed ST depressions
V5/V6. He was given 5 mg IV lopressor in decrease in HR to the
low 100s as well as 1 mg IV ativan. Cardiology was again
consulted, and he was given PO metoprolol such that HR decreased
to the 90s over hours. CXR showed increased pulmonary edema.
Renal was consulted, and he received 80 mg IV furosemide with
diuresis of 250 cc and improvement to 98% O2 Sat on 2L. EKG 3
hours later showed resolution of ST depressions and resolution
of sinus tachycardia. Cardiac enzymes were again cycled.
Troponin I increased to 1.22 8 hours after and subsequently
fell. CK was flat. At no point did he experience chest pain.
.
Upon review of the case, the cardiology consulting service felt
that he because he had inducible ischemia that seemed to be rate
dependent, he was a candidate for non-urgent catheterization.
His beta [**Last Name (LF) 7005**], [**First Name3 (LF) **] 81 mg, and statin were restarted prior to
transfer. Echo showed EF 35-45% with mild LV mild hypokinesis,
moderate concentric LVH, and moderate mitral regurgitation.
.
His course was complicated by bright red blood in the NG tube at
the time of intubation. Hct dropped from 48 on admission, to 35
after agressive fluid resuscitation. It was subsequently stable
for several days
.
For his ESRD he underwent HD Tuesday and Thursday and was
maintained net negative.
Past Medical History:
- End-stage renal disease on HD Tues, Thurs and Sat at [**Doctor First Name 12074**] in
Wellingon Circle [**Location (un) 3786**]
- Stroke [**2150**] without residual deficits, s/p right carotid
endarterectomy
- Chronic obstructive pulmonary disease
- Coronary Artery Disease with two past MIs ([**3-/2151**] and [**2149**])?
of cath previously
- Anxiety
- Tobacco abuse
- Etoh abuse: patient states no EtOH use in the past 10 years
- Peptic Ulcer Disease
- benzodiazepine abuse
- s/p iatrogenic cardiac arrest [**3-/2151**]
Social History:
SOCIAL HISTORY: He was a custodian at [**University/College **], currently retired.
-Tobacco history: he has smoked a PPD x 50 years
-ETOH: he states he quit EtOH 10 years ago
-Illicit drugs: denies
Family History:
not obtained
Physical Exam:
PHYSICAL EXAMINATION:
69" 160#
VS: T=96, BP=111/85, HR=83, RR=20, O2 sat=95% on 3L
GENERAL: comfortable appearing man
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 7 cm
CARDIAC: regular, no murmurs
LUNGS: lungs with bibasilar expiratory rhonchi
ABDOMEN: Soft, NTND. No HSM or tenderness. Normoactive bowel
sounds
EXTREMITIES: L arm fistula with palpable thrill, feet cool
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
[**6-25**] Cardiac cath: 1. Selective coronary angiography of this
right dominant system with a ramus branch revealed severe two
vessel disease. The LMCA had mild plaquing but was free of
critical stenoses. The LAD was heavily calcified and diffusely
diseased with mild tapering of the proximal vessel and diffuse
disease extending from D1 and culminating in a 90% stenosis just
before the small D3 branch with post-stenotic dilatation. S1 had
a moderate origin stenosis. The D1 branch was diffusely disease
with a 60% stenosis in the mid-vessel. There were septal
collaterals to the distal RCA system. The moderate caliber LCx
was diffusely diseased, and it was difficult to quantitate the
reference vessel diameter. It supplied small diffusely diseased
OM branches with distal AV groove collaterals to the distal RCA.
The ramus branch was a modest caliber but patent vessel. The RCA
was totally occluded serially in the proximal vessel after some
severe disease and reconstituted distally (RCA, RPL1, RPL2, and
RPDA) via vasa and left to right collaterals. 2. Resting
hemodynamics revealed normal right heart filling pressures with
a mean RA of 6 mmHg and moderate-severely elevated left heart
filling pressures with a mean PCWP of 19 mmHg and LVEDP of 26
mmHg. There was mild pulmonary arterial hypertension with a PASP
of 31mmHg. The cardiac index was preserved at 3.7 l/min/m2
(using an assumed oxygen consumption). 3. Left ventriculography
was deferred.
[**6-28**] Echo: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is mildly dilated with mild to moderate regional left
ventricular systolic dysfunction including hypokinesis of the
basal half of the inferior and inferolateral walls, distal
septum and apex. The apex is not aneurysmal (LVEF 40%). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Mild to
moderate ([**1-8**]+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
cavity dilation and regional dysfunction c/w multivessel CAD.
Mild-moderate aortic regurgitation. Moderate mitral
regurgitation. Dilated ascending aorta.
[**6-30**] CT of Head: Scattered hypodense foci in bilateral occipital
lobes and bilateral cerebellar hemispheres, most consistent with
acute/subacute embolic infarcts, superimposed on more chronic
infarction. As the patient is unable to tolerate MRI secondary
to presence of epicardial pacer leads, serial CT examinations
could be performed to assess possible evolution.
[**7-1**] MRI of Head: Innumerable foci of slow diffusion with
associated T2/FLAIR signal hyperintensity scattered throughout
the bilateral cerebral and cerebellar hemispheres. Findings are
consistent with acute-subacute infarcts of multiple etiologies,
including embolic infarcts, watershed infarction, and hypoxic
injury.
Brief Hospital Course:
A 68 year-old man with a history of Coronary Artery Disease,
recently admitted to OSH for hypoxic respiratory failure and
found to have EKG changes in the setting of tachycardia, and
currently transferred to [**Hospital1 18**] for consideration of possible
catheterization.
.
# CORONARIES/Post-op: Patient had ST changes prior to transfer
in the setting of tachycardia that may have been demand related.
It's less difficult to tease out whether the ischemia was
primary or secondary, but the ST elevations and elevated
troponin were worrisome. Troponins were trending down prior to
transfer. CK have not been elevated. Medical management of CAD
including [**Hospital1 **], statin, beta [**Hospital1 7005**] were continued. He underwent
cardiac catheterization which showed LAD with 50-60% tubular
stenosis with focal 90% lesion in mid-vessel, LCx with diffuse
disease, and a totally occluded proximal RCA with filling
distally via collaterals. Given 3-vessel CAD, cardiac surgery
was consulted for consideration of CABG. He underwent coronary
artery bypass graft on [**6-29**] without incidence. Please see
operative report for surgical details. Transferred to CVICU for
invasive monitoring in stable condition. Patient remained
intubated due to unresponsiveness. CT/MRI revealed multiple
infarcts. Chest tubes and epicardial pacing wires were removed
per protocol. Multiple attempts to wean patient from ventilator
failed d/t neuro status and a tracheostomy was placed [**7-7**]. Tubes
feeds were given throughout post-op course for nutrional support
and PEG was planned for placement on [**7-7**] but not performed
secondary to patient having fevers and increased WBC. PEG tube
was eventually placed on [**7-13**].
.
#Stroke: On post-op day one sedation was weaned and although
patient would open eyes, there was no movement in extremities or
response to commands. Stat CT and neuro consult were preformed.
CT finding were most consistent with acute/subacute embolic
infarcts, superimposed on more chronic infarction. Neurology
felt in addition to embolic infarcts, there was watershed and
ischemic hypoperfusion bilaterally. They felt prognosis of
recovery was poor. Patient eventually regained very limited
movement in extremities and response to commands. Right pupil
larger than left and blinks eyes to questions.
.
# PUMP: Chronic systolic congestive heart failure with EF 35-40%
on recent echo with evidence of LV wall hypokinesis. Per OSH
records, he has a history of flash pulmonary edema in the
setting of hypertensive urgency 03/[**2151**]. He also seems to have
had flash pulmonary edema this admission at the other hospital,
possibly triggered by a cardiac event, as above. On admission to
[**Hospital1 18**], exam and CXR were indicative of euvolemia.
.
# recent hypoxic respiratory failure: His O2 Sat was normal on
room air upon transfer to [**Hospital1 18**]. Post-operatively patient was
unable to be weaned from ventilator and required tracheostomy.
.
# COPD exacerbation: The patient denied a history of COPD,
although this is noted on his OSH records. He does have a 50
pack-year smoking history, and he was on Combivent and
Tiotropium as an outpatient. He was being treated at the OSH for
COPD exacerbation with nebulizers and steroids. On admission he
was not SOB, wheezing, or hypoxic. A brief steroid taper was
completed. He did not require nebulizer treatments. PFTs done
as part of the pre-operative work-up showed FEV 179% predicted
with FEV1/FVC 114% predicted.
.
# ESRD: Cause was unknown. Tues/Thurs/Sat dialysis was continued
upon admission but changed to Mon/Wed/Friday dialysis after
surgery. Renal followed patient throughout post-op course.
.
# Anxiety and substance abuse: Patient had a history of anxiety
disorder and benzodiazepine over-use. He was supposed to
discontinue lorazepam as an outpatient, per notes from outside
hospital. However, he has been receiving lorazepam on transfer
and was actively withdrawing on arrival to [**Hospital1 18**], with visual
hallucinations and tremors. He was started on a CIWA with
diazepam. He required 10 mg diazepam every 4 hours, and his
hallucinations abated. Diazepam was decreased to 5 mg every 4
hours, and he continued to score high on the CIWA on subjective
measures such as anxiety. He also was quite demanding about
receiving the diazepam. The psychiatry consulting service saw
him to assist with addiction and anxiety issues. At their
recommendation, diazepam with CIWA was stopped, and outpatient
dose of lorazepam resumed. Sertraline was also restarted. He
could not receive Seroquel because of borderline long QT at
baseline. Psych consult was performed post-op and stated no
acute psych issues and to continue with neuro/medical
management.
.
# GI: Patient had upper GI bleed with coffee ground NG output at
OSH. He has a history of PUD but no prior bleeds according to
him. HCT on transfer is stable from OSH (35 on transfer) and
remained stable. Post-op patient was incontinent of stool and
urine and remained that way upon discharge.
.
#Infectious disease: Urine with Citrobacter. Sputum with COAG
positive staph. His WBC remained elevated during post-op
fluctuating between 10.5 and 22.8. He received Vanco/Cipro
during post-op. Cipro d/c'd [**7-13**] after repeat urine culture
negative.
.
#Nutrition: Tubefeeding: Nutren Pulmonary Full strength, Goal
rate:50 ml/hr. PEG tube placed [**7-13**].
On [**7-15**] Dr. [**Last Name (STitle) 914**] felt Mr. [**Known lastname 105259**] was ready for discharge
to a rehabilitation facility.
Medications on Admission:
sertraline 25 mg daily, spiriva, albuterol PRN, [**Known lastname **] 325 mg qam,
colace 100 mg [**Hospital1 **], folate 1 mg daily, simvastatin 80 mg qhs,
lorazepam 1.5 mg tid, lopressor 12.5 mg tid, seroquel 25 mg q6h
prn, zantac 150 mg po bid, senna daily
Discharge Medications:
1. Sertraline 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
2. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
[**Hospital1 **]: One (1) capsule Inhalation once a day.
3. Docusate Sodium 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day).
4. FoLIC Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
5. Lorazepam 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO three times a
day as needed for anxiety.
6. Senna 8.6 mg Capsule [**Hospital1 **]: One (1) Capsule PO once a day.
7. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
9. Insulin Regular Human 300 unit/3 mL Insulin Pen [**Hospital1 **]: per
sliding scale Subcutaneous every six (6) hours.
Disp:*qs * Refills:*2*
10. Atorvastatin 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
injection Injection TID (3 times a day).
Disp:*90 injection* Refills:*2*
12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
13. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Last Name (STitle) **]: [**1-8**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
Disp:*qs * Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 4
Non-ST elevation Myocardial Infarction
End-stage renal disease
Chronic obstructive pulmonary disease
Anxiety
Stroke [**2150**] (no deficits)
Peptic ulcer disease
Tobacco and benzodiazipine abuse
Iatrogenic cardiac arrest [**3-15**]
s/p Carotid endarterectomy right
Discharge Condition:
good
Discharge Instructions:
no lotions, creams or powders to any incision
shower daily and pat incisions dry
call for fever greater than 100.5, redness, drainage, or weight
gain of 2 pounds in 2 days or 5 pounds in one week
no lifting greater than 10 pounds for 10 weeks
Seroquel was stopped (Please do not take this medication without
discussing it with Dr. [**Last Name (STitle) 1147**].)
Adhere to 2 gm sodium diet.
Followup Instructions:
see Dr. [**Last Name (STitle) 105260**] in [**1-8**] weeks
see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1147**] in [**2-9**] weeks
see Dr. [**Last Name (STitle) 914**] (cardiac surgeon) in 4 weeks [**Telephone/Fax (1) 170**]
Please call to make appointments.
Completed by:[**2151-7-15**]
|
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8,109
| 150,646
|
49864
|
Discharge summary
|
report
|
Admission Date: [**2147-8-25**] Discharge Date: [**2147-8-29**]
Date of Birth: [**2088-6-21**] Sex: F
Service: MICU/INPATIENT [**Location (un) 259**]
HISTORY OF THE PRESENT ILLNESS: Ms. [**Known lastname 33858**] is a 59-year-old
female with a history of chronic renal insufficiency,
baseline creatinine 1.2 to 1.3, diabetes mellitus, and
hypertension, who presented to the Emergency Department with
a five day history of fatigue and lightheadedness. Her blood
pressure taken by a coworker at work was 90/60. Of note, the
patient's Zestril dose had been recently increased from 20 mg
to 30 mg on [**2147-8-7**] and then decreased back again to
20 mg on [**2147-8-23**] by her primary care physician. [**Name10 (NameIs) **]
arrival to the ED, the patient's blood pressure was 78/56
with a heart rate of 60. She was given 2 liters of normal
saline but her blood pressure still remained in the 60s to
70s systolically.
An EKG showed junctional bradycardia with a heart rate in the
50s. The patient then began to complain of back pain and
right shoulder pain. Over the next hour, the patient's
mental status began to deteriorate and she was intubated in
order to protect her airway. Some emesis was noted prior to
intubation. The patient was given 1 mg of IV Atropine, 5 mg
of IV calcium gluconate, 5 mg of IV Glucagon for bradycardia
and questionable calcium channel blocker toxicity. She was
started on dopamine for hypotension but then changed to
Neo-Synephrine secondary to tachycardia to the 130s. Her
systolic blood pressure increased to 100-110. She was
transferred to the MICU for further management.
PAST MEDICAL HISTORY:
1. Diabetes mellitus with neuropathy, nephropathy and
retinopathy.
2. Chronic anemia.
3. Chronic renal insufficiency with a baseline creatinine of
1.2 to 1.3.
4. History of CVA.
5. Status post cholecystectomy.
6. Status post bilateral cataract surgery.
7. Status post bilateral carpal tunnel release.
8. Hypertension.
9. Status post tendon repair following a cat bite.
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS:
1. Aspirin 325 mg p.o. q.d.
2. Zestril 20 mg p.o. q.a.m.
3. Nifedipine 60 mg p.o. q.d.
4. Glyburide 5 mg p.o. b.i.d.
5. Hydrochlorothiazide 25 mg p.o. q.d.
6. Questran one pill q.d.
7. Multivitamin.
SOCIAL HISTORY: The patient is single and lives alone. She
denied any history of tobacco use. She denied a history of
alcohol use. She denied a history of drug use. She
currently works as an office manager.
FAMILY HISTORY: Her mother died at the age of 57 from a MI.
She had a history of diabetes. Her father also died but at
age 82 from an MI and he also had a history of diabetes. She
has four sisters, two sisters have diabetes, one sister died
from COPD and another sister died from pancreatic cancer.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
99, blood pressure 105/43, heart rate 79, respiratory rate
16, oxygen saturation 96% on assist control 500 by 16 and a
PEEP of 5. General: This patient was intubated but
following commands. HEENT: Bilateral surgical pupils.
Cardiovascular: Regular rate and rhythm with no murmur.
Lungs: Clear to auscultation bilaterally. Abdomen: Obese,
soft, nontender, nondistended with hypoactive bowel sounds.
Extremities: She had 1+ edema of her hands bilaterally and
1+ pedal edema.
LABORATORY/RADIOLOGIC DATA: White count 19, hematocrit 26.3,
platelets 277,000. Sodium 132, potassium 6.3, chloride 105,
bicarbonate 15, BUN 78, creatinine 2.5, glucose 399, anion
gap 9. Calcium 8.3, phosphorus 3.8, magnesium 2.2. CK 87,
troponin T less than 0.01. Her serum toxicity was positive
only for aspirin at a level of 5. Her AST was 38, ALT 52,
alkaline phosphatase 70, total bilirubin 0.2, lactate 2.0.
Her ABG was 7.21/39/2/61/on assist control 500 by 14, FI02
100% and PEEP 5.
CTA showed no dissection.
Bedside echocardiogram showed no cardiac tamponade.
HOSPITAL COURSE: 1. HYPOTENSION: The patient was placed on
pressors in the ED and when she was transferred to the MICU
she was on Neo-Synephrine which was eventually changed to
Levophed. She was gradually weaned off Levophed following
several liters of normal saline. By the time she was
transferred to the floor on [**2147-8-27**] her blood
pressure had stabilized and she was normotensive. The
hypotension was believed to be secondary to hypovolemia from
decreased p.o. intake as well as possible calcium channel
blocker toxicity.
In the MICU, the patient was slowly put back on Norvasc for
blood pressure control and she remained normotensive on
Norvasc throughout the remainder of her hospital course.
2. BRADYCARDIA: The patient was found to be in junctional
bradycardia in the ED but was given Atropine, calcium
gluconate, and Glucagon and her rhythm converted to normal
sinus rhythm. She was followed by telemetry and EKGs in the
MICU without any further events. A nifedipine serum level
was sent to the [**Hospital1 2025**] laboratory but those results are still
not available. She had two sets of troponins which were
negative. She had no further episodes of bradycardia
throughout the rest of her hospital stay.
3. ACUTE RENAL FAILURE ON CHRONIC RENAL INSUFFICIENCY: The
acute renal failure was believed to be due to her ACE
inhibitor combined with hypovolemia from decreased p.o.
intake. Her FENA was low which is consistent with a prerenal
cause for renal failure. She was continued on IV fluid
boluses and was given Mucomyst following her CTA to prevent
IV contrast nephropathy. There was a question of whether she
had bilateral renal artery stenosis leading to hypotension on
an ACE inhibitor. An MRA was performed which showed normal
renal arteries bilaterally.
The patient's creatinine continued to slowly improve
throughout her hospital course and at the time of discharge
her creatinine is 1.4 which is close to her baseline of 1.2
to 1.3.
4. HYPERKALEMIA: When the patient was admitted, her
potassium was 6.6 and it was believed to be due to her acute
renal failure. She was given insulin and D50 as well as
calcium gluconate and IV fluids in the Emergency Department.
In the MICU, she received Kayexalate to further decrease her
potassium level. Her potassium continued to trend down. At
the time of discharge, her potassium level is 4.1.
5. NONANION GAP METABOLIC ACIDOSIS: The nonanion gap
metabolic acidosis is of unclear etiology. It was believed
that her acidosis was secondary to bicarbonate-free IV fluid
administration. The patient was well compensated on the
ventilator and her bicarbonate slowly increased on its own
and at the time of discharge her bicarbonate level was 25.
6. DIABETES MELLITUS: In the MICU, the patient was started
on an insulin drip for possible calcium channel blocker
toxicity. She was eventually changed to regular insulin
sliding scale and was on regular insulin sliding scale when
transferred to the floor. Her blood sugars continued to
remain within normal limits.
7. ANEMIA: The patient has a history of chronic anemia with
but her hematocrit on admission was slightly down from her
baseline of 30-32. She was transfused 1 unit for a
hematocrit less than 25 and her hematocrit remained stable
throughout the remainder of her hospital course. Iron
studies performed while in-house were within normal limits.
8. HISTORY OF CEREBROVASCULAR ACCIDENT: The patient was
continued on aspirin and she had no focal neurologic
findings.
9. RESPIRATORY: The patient was intubated on admission to
protect her airway due to lethargy and she was slowly weaned
off in the MICU and extubated. On the floor, she continued
to have minimal oxygen requirements. Eventually, she was
weaned off of oxygen. A chest x-ray was done which only
showed resolving left lower lobe atelectasis. No pneumonia.
No CHF. Prior to discharge, she was seen by PT and felt that
she had good ambulating oxygen saturation.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient was discharged to home.
DISCHARGE DIAGNOSIS:
1. Junctional bradycardia.
2. Hypotension.
3. Calcium channel blocker toxicity.
4. Acute renal failure on chronic renal insufficiency.
5. Hyperkalemia.
6. Nonanion gap metabolic acidosis.
7. Diabetes mellitus.
8. Chronic anemia.
9. Hypertension.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q.d.
2. Cholestyramine/sucrose 4 gram packet p.o. q.d.
3. Amlodipine 10 mg p.o. q.d.
4. Glyburide 5 mg p.o. b.i.d.
5. Multivitamin p.o. q.d.
FOLLOW-UP PLANS: The patient is asked to follow-up with Dr.
[**First Name4 (NamePattern1) 3403**] [**Last Name (NamePattern1) **] at the [**Hospital Ward Name 23**] Eye Center on [**2147-12-13**]
for her routine diabetic eye examination. She is also
scheduled to follow-up with Dr. [**First Name8 (NamePattern2) 3122**] [**Name (STitle) 1860**] on [**2148-1-4**]. She is also asked to contact her primary care
physician with any further questions.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Last Name (STitle) 1030**]
MEDQUIST36
D: [**2147-8-29**] 03:21
T: [**2147-8-31**] 11:05
JOB#: [**Job Number 104188**]
|
[
"250.50",
"790.7",
"250.60",
"276.2",
"250.40",
"458.2",
"584.9",
"996.62",
"276.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
2552, 2859
|
8344, 8514
|
8065, 8321
|
3978, 7954
|
2114, 2321
|
8532, 9206
|
2874, 3960
|
1658, 2091
|
2338, 2534
|
7979, 8044
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,787
| 101,908
|
2413
|
Discharge summary
|
report
|
Admission Date: [**2106-5-6**] Discharge Date: [**2106-5-20**]
Date of Birth: [**2045-9-16**] Sex: M
Service:
DISCHARGE DIAGNOSES:
Dyspnea.
Renal cell carcinoma.
HISTORY OF PRESENT ILLNESS: Sixty-year-old male with history
of renal cell carcinoma with recent CT scan showing right
subcranial/hilar mass 6.9 x 3.5 cm with right lower lobe
bronchus obstruction and right lower lobe collapse presented
on the admission date to Interventional Pulmonary for
bronc. The IP team felt that the patient appeared too ill for
a procedure at that point. The exact details were unknown,
directly admitted for further work up, initially to the
service at which point, he denied any nausea, vomiting, fever
or chills, no increased shortness of breath except his
increased cough, complained of rib cage diffuse pain and dry
cough times two days which increased with rib pain and he
also has noticed a loss of seventeen pounds in the past few
months.
PAST MEDICAL HISTORY: His past medical history is significant
for renal cell carcinoma, diagnosed in [**5-/2104**], radical right
sided nephrectomy, RAF, left renal mass, two cycles vial II.
He was on UPenn's experimental protocol, XRT plus steroids
for T5 lytic lesions, resection lung mass in 02/[**2105**]. Other
past medical history, hypertension, rosacea, status post
vasectomy.
HOME MEDICATIONS: His home medications were Oxycodone 5 mg
every six hours PRN, Norvasc PO 10 mg every day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Lives with his wife, CEO of his own company,
occasional alcohol, no tobacco.
PHYSICAL EXAMINATION: Vital signs on admission, temperature
99.3 F, heart rate 60, blood pressure 164/88, respiratory
rate 22, O2 saturation 93% on five liters nasal cannula. On
examination, he was a pleasant gentleman in no acute
distress, well developed male. HEENT, dry oral mucosa. The
neck was supple. Heart, decreased heart sounds, regular rate
and rhythm, no murmurs, gallops or rubs. Lungs, very small
breath sounds felt on the right side, especially basilar up
to one-half up to the right side, left side with mild rales,
mostly rales. Abdomen, bowel sounds were present, mild
hepatomegaly but nontender, nondistended abdomen.
Extremities, no clubbing, cyanosis or edema. Neurologic, he
was alert and oriented times three and grossly intact
neurologically.
LABORATORY DATA: Laboratory studies on admission, white blood
cell count 5.8, hematocrit 34.4 with previous one 34.7,
platelet count 159,000, INR 1.2, PTT 23.7, sodium 132,
potassium 5.0, chloride 97, bicarbonate 21, BUN 34,
creatinine 1.6, which was 1.3, the last check, glucose 238,
ALT 38, AST 45, alkaline phosphatase 99, total bilirubin 0.7,
albumin 2.5 and the blood cultures were drawn and were
pending at the time of admission. Chest x-ray showed right
lower lobe collapse/consolidation and large right pleural
effusion questionably on preliminary.
HOSPITAL COURSE: His course was respiratory alkalosis,
post-obstructive right lower lobe infiltrate with strep
pneumo in two out of two blood cultures from admit. He
defervesced on Levofloxacin and Flagyl, persistent O2
requirement so sent to bronc on [**2106-5-10**], by IP and he is
now since he has been sent to IP, he was status post removal
of endobronchial lesion, right bronchus intermedius and
post-procedure had respiratory distress requiring intubation,
which he was sent to the MICU and since did okay
post-extubation. He was sent back on the floor but now on
[**Hospital Ward Name 517**], admitted to the [**Hospital Ward Name 517**] [**Hospital1 139**] team. Since
being admitted to [**Hospital Ward Name 517**] [**Hospital1 139**] team, he underwent
another interventional pulmonary procedure, initially, it was
planned on him questionably getting a stent done in place but
the procedure was basically a similar procedure to the
previous one, no stent was placed. The patient tolerated the
bronchoscopy well without any problems. His O2 requirements
actually have improved prior to his discharge. The other
thing is that he has remained on Levo and Flagyl. The plan is
continuing him for a three week course. He is going to
continue another two weeks post-discharge and continuation to
be decided by primary physician. [**Name10 (NameIs) **] plan is to wean him off
his O2 nasal cannula, once he gets admitted to the
rehabilitation to keep O2 saturations greater then 92%. On
the day of discharge, he has been weaned down from six liters
to five liters now to four liters nasal cannula. Prior to his
discharge, he had an ultrasound done, which was with a
questionable right sided effusions, which were found not to
be effusions and mostly tissue and no need for tap at the
time by IP service. The patient was planned on following up
with Oncology later on and to continue his Levo-Flagyl since
his cultures have been negative so far. His acute renal
failure that he presented on admission has resolved and he is
now down to 0.7, it was thought to be probably most likely
secondary to pre-renal state, given BUN and creatinine ratio
close to 20 and also the patient being dry on examination.
The patient's hypertension is controlled with outpatient
medications. The patient's pain medications controlling the
patient's rib pain. No acute new problems on discharge. ID
wise, his pneumococcal/pneumonia/CAP plus post-obstructive
pneumonia was as noted, to continue his Levofloxacin and
Flagyl since when he was taken off Flagyl and was taken to
the unit from the, he required Clindamycin for a day and then
he was taken off the Clindamycin but then when he was brought
to the [**Hospital1 139**] service, he actually spiked a temperature. With
the elevated temperature and leukocytosis, it was felt that
the patient could benefit from some anaerobic coverage. At
that point, Flagyl was added, which was last week, prior to
discharge. The patient's elevated blood pressures resolved
since and he was continued on the Levo-Flagyl for resumed
post-obstructive pneumonia. In terms of heme, his hematocrit
has remained relatively stable. He received two units of
packed red blood cells last week and since then, his
hematocrit has remained relatively stable. It is thought that
his low hematocrit is probably secondary to decreased PO
intake, nutritional problem and also could be related to his
eighteen pound weight loss over the past few months. He has
normal LFT's normal platelets and he refused digital rectal
examination but we are guaiacing all of his stools. In terms
of his neurologic, per MRI on [**5-7**], there was no sign of
cord compression from his metastases and there was plan of
following up for XRT per Rad/Onc but Rad/Onc have decided for
now that he is not a candidate for the time being and to be
followed up by Oncology for further follow-up and possibly
maybe later on become a candidate at Oncology and Rad/Onc's
discretion. He also has a tachycardia with ectopy, which has
been pretty stable. We repleted his electrolytes PRN and his
tachycardia has remained sinus tachycardia since admission
and on discharge date, he still continues with the mild
tachycardia. The patient is being discharged to
rehabilitation facility for further rehabilitation care,
stable condition.
FINAL DIAGNOSES: Renal cell carcinoma, status post IP
intervention times two with debridement.
Follow-up with PCP
and primary oncologist as prescribed and the patient was sent
to rehabilitation on the following medications, Neutra-Phos
PRN and following his magnesium and phosphorous close,
Trazodone 12.5 mg PO at bedtime, PRN, Codeine 15 mg IV every
four to six hours PRN, Heparin subcutaneous every eight
hours, 5,000 units, Metronidazole 500 mg PO every eight hours
for fourteen more days and Pantoprazole 40 mg PO every
twenty-four hours, Amlodipine 10 mg PO every day, Metoprolol
50 mg PO twice a day, Levofloxacin 500 mg PO every
twenty-four hours for another twelve days, Docusate 200 mg PO
twice a day, Senna one tablet PO twice a day, Oxycodone 5 mg
PO every four to six hours PRN for pain and also continue on
insulin sliding scale per protocol. Follow-up is as discussed
above. The patient is going to the rehabilitation center
today.
[**Doctor Last Name 2511**],[**Name8 (MD) **] MD. [**MD Number(2) 12441**]
Dictated By:[**Name8 (MD) 6112**]
MEDQUIST36
D: [**2106-5-19**] 08:11
T: [**2106-5-19**] 08:15
JOB#: [**Job Number 12442**]
|
[
"518.82",
"041.2",
"481",
"790.7",
"401.9",
"584.9",
"519.1",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"32.01",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
152, 184
|
2924, 7213
|
1360, 1488
|
7230, 8395
|
1604, 2907
|
212, 957
|
979, 1342
|
1504, 1582
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,056
| 159,036
|
38719
|
Discharge summary
|
report
|
Admission Date: [**2151-9-23**] Discharge Date: [**2151-9-26**]
Date of Birth: [**2067-4-11**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
IVC filter removal
History of Present Illness:
[**Known firstname **] [**Known lastname 86028**] is an 84-year-old woman recently diagnosed with
stage 4 renal papillary carcinoma (not yet started treatment)
and at that time found to have bilateral PEs. On [**9-7**] she had a
staging CTs which showed significant disease (stage 4 with mets
to liver, bone metastases in the L1 and T12 vertebrae) as well
as bilateral basal PEs. She was admitted to [**Hospital1 18**] for
anticoagulation with lovenox. Further work up demonstrated
extensive bilateral lower extermity DVTs. She is scheduled to
begin SUNITINIB trial for her advanced . On [**9-14**] the patient
reported urinary vs vaginal bleeding on anticoagulation. At this
point anticoagulation was stopped and her bleeding resolved.
There is no note as the the amount of bleeding that prompted the
stopping of the anticoagulation. On [**9-20**] she underwent IVC filter
placement with interventional radiology as an outpatient. The
procedure was felt to be a success but the patient was
experiencing increasing exertional SOB since the procedure ans
so she presented to the ED today.
.
In the ED, initial vitals were 97.3 94 111/68 20 97% 2L
Labs and imaging significant for a CXR - IVC filter has migrated
to the right ventricle.
Patient was placed on a heparin ggt and sent to the cardiac cath
lab for percutanous removal of the IVC filter.
Vitals on transfer were 98.0, 113/54,90, 27, 98%2LNC
.
In the cath lab they were able to retrieve the filter without
issue.
.
On arrival to the floor, she is comfortable without concerns.
Past Medical History:
.
Past Oncologic History:
[**Known firstname **] [**Known lastname 86028**] is an 84-year-old healthy woman who presented
approximately 2 years ago for
a 2-cm right complex renal cysts. She was referred to [**Hospital1 18**] in
[**7-25**] and underwent CT imaging which reportedly revealed 2.2 cm
right kidney cyst with no central enhancement, multiple
pulmonary
nodules and a L5 lucent lesion. Repeat CT scan in [**7-27**] was
then
performed and showed infiltrating mass involving most of right
kidney with extensive retroperitoneal lymphadenopathy. Radiology
report stated that findings were C/W possible lymphoma, small
lesions in liver.
.
[**2151-7-23**] Abd/Pelvis CT: Previously in the right kidney, there was
a
focal exophytic slightly complex lesion, but there is now a
diffuse infiltrative mass of much of the right kidney. The
previously identified lesion, exophytic at the interpolar
region,
measures 18 x 25 mm, previously perhaps 20 x 18 mm. The diffuse
infiltrative component, which extends through the cortex of the
renal hilum and involves the hilar fat as well as
circumferential
the vessels of the renal hilum, is new. Also new is extensive
retroperitoneal and retrocrural lymphadenopathy. A left adrenal
lesion is stable. The liver contains new lesions. The findings
are unusual for renal cell carcinoma, the presumptive pretest
pathology. The appearances would be much more suggestive of
lymphoma, possibly a transitional cell carcinoma, with atypical
infection considered extremely unlikely.
[**2151-8-12**] Bx of right kidney mass showed papillary carcinoma
diffusing infiltrating into the renal cortex and medulla. Tumor
is CK903, CK7, P504S positive. Negative for CK20, CDX2 and p63.
Focally positive for CAIX.
.
Past Medical History:
Osteoporosis
Arthritis - s/p TKR bilaterally
Pacemaker
Right sided breast cancer [**2131**] - Underwent lumpectomy, treated
with XRT and TAM x 5 years on ajuvant trial
- Surveillance mammography is normal
.
Social History:
Gen: Works part time at a law office. Has worked at attorney's
office x 50 years. She was forced to retire in [**2134**] and that
lasted 3 weeks.
Tobacco: Smokes 6 cigarettes a day since age 18 (x 66 years).
EtOH: 1 glass of wine daily and occasionally more on the
weekends
Illicits: none
Occupation: Works as admin assistant.
Living situation: Lives with cousin
Exercise: [**Name2 (NI) 6934**] daily
Family History:
Mother: died of CHF at age [**Age over 90 **]
Father: died of MI at age 59
Has other family members with heart disease.
Has no children.
Physical Exam:
GENERAL: WDWN female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 7 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
[**2151-9-23**] 12:05PM BLOOD WBC-15.4* RBC-3.60* Hgb-10.2* Hct-32.1*
MCV-89 MCH-28.3 MCHC-31.8 RDW-15.0 Plt Ct-171
[**2151-9-23**] 12:05PM BLOOD Glucose-134* UreaN-53* Creat-2.4* Na-139
K-5.3* Cl-102 HCO3-19* AnGap-23*
[**2151-9-23**] 12:05PM BLOOD proBNP-[**Numeric Identifier **]*
[**2151-9-23**] 12:11PM BLOOD Lactate-2.0
Echo: There is a number of metal densities in the right
ventricle, some likely representing the migrated IVC filter,
however no further comments can be made regarding its precise
position or interaction with the RV pacemaker lead. The
transtricuspid inflow gradient is slightly abnormal, although
the patient is tachycardic at this time. There is no unusual
metallic objects seen in the visualized portions of the IVC, RA
(besides the pacer leads), or the proximal pulmonary artery.
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). Left ventricular wall
thicknesses are normal. Right ventricular chamber size and free
wall motion are normal. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. Mild (1+)
mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. There is no pericardial effusion
CXR:
IMPRESSION:
1. Displaced IVC filter likely in the right ventricle.
2. Small bilateral pleural effusions.
Brief Hospital Course:
84F w/ renal papillary CA and known bilateral PEs not on
anticoagulation [**3-18**] to hematuria s/p IVC filter placement on [**9-20**]
presented with SOB and was found to have migration of IVC filter
to RV.
# Pulmonary embolism/IVC filter migration - Patient has known
bilateral PEs and had anticoagulation stopped due to hematuria
with IVC filter placed on [**9-20**]. CXR on admission identified
migration of IVC filter to right ventricle. The IVC filter was
able to be removed percutanously. She had resolution of her
symptoms following the procedure. She had a cardiac echo that
did not show any valvular damage and her pacemaker was
interogated and found to be adequetly working. She was
anticagulated with heparin and transitioned to lovenox 70mg
daily at time of discharge. While in the hospital she had no
active bleeding. Pt refused IR placement of another IVC filter.
# Chronic Kidney Disease - The patients creatinine was elevated
to 2.4 on admission. She was given IV hydration in the setting
of dye load at time of admission for retrival of the IVC and had
recieved contrast 3 days prior for placement of the filter. Her
creatinine trended down and was 1.1 at time of discharge. Her
lisinopril was held while in the hospital but as her creatinine
normalized it was felt that she could resume her home dose at
time of discharge.
# Renal Cell Carcinoma - Not active during this hospitalization.
She will follow up with Hematology/Onoclongy as an outpatient.
# HTN - The patient has a history of this. She was continued on
her home medications with the exception of her home lisinopril
while in the hospital with no episodes of hypertension.
Transitional Issues:
-Restarted on Lovenox 70mg Daily. She will need to have factor
Xa level checked after for 3rd-5th dose. Results faxed to her
oncologists at ([**Telephone/Fax (1) 86029**]. She will also need to have a CBC
drawn at that time.
-She will have follow up for her RCC with her oncologists as
scheduled.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Amlodipine 5 mg PO BID
2. CloniDINE 0.1 mg PO BID
3. Lisinopril 20 mg PO BID
4. Acetaminophen 500 mg PO Q6H:PRN Pain
5. Lorazepam 0.5 mg PO QHS
Discharge Medications:
1. Outpatient Lab Work
Dx: Pulmonary embolism Please check:1) Factor Xa level
2) Complete blood count (CBC)Fax results to ([**Telephone/Fax (1) 28908**].
Please fax results to Dr. [**First Name (STitle) **] and Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 86029**]
2. Acetaminophen 500 mg PO Q6H:PRN Pain
3. Amlodipine 5 mg PO BID
4. CloniDINE 0.1 mg PO BID
5. Lorazepam 0.5 mg PO QHS
6. Lisinopril 20 mg PO BID
7. Enoxaparin Sodium 70 mg SC Q24H
RX *enoxaparin 80 mg/0.8 mL daily Disp #*28 Syringe Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Migration of IVC filter to Right Ventricle
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 86028**],
It was a pleasure taking care of you during your
hospitalization. You came to the hospital because you were
feeling short of breath. It was found that your IVC filter had
migrated into the right ventricle of your heart. We were able to
remove it percutanously. You were placed on heparin for
anticoagulation and monitored for several days. Your blood count
initally fell but then stablized without signs of bleeding. You
were discharged home without any of the shortness of breath.
Please Start:
Lovenox 70mg daily
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] and Dr. [**Last Name (STitle) **] as scheduled for
oncology. Please have your labs drawn on Tuesday or Wednesday
([**Date range (1) 19038**]) at your PCPs office with the results faxed to ([**Telephone/Fax (1) 86030**].
|
[
"189.0",
"V10.3",
"733.00",
"305.1",
"V43.65",
"403.90",
"197.7",
"996.1",
"585.9",
"198.5",
"V15.3",
"E879.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.99"
] |
icd9pcs
|
[
[
[]
]
] |
9447, 9453
|
6623, 8281
|
307, 327
|
9540, 9540
|
5255, 6600
|
10263, 10539
|
4318, 4457
|
8901, 9424
|
9474, 9519
|
8626, 8878
|
9691, 10240
|
4472, 5236
|
8302, 8600
|
264, 269
|
355, 1891
|
9555, 9667
|
3674, 3883
|
3899, 4302
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,345
| 160,873
|
9911
|
Discharge summary
|
report
|
Admission Date: [**2120-7-26**] Discharge Date: [**2120-7-31**]
Date of Birth: [**2078-2-14**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Right flank pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
43 yo Italian male with 7 months hx of right flank pain for
which he takes hydrocodone presents at work prior to admission
with increased right flank pain, and ambulance was called and
transfered to [**Hospital1 18**] ED. He had multiple ecchymosis on his body
when initially seen at the ED. Since pt was intoxicated at the
time of arrival and was a poor historian, he was initially
treated as a possible trauma patient and admitted under surgery
service. Pt got CT of the spine, head, abdomen which were all
negative for trauma. But abdominal CT showed cirrhotic liver
and 1.5 cm mass in the liver. Pt was cleared from surgery
standpoint. However pt was noted to have high LFT,
thrombocytopenia, elevated lipase, increased EtOH level=419.
Past Medical History:
Right flank pain
Hx of depression since 3 yrs ago
Social History:
Patient moved from [**Country 2559**] [**12-14**] yrs ago and had a successful
cheese distributory business until [**10-12**] when his business went
bankrupt. Afte that, his wife left him with his 2 children and
he has been depressed since. Now, he lives alone and works at a
deli store. Due to depression and high stress, he comes home
and drink 2-3 bottles of wine/day. Pt denies use of tobacco or
illicit drugs.
Physical Exam:
PE: T 99.6 BP 140/80 HR 84 RR 20
Gen-In bed, somewhat confused and agitated, tremulous
HEENT-NC/AT, PERRL, anicteric sclera, EOMI
Lungs-CTA bilaterall
CV-RRR, nl S1, S2, no m/r/g
Abd- soft, non-distended, right flank pain to palpation. no
hepatosplenomegaly.
Ext-no edema, clubbing.
Skin- multiple ecchymosis on thighs and abodomen. Left groin
with 10x12cm echymosis but no erythema.
Neuro- agitated, attentive but difficult to communicate. CN
II-XII indivudually tested and are WNL. + resting and
intentional tremors bilaterally, +truncal ataxia, unsteady gait
with difficulty with tandem gait.
Pertinent Results:
CT OF THE ABDOMEN WITH IV CONTRAST: The appearance of the liver
is
heterogeneous and low in attenuation. In addition there are two
focal high
attenuation areas of in the right lobe on series 2b image 72 and
75-- probably
calcifications though no precontrast series is available. The
appearance is
consistent with fatty infiltration, though the heterogeneity
raises the
liklihood of a diffuse hepatic process such as cirrhosis. In
addition there is
a 1.5 cm lesion with peripheral enhancement. The pancreas,
spleen, adrenal
glands and kidneys are within normal limits. The gallbladder is
also
unremarkable. There is no suggestion of acute traumatic injury
to any of the
solid or hollow intraabdominal organs. The abdominal aorta is of
normal
caliber.
MRI ABDOMEN WITH CONTRAST: There is diffuse fatty infiltration
of the liver.
In the superior portion of segment 7, there is a 2.2 cm
well-defined mass
which is homogeneously hyperintense on T2-weighted images and
hypointense on
T1-weighted images. There is peripheral puddling of contrast
after
administration of gadolinium. These features are consistent
with hemangioma.
No suspicious hepatic lesions are seen. The gallbladder is
unremarkable. The
bile ducts are not dilated. The portal vein is patent with
hepatopetal flow.
The spleen is not enlarged.
There is a tiny cyst in the body of the pancreas, most likely
related to
pancreatitis. The adrenal glands are normal. There is a simple
cyst in the
upper pole of the right kidney. Slightly prominent nodes are
seen in the
porta hepatis.
IMPRESSION:
1) Fatty liver.
2) Hepatic hemangioma.
LABS
[**2120-7-31**] 05:15AM BLOOD Plt Ct-104*
[**2120-7-30**] 01:20AM BLOOD Plt Ct-111*#
[**2120-7-29**] 05:00AM BLOOD Plt Ct-64*
[**2120-7-27**] 10:11PM BLOOD Plt Ct-53*
[**2120-7-27**] 04:36AM BLOOD Plt Ct-50*
[**2120-7-26**] 08:50AM BLOOD Plt Smr-VERY LOW Plt Ct-69*
[**2120-7-30**] 01:20AM BLOOD WBC-6.6 RBC-4.63 Hgb-16.0 Hct-46.2
MCV-100* MCH-34.5* MCHC-34.6 RDW-13.7 Plt Ct-111*#
[**2120-7-26**] 08:50AM BLOOD WBC-5.6 RBC-4.45* Hgb-15.6 Hct-44.0
MCV-99* MCH-35.2* MCHC-35.5* RDW-13.6 Plt Ct-69*
[**2120-7-31**] 05:15AM BLOOD TotBili-3.5*
[**2120-7-30**] 01:20AM BLOOD ALT-73* AST-127* AlkPhos-97 TotBili-4.1*
[**2120-7-29**] 05:00AM BLOOD ALT-53* AST-124* LD(LDH)-270* AlkPhos-90
TotBili-3.9*
[**2120-7-27**] 10:11PM BLOOD ALT-56* AST-153* AlkPhos-102 TotBili-4.8*
[**2120-7-27**] 04:36AM BLOOD ALT-57* AST-136* AlkPhos-93 Amylase-86
TotBili-2.3*
[**2120-7-26**] 08:50AM BLOOD ALT-75* AST-221* AlkPhos-122* Amylase-83
TotBili-2.2*
[**2120-7-30**] 01:20AM BLOOD Lipase-107*
[**2120-7-27**] 04:36AM BLOOD Lipase-104* GGT-3740*
[**2120-7-26**] 08:50AM BLOOD Lipase-91*
[**2120-7-27**] 04:36AM BLOOD calTIBC-237* VitB12-794 Folate-GREATER TH
Ferritn-1510* TRF-182*
[**2120-7-27**] 04:36AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE IgM HAV-NEGATIVE
[**2120-7-27**] 04:36AM BLOOD AFP-9.5*
[**2120-7-27**] 04:37AM BLOOD Ethanol-11*
[**2120-7-26**] 08:50AM BLOOD ASA-NEG Ethanol-419* Acetmnp-6.2
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
1)Ethanol [**Name (NI) 33226**] - Pt was initially admitted to SICU with
alcohol level of 419 to rule out trauma because of his multiple
bruises. Body, spine CT ruled out trauma, and patient became
tremulous and neurlogy was called to evaluate. Patient was then
transferred to the medicine floor for the management of ethanol
[**Name (NI) **]. Initially, pt was disoriented, agitated and showing
bilateral intentional tremors. Intially he was treated with
standing Ativan 2 mg qid and Ativan 2mg q1hr based on CIWA
scale. His symptoms slowly resolved over 3 days requiring less
Ativan, and was switched from Ativan to Valium 10 mg tid on day
4. By day 5, he required no Valium overnight showing little
tremor and improvement in coordination. Pt was more alert,
oriented, and was able to tell more history as to what happened.
Pt states that he got locked out of his house and was trying to
climb on the roof but then fell on the ground. Patient is being
discharged with no benzodiazepine and will be followed by his
PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **].
2)Liver mass/hepatitis/cirrhosis - Initial CT of abdomen done at
SICU for trauma workup showed a small mass in the liver. AFP
was slightly elevated with 9.5, his intial liver enzymes were
elevated (GGT 3740), and hepatitis panels were all negative.
MRI of abdomen showed fatty cirrhotic liver and 2.2 cm hepatic
hemangioma. Because of hx of alcohol abuse, he most likely has
cirrhosis and hepatitis secondary to alcohol. During his stay,
he was well hydrated with IVF and his liver enzymes came down
during the hospital stay (AST 221->127) However, his total
bilirubin remained increased (2.2-> 4.1 -> 3.5) but showing no
jaundice Patient is aware and understands the risk of continued
drinking. Pt needs to follow up with his PCP for his elevated
bilirubin and liver enzymes.
3)R flank pain - Pt states he had this pain for 7 months. Hx
seems to be consistent with kidney stone given the exacerbation
with urination. CT did not show any stones, but he may have
passed it already. Urine studies did not show any cells. CT
showed no fracture or obvious musculoskeletal findings that
could explain this pain.
4)Thrombocytopenia - Patient came in with initial platelet count
of 69 -> 50. Patient was seen by Hem/Onc on admission, and his
thrombocytopenia is most likely secondary to alcohol induced
marrow suppression and cirrhosis. Platelet count increased from
50-> 104. His thrombocytopenia explains the multiple eccymosis
on his body. Pt will follow up with his PCP regarding his
thrombocytopenia.
6)Cardiovascular - Pt has no known CAD or HTN per history. On
admission, patient was tachycardic (Pulse>100)and hypertensive
(systolic in 140's), but was believed to be secondary to alcohol
[**Last Name (STitle) **]. However, even 3 days after admission when his
withrawl symptom was improving requiring less benzodiazepine,
his BP and pulse remained high. Patient was started on
metoprolol 25 mg [**Hospital1 **] which lowered his BP and heart rate to a
normal range. He is being discharged with atenolol 25 mg qd and
will be followed by his PCP whether or not he needs to remain on
it.
7)Depression - Patient has a hx of depression 3 years ago after
his wife left him. He states that he has been on medication but
discontinued because he believed it was not working. Was not
clear from him if he understood that anti-depressant takes some
time to achieve a therapeutic level. Patient showing all signs
of depression but not suicidal at this time. Patient wants to
get a pscyhopharm therapy as well as psychotherapy. Since he
speaks Italian, it is more beneficial for him to find a Italian
speaking psychiatrist and social worker through his PCP [**Last Name (NamePattern4) **].
[**Last Name (STitle) **] who also speaks Italian. Patient was instructed to ask
his PCP to have him referred to a psychiatrist at his next
appointment.
8)Social - Social worker seen the patient for alcohol addiction.
Pt aware of the risk of binge drinking and desires to quit.
Patient will be followed by his PCP [**Name9 (PRE) 33227**] his alcohol
problem.
Medications on Admission:
Hydrocodone
Discharge Medications:
1. 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*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Multi-Vitamin Hi-Po Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Alcohol [**Name9 (PRE) **]
2. Acute hepatitis
3. Hepatic hemangioma
4. Mild pancreatitis
5. Thrombocytopenia
6. Depression
Discharge Condition:
Fair, stable
Discharge Instructions:
Pt is instructed to take all of the listed medications as
instructed. He is instructed to seek medical attention (PCP or
[**Name9 (PRE) **]) if he develops fainting spell, loss of consciousness,
confusion, tremors, chest pain, shortness of breath, nausea,
vomiting, or if he becomes jaundice.
Followup Instructions:
Pt is instructed to follow up with his primary care physician
[**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**2-2**] weeks. Patient wants to be referred to a
psychiatrist for psychopharmacology therapy. Patient needs to
have his primary care physician refer him to a psychiatirst for
psychpharm therapy and social work for psychotherapy.
Completed by:[**2120-7-31**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
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327, 333
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271, 289
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|
1197, 1617
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,638
| 109,083
|
26450
|
Discharge summary
|
report
|
Admission Date: [**2158-3-14**] Discharge Date: [**2158-3-19**]
Date of Birth: [**2094-3-15**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Cefepime
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Rigors.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known firstname **] [**Known lastname 65370**] is a very nice 63 year-old woman with history of
schizoid personality, CAD s/p stent ([**2154**]), CHF (EF ~10%?), h/o
cardiogenic [**Last Name (LF) **], [**First Name3 (LF) **] 20-30%, Atrial Fibrillation not on
coumadin, chronic L-side pleural effusion and h/o multiple UTIs
who comes complaining of chills and vomit. She was in her prior
state of health at [**Hospital 11851**] Healthcare until last night when
she woke up feeling very cold, with chills. She denied having
her temperature taken at that time. She denied fatigue, nausea,
vomit, diarrhea, chest pain, PND, orthopnea, dysuria,
palpitations, SOB. However, she was [**Doctor Last Name **] to BINeedham's ER.
.
She went to [**Hospital1 **]-[**Location (un) 8062**] ER where her initial vital signs showed
fever of 104, tachycardia up to 120s and 83% on RA. She coughed
with blood tinged sputum. She was guaiac positive. Multiple
attempts were done to contact her appointed legal guardian and
messages were left, but doctors were unable to reach him. Her
labs showed HCT of 28, Trop 0.09. She had large bowel movement.
Suspected sepsis with unknown source, but he considered the left
lung or a UTI. Pt received 1 L NS. She received Levo/vanc and
1g of Tylenol and was transfered to [**Hospital1 18**].
.
In the [**Hospital1 1388**] ER her initial VS were T 99.8 F, BP 90/57 mmHg,
HR 112 BPM, RR 22 BPM, 100% 2L NC. Pt had normal physical exam
and reported "melena" in the rectal vault. Got IV access, 2 U
RBC's, IV PPI.
.
Of note she was admitted to [**Location (un) 620**] ~1 month ago and was treated
for E. coli UTI with Bactrim-DS p.o. b.i.d her HCT at that time
was HCT 26 [**2158-2-1**].
Past Medical History:
-Syncope 3yrs ago
.
PAST MEDICAL HISTORY:
-Coronary Artery Disease (3VD, not a surgical candidate, s/p
stent to LCX in [**12/2154**])
-CHF, h/o cardiogenic [**Last Name (LF) **], [**First Name3 (LF) **] 20-30%
-Severe MR, moderate TR
-Atrial fibrillation on amiodarone
-Syncope 3yrs ago
-Neck pain, eval in 2/99 at [**Hospital1 336**] with some fibromyalgia points,
occured after viral syndrome
-Iron deficient Anemia
-Fibromyalgia
-Diverticulosis
-Internal Hemorrhoids
-Osteopenia
-Cluster A personality (schizoid) with question underlying
dementia, court order made for her to be DNR/DNI at last
admission
-Gastritis
-Bursitis
-Adrenal adenoma
Social History:
Patient lives in [**Hospital 11851**] healthcare. She denies any current or
past history of smoking. Used to drink alcohol occasionaly, but
[**Doctor First Name 1638**] any drink for many years. She denies being sexually
active; no inter-personal relationships; no family or friends
involved. She is DNR/DNI (per guardian [**Name (NI) **] [**Name (NI) **]). Pt denies
ilicit substance use.
Family History:
n/c
Physical Exam:
VITAL SIGNS - Temp 98 F, BP 111/61 mmHg, HR 94 BPM, RR 19 X',
O2-sat 96% RA
GENERAL - well-appearing woman in NAD, comfortable, appropriate,
not jaundiced (skin, mouth, conjuntiva)
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
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. Decreased breath sounds in L
base with decrease conduction of voice in that region.
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs). Swelling of both ankles 1+
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-26**] 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+
Exam on Discharge: Awake, alert, interactive. Denies complaints.
Lungs CTA B, heart RRR, no m/r/g. Abdomen soft, NTND.
Pertinent Results:
[**2158-3-14**] 04:05AM BLOOD WBC-15.0* RBC-3.80* Hgb-7.8*# Hct-26.0*
MCV-68*# MCH-20.5*# MCHC-30.0*# RDW-18.2* Plt Ct-264
[**2158-3-14**] 04:05AM BLOOD Neuts-94.3* Bands-0 Lymphs-2.4* Monos-3.2
Eos-0.1 Baso-0
[**2158-3-14**] 04:05AM BLOOD Hypochr-2+ Anisocy-3+ Poiklo-1+
Macrocy-NORMAL Microcy-3+ Polychr-OCCASIONAL Spheroc-1+
Ovalocy-1+ Schisto-OCCASIONAL Tear Dr[**Last Name (STitle) **]1+
[**2158-3-14**] 05:05AM BLOOD PT-13.0 PTT-22.1 INR(PT)-1.1
[**2158-3-14**] 04:05AM BLOOD Glucose-166* UreaN-38* Creat-1.0 Na-138
K-3.7 Cl-105 HCO3-21* AnGap-16
[**2158-3-14**] 04:05AM BLOOD ALT-5 AST-11 CK(CPK)-25* AlkPhos-60
TotBili-0.2
[**2158-3-14**] 04:05AM BLOOD cTropnT-0.15*
[**2158-3-14**] 11:44PM BLOOD CK-MB-3 cTropnT-0.05*
[**2158-3-14**] 04:05AM BLOOD ALT-5 AST-11 CK(CPK)-25* AlkPhos-60
TotBili-0.2
[**2158-3-14**] 11:44PM BLOOD CK(CPK)-41
[**2158-3-14**] 04:05AM BLOOD Albumin-3.1* Calcium-7.6*
[**2158-3-14**] 04:05AM BLOOD VitB12-401 Folate-5.7
[**2158-3-14**] 09:09AM BLOOD calTIBC-267 Ferritn-154* TRF-205
[**2158-3-14**] 09:09AM BLOOD Cortsol-25.2*
[**2158-3-14**] 04:12AM BLOOD Lactate-1.4
CXR: IMPRESSION:
1. Probable left pneumonia.
2. Persistent moderate-to-large-size left pleural effusion, at
least partially
loculated, presumably infectious or malignant.
ECG:
Sinus tachycardia. Diffuse low voltage. Baseline artifact.
Compared to the
previous tracing of [**2155-4-25**] the T wave inversion recorded in
leads V2-V5 and Q-T interval prolongation have resolved
consistent with prior recording representing active
anterolateral ischemia. The present findings may represent
pseudonormalization. Followup and clinical correlation are
suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
105 170 92 370/448 60 -24 115
CHEST CT ON [**3-15**]
HISTORY: Fever, chills and large left pleural effusion.
Considering
thoracentesis.
TECHNIQUE: Multidetector helical scanning of the chest was
performed without intravenous contrast [**Doctor Last Name 360**] reconstructed as
contiguous 5- and 1-mm thick axial and 5-mm thick coronal and
paramedian sagittal images read in conjunction with chest
radiographs from [**2154**] and [**2-15**] and [**2158-3-14**].
FINDINGS:
The large left pleural abnormality which increased between
[**2-15**] and [**3-14**] is a lenticular collection, extending
along the left costal pleural margin from the apex to the
diaphragm, occupying approximately half of the volume of the
left hemithorax. The wall of the pleural abnormality is
extremely irregular, ranging up to 3 cm in thickness, including
a high-density inner rind that ranges in attenuation up to 70
[**Doctor Last Name **], consistent with either partial calcification or chronic
organized hematoma. The contents are heterogeneous ranging in
attenuation from [**Doctor Last Name **] 30 to [**Doctor Last Name **] 50, conceivably partially
hemorrhagic as well; since there is no level at the interface
with small pockets of gas in the collection, the contents are
either extremely viscous or not fluid at all. The source of the
gas could be a recent attempt at thoracentesis, communication
with the lung/bronchial tree, or, least common, gas-forming
pleural infection.
The left main and upper lobe bronchi are patent, but the
lingular segmental bronchus is moderately narrowed, and the
superior segment of the left lower lobe, the basal trunk and
basal segmental bronchi are all completely occluded. Whether
this is due to mass effect of the pleural collection or a
combination of mass effect with longstanding atelectasis of the
lower lobe and lingula, and some hilar adenopathy is hard to
say, although a segment of the basal trunk with wall
calcification clearly shows occlusion by material or tissue in
the bronchus at that level.
The left ventricle is very dilated, at the expense of the right
ventricle, and there is extreme thinning and bulging of the
posterior and inferior wall, with perimeter calcification,
either a 5 cm wide aneurysm or wide-mouthed pseudoaneurysm.
There is no pericardial effusion or pericardial calcification.
Although the pericardium appears intact and at most levels, the
left ventricular abnormality is separable from the pleural
collection, for a length of roughly 15 mm, 4A:201-215;
communication at those levels is not excluded. Echocardiography
may help in that regard. Inferior to the contained pleural
abnormality is pleural fluid which permeates the epicardial fat
anteriorly and abuts the posterior reflection of pericardium
posteriorly.
Bronchiolar and acinar nodules are present in large numbers in
the right upper lobe, less so at the base of the right lung.
Wall thickening in small bronchi in both regions is more
pronounced in the latter, suggesting that chronic basal
bronchiectasis may be the source of infection for active
bronchiolitis in the upper lobe. Larger irregular opacities in
the lower lobe are most likely infection or atelectasis, but
need to be followed to prove that. A small right pleural
effusion layers posteriorly.
Atherosclerotic calcification is heavy in the coronary,
innominate and left subclavian. Mediastinal lymph nodes are
mildly enlarged, ranging up to 13 mm, 10 mm, and 9 mm in the
subcarinal, prevascular and right lower paratracheal stations
respectively. Pulmonary arteries are normal in size.
This examination is not designed for subdiaphragmatic evaluation
except to note granulomatous calcification in an otherwise
normal left adrenal gland, no right adrenal mass, and large
cysts in the liver. Engorgement of the hepatic veins suggest
elevated right heart pressures.
IMPRESSION:
1. Large possibly hemorrhagic chronic left pleural collection,
most likely empyema, including tuberculosis.
2. Left ventricular dilatation and large posterior wall aneurysm
or
pseudoaneurysm. Right ventricle may be compromised by left
ventricular
dilatation. Connection between the left ventricle and pleural
collection needs to be evaluated by cardiac imaging starting
with ultrasound, MRI if necessary.
3. Left lower lobe and lingular collapse can be explained by
mass effect from the left pleural collection obstructing the
left bronchial tree distal to the superior division of the upper
lobe.
4. Widespread right lung bronchiolitis, most commonly
non-tuberculous
mycobacterial species, but conceivably pyogenic.
Discharge Laboratories: [**2158-3-18**]
WBC:7.7 Hct:27.6 Plt:289
Na:138 K:4.0 Cl:103 HCO3:27 BUN:14 Cr:1.0UreaN Creat Na K Cl
HCO3
Brief Hospital Course:
Ms. [**Known firstname **] [**Known lastname 65370**] is a very nice 63 year-old woman with history of
schizoid personality, CAD s/p stent ([**2154**]), CHF (EF ~10%?), h/o
cardiogenic [**Last Name (LF) **], [**First Name3 (LF) **] 20-30%, Atrial Fibrillation not on
coumadin, chronic L-side pleural effusion and h/o multiple UTIs
who comes complaining of chills and vomit.
.
#. Urinary Tract Infection - Patient initially found to have BP
slightly below her normal baseline of 80-90s, with chills,
rigors and fever. An infectious workup revealed a dirty UA and
Cx grew pan s e coli. She was treated with levofloxacin and she
quickly improved.
.
#. Chronic Left sided pleural effusion: On arrival to our
hospital the patient was not hypoxemic. She had transient
shortness of breath prior to admission but none here. With her
h/o effusion, a CT scan was done that demonstrated multiple
significant findings that were all suspected to be incidental
and unrelated to her presentation. In her left lung she has a
very large pleural effusion with a 3cm rind on the pleura which
at one location is adjacent to her dilated LV aneurysm. There
was concern that the LV scar and pleural rind are contiguous. An
echo was done, but could not sufficiently exclude this. The case
was discussed with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of thoracic surgery who
suggested that a VATS was insufficient to correct the effusion
due to the thick rind and the patient would require a
thoracotomy. The risks and benefits were discussed with the
patient and her health care proxy and they elected to decline
any surgical intervention. She is DNR/DNI, wheelchair bound, and
denies symptoms of dyspnea so if symptoms later arise this can
be readdressed. Per her primary MD, it has been present for
years. Fluid from tap last year demonstrated a sterile exudative
effusion. No record of malignant cytology. Regardless of the
initial cause, surgical management is the only current option. A
PPD was placed on her R forearm for a low possibility of TB,
which was read as negative on [**2158-3-19**]. This plan for
conservative managment was discussed with Dr. [**Last Name (STitle) **], the
[**Name6 (MD) 228**] primary MD who agrees.
.
Bronchiolitis:In the right lung the patient has some small tree
and [**Male First Name (un) 239**] opacities along with changes consistent with chronic
bronchiectasis and possibly a non-tuberculous mycobacterial
infection. Patient seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of pulmonary
who felt these changes are likely chronic and not responsible
for her sepsis presentation and are not consistent with TB. Plan
to follow clinically. Should she develop worsening cough or
shortness of breath, repeat non-contract chest CT recommended
over routine CXR.
.
#. Acute on Chronic Systolic Heart Failure - Pt with known EF of
10%. Hypotension on admission infection related. Euvolemic on
discharge with mild edema in feet.
.
#. Coronary Artery Disease - 3V and poor surgical candidate with
stent in [**2154**]. On Asa/Plavix. Started a low dose statin as no
record of contraindication.
.
#. Atrial Fibrillation - Continuied amiodarone for rhythm
control. patient not anticoagulated on admission.
.
#. Anemia - Iron studies, B12, folate, all wnl.
.
#. Cluster A (schizoid) personality disorder - well compensated.
flat affect, but no psychosis features.
.
#. CODE: Patient was DNR/DNI during this admission, which was
reversed by order or the patient's guardian, [**Name (NI) **] [**Name (NI) **], prior to
discharge. She is now Full Code.
Medications on Admission:
* Plavix 75 Daily (per patient's report
* Vitamin C 500 mg PO Daily
* Senna 8.6 mg PO Daily PRN
* Roxonal 10 mg q4 hrs PRN pain
* MS Contin 30 mg PO QHS
* Aspirin 325 mg PO Daily
* Albuterol inhaler 3 ml PO Qhr PRN resp distress
* Calcium carbonate 500 mg PO Q4 hrs PRN GI upset
* Allopurinol 1 PO Daily
* Tylenol 325 mg PO 1-2 tabs q4 hrs PRN Temp
* Lasix 80 mg PO Daily
* Prilosec 40 mg PO Daily
* Amiodarone 200 mg PO daily
* Klor-Con 8 mEq
* Colace 100 mg PO BID
* Levorhtyroxine 25 mcg PO Daily
* Fregon 27 mg PO TID
* Bisacodyl rectally as needed
* Hyoscyamine 0.125 SL Q4hrs PSN secretions
* Milk of magnesia susp 30 mg PO Daily PRN constipation
* Fluticasone 50 1 Spray at baseline
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Senna 8.6 mg Capsule Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
5. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for Pain.
6. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for SOB / Wheezing.
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for Reflux.
9. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Pain or fever.
11. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day.
12. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Klor-Con 8 8 mEq Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day.
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
16. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Fergon 240 mg (27 mg Iron) Tablet Sig: One (1) Tablet PO
three times a day.
18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
19. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet Sublingual every four (4) hours as needed for secretions.
20. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
spray Nasal once a day.
21. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11851**] Healthcare - [**Location (un) 620**]
Discharge Diagnosis:
Primary Diagnosis: 599.0 URINARY TRACT INFECTION, BACTERIAL
Secondary Diagnosis: 511.9 EFFUSION, PLEURAL
Secondary Diagnosis: 414.01 CAD, NATIVE VESSEL
Secondary Diagnosis: 428.20 HEART FAILURE, (A3) CHRONIC SYSTOLIC
Secondary Diagnosis: 530.11 GASTROESOPHAGEAL REFLUX DISEASE
(GERD)
Secondary Diagnosis: 244.9 HYPOTHYROIDISM
Secondary Diagnosis: 427.31 ATRIAL FIBRILLATION
Secondary Diagnosis: 285.9 ANEMIA, UNSPECIFIED
Secondary Diagnosis: 466.19 AC BRONCHIOLITIS D/T OTH INF ORG
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:
patient being discharged to a facility
Followup Instructions:
Should the decision for surgical management change, please
contact:
Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Hospital1 18**] Thoracic Surgery ([**Telephone/Fax (1) 17398**].
Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Hospital1 18**] Pulmonary ([**Telephone/Fax (1) 65371**].
|
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40,582
| 126,929
|
752
|
Discharge summary
|
report
|
Admission Date: [**2161-3-19**] Discharge Date: [**2161-3-30**]
Service: MEDICINE
Allergies:
Codeine / Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 4028**]
Chief Complaint:
Rectal bleeding
Major Surgical or Invasive Procedure:
-Angiography
-Subclavian cordis / left subclavian central line placed [**3-21**],
removed [**3-23**]
-Colonoscopy
History of Present Illness:
Mrs. [**Known lastname 5480**] is a [**Age over 90 **]-year-old female with a PMH significant
for Celiac Disease, hemorrhoids, old CVA ([**2153**]), hypertension,
hypothyroidism, and known cecal AVM who was recently admitted to
[**Hospital3 **] ([**3-14**]) with a large GIB 5 days prior to this
admission. At that time her Hct was 19, NGL negative, transfused
several units of blood to bring her Hct up to 35. No colonoscopy
performed given her overall good clinical stability and
discussion about risks/benefit of procedure. Patient was
discharged home yesterday and was doing well until the day of
admission to this hospital, when she had several episodes of
BRBPR, associated with lightheadedness, but no CP/SOB. Also
complained of some lower abdominal cramping discomfort that was,
at worse, [**5-3**] in severity and felt better after having a bowel
movement. Bleeding occurred in the setting of her bowel
movements. She had been on Aggrenox for an old CVA, but this was
held in the middle of [**Month (only) 958**], several days before her last
admission.
.
Patient has a history of LGIB in [**2158**], found to have large AVM
on c-scope that was clipped. No subsequent scopes or bleeding
until now.
.
In the ED, initial vitals: 98.4, 89, 152/71, 18, 96% RA. The Hct
was 36.5. On rectal exam by ED resident, hemorrhoids were noted,
and there was BRB in the vault but no active source seen. GI was
consulted. Three PIVs (two 16g and one 18g)were placed and the
patient was typed and crossed by blood bank for 4 units PRBCs.
.
On arrival in MICU, she had no complaints and appeared fairly
stable. On further ROS at time of admission she denied chest
pains, dyspnea, fevers/chills, nusea, vomiting, diarrhea.
Past Medical History:
Celiac Disease
CVA / Right thalamic capsular stroke with resultant left sided
Ataxic hemiparesis [**8-26**]
HTN
Glaucoma L eye
Hypothyroidism
Hyperlipidemia
Restless legs
OA
Diverticulitis
Fe-deficiency anemia
Osteoporosis
Borderline pulm HTN
LGIB in [**2158**], found to have large AVM in the cecum on c-scope
that was clipped
Social History:
Lives in [**Location (un) 5481**] retirement facility. She is a widow and
has one son who lives close by and is very involved with her
care. Denies alcohol, drugs, or smoking. Extremely independent
at baseline with her ADLs, IADLs prior to this admission.
Family History:
No known h/o CA, blood disorders, GI disorder
Physical Exam:
PHYSICAL EXAM ON ADMISSION TO MICU :
VS T 96.1F, HR 85, BP 130/65, RR 17, Oxygen saturation 94% on
room air
Gen: Elderly female in NAD, pleasant & conversant
HEENT: PERRL, anicteric, MMM
Heart: s1s2 RRR
Pulm: Scattered rhonchi
Abd: + BS, soft, minimal TTP in the lower quadrants, no rebound
or guarding
Ext: no c/c/e
Rectal: + ext hemorrhoids; trace amt BRB in vault
Neuro: A&O x 3, MAE, nonfocal
.
.
PHYSICAL EXAM ON TRANSFER TO GENERAL MEDICAL FLOOR :
VS: afebrile, BP 160s/60s, HR 70s, RR 18-20, oxygen saturation
93-94% on 4L NC
General: Alert, oriented, no acute distress, on 4L NC
HEENT: Sclera anicteric, MMM, oropharynx clear, clear scant
rhinorrhea noted
Neck: supple, JVP not elevated, no LAD
Lungs: Coarse rhonchi over mid lung fields, R>L, decreased lung
sounds at bases bilaterally, expiratory scattered wheezes
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, tender to palpation over right lower quadrant and
right flank/large ecchymoses noted over right groin -->
flank/lower right inguinal region, bowel sounds present and
normoactive x 4 quadrants, guarding at RLQ
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
.
ADMISSION LABS:
[**2161-3-19**] 09:20PM HGB-12.5 calcHCT-38
[**2161-3-19**] 09:10PM GLUCOSE-142* UREA N-30* CREAT-1.2* SODIUM-137
POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-24 ANION GAP-16
[**2161-3-19**] 09:10PM CALCIUM-9.3 PHOSPHATE-3.4 MAGNESIUM-2.3
[**2161-3-19**] 09:10PM WBC-9.5 RBC-4.11*# HGB-12.1# HCT-36.5# MCV-89
MCH-29.3 MCHC-33.1 RDW-15.5, PLT COUNT-367
[**2161-3-19**] 09:10PM NEUTS-71.6* LYMPHS-18.6 MONOS-4.1 EOS-5.1*
BASOS-0.6
[**2161-3-19**] 09:10PM PT-12.1 PTT-33.6 INR(PT)-1.0
.
.
CARDIAC ENZYMES:
[**2161-3-19**] 09:10PM CK(CPK)-126
[**2161-3-19**] 09:10PM cTropnT-<0.01
[**2161-3-19**] 09:10PM CK-MB-9
[**2161-3-20**] 07:36AM BLOOD CK-MB-6 cTropnT-<0.01
.
.
ADDITIONAL STUDIES:
[**2161-3-19**] EKG: rate 80s, Normal sinus rhythm. Normal tracing with
normal intervals and no abnormal ischemic changes
.
IMAGING:
.
[**2161-3-28**] -RLE DOPPLER US: IMPRESSION- No acute deep vein
thrombosis of the right lower extremity.
.
[**2161-3-26**]: CXR / PA and Lateral views: Moderate bilateral pleural
effusions, increased from [**3-21**]. Persistent mild pulmonary
edema.
.
[**2161-3-24**] VIDEO SWALLOW STUDY: ASPIRATION/PENETRATION: There was
one episode of penetration before the swallow with a cup sip of
thin liquids due to premature spillover and swallow delay,
however, cleared at the height of the swallow. IMPRESSION: Mild
oral and pharyngeal dysphagia, with no aspiration to account for
persistent cough following meals.
.
[**2161-3-24**] UGI AIR W/O KUB:
IMPRESSION:
1. No gastroesophageal reflux observed.
2. Persistent irregularity along the wall of the mid third of
the esophagus,which could be due to tertiary contractions,
however may indicate presence of esophagitis. Endoscopy could be
performed for confirmation.
.
[**2161-3-23**] CXR - IMPRESSION: The left subclavian line tip again
projects over the expected location of the aorta, suggest
rechecking position. Cardiomegaly with worsening effusions and
mild overhydration. Bibasilar atelectasis.
.
[**2161-3-21**] CXR for LINE PLACEMENT - (Left Subclavian)- INDICATION:
Line placement.Left subclavian vascular sheath has been placed,
terminating in the left brachiocephalic vein. Focal kinking of a
catheter sheath is present at the expected skin insertion site.
Nasogastric tube terminates in proximal stomach with distal tip
directed cephalad. New patchy right lower lobe opacity and
worsening patchy left retrocardiac opacity. Differential
diagnosis includes aspiration, atelectasis and developing
infectious pneumonia.
.
[**2161-3-21**] CT of ABD/PELVIS:
CT OF THE ABDOMEN: There is mild bibasilar atelectasis
identified. There is
no pleural effusion or pneumothorax identified. There is no
pericardial
effusion identified. There is calcification of the descending
aorta and its
branches identified. The kidneys demonstrate contrast within the
collecting
systems, likely from prior procedures. The spleen, liver, and
adrenal glands are unremarkable. The pancreas demonstrates
hypodensities which are
incompletely characterized on this non-contrast exam ( 2, 30 and
29). The
gallbladder is distended. Small bowel loops are normal in
caliber. There is
no mesenteric or retroperitoneal lymphadenopathy.
There is extensive right-sided retroperitoneal hemorrhage
extending from the liver to the right inguinal region.
High-density blood is seen within the perihepatic space as well
as displacing the right kidney medially (2, 31). High-density
fluid is also seen tracking into the presacral space (2, 63). CT
OF THE PELVIS: The bladder, rectum, and sigmoid colon are
unremarkable. There is a small right-sided fat-containing
inguinal hernia. There is no significant pelvic or inguinal
lymphadenopathy.
BONE WINDOWS: There is diffuse osteopenia and degenerative
changes throughout the spine. There are no focal lytic or
sclerotic lesions identified.
IMPRESSION:
1. Extensive retroperitoneal bleed extending from the hepatic
dome to the
right inguinal region.
2. Pancreatic hypodensities, evaluated on this non-contrast
exam.
.
[**2161-3-20**] CXR : Scoliosis is noted, moderate to severe with right
convexity. The position, contour and width of the mediastinum
are stable since [**2158-8-9**]. Lungs are essentially clear.
There is no pleural effusion or pneumothorax. No evidence of
acute abnormality demonstrated on the current radiograph.
[**2161-3-20**] - ANGIOGRAM w/IR : Given the lack of active contrast
extravasation or vascular abnormality,the catheter was removed
and the sheath left in place for repeat angiography if indicated
at a later time.
IMPRESSION: Mesenteric angiogram demonstrating a replaced common
hepatic
artery arising from the SMA. No evidence for contrast
extravasation noted on our study.
.
[**2161-3-20**] MESENTERIC ANGIOGRAM:
IMPRESSION: Mesenteric angiogram including the celiac, SMA, and
[**Female First Name (un) 899**] with no
evidence for active contrast extravasation, angiodysplasia, or
neovascularity. Incidental note made of a replaced common
hepatic artery arising from the SMA
.
.
MICROBIOLOGY:
[**2161-3-30**] C.Difficile stool assay -negative
[**2161-3-29**] Urine Culture -negative to date at discharge, final
pending
[**2161-3-27**] Blood Cultures x 2-no growth to date
[**2161-3-21**] 2:23 pm SPUTUM
Source: Expectorated.//**FINAL REPORT [**2161-3-24**]**
GRAM STAIN (Final [**2161-3-21**]):
[**10-18**] PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2161-3-24**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
STREPTOCOCCUS PNEUMONIAE. MODERATE GROWTH.
PRESUMPTIVELY PENICILLIN SENSITIVE BY OXACILLIN SCREEN.
[**2161-3-20**] MRSA nasal swab - negative
.
URINE STUDIES:
[**2161-3-20**] 12:43AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2161-3-20**] 12:43AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
.
DISCHARGE LABS:
WBC 8.4, Hemoglobin 11.4, Hematocrit 33.7, MCV 86,
MCH 29.2, MCHC 33.8, Platelet Count 443
Glucose 87, BUN 19, Creatinine 0.9, Sodium 143, K 3.9, Cl 106
Brief Hospital Course:
INITIAL ADMISSION AND BRIEF MICU COURSE:
The patient was admitted to the MICU in stable condition. GI
advised starting Golytely with plan for colonscopy in the AM on
the day after admission. On the night of admission, however, her
hematocrit dropped to 28 and she was noted to have voluminous
blood from the rectum. General Surgery and IR were consulted
simultaneously given the volume of bleeding, and it was felt
that waiting for a tagged RBC scan would be unsafe so the
patient was taken emergently to the IR suite. NGL negative. 4
units pRBCs and one unit of platelets were transfsued
immediately via the Level One. No source of bleeding was
identified on angio. The patient remained HD stable and returned
to the MICU with the sheath in the R femoral artery left in
place in case of rebleeding. GI performed a colonscopy the next
AM w/o finding obvious source, concern for bleeding from small
bowel. She returned to the IR suite; again no source could be
identified. Within one hour of patient returning to floor,
abdomen became exquisitely tender, pt was already being
transfused upon return then dropped BP. Pt required 8u pRBCs, 3
FFP, 3 platelets. A stat CT ABD/PEL revealed a large
retroperitoneal hematoma, and the blood presure transiently
dropped to the 70s. The patient had an epiosde of emesis with
likely aspiration. Vascular and IR were consulted, no
intervention thought to be warranted as patient had stabilized.
A left subclavian cordis line was placed. In total, the patient
was transfused 13 units PRBCs before her Hct stabilized at 29.
On Hospital Day 3, the patient was feeling better, without
further rectal bleeding. She had a productive cough with
evidence of aspiration on the CXR, sputum with GPCs and GNRs,
and she was started on a course of IV Levaquin/Vancomycin before
transfer to the general medical floor on the evening of [**2161-3-23**]
.
.
ADDITIONAL HOSPITAL COURSE AFTER TRANSFER FROM MICU TO GENERAL
MEDICAL [**Hospital1 **]:
In summary, Mrs. [**Known lastname 5480**] is a [**Age over 90 **]-year-old female with known
recurrent BRBPR, and recent complication of retroperitoneal
bleed after IR angiography procedure during GI bleed workup, and
new aspiration PNA, who was afebrile with stable hematocrits for
nearly 2 days by the time she was transferred from MICU to
general medical floor on [**2161-3-23**].
.
# GI Bleed /BRBPR: Prior to this admission Mrs. [**Known lastname 5480**] had a
known history of cecal AVM per records, as well as
diverticulosis. She had gross blood noted in ED on rectal exam.
It was thought that her known AVM was the likely source although
it was unable to be definitively located on both colonoscopy and
repeat angiography. Rectal bleeding had subsided by time of
transfer to the medical floor. As above, her second
interventional radiology angiography was complicated after
sheath removal and sudden blood pressure drops, hematocrit drips
and RLQ / right inguinal and flank pains. NGT placed on [**3-20**] for
aspiration concerns and airway protection after an emesis
episode with coughing. This was due to a confirmed
retroperitoneal bleed. She needed IVFs,pressor support for BP
control, about 13 Units of blood and several bags of platelets
and FFP to stabilize. She had been on Aggrenox for CVA history
but this was held as of [**3-15**] after presentation to an outside
hospital prior her re-admission only days latter to [**Hospital1 18**] for
recurrent BRBPR. GI team followed patient while she was in
hospital and recommended another follow-up outpatient
colonoscopy in 8 weeks time. The patient wished to resume her
care with her prior GI physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3315**] here at [**Hospital1 18**] so
she was asked to set up a follow-up appointment within a few
weeks of discharge.
Left subclavian trauma line placed for about 2 days and then
removed and she also had IV access with 2 large guage PIVs up
until [**2161-3-28**] and she was switched to one IV. Team kept an active
type and cross. She was kept NPO immediately after the large
blood loss and GI/RP bleeding over [**3-19**] -[**3-22**] but was then
started back slowly on clears, then she had a video swallow
study that confirmed no major aspiration issues so she was
advanced to a regular PO diet with gluten restrictions in place
for her Celiac Disease. Nutrition consult assisted with helpful
diet recommendations and she tolerated a regular diet very well,
although she limited some of her intake due to her worry that
some of her loose stools from Celiac Disease would worsen. She
was reassured that she was on a gluten free diet and that she
needed to preserve her nutrition as much as possible given her
deconditioned state. She had been placed on [**Hospital1 **] IV Protonix
during her active bleeding but this was transitioned to an oral
40mg Protonix tablet several days prior to discharge. Admission
Hct was 36.5 and nadir was to 27. If she was not given back
multiple transfusions so rapidly in setting of heavy GI/RP
bleeding her hematocrit would have likely plunged much lower,
much quicker. By time of discharge her Hct was stable for days
at about the 31-34 range.
.
#Retroperitoneal bleed: As above, hematocrits have been stable
and climbing. Abdominal pain at RLQ continues to improve slowly.
Able to sit up in chair and ambulate with a walker. She was
reminded not to lift any heavy objects >10-lbs. or to do any
straining/strenuous activities for 2-3 weeks. PT/OT worked with
patient and she progressed slowly. RP bleed should eventually
fully reabsorb and this was explained to patient. As she was
clinically stable the team felt there was no need to repeat CT
again, and she can discuss timing of repeat imaging, if any, at
her outpatient follow-up with PCP [**Name Initial (PRE) **]/or Dr. [**Last Name (STitle) 3315**], her GI
physician here at [**Hospital1 18**].
.
# Prior CVA: She had a right thalamic capsular stroke with
short-lived resultant left sided ataxic hemiparesis in [**2153**]. Now
she ambulates well at baseline with slight unsteadiness at times
from her RLQ discomfort but has been given a walker to be used
for better stability. She was taken off of Aggrenox 3/22 per
records and was asked not to restart her Aggrenox or aspirin.
Despite sudden drops in her blood pressure due to hemorrhage in
retroperitoneum while in the ICU, she has no signs of any
lasting mentation deficits. A&Ox3 and no focal deficits on
neurological exam for the entirety of her hospital course.
Physical therapy followed patient during hospitalization and
felt she was stable for discharge back to her [**Hospital3 **]
facility with some home services and use of a walker for
ambulation while she fully recuperates.
.
# Hypertension: Blood pressures slightly elevated to 140-160s
systolic ranges for a few days after transfer out of the ICU.
The medical team was purposefully allowing more laxity due to
recent bleeds. She was continued on her usual home Valsartan and
Norvasc was initially held but gradually added back and the dose
was slowly uptitrated to her usual 10mg daily dose, which is the
dose she was discharged on. Blood pressures on day of discharge
were predominantly normotensive in the 118-140/50-70s range.
.
#Aspiration PNA: Per notes and patient reports, Mrs. [**Known lastname 5480**]
has a chronic cough at baseline in recent months. Sputum
production and coarse rhonchi with progressive cough occurred
soon after she had an aspiration event. CXR infiltrates all
appeared new from prior comparisons and her cough flared up
within minutes after she had an aspiration on [**3-20**]. Sputum
production but no hemoptysis. No CP, mild SOB with improving
oxygen requirement now. She weaned quickly from 4L to 2L NC and
is now comfortable on room air with oxygen saturation levels in
the mid-90s. Sputum culture confirmed Streptococcal pneumonia.
She was given 10 days of IV vancomycin and levaquin with
improvement in her breathing and cough. She was also given nasal
saline spray and guaifenisen for more cough suppression.
Shortness of breath and cough markedly improved by time of
discharge and she had no fevers or leukocytosis so she was not
placed on any extended oral antibiotics at discharge. She will
plan to see her PCP on Thursday, [**2160-4-2**] for close follow-up.
.
# Chronic facial neuralgia: Chronic issue, symptoms for > 1
year. Most painful around forehead area. Continued on Tylenol
and avoided NSAIDs/Motrin due to GI & RP bleeding.
.
#Right lower extremity swelling: On [**2161-3-28**] the team noticed that
her right lower extremity was a little more swollen and there
was asymmetry. Given her immobility she was certainly at risk
for DVT. Fortunately, lower extremity ultrasound showed no
evidence of any DVTs. Edema is on same side a her large RP bleed
which may explain the swelling.
.
#Cellulitis left forearm: After her IV was pulled out on [**2161-3-27**]
she had an erythematous 2" diameter circular area over her left
antecubital region with some tenderness, and some purulent fluid
at prior IV site. She was given local bacitraicin ointment and
continued on her usual IV Vancomycin and Levaquin through the
weekend, prior to discharge. On day of discharge the area was
nonedematous, and there was no additional expressible discharge
and erythema had abated so an additional oral antibiotic was not
added.
.
# Hypothyroidism: She was continue on her usual home dose of
Levoxyl therapy daily.
.
# Glaucoma of left eye: She was continued on home eye drop
routine daily with
Cosopt drops to left eye twice daily and she also got her
nightly left eye Latanoprost drops as well. No loss of vision or
report of any visual changes while in the hospital.
.
# Celiac disease: Stable, gluten free regular diet continued.
She had some loose stools which were likely due to her Celiac
condition. However, given her recent hospitalizations and
antibiotics a C.difficile assay was collected and was negative.
If results return positive, team will notify PCP. [**Name10 (NameIs) **] above, she
was followed by the inpatient nutrition service as well.
.
# Code Status: DNR/DNI, confirmed with patient
.
Medications on Admission:
- Valsartan 160 qd
- Amlodipine 10 qd
- mirapex 0.25 qd
- protonix 40 qd
- lumigan 0.03% one drop qhs
- tramadol 50mg q6h prn
- levothyroxine 0.112 mg qd
- klonopin 0.25mg q 12h prn
- cosopt one drop [**Hospital1 **] OS
- tylenol 1000mg q6 h
saline nasal spray 2 sprays each q2h prn
- colace 100mg qd prn
Discharge Medications:
1. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic twice a day: one drop to LEFT EYE
only; twice daily .
2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical once a day.
3. Clonazepam 0.5 mg Tablet Sig: [**12-26**] Tablet PO BID (2 times a
day) as needed for insomnia.
4. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO qd ().
5. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. 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*
9. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime): one drop in left eye at bedtime .
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
11. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
12. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day as
needed for constipation.
13. Ultram 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
14. Saline Nasal 0.65 % Aerosol, Spray Sig: One (1) Nasal
q2-4hrs as needed for congestion.
15. Bacitracin 500 unit/g Ointment Sig: One (1) Topical twice a
day for 1 weeks: Please apply a coat of topical ointment to left
forearm affected area twice daily x 1 week. .
Disp:*1 1* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] senior life [**Hospital6 **]
Discharge Diagnosis:
Primary:
-Lower GI Bleed
-Pneumonia
-Retroperitoneal Bleed
.
Secondary:
-Celiac Disease
- Hypertension
- Hypothyroidism
- Iron-deficiency anemia
- Osteoarthritis
- prior right thalamic capsular stroke (left sided ataxic
hemiparesis for several months in [**2153**])
- Osteoporosis
- Glaucoma (left eye)
Discharge Condition:
Stable. Alert and oriented to person, time and place. No
apparent distress.
Discharge Instructions:
It was a pleasure taking care of you here at [**Hospital1 771**].
.
You were admitted after having some bloody bowel movements. You
continued to have dropping levels of red blood cells and
required multiple blood transfusions. You had an interventional
radiology procedure to try to find the bleeding source in your
GI tract. After having a sheath placed and then removed from a
major blood vessel in your groin area you had a complication
called a retroperitoneal bleed with some bleeding into your
right lower abdominal region. This eventually stabilized after
additional blood transfusions, IVFs and medications to help keep
your blood pressure from dropping.
.
Shortly after having a colonoscopy you experienced some nausea
and vomiting which may have been from bloating post-colonoscopy
or from increased abdominal pressure from some internal bleeding
you had. This vomiting episode unfortunately involved some
aspiration which is when droplets of digestive contents and
vomit can go down the wrong passage way and end up in the lungs.
This led to a cough, fevers, and a pneumonia that was identified
on chest x-ray. Therefore, you were placed on antibiotics which
helped you to recover. Later in your hospital course you also
had some redness over your left arm where an IV had been placed.
This was concerning for a local skin infection but improved
within 48 hours. Please continue to cover it with Bacitraicin
ointment topically for 1 week.
.
Please follow-up with all of your appointments as outlined
below. Also, please be sure to have a repeat colonoscopy in
about 8 weeks time.
.
Lastly, please do not lift any heavy objects greater than 10 lbs
for at least 2 weeks time after being discharged. If you
experience any acute worsening abdominal pain, enlargement or
spread of the bruising over your right flank/lower abdomen,
dizziness, fainting, visual changes, recurrent bloody stools,
excessive diarrhea, chest pains, shortness of breath, chills,
fevers, night sweats, burning with urination, or an other health
concerns please return to the emergency room or call your
primary care physician.
.
MEDICATION CHANGES:
1)Your Tylenol dose has been slightly altered to 325-650mg
every 6 hours as needed
2)Please continue the anti-acid medication called Protonix
(pantoprazole) daily
3) Do not take Aspirin or your previous Aggrenox medication for
several more weeks ; discuss specific timeline with your PCP as
an outpatient.
4) Please continue application of topical bacitraicin ointment
to your left forearm twice daily for 1 week.
5)Otherwise, your usual eye drops, blood pressure medications,
and all of your other home medications have not been changed,
please continue taking all of your usual medication as
previously prescribed
Followup Instructions:
1) Please make a follow-up to see your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5482**],
over the next 10 days. Phone #[**Telephone/Fax (1) 5483**]
.
2) Please call [**Telephone/Fax (1) 463**] to schedule a follow-up colonoscopy
in 8 weeks time.
.
3) Please make a follow-up appointment with [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5484**],
MD, PhD, in the gastroenterology department. Phone #[**Telephone/Fax (1) 4538**]
Completed by:[**2161-3-30**]
|
[
"V12.54",
"365.9",
"729.81",
"998.12",
"E879.8",
"733.00",
"272.4",
"999.39",
"451.84",
"579.0",
"514",
"333.94",
"244.9",
"682.3",
"715.90",
"999.2",
"569.85",
"507.0",
"401.9",
"351.8",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"38.93",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
22287, 22363
|
10228, 20385
|
268, 383
|
22712, 22790
|
4038, 4040
|
25586, 26083
|
2767, 2814
|
20741, 22264
|
22384, 22691
|
20411, 20718
|
22814, 24925
|
10049, 10205
|
2829, 4019
|
4558, 10033
|
24945, 25563
|
213, 230
|
411, 2125
|
4056, 4541
|
2147, 2477
|
2493, 2751
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,162
| 136,382
|
48740
|
Discharge summary
|
report
|
Admission Date: [**2114-3-7**] Discharge Date: [**2114-3-8**]
Date of Birth: [**2057-2-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
sypnea on exertion, orthopnea
Major Surgical or Invasive Procedure:
[**2114-3-7**] Redo AVR (23mm St. [**Male First Name (un) 923**] mechanical)/ CABG x1 (SVG to
PDA)
History of Present Illness:
56 yo male with prior tissue AVR in [**2110**] presented to ER in [**2-5**]
with 2-3 weeks gradual orthopnea and DOE. Admitted to ICU for
CHF and hypertensive emergency and was diuresed. Originally
evaluated by Dr. [**Last Name (STitle) **] at that time. Returned for surgery
after pre-op evaluation completed.
Past Medical History:
s/p renal transplant [**2090**], baseline creatinine 3.0
AVR [**2110**], bovine valve
s/p endocarditis [**2080**], [**2082**], [**2093**]
Prostate CA s/p XRT [**2109**]
Melanoma on neck s/p resection
Hypertension
Hyperlipidemia
Gout
GI bleed/hemorrhoids ( banded)
remote fracture left shoulder
s/p parathyroidectomy [**2085**]
Social History:
Social history is significant for the absence of any tobacco
use. There is no history of alcohol abuse.
Lives with wife.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Father had MI when he was older.
Physical Exam:
69" 160#
HR 72 RR 20 BP 144/91
normocephalic, well-nourished
skin/HEENT unremarkable
neck incison healed
CTAB
RRR with 3/6 systolic murmur
abd soft/ND
extrems warm, well-perfused; 1+ edema
no varocosities noted
neuro grossly intact
3+ bil. femorals
2+ bil. DP/PT/radials
left carotid bruit noted
Pertinent Results:
Conclusions
Pre Bypass: This study is limited by poor image quality and a
rotated heart with off axis views only. Right ventricular
chamber size and free wall motion are normal. There are complex
(>4mm) atheroma in the aortic arch. There are complex (>4mm)
atheroma in the descending thoracic aorta. The prosthetic aortic
valve leaflets are thickened. Significant aortic stenosis is
present (not quantified) Insitu aortic valve prosthesis appears
heavily calcified. No aortic regurgitation is seen. The mitral
valve leaflets are moderately thickened. Mild to moderate ([**12-1**]+)
mitral regurgitation is seen.
Post Bypass: Patient is on Epinepherine 0.02 mcg/kg/min, and
phenylepherine 1 mcg/kg/min, V paced
Biventricular funciton is slightly improved with mild to
moderate residual hypokinesis in the inferior wall. A mechanical
prosthethesis is seen in the aortic position with a peak
gradient of 20 on average. No AI or perivavlvuar leaks are seen.
Mitral regurgitation is now mild. Aortic contours are intact.
Remaining exam is unchanged. All finidings discussed with
surgeons at the time of the exam.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Known firstname **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2114-3-9**] 14:22
?????? [**2107**] CareGroup IS. All rights reserved.
Brief Hospital Course:
Admitted [**3-7**] and underwent surgery with Dr. [**Last Name (STitle) **]. Transferred
to the CVICU in stable condition on epinephrine, phenylephrine,
and propofol drips. Transfused overnight with 4 units PRBCs for
chest tube output. Extubated per protocol.Renal service
consulted. On [**3-8**], team was talking with pt at bedside when he
suddenly complained of sharp back pain. He then developed agonal
breathing, became rapidly hypotensive, with increased bleeding
noted in chest tubes. Code called with Dr. [**Last Name (STitle) **] opening chest
at bedside. Hemorrhage noted from aortic suture line. Unable to
be resuscitated with multiple attempts at defibrillation and pt
expired at 18:06.
Medications on Admission:
allopurinol 100 mg [**Hospital1 **]
calcitriol 0.5 mg 5 days/week
sensipar 30 mg [**Hospital1 **]
sandimmune one cap daily
aranesp one SC every 2 weeks
lasix 160 mg daily
[**Doctor Last Name **] facine 1 mg [**Hospital1 **]
lisinopril 40 mg daily
metoprolol 50 mg [**Hospital1 **]
cellcept [**Pager number **] mg [**Hospital1 **]
nifedipine 60 mg daily
prednisone 5 mg daily
simvastatin 60 mg daily
tamsulosin 0.4 mg daily
diovan 320 mg daily
zolpidem one tab QHS
Vit. C 250 mg daily
MVI daily
recently completed lupron therapy
Discharge Disposition:
Expired
Discharge Diagnosis:
redo AVR/CABG x1 [**2114-3-7**]
s/p renal transplant [**2090**], baseline creatinine 3.0
AVR [**2110**], bovine valve
s/p endocarditis [**2080**], [**2082**], [**2093**]
Prostate CA s/p XRT [**2109**]
Melanoma on neck s/p resection
Hypertension
Hyperlipidemia
Gout
GI bleed/hemorrhoids ( banded)
remote fracture left shoulder
s/p parathyroidectomy [**2085**]
Discharge Condition:
expired
Completed by:[**2114-3-21**]
|
[
"424.1",
"426.3",
"401.9",
"455.6",
"414.01",
"997.99",
"428.21",
"600.00",
"V43.3",
"428.0",
"E878.1",
"998.0",
"427.31",
"274.9",
"V42.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"99.62",
"96.04",
"35.22",
"39.61",
"99.60",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
4461, 4470
|
3182, 3882
|
349, 450
|
4876, 4914
|
1744, 3159
|
1295, 1410
|
4491, 4855
|
3908, 4438
|
1425, 1725
|
280, 311
|
478, 790
|
812, 1141
|
1157, 1279
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,819
| 144,995
|
1921
|
Discharge summary
|
report
|
Admission Date: [**2148-3-15**] Discharge Date: [**2148-3-21**]
Date of Birth: [**2087-8-12**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
perineal pain
Major Surgical or Invasive Procedure:
perineal I&D [**2148-3-16**]
re-exploration of perineal abscess [**2148-3-17**]
History of Present Illness:
60 y.o. male with h/o DM I s/p combined kidney and pancreas
transplant in [**2138**] who c/o painful urination x3months. Now c/o
painful pernineal pain x 1 month. At [**Hospital6 4620**]
ER [**3-12**] with GU sx. He had pyuria with negative cultures but was
empirically treated with cipro. He returned to [**Hospital **] Hospital with
increasing GU sx of pain on void with retention. He had 800 cc
residual urine in the bladder. A foley was placed. He was noted
to have left buttock lump and perineal swelling. ID was
consulted. Unasyn was started. On [**3-14**] 10cc was aspirated and
had 30,000 wbc, amylase was 889 and serum amylase was 90. He was
transferred to [**Hospital1 18**] SICU.
Normal creatinine is ~1.5.
Past Medical History:
kidney pancreas transplant [**2138**], esophageal CA, DM I,
gastroparesis, TIA, cataracts, neuropathy, HTN, old avf on right
forearm, hypercholesterolemia, s/p appy, Barretts s/p esoph
resection, h/o right foot cellulitits, ?rheumatic fever (per pt)
Social History:
[**Name (NI) **] [**Name (NI) 10680**] (sister)is HCP
Family History:
N/C
Physical Exam:
99.3 68 133/46 15 96%
A&O, anicteric sclerae
neck supple
chest clear
cor no jvd,[**1-9**] sys murmur at LUSB
abd soft NT/ND, NABS, UQ graft-nt/no bruit
GU + purulent drainage at meatus, erythema & induration in L>R
scrotum & suprapubic area to L perineum.
Pertinent Results:
On Admission: [**2148-3-15**]
WBC-11.7* RBC-3.41*# Hgb-9.4*# Hct-29.4*# MCV-86 MCH-27.6
MCHC-32.0 RDW-17.1* Plt Ct-408
PT-12.6 PTT-23.1 INR(PT)-1.1
Glucose-106* UreaN-15 Creat-1.3* Na-134 K-4.4 Cl-100 HCO3-22
AnGap-16
ALT-11 AST-10 LD(LDH)-152 AlkPhos-138* Amylase-64 TotBili-0.2
Lipase-41
Albumin-3.2* Calcium-9.0 Phos-2.6* Mg-2.0
[**2148-3-16**] PSA-1.1
[**2148-3-15**] URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009
Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD RBC-0-2 WBC-[**2-5**]
Bacteri-FEW Yeast-NONE
Epi-0-2
Urine Culture: No Growth
RT PENILE COLLECTION Culture:
GRAM STAIN: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN, NO
MICROORGANISMS SEEN. FLUID CULTURE NO GROWTH, ANAEROBIC CULTURE:
NO GROWTH.
ACID FAST SMEAR (Final [**2148-3-19**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Pending):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Brief Hospital Course:
Vanco and Zosyn were started on [**3-14**] and Urology was consulted.
It was felt that he had bulbar urethral injury with
extravasation and abscess. On [**3-15**] CT with contrast showed
multiple loculated fluid collections within the perineal region
adjacent to the urethra. There was concern for urethral fistula
from the pancreatic graft. Peri-anal fistula was thought to be
less likely given the location of the loculated collections. On
[**3-15**] a retro urogram revealed no evidence of bladder or urethral
leak. Irregularity along the membranous urethra extending to the
prostatic urethra was suggestive of chronic inflammatory or
edematous state.
On [**3-16**] he had incision and drainage of perineal abscess and
exam under anesthesia for pernieal abscess. A swab revealed 2+
PMNs and no growth. Wound dressings consisted of packed with
Iodiform and external gauze. A foley catheter remained in place.
On [**3-17**] CT without contrast showed significant improvement.
Stable peripenile multiloculated fluid collections stable
surrounding inflammatory change. New air within the renal pelvis
of the left pelvic transplanted kidney.
On [**3-17**] he underwent re-exploration of perineum for perineal
abscess on [**2148-3-17**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
On [**3-18**], he had successful CT fluoroscopic-guidance drainage of
multiloculated fluid perineal collection. This aspirate has been
negative to date including AFB. Fluid was sent for amylase and
lipase of which both were high.
Nephrology followed him during this hospital stay.
The plan was to send him to [**Hospital 100**] Rehab for iv vanco and po
augmentin [**Hospital1 **] for 2 weeks with left buttock dressing changes qd.
The wound tract was ~8cm and was loosely packed with saline wet
to dry kerlex ~5cm. A foley was left in place. UA was repeated
on [**3-21**] for wbc of 13.1. UA demonstrated [**5-12**] wbc, lg RBC, mod
leukocytes, 1 eosinophil and negative nitrites. A urine culture
was also sent.
The long term plan is to convert the pancreas transplant from
bladder drainage to enteric drainage once the infection resolved
and the wound healed. Foley needs to remain in place until
surgery.
Medications on Admission:
Bicarb 325mg Daily Cellcept 1000mg PO BID Prograf 1mg PO BID
Prednisone 5mg PO Daily Atenolol 100mg PO Daily Cardizem 240mg
PO Daily MS Contin 15mg PO BID Senokot 2 tab PO BID ASA 325
Daily
Discharge Medications:
1. Picc Line Supplies
heparin & saline flushes Supply:2 weeks
pump Refill:x1
tubing
dressing supplies
2. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram
Intravenous Q 24H (Every 24 Hours).
Disp:*14 gram* Refills:*1*
3. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*28 Tablet(s)* Refills:*0*
4. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
hold sbp <110 or HR <60.
7. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily): hold sbp <100 or HR
<60.
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q8 PRN ().
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Sodium Bicarbonate 650 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
13. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
14. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
perineal abscess
Discharge Condition:
good
Discharge Instructions:
Please call transplant office if fevers, chills, increased
perineal/scrotal pain, increased drainage or any questions.
Resume previous lab schedule
Vanco/Zosyn via picc x2 weeks
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2148-3-25**] 1:40
Completed by:[**2148-3-27**]
|
[
"250.61",
"997.4",
"V10.03",
"V42.83",
"566",
"401.9",
"577.8",
"536.3",
"357.2",
"V42.0",
"682.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"86.04",
"49.02",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6682, 6748
|
2798, 5021
|
327, 409
|
6809, 6816
|
1816, 1816
|
7042, 7224
|
1516, 1521
|
5262, 6659
|
6769, 6788
|
5047, 5239
|
6840, 7019
|
1536, 1797
|
2753, 2775
|
2720, 2720
|
274, 289
|
437, 1156
|
1830, 2687
|
1178, 1429
|
1445, 1500
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,435
| 111,206
|
29716
|
Discharge summary
|
report
|
Admission Date: [**2146-5-24**] Discharge Date: [**2146-6-2**]
Date of Birth: [**2077-10-17**] Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin / Zometa / Keflex / Tetracycline / erythromycin /
Iodine Containing Agents Classifier / nuts / fish derived /
lisinopril
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
syncopal episode
Major Surgical or Invasive Procedure:
pacer setting adjustment
History of Present Illness:
68-year-old female with nonischemic cardiomyopathy(EF 10-15%),
NYHA class III heart failure s/p BiV ICD placement, PAF s/p
ablation, severe asthma, recently discharged from [**Hospital1 18**] on
[**2146-5-9**] on milrinone for decompensated heart failure,
transferred from the ED of [**Hospital1 1774**] for VT/VF requiring multiple
ICD shocks.
She reports a few day history of severe generalized weakness and
nausea. She had one episode of syncope, which was witnessed by
her husband while she was sitting in bed. She went to an OSH and
was found to have polymorphic VT requiring ICD shocks. She was
tranferred to [**Hospital1 18**] because her cardiac issues are managed here.
Of note, on arrival she was off milrinone and had a 2:1 AV block
at a rate of 60 beats per minute with QTc 555ms.
On systems review, patient has had nausea, loose stools that
were green today, containing mucous. No fever, headache, head
injury, chest pain, SOB. No abdomional pain. Otherwise systems
review normal.
She has been followed by Dr. [**Last Name (STitle) **] and Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**]. She
received cardiac resynchronization therapy in [**2141**] which
resulted in a transient marked improvement in her functional
status. However, during the past year or so, there has been a
progressive and severe decline in her functional status,
accompanied by the development of significant mitral
regurgitation, pulmonary hypertension, and tricuspid
regurgitation. She was hospitalized from [**5-2**] through [**5-9**],
during which time milrinone IV therapy was initiated.The patient
was noted to have a considerable clinical response with
considerable improvement in functional capacity going from
having difficulty just speaking and holding up her head in bed
to being able to walk around her home where she lives on a [**Doctor Last Name **]
and participated most if not all of her activities of daily
living.
Past Medical History:
1. Severe nonischemic cardiomyopathy with LVEF of 10% s/p BiVICD
placment
2. Severe mitral regurgitation, severe tricuspid regurgitation
and moderate pulmonary hypertension.
3. PAF status post ablation.
4. Severe asthma.
5. Old compression fractions of T8 and T10.
6. Venous stasis disease.
7. Anxiety, depression.
8. Restless legs syndrome.
9. Recent septic bursitis of the right knee.
Social History:
The patient used to work as a jeweler and makes jewelry. She
lives with her husband. Remote smoking history, quit over 40
years ago, occasional ETOH and no illicit drug use
Family History:
Father may have had a heart attack, but died from a blood clot
to the brain. Mother had diabetes and cirrhosis. Son with
[**Name2 (NI) 14595**]-1 antitrypsin deficiency.
Physical Exam:
Physical Exam on Admission:
Vital signs- BP- 94/61, HR 120, SpO2 96% on 6L via nasal
cannula, RR 24. A-sense V-Paced rhythm on telemetry.
GENERAL: Lethargic, in distress.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, JVP raised to angle of the jaw.
CARDIAC: PMI displaced laterally, RR, normal S1, S2. No m/r/g.
No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. crackles bilaterally
half- way up the lung fields.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: 2+ pitting edema to the level of the mid-shin. No
femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Physical Exam on Discharge:
VS 97.3, 100/70, 94, 18, 96% RA
exam unchanged except:
JVD is not elevated
Pertinent Results:
Labs on Admission:
[**2146-5-24**] 04:13PM WBC-12.9* RBC-3.96* HGB-12.1 HCT-38.7 MCV-98
MCH-30.5 MCHC-31.1 RDW-14.7
[**2146-5-24**] 04:13PM NEUTS-80.9* LYMPHS-12.5* MONOS-5.0 EOS-1.2
BASOS-0.4
[**2146-5-24**] 04:13PM PT-30.5* PTT-41.4* INR(PT)-3.0*
[**2146-5-24**] 04:13PM DIGOXIN-1.1
[**2146-5-24**] 04:13PM TSH-6.0*
[**2146-5-24**] 04:13PM CALCIUM-8.6 PHOSPHATE-2.9 MAGNESIUM-1.7
[**2146-5-24**] 04:13PM CK-MB-2 cTropnT-<0.01
[**2146-5-24**] 04:13PM ALT(SGPT)-17 AST(SGOT)-28 CK(CPK)-64 ALK
PHOS-90 TOT BILI-1.2
[**2146-5-24**] 04:13PM GLUCOSE-153* UREA N-11 CREAT-1.1 SODIUM-141
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-27 ANION GAP-17
[**2146-5-24**] 09:32PM LACTATE-0.9
.
MICRO:
Urine cx [**5-24**]: negative
blood cx [**5-24**]: negative
c. diff [**5-25**]: negative
.
Imaging:
Chest x-ray [**5-24**]
Comparison is made with prior study [**5-16**].
Moderate-to-severe cardiomegaly is unchanged. Pacemaker leads
are in standard position. Right PICC tip is in the lower SVC.
There are low lung volumes. There has been interval worsening
of moderate
pulmonary edema and bibasilar opacities. Bibasilar opacities
could be due to a combination of atelectasis and small pleural
effusions, larger on the left side, though superimposed
pneumonia cannot be totally excluded. Asymmetric opacity at the
periphery of the right upper lobe, is also worrisome for
pneumonia.
.
Echocardiogram [**2146-5-4**]:
The left atrium is mildly dilated. The left atrium is elongated.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. Overall left
ventricular systolic function is severely depressed
(quantitative biplane LVEF= 20 % ) secondary to severe global
hypokinesis with the basal infero-lateral and antero-lateral
segments contracting best. A left ventricular mass/thrombus
cannot be excluded. Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). The right
ventricular cavity is markedly dilated with severe global free
wall hypokinesis. There is abnormal septal motion/position. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. The mitral valve leaflets do not fully
coapt. Moderate (2+) mitral regurgitation is seen. The left
ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the prior study dated [**2146-5-2**] (images reviewed),
LVEF has improved slightly, mainly due to more vigorous
contraction of the basal lateral segments. Other findings are
similar.
.
[**5-3**] Cardiac Catherization:
1. Limited resting hemodynamics revealed modereately elevated
right and left sided filling pressures with an RVEDP of 24mmHg
and LVEDP of 29mmHg. There was severely elevated pulmonary
artery systolic pressure at rest of 78mmHg. At rest there was
severely depressed cardiac index of 1.39L/min/m2. Patient was
infused with Milrinone, first bolused with 50mcg/kg over 3
minutes then 0.375mcg/kg/min over 15 minutes. With milrinone
infusion there was a significant improvement in cardiac index
from 1.39 to 2.22L/min/m2. There was a significant reduction in
PASP from 78 to 58mmHg.
.
Echo [**2146-5-26**]:
The left atrium is mildly dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. The estimated right atrial pressure is 0-5 mmHg.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is severely depressed (LVEF= [**10-17**] %). No
masses or thrombi are seen in the left ventricle. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The right ventricular cavity is dilated with
severe global free wall hypokinesis. The diameters of aorta at
the sinus, ascending and arch levels are normal. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. The mitral valve leaflets
do not fully coapt. Moderate (2+) mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Severely dilated, globally hypokinetic left
ventricle. Increased left ventricular filling pressure. Dilated,
hypokinetic right ventricle. Moderate mitral regurgitation.
Tricuspid regurgitation. Moderate pulmonary artery systolic
hypertension. Left pleural effusion.
Compared with the prior study (images reviewed) of [**2146-5-4**], the
left ventricle has increased in size (from 6.2 to 6.5
centimeters). Global left ventricular systolic has further
declined from 20% to 10-15%.
.
ECHO [**5-27**]: echocardiographic optimization of LV-to-RV offset
LV-RV offset = 0 msec: LVOT VTI = 14.5 cm
LV-RV offset = 40 msec: LVOT VTI = 17.0 cm
LV-RV offset = 50 msec: LVOT VTI = 19.5 cm
LV-RV offset left at 50 msec
.
CXR ([**5-27**]):
As compared to the previous radiograph, a left pectoral
pacemaker
and the right PICC line are unchanged. Lung volumes have
increased, likely reflecting improved ventilation. The
pre-existing signs of fluid overload have decreased in severity.
However, there is unchanged moderate cardiomegaly with signs of
retrocardiac atelectasis. No newly appeared focal parenchymal
opacities.
.
CXR ([**5-28**]):
The pacemaker and right-sided PICC line are unchanged. There is
unchanged
cardiomegaly. There is improved aeration at the left lung base.
There is
persistent mild pulmonary edema, stable.
.
CTA CORONARIES [**2146-6-1**]:
1. Global cardiomegaly. Conventional anatomy of the pulmonary
veins, no
evidence of stenosis or thrombosis in left atrium or left atrial
appendage.
2. Biventricular pacemaker leads with left ventricular lead
coursing through the coronary sinus into one of the epicardial
vein up to the epicardial surface.
3. Mild diffuse pulmonary edema.
4. The study was not targeted for evaluation of coronary veins.
If repeated study is nessesary, it would be obtained with no
charge
Brief Hospital Course:
BRIEF CLINICAL SUMMARY
Ms. [**Known lastname 71175**] is a 68-year-old female with nonischemic
cardiomyopathy(EF 10-15%), NYHA class III heart failure s/p BiV
ICD placement, paroxsymal atrial fibrillation (PAF) s/p ablation
on milrinone for decompensated heart failure, transferred from
the ED of [**Hospital1 1774**] for VT.
ACTIVE ISSUES:
# Polymorphic VT: She had 5 episodes of polymorphic VT which
required ICD shock. There is likely multifactorial etiology
including 2:1 AV block due to BiV pacemaker settings, fever due
to pneumonia, and milrinone. BiV pacer interrogated and we
decreased her refractory time allowing her to be paced 1:1 AV.
She was also given magnesium. She was given tylenol for the
fever and her pneumonia was treated (see below). Milrinone
turned down initially, but then it was titrated back to her home
dose. Review of her med list revealed particularly high dose of
sertraline at 200mg daily so this was titrated down to 100mg
daily due to the arrythmogenic risk caused by sertraline. Her
digoxin was stopped. She was monitored on tele and had no
further episodes of VT.
# Acute on chronic systolic heart failure: She has a history of
heart failure with an LVEF of 20%. On exam she appeared to have
hypervolemia with crackles, peripheral edema and an elevated
JVD. Diuresed with a lasix drip. Stopped digoxin. Held
valsartan and spironolactone initially, restarted
spironolactone at half of home dose due to hypotension during
admission. started metoprolol tartrate 12.5mg po BID because HR
elevated in low 100s. Increased home torsemide to 50mg daily.
Discharge regimen was: torsemide 60 mg daily, spironolactone
12.5 mg daily, metoprolol succinate 50 mg daily, aspirin 162 mg
daily, milrinone drip.
We continued with the 1:1 BiV settings initially but echo on
[**2146-5-26**] was read "Compared with the prior study of [**2146-5-4**], the
left ventricle has increased in size (from 6.2 to 6.5
centimeters). Global left ventricular systolic has further
declined from 20% to 10-15%." repeat echo revealed somewhat
dyssynchronous A-V function. Thus, she underwent a CTA of the
coronary veins to assess the placement of her BiV leads. It
turns out that the left ventricle lead is located very
anteriorly and so is stimulating not far from the septum. The
CTA did show other coronary veins accessible for lead
replacement. She was scheduled to return to the hospital for
Dr. [**Last Name (STitle) **] to replace the left lead more posterio-laterally
which will allow for better ventricle stimulation and improved
BiV synchrony. She will return on Tuesday or Wednesday, [**6-7**].
# Sinus tachycardia: Unclear whether from fever or heart
failure. Did improve during admission and was discharged on
metoprolol 50 mg daily.
# Pneumonia: Pt febrile on admission. Blood cx and urine cx
showed no growth. CXR showed pulm edema initially but also
showed findings concerning for LLL and RUL PNA. She was started
on empiric antibiotics with vanc, aztreonam and tobramycin for
HCAP coverage due to her multiple drug allergies. She was
treated with an 8 day course (last dose [**2146-5-31**]).
# Paroxysmal Atrial fibrillation: Continued warfarin.
# Depression: on very large dose of sertraline which can be
arrythmogenic. Weaned to 100mg sertraline.
TRANSITIONAL ISSUES:
- Continue Milrinone infusion at home
- Return to the hospital on [**6-7**] or 6th for repositioning of
left ventricle BiV pacer lead with Dr [**Last Name (STitle) **]
Medications on Admission:
1. milrinone in D5W 200 mcg/mL Piggyback Sig: 0.38 mcg/kg/min
Intravenous INFUSION (continuous infusion).
2. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Please continue to taper your Prednisone dose as previously
directed. -- patient unsure if she is taking this medication
4. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY.
10. Tums 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1)
tablet, Chewable PO once a day.
11. valsartan 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
12. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
13. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: 1.5 Tablet Extended Release 24 hrs PO DAILY (Daily).
14. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
15. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
16. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY.
17. warfarin 2.5 mg Tablet Sig: as directed by the coumadin
clinic Tablet PO once a day.
18. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
19. ropinirole 0.25 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
20. montelukast 10 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
21. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
22. sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day.
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. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. magnesium oxide 400 mg Capsule Sig: One (1) Capsule PO once a
day.
6. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation every six (6) hours as needed for SOB.
7. montelukast 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. ropinirole 0.25 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
10. Milrinone
0.5mg/1ml @ 0.38mcg/kg/min via continuous infusion; weight 160
pounds
Disp# 30
Refills: 6
11. ferrous sulfate 325 mg (65 mg iron) Capsule, Extended
Release Sig: One (1) Capsule, Extended Release PO once a day.
12. sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day.
13. prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for shortness of breath or wheezing: start taper if
having asthma attack.
14. Tums 200 mg calcium (500 mg) Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO once a day.
15. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
16. torsemide 20 mg Tablet Sig: 2.5 Tablets PO once a day: if
you gain 3 lbs in 1 day: take 60mg.
17. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
18. Coumadin 5 mg Tablet Sig: 0.5 Tablet PO once a day.
19. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation every six (6)
hours as needed for shortness of breath or wheezing.
20. loratadine 10 mg Capsule Sig: One (1) Capsule PO once a day.
21. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
22. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
23. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) 6438**]
Discharge Diagnosis:
VT/VF s/p multiple shocks
nonischemic cardiomyopathy(EF 10-15%)
NYHA class III heart failure s/p BiV ICD placement
PAF
Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 71175**],
You were admitted to the hospital after multiple ICD shocks.
The settings on your pacemaker were adjusted and you were not
shocked again.
We have made the following changes to your medications:
STOP your Digoxin
STOP your Gabapentin
STOP your Valsartan (Diovan)
START Potassium 20 MEQ daily (this is a potassium supplement)
RESUME your Coumadin at 2.5mg daily until you hear from Dr. [**Name (NI) 71181**] office about stopping it pre procedure
You should have your INR checked tomorrow (VNA can check it at
home).
Dr.[**Name (NI) 29750**] office will call you with instructions for next
week.
For your heart failure diagnosis: Weigh yourself every morning,
[**Name8 (MD) 138**] MD if weight goes up more than 3 lbs in 3 days or 5 lbs in
2 days.
It was a pleasure taking care of you, we wish you all the best!
Followup Instructions:
Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 62**]) the office will call you to schedule
your lead revision either next Tuesday or Wednesday. They will
give you instructions about eating and taking your medications.
You will need to hold your Coumadin for 2 days pre procedure.
|
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10,809
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21980
|
Discharge summary
|
report
|
Admission Date: [**2153-11-5**] Discharge Date: [**2153-11-24**]
Date of Birth: [**2077-7-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Tape
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
tracheal stent removal, tracheoplasty
Major Surgical or Invasive Procedure:
[**2153-11-5**] Rigid Bronchoscopy with Stent removal
[**2153-11-12**] Tracheobronchoplasty
[**2153-11-13**] Flexible Bronchoscopy
[**2153-11-16**] Flexible Bronchoscopy
[**2153-11-18**] Flexible Bronchoscopy
[**2153-11-23**] Flexible Bronchoscopy
History of Present Illness:
71 year old male with past medical history significant for
quadruple CABG in [**2129**], tracheomalacia [**2139**] (stent placement in
[**2152**]), frequent pneumonias (on chronic antibiotics) who presents
for stent removal by rigid bronchoscopy. The patient complains
of progressive DOE over the last few years where he can only
exert himself over 5 minutes. He denies chest pain and reports
that dyspnea is secondary to mucous plugging and a feeling that
"it's getting all clogged up". The patient was planned to go
home after his procedure but in the PACU, he required CPAP 10
and was persistently coughing. These symptoms resolved with
frequent nebulizer treatments and is admitted for close
monitoring in light of likely tracheoplasty.
Past Medical History:
* s/p CABGx4 [**2129**]
* tracheomalacia [**2139**]
* trach placed [**2149**], reversed [**2152**] with stent placed [**2152**]
* frequent pneumonias, on chronic antibiotics
* s/p ccy
* s/p hernia repair
* s/p bilateraly hip replacement
Social History:
no smoking, rare ethanol, lives with wife in [**Name (NI) 9012**], works
part-time as CPA
Family History:
noncontributory
Physical Exam:
VS: 98.4 121/65 85 18 94%CPAP 10
GEN: pleasant, NAD, comfortable appearing 71 year-old man
appearing his stated age, well-nourished
HEENT: PERLLA, EOMI, sclera anicteric, no conjuctival injection,
mucous membranes slightly dry, no lymphadenopathy, no thryroid
nodules or masses, no supraclavicular lymph nodes, no posterior
lymphadenopathy, neck supple, full ROM, neg JVD, no carotid
bruits
[**Last Name (un) **]: coarse breath sounds bilaterally but otherwise clear
COR: RR, S 1 and S2 wnl, no murmur, rubs or gallops
ABD: non-distended with positive bowel sounds, non-tender,no
guarding,rebound or masses
BACK: neg CVA tenderness
EXT: no cyanosis, clubbing, edema
NEURO: Alert and oriented x3. No focal deficits. CNII-XII are
intact, and patient with 5/5 strength throughout, normal
sensation throughout. No pronator drift.
Pertinent Results:
MICROBIOLOGY:
[**2153-11-7**] Bronchoscopy washings culture: SERRATIA MARCESCENS,
YEAST, GRAM NEGATIVE ROD(S)
BRONCHOSCOPY:
[**2153-11-5**]: Stent loose in trachea, copious purulent secretions
[**2153-11-7**]: Diffuse and severe tracheobronchomalacea with 100%
collapse and copious secretions
[**2153-11-13**]: Medium secretions, generalized airway swelling
[**2153-11-16**]: mild bronchomalacea, copious secretions
[**2153-11-18**]: mild malacia, mild secretions
[**2153-11-23**]: Patent airways, mild secretions
SEROLOGIES:
[**2153-11-5**] 10:20AM BLOOD WBC-8.8 RBC-4.70 Hgb-13.3* Hct-41.3
MCV-88 MCH-28.4 MCHC-32.3 RDW-15.5 Plt Ct-382
[**2153-11-7**] 07:35AM BLOOD WBC-9.5 RBC-4.54* Hgb-13.2* Hct-38.8*
MCV-86 MCH-29.1 MCHC-34.1 RDW-15.2 Plt Ct-275
[**2153-11-11**] 06:10AM BLOOD WBC-11.6* RBC-4.02* Hgb-11.6* Hct-34.1*
MCV-85 MCH-28.9 MCHC-34.0 RDW-15.3 Plt Ct-267
[**2153-11-13**] 03:22AM BLOOD WBC-24.5* RBC-3.50* Hgb-10.0* Hct-29.9*
MCV-85 MCH-28.7 MCHC-33.6 RDW-15.3 Plt Ct-338
[**2153-11-17**] 03:07PM BLOOD WBC-12.0* RBC-3.58* Hgb-10.4* Hct-29.9*
MCV-84 MCH-29.2 MCHC-34.9 RDW-14.7 Plt Ct-364
[**2153-11-19**] 03:00AM BLOOD WBC-11.3* RBC-4.04* Hgb-11.9* Hct-34.2*
MCV-85 MCH-29.4 MCHC-34.7 RDW-14.5 Plt Ct-474*
[**2153-11-23**] 06:35AM BLOOD WBC-13.2* RBC-3.94* Hgb-11.4* Hct-34.2*
MCV-87 MCH-28.9 MCHC-33.3 RDW-15.3 Plt Ct-513*
[**2153-11-22**] 07:23AM BLOOD Neuts-76.4* Lymphs-10.3* Monos-3.6
Eos-9.3* Baso-0.4
[**2153-11-20**] 03:35AM BLOOD PT-12.8 PTT-29.1 INR(PT)-1.0
[**2153-11-5**] 04:54PM BLOOD Glucose-84 UreaN-20 Creat-1.1 Na-141
K-4.2 Cl-105 HCO3-27 AnGap-13
[**2153-11-11**] 06:10AM BLOOD Glucose-109* UreaN-14 Creat-0.9 Na-139
K-3.4 Cl-100 HCO3-30* AnGap-12
[**2153-11-12**] 07:15AM BLOOD Glucose-127* UreaN-12 Creat-1.0 Na-139
K-4.0 Cl-101 HCO3-33* AnGap-9
[**2153-11-12**] 08:29PM BLOOD Glucose-166* UreaN-14 Creat-1.4* Na-137
K-4.9 Cl-105 HCO3-25 AnGap-12
[**2153-11-14**] 03:09AM BLOOD Glucose-130* UreaN-24* Creat-2.8* Na-140
K-4.4 Cl-105 HCO3-26 AnGap-13
[**2153-11-14**] 01:49PM BLOOD Glucose-154* UreaN-29* Creat-3.0* Na-136
K-4.3 Cl-102 HCO3-26 AnGap-12
[**2153-11-16**] 03:10AM BLOOD Glucose-135* UreaN-43* Creat-3.6* Na-138
K-4.0 Cl-99 HCO3-30* AnGap-13
[**2153-11-18**] 04:12AM BLOOD Glucose-92 UreaN-47* Creat-3.1* Na-139
K-3.4 Cl-98 HCO3-28 AnGap-16
[**2153-11-21**] 11:35AM BLOOD Glucose-124* UreaN-52* Creat-3.4* Na-137
K-4.5 Cl-98 HCO3-30* AnGap-14
[**2153-11-22**] 07:23AM BLOOD Glucose-116* UreaN-50* Creat-3.4* Na-137
K-4.0 Cl-98 HCO3-30* AnGap-13
[**2153-11-23**] 06:35AM BLOOD Glucose-106* UreaN-51* Creat-3.7* Na-138
K-4.5 Cl-98 HCO3-29 AnGap-16
URINE STUDIES
[**2153-11-14**] 01:49PM URINE Hours-RANDOM Creat-34 Na-103 K-23
Phos-18.4 Mg-5.7
[**2153-11-14**] 01:49PM URINE Osmolal-305
[**2153-11-11**] 07:28PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
Brief Hospital Course:
1) Tracheomalacia: The patient has a history of tracheomalacia,
which according to the patient is unknown in etiology but likely
related to bypass surgery [**73**] years ago. Since the diagnosis of
tracheomalacia in [**2139**], the patient has had recurrent antibiotic
resistent bacterial pneumonias. The patient lives in [**Location 9012**]
but came to the [**Hospital1 18**] to have stent removal performed via rigid
bronchoscopy. This procedure was successfully performed on
hospital day #1, but post procedure, the patient experienced
severe coughing secondary to mucous secretions and as such, he
had to be admitted for further evaluation. On the floor, the
patient did not experience any further episodes of persistent
coughing. He was switching from outpatient linezolid to
vancomycin without consequence. The patient was maintained on
CPAP with a pressure of 10 to assist in keeping his airway open
in the setting of significant mucous secretions and tracheal
collapse. Repeat bronchoscopy was performed on hospital day #2,
at which point it was found that tracheomalacia was quite
severe, wherein the trachea collapsed nearly 100%, even on
expiration. At this point, it was arranged that the patient be
sent for tracheoplasty. He underwent a tracheobronchoplasty on
[**2153-11-12**] without complication. Post-operatively he was admitted
to the intensive care unit for close monitoring. He was
extubated on post-operative day 2. Bronchoscopy on [**2153-11-13**] and
[**2153-11-16**] showed significant airway secretions which were
aspirated, and generalized airway edema. He remained in the
intensive care unit until post-operative day 8. His respiratory
status improved on the floor and physical therapy assisted with
ambulation; the patient noted some shortness of breath initially
while ambulating but these symptoms markedly improved after a
few days. He was able to tolerate a regular diet by
post-operative day 3 and his pain was well-controlled throughout
his hospital stay. He had a bronchoscopy on [**2153-11-23**] which
showed patent airways bilaterally with minimal secretions. Upon
discharge, he had planned follow-up with thoracic surgery in [**1-5**]
weeks.
2) h/o CHF: The patient's outpatient regimen of lasix was
continue. There were no acute cardiac issues during the
patient's admission. Because of the risk of thoracic surgery,
the cardiology service was consulted for a pre-op evaluation.
It was suggested that
3) Acute Renal Failure: The patient was noted to have elevated
creatinine post-operatively to a range close to 3.5. This was
above his baseline around 1.0. After extensive renal work-up, it
was felt that this increase was due to acute interstitial
nephritis secondary medications, with the likely etiology
piperacillin which the patient had been started on for Serratia
found on one of his bronchoscopy wash cultures. This medication
was discontinued and switched to Levoquin. His creatinine
stabilized at the 3.5 range and it was felt that this would
eventually resolve, but would take several weeks to months.
Medications on Admission:
* claritin
* lasix
* lipitor
* prilosec
* albuterol nebs
* mucomyst nebs
* zyvox
* cloistin nebs
Discharge Medications:
1. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*80 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*40 Capsule(s)* Refills:*0*
5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-5**]
Puffs Inhalation Q4H (every 4 hours) as needed.
6. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*2*
7. 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*
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 3 times/week.
11. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*2 cartridges* Refills:*2*
12. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours) for 2 weeks.
Disp:*7 Tablet(s)* Refills:*0*
13. Ocean Nasal Mist 0.65 % Aerosol, Spray Sig: [**1-5**] sprays Nasal
every 4-6 hours as needed for nasal pain.
Disp:*2 units* Refills:*0*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
(1) Tracheobronchomalacea
(2) Acute Renal Failure
(3) Constipation
Discharge Condition:
Fair
Discharge Instructions:
Please contact the office or come to the emergency room with any
worsening shortness of breath, pain not improved with pain
medications, worsening production of mucous, fever > 101.0. You
may eat a regular diet. Do not drive while taking narcotic pain
medications. Please try to ambulate at least 3 times a day.
Please call with any questions.
Followup Instructions:
Please contact the office of Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**] at [**Telephone/Fax (1) 170**] to
set up a follow-up appointment at a time of your convenience
within the next 1-2 weeks. You should have your serum creatinine
checked during your follow-up appointment.
Completed by:[**2153-11-24**]
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285
| 165,312
|
28048
|
Discharge summary
|
report
|
Admission Date: [**2152-9-21**] Discharge Date: [**2152-10-20**]
Date of Birth: [**2107-5-16**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
1. status post fall from roof at work.
2. T3 burst fracture with evidence of complete spinal cord
injury and spinal instability.
3. C6, C7 spinous process fracture, T1 spinous process
fracture,
T2 spinous process fracture and T4 spinous process
fracture.
4. Left displaced distal radius fracture.
5. sternal manubrial fx. dissociation
Major Surgical or Invasive Procedure:
1. Anterior fusion T2 to T4 with application of interbody
cage and morselized autograft [**9-22**].
2. Posterior C5 to T9 arthrodesis [**9-22**].
3. Posterior C5 to T9 nonsegmental instrumentation [**9-22**] .
4. Corpectomy of T3 with from the posterior approach
decompression from T2-3 to T3-T4 [**9-22**].
5. Posterior decompression laminectomy, medial facetectomy
T1-2 to T3-4 [**9-22**].
6. Right posterior iliac crest bone graft with application
of morselized autograft [**9-22**].
7. Application of morselized allograft [**9-22**].
8. Closed reduction of left distal radius fracture [**2152-9-21**].
9. Tracheostomy [**10-3**].
10. Percutaneous endoscopic gastrostomy [**10-3**]
11. [**Location (un) 260**] inferior vena caval filter [**10-3**]
12. Transesophageal echocardiogram
13. Percutaneous drainage of fluid collection by Interventional
Radiology [**10-17**].
History of Present Illness:
45year old, Spanish speaking male s/p fall from roof while
working. Fell 15-20 feet. Landed on head. No LOC. Unable to feel
or move LE, [**Month (only) **] sensation below nipples on arrival. Given 2.5g
salumedrol in field by EMS.
Past Medical History:
none
Social History:
From [**Country 149**]. In United States for work. Living with cousin and
her husband. Wife and children live in [**Country 149**].
Family History:
noncontributory
Pertinent Results:
[**2152-9-21**] 05:25PM GLUCOSE-114* LACTATE-1.5 NA+-143 K+-3.9
CL--107 TCO2-24
[**2152-9-21**] 05:22PM WBC-11.3* RBC-4.47* HGB-14.0 HCT-38.0* MCV-85
MCH-31.3 MCHC-36.8* RDW-13.1
[**2152-9-21**] 05:22PM FIBRINOGE-226
[**2152-9-21**] 05:22PM FIBRINOGE-226
[**2152-9-23**] 01:04AM BLOOD WBC-25.2* RBC-3.71* Hgb-11.3* Hct-31.8*
MCV-86 MCH-30.6 MCHC-35.6* RDW-14.8 Plt Ct-143*
[**2152-10-4**] 02:01AM BLOOD WBC-26.5*# RBC-3.02* Hgb-9.0* Hct-25.9*
MCV-86 MCH-30.0 MCHC-34.9 RDW-15.0 Plt Ct-637*
[**2152-10-5**] 02:20AM BLOOD WBC-10.8# RBC-2.84* Hgb-8.2* Hct-25.0*
MCV-88 MCH-29.0 MCHC-32.9 RDW-15.0 Plt Ct-686*
[**2152-10-17**] 03:32AM BLOOD WBC-8.4 RBC-3.11* Hgb-9.6* Hct-26.9*
MCV-87 MCH-30.9 MCHC-35.7* RDW-15.3 Plt Ct-341
[**2152-10-17**] 03:32AM BLOOD Plt Ct-341
[**2152-10-17**] 03:32AM BLOOD Glucose-101 UreaN-21* Creat-0.6 Na-136
K-3.7 Cl-105 HCO3-23 AnGap-12
[**2152-10-11**] 03:30AM BLOOD ALT-126* AST-54* CK(CPK)-304*
AlkPhos-187* TotBili-0.6
[**2152-10-8**] 04:32AM BLOOD Lipase-60
[**2152-9-21**] 05:22PM BLOOD CK-MB-15* MB Indx-2.1
[**2152-9-21**] 05:22PM BLOOD cTropnT-<0.01
[**2152-9-22**] 01:11AM BLOOD CK-MB-31* MB Indx-1.7 cTropnT-<0.01
[**2152-10-17**] 03:32AM BLOOD Calcium-8.2* Phos-3.8 Mg-2.0
[**2152-10-8**] 10:10AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HAV-NEGATIVE
[**2152-10-10**] 09:17PM BLOOD HIV Ab-NEGATIVE
[**2152-9-21**] 05:22PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2152-10-8**] 10:10AM BLOOD HCV Ab-NEGATIVE
[**9-22**]: MRSA screen
[**9-24**]: Bl Cx -> MR S. Aureus Coag Neg
[**9-26**]: Sputum: P. AERUGINOSA, K. PNEUMONIAE, M. CATARRHALIS
[**9-30**]: Acinetobacter pansens.
[**10-1**]: C. diff neg, BL/[**Last Name (un) **]/Sputum neg, VANCO trough 5.8
[**10-3**]: LFTs elevated, WBC 14.6, Hct 28, VANCO trough 6.9
[**10-4**]: WBC 26.5, NA 132, BAL GS -/cx P
[**10-5**]: CL tip cx P., Vanco trough 15.4
[**10-7**]: vanco 9.9
[**10-8**] BAL: g+ cocci pairs/clusters, g- rods. ID P
[**2071-10-10**]: acinetobacter in sputum
[**2074-10-11**]: AFB neg x 3
[**10-12**]: Leg. Urine neg
[**10-13**]: O&P: neg
[**10-16**]: MRSA neg (nasal)
[**10-17**] Back cx: GS - , Cx-
Radiology:
[**9-21**] CT Head: No evidence of intracranial hemorrhage or mass
effect.
[**9-21**] CT C-Spine: Burst fracture of the T3 vertebral body.
Multiple fractures of the posterior elements of C6, C7, T1, and
T2. No impingement on the bony cervical spinal canal.
[**9-21**] CT Thorax: burst fracture of T3, retropulsion of fragments
into canal. multiple fractures of the distal cervical and upper
thoracic posterior elements. no aortic injury seen, sternal
dislocation.
no abd/pel injury. old fx in the inferior ribs bilaterlly.
[**9-21**] CT Pelvis: No fractures of the lumbar spine, sacrum, or
pelvis are identified.
[**9-21**] MRI C/T Spine: T2-T3 Fx-Disloc c intraspin/PLL disrupt. c
txn of cord. Intraspinal hematoma.
[**9-21**] R Wrist/Elbow/Shoulder: 1. R Colles Fx. 2. R ulnar styloid
pr.
[**9-28**]: CT thorax: Bilat Pl. Eff., pneumonia
[**10-4**]: L lung atelectasis improved; new opacification R lung ?
lg aspiration; incr small R pleural effusion
[**10-4**] R wrist post-cast
[**10-6**] port CXR: Worsening Llung air space opacity, ?asp PNA
[**10-7**]: RUQ US neg
[**10-9**] CT torso: Diffuse ground glass opacities, ? PNA, wedge
shaped kidney infarcts
[**10-11**]: TEE >55%, nl.
[**10-16**] MRI: demonstrating no definite discitis/osteomyelitis.
Small irregularly enhancing region in what appears to be right
sided
epidural space at T2/T3 level, as described above, which could
be
postoperative scar or a phelgmon.
Two additional peripherally enhancing fluid collections, one in
the
posterior epidural space at T2 level; the larger one in the
posterior
paraspinal soft tissues at approximately the same level, as
described above, which may represent postoperative seromas
versus abscess.
[**10-17**]: IR percutaneous drainage of subcutaneousx tissue
Brief Hospital Course:
45 year old Spanish speaking male admitted to T/SICU status post
fall from 15-20 feet at work. Landed on head with resultant
injuries including, traumatic burst fracture of the T3 vertebral
body with retropulsion of multiple fragments posteriorly as well
as angulation of the spinal canal at this level, fracture of the
posterior elements of T1 and T2 -> s/p Fusion, Right transverse
distal radial fracture, sternal manubrial fracture dissociation,
and a head laceration. Patient underwent C5-T10 posterior spinal
fusion with L1-L4 posterior decompression as well as open
reduction and internal fixation of his right wrist fracture
[**2152-9-22**]. He was given 7 liters of crystalloid and 1200 cc of
red blood cells in the operating room during the spinal fusion.
See operative reports for procedure details. Patient tolerated
both procedures reasonably well but was found to be hypotensive
after spinal fusion and was transfused 2 additional units of
packed red blood cells when transported back to the Trauma/SICU
after surgery. He was placed on spinal precautions and given a
[**Location (un) 36323**] brace to wear after extubation. The patient's
respiratory status was managed on a ventilator.
On [**9-24**], patient was transfrused 2 units of packed red blood
cells and was febrile to 104 with a whit blood cell count to
16.4 He was started on Vancomycin and ZIsyn for broad spectrum
coverage. Physical and Occupational therapy were consulted on
[**9-25**] and followed patient throughout hospital course with
satisfactory results.
On [**9-26**], patient was taken to operating room for ORIF of right
distal radius fracture without event. See operative reports for
procedure details. Infectious Disease was consulted for
continued fevers and recommended standard fever workup including
pan culture, d/c lines fpr 2 days with central line exchange,
stool studies, sputum cultures (patient underwent multiple
bronchial alveolar lavages for sputum collection), and
strongyloides. Please see microbiology results above for
details. An ascaris worm was removed from patient's nostril in
entirety and sent to pathology for identification. ID followed
patient throughout hospital stay and recommendations were
followed. Levoquin was added to antibiotic regimen on [**10-2**].
Vanco/Zosyn discontinued on [**10-14**]. Patient is to continue
Levaquin until [**10-23**] for sputum culture positive for Acintobacter
10/24 per ID recommendations.
On [**9-28**], arterial line was reinserted and received 2 untis PRBC
for hematocrit of 23 and CT of spine was performed to eval for
abscesses. Please see results section for details. Nutrition
followed patient throughout course and recommendations followed
regarding tube feeds/TPN. On [**9-29**] social work wrote letter to
Mexican Vice Consul in [**Location (un) 86**] regarding patient's status and was
instrumental in obtaining family contact and visas. Social work
was actively involved in patient's care throughout stay. On
[**9-29**] had spontaneous breathing trail but tired after 4 hours
and was placed back on mechanical ventilation.
Please note patient had multiple fever spikes throughout course,
was pan cultured with each spike > 102. Please see above culture
data for details. On the final spike before discharge, he
underwent an interventional radiology drainage of a superficial
fluid collection over T2 and T3. Fluid was cultured and found to
be without infection. He was also tested for tuberculosis,
Hepatitis A/B/C, CMV, HIV, Legionella, which were all negative.
AFB was negative x 3.
On [**10-3**] he underwent tracheostomy, PEG, and IVC filter
placement for spinal cord injury with prolonged respiratory
dependency, malnutrition and right risk for venous embolic
disease. See operative reports for details. He tolerated that
procedure without complication. Initially after tracheostomy,
the patient's respiratory status was managed with assist control
ventilation. However, as he recovered and gained muscle
strength, he was weaned over to CPAP with pressure support and
remained stable throughout the rest of his hospital stay. His
pressure support was slowly weaned to 5.
Forehead staples removed on [**10-5**] and arterial line was removed.
On [**12-10**], a fiberoptic endoscopic evaluation of swallowing was
performed which showed mild oral pharyngeal dysphagia with
minimal aspiration. With recommendation to repeat swallowing
evaluation at rehab facility. On [**10-11**] patient underwent a TEE
which showed no evidence of subacute bacterial endocardiditis.
On [**10-12**], patient complained of a visual field defect and
Ophthalmology was consulted with no recommendations for
intervention. Thoughts were consistent with traumatic
maculopathy which should slowly improve. Patient should follow
up in [**Hospital 68264**] clinic as an outpatient in [**1-21**] weeks.
Patient remained stable, cooperative, and cordial throught
duration of hospital stay. He was afebrile for > 48 hours before
discharge.
Medications on Admission:
None
Discharge Medications:
1. [**Location (un) 36323**] brace Sig: One (1) at all times.
Disp:*1 * Refills:*0*
2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
6. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) PO BID (2 times a
day).
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
8. Acetaminophen 160 mg/5 mL Solution Sig: [**12-20**] PO Q4H (every 4
hours) as needed for fever>101.5.
9. Ibuprofen 100 mg/5 mL Suspension Sig: One (1) PO Q6H (every
6 hours) as needed for fever>101.5.
10. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
11. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous Q
24H (Every 24 Hours).
12. Potassium Chloride Oral
13. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
14. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for agitation.
15. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 4 days: Through [**2152-10-23**].
Disp:*4 Tablet(s)* Refills:*0*
16. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
17. Calcium Gluconate 2 gm / 100 ml D5W IV PRN
please administer for ionized calcium less than 1.12
18. Magnesium Sulfate 2 gm / 100 ml D5W IV PRN Mg<2.0
19. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
1. Traumatic burst fracture of the T3 vertebral body with
retropulsion of multiple fragments posteriorly as well as
angulation of the spinal canal at this level. Status post
fusion.
2) Fracture of the posterior elements of T1 and T2 . Status post
Fusion
3) Right transverse distal radial fracture. Status post ORIF.
4) sternal manubrial fracture. dissociation
Discharge Condition:
Good
Discharge Instructions:
Go to an Emergency Room if you experience new and continuing
nausea,
vomiting, fevers (>101.5 F), chills, or shortness of breath.
Also go to the ER if your wound becomes red, swollen, warm, or
produces pus.
If you experience clear drainage from your wounds, cover them
with a
clean dressing and stop showering until the drainage subsides
for at
least 2 days.
Narcotics can cause constipation. Please take an over the
counter stool softener such as Colace or a gentle laxative such
as Milk of Magnesia if you experience constipation.
Be sure to take your complete course of antibiotics.
You may resume your regular diet as tolerated.
You may resume all of your previously prescribed medications.
You may take showers.
You should wear your [**Location (un) 36323**] back brace at all times.
Followup Instructions:
With Dr. [**Last Name (STitle) 1352**] in Orthopedic Spine Clinic in 1 month. Please
call [**Telephone/Fax (1) 1228**] to make that appointment. Location [**Hospital Ward Name 23**] 2,
[**Hospital Ward Name 516**] [**Hospital3 **] Deaconness.
With Dr. [**Last Name (STitle) **] in General Orthopedic Surgery for right
radial fracture and shoulder pain in 2 weeks. Call [**Telephone/Fax (1) 1228**]
to make that appointment.
With [**Hospital 8183**] Clinic for visual field defect in [**2-19**] weeks.
Call [**Telephone/Fax (1) 253**] to make that appointment.
|
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[
"81.64",
"38.7",
"31.1",
"03.09",
"03.53",
"84.51",
"99.04",
"81.03",
"83.95",
"33.24",
"86.59",
"81.04",
"88.72",
"43.11",
"96.6",
"77.79",
"38.91",
"81.05",
"38.93",
"79.02",
"96.72",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
12798, 12868
|
6030, 11014
|
666, 1567
|
13272, 13278
|
2056, 4256
|
14124, 14689
|
2020, 2037
|
11069, 12775
|
12889, 13251
|
11040, 11046
|
13302, 14101
|
276, 628
|
1595, 1827
|
4265, 6007
|
1849, 1855
|
1871, 2004
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,712
| 113,665
|
29936
|
Discharge summary
|
report
|
Admission Date: [**2196-11-30**] Discharge Date: [**2196-12-3**]
Date of Birth: [**2146-5-1**] Sex: F
Service: SURGERY
Allergies:
Baclofen
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
The patient was initially admitted for diarrhea and jaundice.
Major Surgical or Invasive Procedure:
Emergent exploratory laparotomy for control of life-threatening
intraperitoneal variceal hemmorhage [**2196-12-3**]
Transfusion of 35 units of packed red blood cells, 20 units of
FFP, 6 units of platelets, 2 units of cryoprecipitate, and one
dose of recombinant Factor VIIa over [**Date range (1) 71513**]/09
History of Present Illness:
This 50 year old lady with hepatitis C cirrhosis was initially
admitted for diarrhea and jaundice. The diarrhea had resolved
and jaundice with ARF secondary to volume depletion was
correcting early in her hospital course.
During the night of [**2196-12-2**], she transferred to the ICU for
abdominal pain, hemodynamically stable and repeat hematocrit
drops consistent with a bleed. Prior to transfer the patient
received 9 units of pRBCs, 4 units FFP, 3 units platelets and 1
Unit cryoprecipitate with appropriate hematocrit increase, but
without platelent increase or resolution of coagulopathy.
Diagnostic paracentesis revealed sanguinous fluid with a
hematocrit of 13. Tagged RBC scan was non-revealing. CT scan
suggested no retroperitoneal bleed (full report below). The
patient remained hemodynamically stable with systolic blood
pressures 90-100 and heart rate 70-80 while on Nadolol.
Past Medical History:
1.Cirrhosis [**12-26**] HCV (genotype 1) and EtOH
- h/o ascites, SBP, and encephalopathy
- currently listed for liver [**Month/Day (2) **]
- Abdominal CT [**5-/2196**] showed stable cirrhosis, portal
hypertension, and extensive variceal formation, patent portal
vein, cholelithiasis, splenomegaly, anterior pelvic midline
hernia containing a small bowel loop without obstruction,
ascites, and mild cecal thickening.
- Abdominal U/S [**5-/2196**] showed no liver mass, splenomegaly, and
patent main portal vein with hepatopetal flow and large patent
umbilical vein shunting portal venous flow (no flow detected in
right portal vein)
- EGD [**5-/2196**] showed grade 1 esophageal varices, grade 1
esophagitis, a small hiatal hernia, portal hypertensive
gastropathy, and an ulcer in the duodenal bulb
2.Asthma
3.mildly dilated left atrium, trace AR, trivial MR, EF>55%, no
[**Last Name (un) 6879**] on TTE [**12-1**]
4.No h/o diabetes, cancer, stroke, MI, epilepsy, seizures, high
cholesterol or hypertension
5.s/p fractured jaw repair [**2185**]
6.s/p ankle surgery [**2177**]
7.Endometriosis and right simple ovarian cyst s/p BSO [**3-/2195**]
Social History:
Lived with her sister, has a very supportive family. Formerly
employed in social work but currently unemployed [**12-26**] fatigue and
poor memory. Smokes 2 packs/week, used to smoke 1 PPD. Drank
heavily for 20 years, but no EtOH use since [**2194-2-22**]. +Prior
marijuana and intranasal cocaine use, but no h/o IVDU.
Family History:
Significant for the absence of any colon cancer or breast
cancer. No liver disease. Her mother is healthy. Her dad has
prostate cancer. She has three sisters and two brothers who are
all healthy.
Physical Exam:
Wt 90.6 kilograms, up from 86 kilograms. 02 sat is 100%.
HEENT -does reveal marked sclera icterus.
Heart normal rate and rhythm, no murmurs
Lungs clear to auscultation bilaterally,no wheezes.
Abdomen soft, distended, obvious ascites on exam. Extremities
reveal 1+ edema pitting edema bilaterally and there is increased
swelling in the left lower extremity with some bruises and cuts.
Neurologic exam: postivie for asterixis but she is alert and
oriented x3.
Pertinent Results:
[**2196-11-30**] 09:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2196-11-30**] 05:12PM GLUCOSE-123* UREA N-28* CREAT-1.6*
SODIUM-132* POTASSIUM-4.5 CHLORIDE-99 TOTAL CO2-28 ANION GAP-10
[**2196-11-30**] 05:12PM ALT(SGPT)-12 AST(SGOT)-68* LD(LDH)-413* ALK
PHOS-93 TOT BILI-10.7*
[**2196-11-30**] 05:12PM ALBUMIN-2.4* CALCIUM-8.4 PHOSPHATE-3.9
MAGNESIUM-2.2
[**2196-11-30**] 05:12PM WBC-3.8* RBC-1.96* HGB-7.0* HCT-20.4*
MCV-104* MCH-35.9* MCHC-34.5 RDW-17.8*
[**2196-11-30**] 05:12PM PLT COUNT-31*
[**2196-11-30**] 05:12PM PT-24.0* PTT-40.0* INR(PT)-2.3*
[**2196-11-30**] Abdominal ultrasound:
IMPRESSION:
1. Coarsening of the hepatic parenchyma, consistent with known
history of
cirrhosis. Portal hypertension is evidenced by massive
splenomegaly, moderate ascites, and recanalization of the
paraumbilical vein.
2. Unchanged cholelithiasis without son[**Name (NI) 493**] evidence for
cholecystitis. There is no intra- or extra-hepatic biliary
ductal dilatation. Mild gallbladder wall thickening and edema is
nonspecific, and can be seen in cirrhosis.
3. No focal liver lesions identified.
4. There is normal antegrade flow in the main portal vein,
dilation of the
left portal vein, and continuation into a recanalized
paraumbilical vein. The intrahepatic portal veins are difficult
to identify as discribed above but show likely flow reversal in
right anterior and posterior portal veins, an unchanged finding.
[**2196-12-1**] CT without contrast:
1. Moderate-to-large amount of ascites. Shrunken nodular liver
with numerous varices notably in the distal esophagus consistent
with cirrhosis and decompensated liver disease.
2. No retroperitoneal bleed.
3. Largely distended gallbladder with layering stones within the
lumen.
Evaluation is otherwise limited given surrounding ascities and
non-constrast enhanced evaluation. HIDA may be pursued as
indicated.
4. Tiny 3 mm non-obstructing renal calculus within the right
kidney.
5. 3.8 cm venous varix within the subcutaneous tissues of the
anterior
abdominal wall without change.
[**2196-12-2**] CT with contrast:
1. New layering high-density within large ascites concerning for
interval
bleeding into the ascitic fluid. While source of bleeding is not
identified on non-contrast study, note is made of slight higher
density material in the pelvis and near the gallbladder. No
retroperitoneal hematoma seen.
2. Fat-containing umbilical hernia, unchanged. Multiple fluid-
containing
ventral wall hernias, also containing fluid-fluid levels.
3. Cirrhotic liver with large ascites and extensive variceal
formation.
4. Anasarca, enlarged ascites, small left and tiny right pleural
effusions.
5. Largely distended gallbladder with layering gallstones as
seen one day
prior on CT. If clinically concerning for acute cholecystitis,
again HIDA may be performed.
6. Nonobstructing 2-mm right renal calculus
Brief Hospital Course:
Patient was transferred from [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] to MICU for increasing
abdominal pain and repeated hematocrit drop in the face of
multiple units of blood. The patient was transfused with 4
additional units as well as fresh frozen plasma and platelets to
achieve hemostasis. She remained hemodynamically stable and
pain controlled on morphine. At approximately 10am, the patient
experienced an acute drop in blood pressure to the 70s with
severe abdominal pain. At this time she had evidence of an
acute abdomen. Surgery and anesthesia were called immediately
and transfusions started. The patient was intubated, sedated
and central access was obtained. With multiple units of PRBCs
transfusing the patient was taken to the OR by [**Doctor Last Name **]
surgery.
Operative Course
Upon entering the abdomen, there was a tremendous amount of
bloody ascites. The liver was obviously cirrhotic and she had
extensive abdominal and subcutaneous
varices measuring greater than 1-2 cm in diameter. Uponentering
the peritoneal cavity, there was a very large amount of bleeding
with massive exsanguinating hemorrhage coming from the hilum of
the liver, which was ultimately found to come from a recanalized
umbilical vein. The vein itself measured about 3 cm in diameter
and there was a hole in the side of the umbilical vein that
measured about 1.5 cm. There was a significant hemorrhage coming
from this likely 500-600 mL a
minute. Control of this vein was achieved by ligating the
umbilical vein proximally and distally to the venotomy and this
essentially caused the hemorrhage to cease. At this time, the
abdominal closure was aborted due to furthing variceal bleeding
encounted upon attempted fascial closure. A [**Location (un) 5701**] bag was
placed into the abdomen as a temporary closure followed by two
19 [**Doctor Last Name 406**] drains above the [**Location (un) 5701**] bag and
[**Last Name (un) 71514**] laparotomy pads, blue sterile towel, and then an Ioban.
The patient was then returned to the surgical intensive care
unit in critical condition.
Hours after return from the OR, the patient experienced a
pulseless electrical activity cardiac arrest in the SICU. Chest
compressions were immediately initiated, resulting in a return
of heart rhythm.
Discussions were held with the patient's family regarding the
patient's overwhelmingly poor prognosis in light of the events
which had occured. The family elected to make patient no
compressions no shocks initally. Later on [**12-3**], the family
changed the patient's status to comfort measures only and
life-sustaining measures and treatments were discontinued. The
patient expired on [**2196-12-3**].
Medications on Admission:
Ciprofloxacin 250mg daily
Folate 1mg daily
Furosemide 40mg daily
Lactulose 30cc QID
Omeprazole 20mg daily
Rifaximin 600mg [**Hospital1 **]
Spironolactone 200mg daily
Multivitamin daily
Thiamine 250mg daily
Discharge Medications:
Not applicable
Discharge Disposition:
Expired
Discharge Diagnosis:
Death due to exsanguination and subsequent hypovolemic shock
from intraperitoneal variceal bleeding secondary to end stage
liver disease
Discharge Condition:
Expired
Discharge Instructions:
Not applicable
Followup Instructions:
Not applicable
|
[
"E879.9",
"286.9",
"998.11",
"584.9",
"998.0",
"997.1",
"070.54",
"571.5",
"285.1",
"789.59",
"592.0",
"427.5",
"868.03",
"572.3",
"276.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"38.87",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
9704, 9713
|
6699, 9408
|
329, 639
|
9893, 9902
|
3773, 6676
|
9965, 9982
|
3080, 3277
|
9665, 9681
|
9734, 9872
|
9434, 9642
|
9926, 9942
|
3292, 3678
|
228, 291
|
667, 1560
|
3695, 3754
|
1582, 2727
|
2743, 3064
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,962
| 161,129
|
24105
|
Discharge summary
|
report
|
Admission Date: [**2144-11-2**] Discharge Date: [**2144-11-6**]
Date of Birth: [**2088-9-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4365**]
Chief Complaint:
S/p fall
Major Surgical or Invasive Procedure:
Paracentesis
History of Present Illness:
Mr. [**Known lastname 30949**] is a 56yo gentleman with h/o ESRD on HD and
Hepatitis C cirrhosis with portal HTN and SBP who presented to
the ED after a mechanical fall. He tripped on the sidewalk;
there was no loss of consciousness, but he had some pain in his
left hand and came to the ED.
Initial ED VS were: 98.4 80 124/80 18 98%RA. At first, his
work-up was targetted towards his trauma: he had plain films
that demonstrated a comminuted fracture of his left finger.
[**Known lastname 1957**] provided him with a boxer splint for his left hand and
advised he f/u in clinic. He received IM tetanus as well as some
percocet for pain. He was discharged and then called back to the
ED when blood sugar was found to be 1000.
Upon review of his labs, he was noted to have hyperkalemia of
6.3 with no EKG changes. He was given 1 amp of calcium
gluconate, albuterol neb x 1, kayexalate 30g PO x 1, and 1 amp
of bicarbonate. CK was noted to be elevated with negative MB and
trop of 0.14, so he was given ASA 325mg x 1. After multiple
attempts at central access, the team eventually placed a R groin
line. Patient continued to refuse insulin despite many attempts
to convince him of its importance. Renal fellow was contact[**Name (NI) **]
and he was given 500cc of NS.
On ROS, patient has been feeling fine recently. He has had a
slight, non-productive cough. No fevers, chills. No N/V/D. He is
thirsty. He does not make urine. He gets short of breath with
walking a block at baseline. No orthopnea, no chest pain.
Past Medical History:
- HCV cirrhosis - Not on L-K transplant list for +tox on
[**2143-12-23**]
- ESRD on HD MWF - receives epo
- Anemia
- HTN
- substance abuse (IV heroin)
- seizures in setting of HD
- Chronic L knee pain - to see [**Date Range **] soon
Social History:
Lives with his mother. Currently unemployed. Spends most of his
time with his family. ETOH abuse in past, IVDU- last +tox screen
in [**12-18**]. Smokes [**2-12**] pack per day.
Family History:
Significant for DM
Physical Exam:
97.7 88 134/94 11 97% RA.
Pleasant, oriented to "[**Hospital3 **]" and date. Sleepy but answers
all questions appropriately.
Mucous membranes are dry. OP clear.
Neck supple, no thyroid enlargement. No bruits.
Regular rate and rhythm with systolic murmur at base and at
apex.
Lungs clear b/l.
Abd has significant ascites. +BS. No tenderness to palpation
throughout.
R groin line in place with some blood on bandage. LUE AV fistula
with thrill.
+1 LE edema b/l, pneumoboots in place.
DP +1 on right and +2 on left.
+ asterixis
Pertinent Results:
[**2144-11-6**] 05:15AM BLOOD WBC-8.1 RBC-3.87* Hgb-12.8* Hct-39.9*
MCV-103* MCH-33.1* MCHC-32.1 RDW-17.0* Plt Ct-147*
[**2144-11-3**] 01:00AM BLOOD Neuts-77.7* Lymphs-16.1* Monos-4.4
Eos-1.1 Baso-0.6
[**2144-11-5**] 04:05PM BLOOD PT-16.1* PTT-39.8* INR(PT)-1.4*
[**2144-11-6**] 05:15AM BLOOD Glucose-204* UreaN-54* Creat-12.4*#
Na-138 K-4.7 Cl-98 HCO3-21* AnGap-24*
[**2144-11-6**] 05:15AM BLOOD ALT-40 AST-64* AlkPhos-170* TotBili-1.2
[**2144-11-5**] 04:50AM BLOOD Lipase-103*
[**2144-11-3**] 01:00AM BLOOD Lipase-516*
[**2144-11-2**] 11:34PM BLOOD Lipase-493*
[**2144-11-3**] 01:23PM BLOOD CK-MB-10 MB Indx-2.6 cTropnT-0.20*
[**2144-11-3**] 04:54AM BLOOD CK-MB-7 cTropnT-0.14*
[**2144-11-2**] 11:34PM BLOOD CK-MB-8 cTropnT-0.14*
[**2144-11-2**] 02:25PM BLOOD CK-MB-6 cTropnT-0.14*
[**2144-11-6**] 05:15AM BLOOD Calcium-7.3* Phos-5.6* Mg-2.1
[**2144-11-4**] 03:02AM BLOOD %HbA1c-8.1*
[**2144-11-5**] 04:50AM BLOOD Triglyc-85 HDL-27 CHOL/HD-3.8 LDLcalc-59
[**2144-11-3**] 04:54AM BLOOD Osmolal-335*
[**2144-11-3**] 01:00AM BLOOD Osmolal-336*
[**2144-11-2**] 02:25PM BLOOD TSH-2.3
[**2144-11-5**] 04:50AM BLOOD PTH-574*
[**2144-11-3**] 04:54AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
EKG - NSR at 81 with normal axis. Good R wave progression. J
point elevation in V2. Isolated TWI in aVL. No significant
change as compared to baseline from 11/[**2143**].
L wrist [**11-2**]:
Again noted is a comminuted fracture through the base of the
fifth metacarpal bone with extension into the 5th CMC joint. In
addition there is a nondisplaced fracture of the hamate.
There is a radiopaque density projected in the soft tissues over
the palmar aspect of the hand on the lateral projection. This
may be artifactual versus a radiopaque foreign body within the
soft tissues and clinical correlation is recommended.
There is marked soft tissue swelling of the wrist.
L hand [**11-2**]:
There is a comminuted fracture through the base of the fifth
metacarpal bone that extends proximally into 5th CMC joint. A
nondisplaced hamate fracture is also identified. In addition,
there is a nondisplaced fracture of the 5th proximal phalangeal
base at the MCP joint.
L knee film [**11-2**]:
Moderate-to-severe tricompartment osteoarthritis, unchanged
since the prior examination with no evidence of an acute
fracture.
CXR PA and lat [**11-2**]: Grossly unchanged chest radiograph with
stable small left effusion and no pneumothorax.
Brief Hospital Course:
Mr. [**Known lastname 30949**] is a 56 year old gentleman with a PMH significant
for ESRD on HD, cirrhosis [**3-14**] HCV complicated by ascites,
encephalopathy, and varices admitted s/p fall with left wrist
found to be hyperglycemic and hyperkalemic in the ED.
1. Hyperglyemia: Patient has no past history of diabetes, but
was found to have HbA1C of 8.1 with significant hyperosmolar
hyperglycemia (serum glucose >1000) on admission. Patient was
evaluated during his hospital course by [**Last Name (un) **] with regard to
management and etiology to new onset diabetes. There was
concern for a pancreatic process given hyperglycemia and
elevated lipase. CT scan of the abdomen during hospital course
was negative for pancreatic lesions. Other antibodies for
further work up of the etiology of his diabetes were sent during
the hospital course which were pending at discharge. [**First Name8 (NamePattern2) **]
[**Last Name (un) **], there was concern for "flatbush diabetes", also known as
Diabetes type 1.5 or Diabetes type 1B. The patient was
discharged on an insulin regimen [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations.
The patient declined follow-up at the [**Hospital **] Clinic as an
outpatient, and was instructed to follow-up with his PCP at [**Name9 (PRE) 191**].
Prior to discharge, the patient also received diabetic
education including glucometer and insulin administration. He
also was scheduled for a diabetic education class at [**Hospital **]
Clinic for the following week.
2. Hyperkalemia: Most likely etiology of hyperkalemia was
secondary to renal failure and hyperkalemia. On discharge, the
patient had a normal serum potassium level.
3. Hyponatremia: Likely secondary to hyperglycemia as patient
had serum hypertonicity. Serum sodium corrected during
admission and on discharge was within normal limits.
4. ESRD on HD: Patient received HD during admission. On
discharge, he was instructed to continue with his outpatient
Tues, Thurs, Saturday schedule.
5. Left hand/wrist fracture: Patient evaluated by orthopedics
during admission. On discharge, he was instructed to follow-up
as an outpatient with orthopedic surgery.
6. HCV cirrhosis: During his hospitalization, the patient had
encephalopathy and asterixis. His lactulose was increased and he
was continued on rifaxamin. He also had two negative
paracenteses during his admission that were negative for SBP.
On discharge, he was instructed to follow-up with the liver
center.
7. HTN: Patient has been normotensive during admission. On
discharge, he was instructed to continue with his BB and
diltiazem.
8. Anemia: Baseline Hct 33-37, elevated to hct 41 during
admission likely secondary to hemoconcentration. Hct has since
trended down and was at baseline at discharge.
9. Leg pain: Patient with chronic leg pain secondary to
neuropathy. He was continued on topamax during admission.
10. Prophylaxis: Patient was treated with heparin SQ for DVT
prophylaxis during admission.
11. Access: Patient had femoral CVL placed during admission.
Medications on Admission:
Diltiazem 240mg SR daily
Doxercalciferol 1mcg QHD
EpoAlfa 10,000 unit/ml QHD
Folate 800mcg daily
Lactulose 20g [**Hospital1 **] to [**4-14**] BMs daily
Metoprolol succinate 100mg daily
Phoslo 3 tablets TID
Rifaximin 400mg TID
Topiramate 15mg sprinkle
Valsartan 160mg [**Hospital1 **]
Discharge Medications:
1. Diltiazem HCl 240 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO once a day.
2. Doxercalciferol 0.5 mcg Capsule Sig: Two (2) Capsule PO qHD.
3. Epoetin Alfa 10,000 unit/mL Solution Sig: [**Numeric Identifier 961**] ([**Numeric Identifier 961**]) units
Injection qHD.
4. Folic Acid 800 mcg Tablet Sig: One (1) Tablet PO once a day.
5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day).
6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
7. Calcium Acetate 667 mg Capsule Sig: Four (4) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
9. Topiramate 15 mg Capsule, Sprinkle Sig: One (1) Capsule,
Sprinkle PO once a day.
10. Valsartan 160 mg Tablet Sig: One (1) Tablet PO twice a day.
11. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
12. Insulin Lispro Protam & Lispro 100 unit/mL (75-25) Insulin
Pen Sig: Thirty (30) units Subcutaneous qAM and qPM (at dinner).
Disp:*qs pens* Refills:*2*
13. One Touch SureSoft Lancing Dev Misc Sig: One (1) lancet
Miscellaneous four times a day.
Disp:*qs lancets* Refills:*2*
14. One Touch Test Strip Sig: One (1) strip In [**Last Name (un) 5153**] four
times a day.
Disp:*qs strips* Refills:*2*
15. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain: Do not take prior to your dialysis
or if you are going to drive or operate heavy machinery.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
1. Diabetes
2. Hyperkalemia
3. 5th metacarpal fracture
4. Encephalopathy
Secondary
HCV cirrhosis - Not on L-K transplant list for h/o positive tox
Portal HTN with ascites; undergoes frequent paracentesis as
outpatient
h/o SBP, admitted [**12/2143**]
h/o esophageal varices on EGD [**5-19**]
ESRD on HD TThSa
Anemia, on epo
HTN
Substance abuse (IV heroin)
h/o seizures in setting of HD
Severe OA of L knee
Neuropathy
Discharge Condition:
Patient was discharged in stable condition.
Discharge Instructions:
1. You were admitted for high blood glucose, and you were found
to have diabetes. You will need to take insulin at home as
instructed. You will also need to follow-up with Dr. [**Last Name (STitle) **] at
[**Hospital6 733**] as indicated below.
2. You were also found to have a broken hand. You will need to
follow-up with the orthopedic surgeons as indicated below.
3. You will need to go to hemodialysis tomorrow (Saturday,
[**2144-11-7**]). It is very important that you make this session.
4. You will need to take your medications as indicated. It is
very important that you take your medications as prescribed.
5. It is very important that you keep all of your doctors'
appointments.
6. If you develop a fever, chest pain, shortness of breath, or
other concerning symptoms, please call your PCP or go to your
local Emergency Department immediately.
Followup Instructions:
You have an appointment for a diabetic education class on
[**Last Name (LF) 766**], [**11-9**] at 1:30 pm. This will be at the [**Hospital **]
[**Hospital 982**] Clinic on the [**Location (un) **]. The main telephone number for
the [**Hospital **] Clinic is ([**Telephone/Fax (1) 4847**].
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2144-11-18**] 3:40
Provider: [**Name10 (NameIs) 6821**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 2977**] Date/Time:[**2144-12-7**]
10:45
Provider: [**Name10 (NameIs) 1382**] [**Name11 (NameIs) 1383**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2144-12-7**] 10:50
Provider: [**Name10 (NameIs) **] CLINIC Phone:[**Telephone/Fax (1) 3009**] Date/Time:[**2144-11-10**]
11:00
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2144-11-10**] 10:40
Completed by:[**2144-11-7**]
|
[
"403.91",
"E880.1",
"585.6",
"070.44",
"287.5",
"815.02",
"250.22",
"572.3",
"814.08",
"276.7",
"276.1",
"571.5",
"355.8",
"285.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"39.95",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10418, 10424
|
5391, 8456
|
324, 339
|
10894, 10940
|
2931, 5368
|
11848, 12837
|
2350, 2371
|
8790, 10395
|
10445, 10873
|
8482, 8767
|
10964, 11825
|
2386, 2912
|
276, 286
|
367, 1882
|
1904, 2138
|
2154, 2334
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,539
| 135,048
|
34217
|
Discharge summary
|
report
|
Admission Date: [**2173-5-23**] Discharge Date: [**2173-5-27**]
Date of Birth: [**2102-4-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
The patient is a healthy 71 y.o.m. with metastatic melanoma who
gets all of his care at [**Hospital3 328**] and [**Hospital1 112**] who presents with
hemoptysis. History is obtained as best as possible from the
patient's recollection of events and medical history as we have
no records in our system. He developed hemoptysis 1 week ago,
intially only in the a.m., <1 tsp, but increased in frequency
over the week. Also with increasing DOE when climbing stairs
(normally able to do this without difficulty) over the last week
and developed right flank pain with coughing. No orthopnea or
PND, although has been sleeping upright in a chair for the last
6 months due to sinus congestion. Went to his oncologist Dr.
[**Last Name (STitle) 62563**] on Wednesday and a CXR was done which showed a
pneumonia per the patient, and he was given 10 days of an
antibiotic, although he does not know which one. Denies fevers,
chills, nausea, emesis or hematemesis. Has LE edema, L>R due to
recently diagnosed DVT - treated with lovenox but not on
coumadin. Presented to [**Hospital3 1443**] for hemoptysis, no
beds at [**Hospital3 328**], and transferred to [**Hospital1 18**] for evaluation.
In the ED vitals were 98.9, 100, 115/55, 27, 99% RA. CTA done
and was negative for PE but showed many large bilateral
pulmonary nodules and masses c/w widespread metastatic disease
with a dominant right hilar mass encasing and narrowing the
right inferior pulmonary vein and likely occluding the right
lower lobe segmental bronchus with resultant extensive airspace
opacity throughout the right lower lobe, most consistent with
postobstructive pneumonia. He is admitted to the ICU for
observation and possible bronchoscopy.
Past Medical History:
# Melanoma - diagnosed in [**2169**] in left upper arm. Resected with
LN dissection and free of disease until [**2172**] when found to have
bony disease in left shoulder and lump on L flank. Underwent
XRT for shoulder and resection of left flank lesion that was
found to be melanoma. At some point had PET showing 1cm lung
nodules bilaterally, and two small lesions in his intestine.
Treated with 'standard chemo' and steroids and responded to
treatment. Most recently enrolled in trial with new study drug
- received first dose ?2 weeks ago last Wed with next dose due
this coming up Wed. Had MRI and repeat PET prior to
enrollement.
# Umbilical hernia s/p repair [**2170**]
# HTN
# Hypercholesteremia - diet controlled
Social History:
Occupation: Retired
Drugs: None
Tobacco: None
Alcohol: None
Other:
Family History:
Longevity in family.
Physical Exam:
Tmax: 37.8 ??????C (100 ??????F)
Tcurrent: 37.8 ??????C (100 ??????F)
HR: 101 (101 - 106) bpm
BP: 130/69(84) {130/69(84) - 138/71(88)} mmHg
RR: 24 (24 - 24) insp/min
SpO2: 100%
Heart rhythm: ST (Sinus Tachycardia)
Height: 6 Inch
General Appearance: Well nourished, No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t)
S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic, No(t)
Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
No(t) Clear : , Diminished: decreased BS at right base, No(t)
Absent : )
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: Trace, Left: 1+, left leg larger than right
Skin: Warm, No(t) Rash: , No(t) Jaundice
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Oriented (to): x3, Movement: Purposeful, Tone: Not
assessed
Brief Hospital Course:
The patient is a 71 y.o.m. with metastatic melanoma on
chemotherapy who presents with hemoptysis.
# Hemoptysis - CTA concerning for widespread metastatic disease
and encasement of pulmonary vein leading to hemoptysis and
obstruction of RLL bronchus leading to postobstructive PNA.
Recently received a prescription for antibiotics for the PNA,
upon review of records it appears he completed a 10 day course
of levaquin. The differential for his hemoptysis is most likely
pulmonary related to bleeding from his mets, especially in light
of recent chemo trial where increased frequency of bleeding has
been seen and with bronch showing clot in the airway. Also on
ddx is nasal polyp. Pt reports having epistaxis and difficulty
breathing in the past for which he was evaluated by ENT at [**Hospital1 112**],
last time 6 months ago, found to have large nasal polyp.
Patient underwent bronchoscopy that revealed no evidence of
active bleed and old blood in RLL.
Patient's hemoptysis significantly improved during his
admission. On last day of admission, the patient had about two
tablespoons of total hemoptysis in 24 hours.
The patient was repeatedly instructed of warning signs to
immediately return to the emergency room.
# PNA - Appears to have post obstructive PNA based on CT scan.
Slight fever with mild leukocytosis. Likely immunosuppressed
given recent chemotherapy (although may be placebo pill).
Patient discharged to complete 7 day course of antibiotics.
# H/O DVT - Occurred approximately one month ago and received
lovenox, but no longer anticoagulated for unclear reasons. This
was confirmed with [**Hospital3 328**]. The patient is no longer on
anti-coagulation.
# Anemia ?????? Patient's hct did not drop significantly during his
admission.
# HTN - Continue outpatient meds.
Medications on Admission:
Lisinopril - unknown dose
MVI
Discharge Medications:
1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
5. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
6. Bisacodyl 5 mg Tablet Sig: 1-2 Tablets PO at bedtime as
needed for constipation.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Hemoptysis
Pneumonia, Bacterial, Post-Obstructive
Metastatic Melanoma
Discharge Condition:
Vital Signs Stable
Discharge Instructions:
Return to ED if coughing up more blood, difficulty breathing,
fevers, chills.
Followup Instructions:
Patient to schedule f/u with his oncologist at [**Hospital3 328**] in
the next week.
|
[
"485",
"285.22",
"V10.82",
"786.3",
"198.5",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
6569, 6575
|
4082, 5882
|
326, 340
|
6688, 6708
|
6834, 6922
|
2934, 2957
|
5963, 6546
|
6596, 6667
|
5908, 5940
|
6732, 6811
|
2972, 4059
|
276, 288
|
368, 2083
|
2105, 2833
|
2849, 2918
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,149
| 129,930
|
22126
|
Discharge summary
|
report
|
Admission Date: [**2142-8-1**] Discharge Date: [**2142-8-2**]
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Esophageal varicies
Major Surgical or Invasive Procedure:
none
History of Present Illness:
79 yo woman w/ h/o primary biliary cirrhosis complicated by
portal hypertension, Grade III-IV esophageal varices, who was
transferred to [**Hospital1 18**] MICU today for actively bleeding esophageal
varices.
She had recently undergone thoracentesis in mid-[**Month (only) **] for
dyspnea,
which revealed 1200cc of transudative pleural fluid and on [**7-26**]
she underwent VATS procedure and lung biopsy for question of
pulmonary fibrosis. She was discharged home on [**2142-7-31**].
The patient was readmitted to [**Hospital3 934**] Hospital [**2142-8-1**]
when she developed hematemesis with initial BP recorded 80/30.
She was resuscitated with IV fluids, given sandostatin and
levofloxacin for prophylaxis, and transfused with red blood
cells
and fresh frozen plasma. An attempt at banding was made there
with sclerotherapy, but she became hypotensive to 50 systolic.
She was reportedly never pulseless. She was subsequently
intubated and started on pressors and 30 minutes later her
BP was up to 130 systolic. Endoscopy continued with further
injections. Her hematocrit at 3pm was 44% but she was noted to
be
unresponsive since endosopy. She was observed to open her eyes
spontaneously but not follow commands. She was thought to have
twitching of the right face and rigidity of the right arm and
also some fixed rightward eye deviation. She was also thought to
be moving her left side less than her right side. She was
started
on propofol gtt and then given a load of dilantin 1200mg. She
also did received 2mg iv ativan at 1600 for a questionable 3
minute period of "activity". Otherwise, no paralytics, no other
benzodiazepines, or other opioids have been given today.
She was transferred here to the MICU on pressors.
Past Medical History:
1. primary biliary cirrhosis- biopsy done at [**Hospital1 882**]
2. portal hypertension
3. hepatic hydrothorax
4. grade iii-iv esophageal varices
5. pulmonary fibrosis
Social History:
not obtainable from patient
Family History:
not obtainable from patient
Physical Exam:
T 97.4 HR 93 BP 133/72 100%O2 sat on 0.40
FiO2/450x14/PEEP 5
General: ill appearing, intubated
R pupil 5-6mm not responsive, L pupil 2mm, minimally responsive
HEENT: MMM
Lungs: CTA bilaterally, not overbreathing the vent
CV: RRR, no m/r/g, no carotid bruits
Abd: soft, NT
Ext: no pedal edema, no rashes
Neuro: no response to painful stimuli. no blink to visual
threat. There is no doll's eye reflex. There are no corneals.
There is no gag.
Motor/Sensory: There is no spontaneous movement nor any movement
with deep nail bed pressure.
Reflexes: There is no triple flexion nor movement of the toes
with plantar stimulation.
Pertinent Results:
[**2142-8-1**] 08:30PM GLUCOSE-158* UREA N-23* CREAT-0.9 SODIUM-138
POTASSIUM-5.0 CHLORIDE-108 TOTAL CO2-17* ANION GAP-18
[**2142-8-1**] 08:30PM ALT(SGPT)-24 AST(SGOT)-89* LD(LDH)-535* ALK
PHOS-195* TOT BILI-3.1*
[**2142-8-1**] 08:30PM ALBUMIN-2.2* CALCIUM-7.4* PHOSPHATE-5.0*
MAGNESIUM-1.6
[**2142-8-1**] 08:30PM WBC-38.6* RBC-4.49 HGB-14.5 HCT-40.8 MCV-91
MCH-32.2* MCHC-35.5* RDW-15.0
[**2142-8-1**] 08:30PM PT-14.6* PTT-32.4 INR(PT)-1.4
CT head:
There is a large right sided hypodensity in the distribution of
the right middle cerebral artery with subfalcine herniation and
midline shift of about 5mm, near obliteration of the right
lateral ventricles, presence of hyperdensities in the bilateral
basal ganglia, obliteration of the prepontine cistern and
probable bilateral uncal herniation.
Brief Hospital Course:
MrsInitial plan was to EGD and assess status of esophageal
varicies. However, given the finding of the blown pupil, and ?
seizure activty and unresponsiveness, it was decided to first CT
head. Ct showed a large right sided hypodensity in the
distribution of the right middle cerebral artery with subfalcine
herniation and
midline shift of about 5mm, near obliteration of the right
lateral ventricles, presence of hyperdensities in the bilateral
basal ganglia, obliteration of the prepontine cistern and
probable bilateral uncal herniation.
Given this finding, neurology was consulted. They performed a
complete neuro exam including cold calorics which demonstrated
absence of any brainstem reflexes.
Family was contact[**Name (NI) **] and informed of the situation and
prognosis.
Family arrived in the morning and it was decided that the
patient would not have wanted any further interventions. Care
was withdrawn in the morning, and the patient expired.
NE Organ bank was contact[**Name (NI) **] and screened the patient - it was
determined that she was not a candidate for donation.
Medications on Admission:
Medications (upon transfer):
1. Protonix 40mg iv given at 1545
2. Propofol 5mcg/kg/min until 1600
3. Neosynephrine gtt
4. Lasix 20mg iv at 1245
5. Ativan 2mg iv at 1600
6. Sandostatin 50mcg at 0815 and continued on gtt
7. Dilantin 1200mg iv at 1730 over 45 minutes
1. Famotidine 20 mg IV Q24H [**8-1**] @ 2200 View
2. Heparin Flush CVL (100 units/ml) 1 ml IV QD:PRN
3. Octreotide Acetate 50 mcg/hr IV DRIP INFUSION
Discharge Medications:
none
Discharge Disposition:
Home
Facility:
deceased
Discharge Diagnosis:
esophageal varicies
CVA - herniation
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"571.5",
"434.91",
"456.20",
"578.0",
"515",
"572.3",
"456.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.91",
"42.33",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
5409, 5435
|
3827, 4914
|
282, 288
|
5515, 5525
|
2995, 3447
|
5582, 5729
|
2302, 2331
|
5380, 5386
|
5456, 5494
|
4940, 5357
|
5549, 5559
|
2346, 2976
|
223, 244
|
316, 2049
|
3456, 3804
|
2071, 2241
|
2257, 2286
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,452
| 133,470
|
26551
|
Discharge summary
|
report
|
Admission Date: [**2142-2-20**] Discharge Date: [**2142-2-20**]
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
"found down"
Major Surgical or Invasive Procedure:
intubation
right IJ placement
History of Present Illness:
Patient is 88 yo man with PMH CAD (s/p multiple MI's), CHF
(EF=40%), mod-severe AS, PVD, CRF, presented to [**Hospital 16843**]
hospital after being found down on floor. On arrival, c/o L
shoulder and back pain. On arrival, patient noted to be
bradycardic w/ HR 54, BP 130/60 w/ doppler, O2 sat 88% on NRB,
which increased to 100% on NRB. Was noted to be alert,
uncooperative. EKG demonstrated complete heart block w/
bradycardia, HR=?20-25 per report (no records - per OSH records
HR 40's-60's). Initial K=6.5, CK=180, MB=5.6, Index=3.1,
Trop=2.59 (nl 0.0-0.4), BUN=34, Cr=4.1 (unknown baseline),
WBC=8.2 w/ 75% segs, 10% bands, HCT=33.3. U/A was negative,
urine tox negative. CT spine was negative for fracture. Head
CT was negative for acute intracranial process. Pt given D50,
insulin, Ca gluconate, kayexolate, MSO4, clindamycin 600mg IV x
1 and then transferred to [**Hospital1 18**] for further managment.
.
On presentation to ED, patient was awake, alert, complaining
only of LBP. Inital vitals included HR=44, BP=84/42, RR=16,
O2=95%. Labs in ED notable for K=6.1, Cr=3.9, CK=175, MB=8,
Trop=0.69, ALT=163, AST=332, Lipase=102. R IJ was placed. For
his persistent hyperkalemia, patient was again was given D50,
insulin, Ca gluconate, bicarb and kayexolate. Given atropine
for his bradycardia, which increased HR 44->65, but patient had
continued hypotension, so therefore was started on dopamine gtt
for BP management. At this time pt c/o chest pain. Therefore
patient was started on heparin gtt. Clinical picture
progressed, and could not get pleth on O2 sat [**Location (un) 1131**] -
therefore patient was intubated - used rocuronium, ativan and
versed - no succinate used due to pt's hyperkalemia. CCU fellow
called initially for heart block, which resolved upon resolution
of hyperkalemia with above therapy. Then patient underwent
urgent ECHO to evaluate his hypotension that demonstrated
depressed EF (<=20%) with globally hypokinetic LV, 2+ AR, 3+ MR,
significant PR, at least moderate AS, dilated and globally
hypokinetic RV, no evidence of tamponade. Patient then admitted
to CCU for further management.
.
On presentation to CCU, patient sedated, intubated, NAD.
.
Of note, received fax from pt's PCP indicating DNR/DNI order,
identifying son, [**Name (NI) **] as HCP. [**Name (NI) **] on his way to hospital for
discussions.
Past Medical History:
1.) CAD, multi-vessel, ?last cath in [**2134**], s/p multiple MI's,
severe angina
2.) CHF - ischemic cardiomyopathy, s/p numerous hospital
admissions for CHF, EF=40% per ECHO from [**4-20**]
3.) Moderate-severe AS
4.) PVD s/p aorto-bifem bypass
5.) s/p Left CEA in [**2128**], ?occluded Right ICA
6.) CRF, baseline Cr ?1.8
7.) Hyperlipidemia
8.) Hepatits C
9.) PUD s/p upper GI bleed in [**2140-3-17**] thought [**1-18**] aspirin
use
10.) Chronic mild thrombocytopenia
11.) s/p appendectomy
12.) s/p SBO in [**2137-5-17**]
13.) s/p cataract surgery
Social History:
Past smoker
Family History:
NC
Physical Exam:
Vitals - Wt 77, T100.2, HR 97, BP 127/68,
General - sedated, intubated, NAD
HEENT - pinpoint pupils b/l, reactive, tube in mouth
Neck - R IJ in place, surrounding hematoma, difficult to assess
JVD [**1-18**] IJ and hematoma
CVS - RRR, Grade II/VI SEM heard throughout thorax
Lungs - crackles @ bases b/l
Abd - large, soft, + BS, could not assess tenderness [**1-18**] pt's
sedation
Ext - 3+ b/l pitting edema b/l extending beyond level of knee,
mottled and cool LE b/l with evidence of vascular insufficiency
ulcer on L great toe.
Neuro - intubated, sedated, appears to move all 4 extremities
Pertinent Results:
Labs on admission:
[**2142-2-20**] 07:06AM BLOOD WBC-9.2 RBC-3.34* Hgb-10.4* Hct-32.0*
MCV-96 MCH-31.2 MCHC-32.6 RDW-17.7* Plt Ct-102*
[**2142-2-20**] 03:00PM BLOOD WBC-11.5* RBC-3.31* Hgb-10.5* Hct-30.9*
MCV-93 MCH-31.8 MCHC-34.1 RDW-17.5* Plt Ct-115*
[**2142-2-20**] 07:06AM BLOOD Neuts-87.0* Lymphs-6.5* Monos-5.9 Eos-0.1
Baso-0.5
[**2142-2-20**] 03:00PM BLOOD Neuts-88.9* Lymphs-6.5* Monos-4.3 Eos-0.2
Baso-0.1
[**2142-2-20**] 07:06AM BLOOD PT-20.2* PTT-35.5* INR(PT)-1.9*
[**2142-2-20**] 03:00PM BLOOD PT-23.3* PTT-150* INR(PT)-2.3*
[**2142-2-20**] 07:06AM BLOOD Glucose-75 UreaN-129* Creat-3.9* Na-138
K-6.1* Cl-99 HCO3-21* AnGap-24*
[**2142-2-20**] 03:00PM BLOOD Glucose-146* UreaN-134* Creat-4.2* Na-137
K-5.8* Cl-98 HCO3-25 AnGap-20
[**2142-2-20**] 07:06AM BLOOD ALT-163* AST-332* CK(CPK)-175* AlkPhos-94
Amylase-100 TotBili-1.5
[**2142-2-20**] 03:00PM BLOOD ALT-223* AST-533* LD(LDH)-597*
CK(CPK)-590* AlkPhos-91 Amylase-106* TotBili-1.5
[**2142-2-20**] 07:06AM BLOOD Lipase-102*
[**2142-2-20**] 03:00PM BLOOD Lipase-79*
[**2142-2-20**] 07:06AM BLOOD CK-MB-8
[**2142-2-20**] 07:06AM BLOOD cTropnT-0.69*
[**2142-2-20**] 03:00PM BLOOD CK-MB-52* MB Indx-8.8* cTropnT-2.68*
[**2142-2-20**] 07:06AM BLOOD Albumin-3.7 Calcium-9.7 Phos-5.5* Mg-2.5
[**2142-2-20**] 03:00PM BLOOD Albumin-3.4 Calcium-9.7 Phos-5.2* Mg-2.4
[**2142-2-20**] 12:13PM BLOOD Type-ART pO2-38* pCO2-40 pH-7.36
calHCO3-24 Base XS--2
[**2142-2-20**] 05:14PM BLOOD Type-[**Last Name (un) **] pO2-30* pCO2-46* pH-7.37
calHCO3-28 Base XS-0
[**2142-2-20**] 12:13PM BLOOD Lactate-2.9* K-6.0*
[**2142-2-20**] 05:14PM BLOOD Lactate-2.3* K-5.6*
.
Microbiology:
[**2142-2-20**] Urine culture - negative
[**2142-2-20**] Blood culture - NGTD
.
CXR [**2142-2-20**]: evidence of failure
.
ECHO [**2142-2-20**]:
IMPRESSION: Biventricular cavity enlargement with severe global
hypokinesis c/w diffuse processs (toxin, metabolic, multivessel
CAD; cannot exclude pulmonary embolism with resultant LV
ischemia). At least moderate aortic valve stenosis. Moderate
aortic regurgitation. Moderate to severe mitral regurgitation.
Pulmonary artery systolic hypertension.
Based on [**2132**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate a moderate risk (prophylaxis
recommended). Clinical decisions regarding the need for
prophylaxis should be based on clinical and echocardiographic
data.
Brief Hospital Course:
Patient is an 88 yo man with PMH CHF, CAD presented to OSH with
hyperkalemia, complete heart block, [**Hospital **] transferred to [**Hospital1 18**]
for further care. On presentation, patient remained in complete
heart block, was hypotensive, was noted to be hyperkalemic with
K = 6.1, had elevated cardiac enzymes, elevated creatnine,
elevated transaminases.
He was initially started on dopamine gtt for BP control and
intubated for hypoxia. However, on further discussions with
family and patient's outpt PCP, [**Name10 (NameIs) **] patient was discovered to be
DNR/DNI, having signed the form at his PCP's office, listing his
son as his HCP. These forms were faxed over and on his son's
arrival at [**Hospital1 18**], discussions ensued and the family agreed that
the patient had wanted to be DNR/DNI and the decision was made
to withdraw care. Therefore the patient was extubated and
maintained on a morphine drip and scopolamine patch for comfort
and expired on night of admission.
Medications on Admission:
Plavix 75mg QD
ASA 81mg QD
Atenolol 12.5mg [**Hospital1 **]
Lisinopril 2.5mg QD
Isordil 10mg TID
Lasix 80mg qam, 40mg qpm
NTG PRN
MVI
Iron
Tylenol
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
respiratory failureshock
ARF
CHF
CAD
AS
PVD
Discharge Condition:
expired
Discharge Instructions:
None
Followup Instructions:
expired
|
[
"396.8",
"412",
"414.8",
"276.7",
"584.9",
"070.70",
"287.5",
"426.0",
"443.9",
"785.50",
"398.91",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
7552, 7561
|
6331, 7325
|
255, 287
|
7649, 7659
|
3937, 3942
|
7712, 7723
|
3300, 3304
|
7523, 7529
|
7582, 7628
|
7351, 7500
|
7683, 7689
|
3319, 3918
|
203, 217
|
315, 2682
|
3957, 6308
|
2704, 3255
|
3271, 3284
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,433
| 144,885
|
602+55225
|
Discharge summary
|
report+addendum
|
Admission Date: [**2185-12-22**] Discharge Date: [**2186-1-4**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 88 year-old
female with a history of coronary artery disease status post
coronary artery bypass graft times two, congestive heart
failure with ejection fraction of 35%, paroxysmal atrial
fibrillation status post DDD pacer placement, admitted
[**2185-12-22**] with sudden onset of right eye pain at home. She
subsequently developed slurred speech and was taken to the
Emergency Department via EMS. In the Emergency Department
the patient was noted to have slurred speech and a left
hemiparesis. CAT scan was negative for hemorrhage, but
positive for a probable embolic right MCA stroke. TPA was
administered in the Emergency Department without benefit.
The patient developed respiratory distress in the Emergency
Department requiring supplemental oxygen, Lasix and a trial
of a noninvasive ventilator.
The patient was subsequently transferred to the MICU. Blood
pressure was elevated on admission to 160 to 180. Symptoms
of congestive heart failure were controlled with a
nitroglycerin drip initially. Neurological examination
revealed complete left sided hemiplegia with decreased
sensation of the left arm and a left facial droop. The
patient has required no further diuresis in the MICU. Blood
pressures were running in the 120s to 130s. Nitroglycerin
drip was discontinued on [**2185-12-22**] upon arrival to the Medical
Intensive Care Unit. Speech and swallow evaluation on
[**2185-12-23**] recommended nectar thick liquids since the patient
was considered to be at aspiration risk. A repeat head CT on
[**12-22**] showed a large right MCA stroke unchanged from prior.
The patient's creatinine was slightly increased from
baseline, but her urine output was good. An increased white
blood cell count was noted on [**12-22**] considered to be stress
response versus evidence of infection and cultures were sent.
On [**12-22**] and [**12-23**] the patient was noted to have increased
alertness complaining of a headache with an unchanged
neurological examination. On [**12-23**] systolic blood pressure
was running 100 to 110 with the head of the bed at 30 degrees
elevation. The patient was alert and interactive though not
opening her eyes. She was subsequently transferred to the
floor.
PAST MEDICAL HISTORY: 1. Coronary artery disease status
post coronary artery bypass graft times two in [**2181**]
complicated by a left ventricular aneurysm status post
patched graft and third degree heart block. 2. History of
paroxysmal atrial fibrillation status post DDD pacer. 3.
Congestive heart failure with ejection fraction of 35%. 4.
Hypertension. 5. Hyperthyroid. 6. Chronic renal
insufficiency with a baseline creatinine of 1.4.
MEDICATIONS AT HOME: Cozaar 25 mg po q.d., Lasix 40 mg po
q.d., enteric coated aspirin, Ambien, Lipitor, Levoxyl.
MEDICATIONS AT MICU: Protonix 40 mg q.d., Tylenol, subQ
heparin and enteric coated aspirin.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION ON TRANSFER FROM THE MICU: Vital signs
temperature 98.2. Pulse 61. Blood pressure 121/56.
Respiratory rate 20. Pulse ox 100% on room air.
Examination, the patient is lying in bed with her eyes
closed, unable to open them, but is interactive and responds
to questions and commands. Mental status, the patient is
oriented to hospital, state, but not year. She is oriented
to the reason for her hospitalization and answers questions
appropriately. HEENT she has dry oral mucosa. The tongue is
midline. She is unable to raise her eyelids. The pupils are
poorly reactive bilaterally, but the patient does respond to
light stimuli. There is poor response to threat bilaterally.
We were unable to assess visual fields and extraocular
movements at this time. Neck was supple with no bruits.
Cardiovascular, regular, 2 out of 6 systolic murmur best at
the right upper sternal border. Lungs were with rhoncerous
breath sounds bilaterally in the anterior lung fields.
Abdomen is soft, mild, diffuse tenderness to palpation with
no rebound or guarding and active bowel sounds. Extremities
no edema. There are several small raised red lesions on the
distal lower extremities.
Neurological examination the patient's sensation is intact.
The patient is able to open her jaw against resistance and
shrug her shoulders. She has a left sided visual field
defect/neglect. Sensation, there is no response to light
touch to the left arm. She does sense touch on the right
arm. Light touch sensation is intact bilaterally in the
lower extremities. Strength of the left arm is flaccid with
0 out of 5 strength. The left leg is also flaccid. The
right arm shows 5 out of 5 biceps and triceps. The right leg
3 out of 5 hip extension, 5 out of 5 ankle flexion and
extension. Reflexes, biceps 2+ bilaterally, brachial
radialis 2+ bilaterally, patellar 1+ bilaterally. Toes are
down going on the right and up going on the left.
LABORATORY STUDIES ON TRANSFER FROM INTENSIVE CARE UNIT:
Hematocrit 34.9, white blood cell count 10.4, INR 1.1.
Urinalysis showed large blood, negative nitrite, greater then
50 red blood cells, 3 to 5 white blood cells, few bacteria
and no epithelial cells. Sodium 150, potassium 3.5, chloride
110, bicarbonate 32, BUN 39, creatinine 1.5, glucose 350,
calcium 8.0, phosphate 32.6, magnesium 2.2, albumin 3.2.
Blood cultures and urine cultures were negative at that time.
HOSPITAL COURSE: 1. Neurological: The patient is admitted
with a large right MCA stroke of embolic origin. The patient
was administered tissue plasminogen activator in the
Emergency Room without benefit. The patient's residual
defects were a left facial droop, left hemiparesis and left
hemisensory deficits. The patient's mental status seemed to
fluctuate at intervals during the course of the
hospitalization with intermittent periods of somnolence.
However, the patient was generally awake and easily oriented.
There were no new focal neurological findings during this
admission and there was no reimaging of the head after
transfer to the floor on [**2185-12-23**]. The blood pressure goal on
transfer to the floor was 130s to 140s to maintain adequate
cerebral perfusion. The patient remained intermittently
hypotensive and had to be bolused with fluids in order to
maintain a blood pressure in the low 100s. Despite periods
of hypotension the patient's mental status remained largely
unchanged. For the latter portion of the patient's admission
blood pressure remained stable in the 110s to 120s. The
patient will follow up with the stroke service in several
weeks following discharge.
2. Cardiovascular: Patient with a history of coronary
artery disease. She was continued on aspirin during this
admission. Captopril was added shortly after the [**Hospital 228**]
transfer to the floor for treatment of congestive heart
failure. The patient was known to be prone to flash
pulmonary edema as she had experienced in the Emergency
Department. After her transfer to the floor she developed
increased respiratory distress over several days. Pulmonary
examination and x-ray were consistent with moderate
congestive heart failure. The patient was initially gently
diuresed with Lasix. Following diuresis the patient became
transiently hypotensive to the 70s and 80s with mildly
depressed level of alertness and responsiveness. At that
time the patient was bolused with 250 cc boluses of normal
saline to elevate the blood pressure to the low 100s.
Despite these boluses, the patient did not drop her O2
saturation.
As the patient's po intake improved over the course of the
admission. She was ultimately taken off of maintenance
hydration and required no further fluid boluses to maintain a
blood pressure in the 110s to 120s. She also maintained good
urine output and was considered to be essentially euvolemic
with a creatinine at or near baseline of 1.6 at the time of
discharge. On [**2185-12-27**] during one period of relative
hypotension the patient was noted to be in atrial
fibrillation/flutter. On further review of the patient's
vital signs and telemetry it was clear that the patient may
have been in flutter at least intermittently over the course
of two to three days. It was felt that this might be
contributing to her difficulty breathing and to her
congestive heart failure. She was initially loaded on
Amiodarone 400 mg po b.i.d. and this dose was continued up
until discharge. On [**2185-12-27**] electrophysiology was consulted
for adjustment of the patient's pacemaker as she was
conducting her atrial rate at approximately 120 beats per
minute to the ventricle. After adjustment of the pacemaker,
the patient was in continued atrial fibrillation/flutter, but
ventricularly paced at 60 beats per minute. Cardioversion
was considered, but will be deferred.
We also discussed the possibility with anticoagulation with
the neurology service given the patient's atrial
fibrillation/flutter and risk for further embolic stroke.
Given the patient's recent stroke, this was held off.
However, after the patient was more then ten days out from
the stroke on the day of discharge [**2186-1-4**] the patient was
initiated on Coumadin anticoagulation at a low dose. After
the patient achieves a goal INR of 2 to 3 the patient will be
considered for reattempt at cardioversion. This will be done
after a therapeutic INR for three to four weeks by the
electrophysiology service. Will attempt an interruption of
the flutter with overdrive atrial pacing.
3. Pulmonary: As noted the patient experienced mild
congestive heart failure early in this admission. She was
effectively diuresed and became transiently hypotensive. She
then responded to fluid boluses and continuous intravenous
fluids for several days. During the latter several days of
the admission the patient was taken off intravenous fluids
and maintained good po intake to support her blood pressures.
She was essentially euvolemic at the time of discharge. The
patient also spiked a fever and while she did grow out
positive blood cultures or have positive sputum specimens,
chest x-ray was suggestive of a retrocardiac opacity perhaps
most consistent with an aspiration pneumonia. The patient
was started on Levaquin and Flagyl for a fourteen day course.
Although chest x-ray revealed a persistent left lower lobe
opacity at the time of discharge, the patient was afebrile
with no new respiratory complaints. She should complete a
fourteen day course of Levaquin and Flagyl and should be
reimaged if she becomes febrile or new respiratory complaints
develop.
4. Infectious disease: As noted the patient was treated for
a possible aspiration pneumonia with Levaquin and Flagyl.
The patient was also noted to have a urinary tract infection
positive for both proteus and enterococcus. Both organisms
were sensitive to Levaquin. Hematuria noted during the
initial presentation to the floor resolved over time and was
attributed to Foley trauma.
5. Hematologic: The patient's hematocrit remained stable
throughout this admission after initial drop in the MICU.
6. Fluids, electrolytes and nutrition: The patient's fluid
status was essentially euvolemic at the time of discharge.
She was requiring no supplemental intravenous fluids and was
maintaining good urine output. She should be continued on
her prior dose of Lasix, however, should she become
hypovolemic, Lasix should be discontinued and the patient
should be further hydrated especially if her po intake should
taper off. From an electrolyte standpoint the patient's
magnesium and potassium should be closely followed especially
given current Amiodarone use. The patient should be
maintained on a diet of pureed foods and thickened liquids.
These should be administered to the right side of the mouth.
Thin liquids should be avoided for the most part. The
patient should be sitting upright for her meals.
7. Gastrointestinal: The patient was maintained on Protonix
during this admission for ulcer prophylaxis. She had
multiple repeated loose stools. Stool cultures were negative
for clostridium difficile.
8. Endocrine: Patient with a history of hypothyroidism.
Her TSH was seemed to be elevated with a low T4 and her
Levoxyl dose was subsequently increased from 50 to 75 mcg po
q.d.
DISCHARGE DIAGNOSES:
1. Middle cerebrovascular artery stroke with left
hemiparesis.
2. Atrial fibrillation/flutter.
3. Congestive heart failure.
4. Aspiration pneumonia.
5. Urinary tract infection.
DISCHARGE MEDICATIONS: 1. Coumadin 2.5 mg po q.d. as
starting dose with a goal INR of 2 to 3. This dose can be
adjusted upward to attain this goal, but should be initiated
at the low current dose. 2. Protonix 40 mg po q.d. 3.
Enteric coated aspirin 325 mg po q.d. 4. Senokot one tab po
q.h.s. prn constipation. 5. Colace 100 mg po b.i.d. prn
constipation. 6. Lipitor 10 mg po q.d. 7. Captopril 3.25
mg po b.i.d. held for systolic blood pressure less then 100.
8. Flagyl 500 mg po t.i.d. until [**1-8**]. 9. Levaquin 250 mg
po q.d. until [**1-8**]. 10. Levoxyl 75 micrograms po q.d. 11.
Lasix 40 mg po q.d. 12. Amiodarone 400 mg po q.d. This
dose should be changed to 200 mg po t.i.d. on [**1-6**]. It
should be then changed to 200 mg po b.i.d. on [**2186-1-13**]. 200
mg b.i.d. will then remain as a maintenance dose. 13.
Tylenol 650 mg po q 4 to 6 hours prn pain.
INSTRUCTIONS: 1. Diet: The patient should be maintained on
pureed food and thickened liquids only diet. Food should be
placed on the right side of the patient's mouth. Thin
liquids should be avoided. The patient should be seated
upright for all meals to avoid aspiration. 2. The patient's
left hand and arm should be put through passive range of
motion and elevated periodically from an IV pole. 3. INR
should be maintained at a goal of 2 to 3. Coumadin is just
being initiated at the time of discharge at 2.5 mg q.d. Low
dose Coumadin should be continued with potential further
adjustment to achieve goal INR of 2 to 3. Follow up will be
scheduled with the electrophysiology cardiology team in
several weeks for evaluation of pacemaker and potential
override atrial pacing. The patient will also be scheduled
for follow up with the neurological stroke team. Please see
discharge page one for the dates of these follow up
appointments. At her skilled nursing facility the patient
should receive a repeat swallow evaluation as well as
physical and occupational therapy.
[**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**]
Dictated By:[**Last Name (NamePattern4) 4689**]
MEDQUIST36
D: [**2186-1-4**] 07:00
T: [**2186-1-4**] 07:07
JOB#: [**Job Number 4690**]
Name: [**Known lastname 552**], [**Known firstname 553**] Unit No: [**Numeric Identifier 554**]
Admission Date: [**2185-12-22**] Discharge Date: [**2186-1-13**]
Date of Birth: [**2097-4-27**] Sex: F
Service:
DATE OF DEATH: [**2186-1-13**].
ADDENDUM TO HOSPITAL COURSE: While previously considered
possible candidate for skilled nursing facility the patient
then took a turn for the worst over the latter days of her
hospitalization. She became increasing dyspneic and less
responsive. Her fluid status was difficult to manage in the
absence of aggressive re-intervention. In accordance with
the patient's wishes and following extensive discussions with
the family the patient was made comfort measures only.
Preparations were made to transition the patient home with
Hospice care. On [**2186-1-12**] the patient was noted to be
minimally responsive with evidence of continued clinical
deterioration. On the morning of [**2186-1-13**] the patient was
noted not to be responding to verbal or physical stimuli.
She had no respirations or heart sounds. Her pupils were
fixed and dilated. The patient was declared dead at 08:30
A.M. The attending and family were notified. No autopsy was
requested by the family.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-766
Dictated By:[**Last Name (NamePattern4) 555**]
MEDQUIST36
D: [**2186-2-15**] 20:38
T: [**2186-2-17**] 10:15
JOB#: [**Job Number 556**]
|
[
"V45.81",
"507.0",
"276.0",
"427.31",
"599.0",
"434.11",
"V42.2",
"414.01",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
12362, 12545
|
12569, 15128
|
15145, 16331
|
2814, 5461
|
113, 2341
|
2364, 2792
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,305
| 184,754
|
19788
|
Discharge summary
|
report
|
Admission Date: [**2115-10-14**] Discharge Date: [**2115-10-22**]
Date of Birth: [**2064-1-27**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 51 year old
alcoholic man with a history of alcoholic pancreatitis, who
recently presented to [**Hospital 8641**] Hospital on [**9-29**] with abdominal
pain, increased abdominal girth and jaundice. The patient
was found to have an obstructive mass in the duodenum, left
inguinal lymphadenopathy, ascites, pancreatitis and a
bilirubin of 14.4.
The patient underwent an endoscopic retrogram
cholangiopancreatography on [**10-7**] with failure to cannulate
ampulla resulting in respiratory failure during procedure and
intubation. The patient was found to have bilateral
infiltrates and pulmonary effusions, thought to have adult
respiratory distress syndrome, required minimal ventilatory
settings, though. The patient was started on Levofloxacin,
Flagyl, Zosyn for concern of hospital acquired pneumonia.
The patient was transferred to [**Hospital1 188**] for percutaneous attempt at biliary drain.
PAST MEDICAL HISTORY:
1. Diabetes mellitus type 2.
2. Alcoholism.
3. Alcoholic pancreatitis. Recently diagnosed with
obstructive jaundice and duodenal mass.
ALLERGIES: No known drug allergies.
MEDICATIONS: No medications at home.
MEDICATIONS ON TRANSFER:
1. Zosyn 3.375 four times a day.
2. Diprivan 20 mics per kg per minute.
3. Regular insulin sliding scale.
4. Levofloxacin 500 q. day.
5. Flagyl 500 mg three times a day.
6. Versed GTTS.
7. Ipratropium.
8. Albuterol.
SOCIAL HISTORY: Homeless; two pack a day smoker. Denies
alcohol consumption in the past two months.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: In evaluation on arrival, he was found
to have a temperature spike of 104.5 F.; temperature on the
Medical Intensive Care Unit was 100.0 F.; 88 pulse; 111/65
blood pressure; MAP 82; respiratory rate 20; 97% on
ventilation. In no acute distress, intubated and sedated.
Pupils equally round and reactive to light and accommodation.
Communications through use of hands. Lung sounds are coarse
bilaterally, diffuse expiratory and inspiratory wheeze.
Regular rate and rhythm, no murmurs, rubs or gallops.
Abdomen soft, mildly distended, positive biliary drain in
right upper quadrant; no erythema. Positive for ascites and
shifting dullness, left inguinal mass with post surgical scar
exudates. Chronic venous stasis changes in lower legs
bilaterally. Plus two dorsalis pedis and posterior tibial.
Two plus pitting edema. Cranial nerves difficult to assess
secondary to sedation.
LABORATORY: White blood cell count on admission 13.3,
hematocrit 41, bilirubin 3.1, albumin 2.6, AST 75.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit for work-up of obstructive jaundice and
history of alcoholic pancreatitis.
Endoscopic retrogram cholangiopancreatography was consulted
with the recommendation of PTC. Sections of the duodenum
were obtained that showed mucosal eroding ulcerations with
active inflammation; biopsy was obtained later which showed
chronic inflammatory change and fibrosis; no evidence of
malignancy. Common bile duct brushings negative for
malignancy as well.
Ca-19 was found to be 77; CEA 6.9.
Abdominal CT scan with intravenous contrast was obtained
showing bilateral pleural effusions, right greater than left,
ascites with hepatobiliary dilatation, presumed pancreatitis,
no pancreas masses seen although small probably cystic area
in the head of the pancreas seen. There are additional left
inguinal lymphadenopathy.
Interventional Radiology placed bilateral biliary drains,
internal exiting with decompression of biliary ductal system.
Per IR, long area of stricture of the common bile duct, mild
dilatation of the right and left intrahepatic ducts, and a
biopsy was obtained of the lower common bile duct which again
was negative for malignancy, positive for chronic
inflammation changes.
The patient's bilirubin continued to be trending down and
right internal hepatic drain was internalized on [**2115-10-21**].
The patient began tolerating sips of clear and p.o. intake
with normal bowel movements. Liver enzymes remained flat.
Concern for portal vein thrombus as seen on CT scan. Repeat
right upper quadrant ultrasound revealed normal flow, no
evidence of complete obstruction, although presence of
thrombus could not be eliminated via this modality.
Ascites were sent for analysis and cytology was pending at
time of dictation.
2. ONCOLOGY: Preliminary results from lymph node obtained
from outside hospital was negative for malignancy. Lymph
node showed reactive vascular transformation. Surgery was
consulted and repeat biopsy was obtained; preliminary results
show that it is positive for LCA, CD20 strong positive as
well as 100% myotic index, is an indication of a high grade B
cell lymphoma histologically, although clinically, the
patient does not appear to be succumbing to a high grade
lymphoma process. The patient, at this time, declined
further staging work-up and would recommend PET CT scan of
the chest to delineate the presence or absence of mediastinal
nodes. CT scan of the abdomen done for obstructive jaundice
was negative for intraperitoneal nodes.
3. RESPIRATORY FAILURE: The patient was transferred after
intubation from the endoscopic retrogram
cholangiopancreatography. He was subsequently weaned from
the ventilator and extubated on hospital day three, requiring
nebulizers and respiratory toilet therapy. Subsequently he
was breathing 98% on room air without sequelae. He has small
bilateral effusions which were tapped. Cytology and
chemistries are pending at this time of dictation. Currently
he is without evidence of pneumonia. He was continued on
course of Levofloxacin.
4. INFECTIOUS DISEASE: Sputum, bile gram stain negative,
blood cultures negative to date. Outside hospital reported
positive ventilator related pneumonia, continued on broad
spectrum antibiotics and defeversced on hospital day five
without temperature spikes. Unasyn and Bactrim were
discontinued. The patient remained on Vancomycin and Zosyn
to protect for SBP. Currently afebrile without leukocytosis.
HIV serology is negative. Hepatology viral cultures pending
at time of dictation.
5. DERMATOLOGIC: The patient was found to have likely
Condyloma on penis with areas around genitalia consistent
with herpes simplex one and two, DFA sent. Pending at time
of dictation. The patient continued on Famvir 300 three
times a day to be discontinued on [**10-26**].
6. DIABETES MELLITUS: The patient switched over to an
American Diabetic Association diet, tolerating p.o. well,
coverage with regular insulin sliding scale with good control
of blood sugar.
7. PROPHYLAXIS: The patient was continued on subcutaneous
heparin and continued ambulation per recommendations of
Physical Therapy.
DISPOSITION: The patient very uncooperative to nursing
staff and recommendations of further work-up for positive
lymph node biopsy. Declining studies for further evaluation
and management. Per request, would like to return to [**Hospital 8641**]
Hospital for continuation of care and possible outpatient
management of oncologic issues.
Would recommend staging CT scan, PET preferably.
DISCHARGE MEDICATIONS:
1. Famvir 500 p.o. three times a day to be continued until
[**2115-10-26**].
2. Lactulose 30 ml p.o. three times a day. Hold for
stooling.
3. Zosyn 4.5 intravenous q. eight.
4. Vancomycin 1.5 grams intravenous q. 12.
5. Regular insulin sliding scale.
6. Tylenol p.r.n.
7. Albuterol and Ipratropium nebulizers q. four two puffs.
8. Heparin 5000 units q. eight subcutaneously.
DISCHARGE INSTRUCTIONS:
1. Follow-up acute transfer to [**Hospital 8641**] Hospital in [**Location (un) 8641**],
[**Location (un) 3844**].
CONDITION AT DISCHARGE: The patient is transferred in Fair
condition.
Summary:
1.ampullary mass- noted on ERCP as well as on abdominal CT. DDX
includes adenocarcinoma and lymphoma (less likely). Reccommend
outpatient follow up after treatment forlymphoma.
2. obstructive jaundice- from #1. Only intervention here at
[**Hospital1 18**] was internalization of the external biliary stent. Patient
did not have an ERCP at [**Hospital1 18**].
3. lymphoma- noted on left inguinal node biopsy. Needs treatment
in near future. Needs staging. Considdr PET vs torso CT.
4. ID- had been on Bactrim for xanthomonas maltophilia in his
sputum though no overt evidence of pneumonia. Bacrtim stopped
[**10-22**]. Presumably on Zosyn for biliary coverage. Would
discontinue soon. Has been afebrile for several days. DDX for
source of fevers are SBP ( no evidence), ascending cholangitis,
lung, decubitus, B symptoms from lymphoma. All blood cultures
here are negative to date. Had been on vancomycin as well stopped
[**10-22**].
5. hypercalcemia- presumed hyperparathyroidism with PTH level of
78 in setting of mild hypercalcemia
6. portal vein thrombosis- partial. Noted on CT. Maintained on
lovenox.
7. ascites- unclear etiology. DDX includes portal
hypertension, related to portal vein thrombosis, malignancy,
pancreatic ascites.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
Dictated By:[**Last Name (NamePattern1) 972**]
MEDQUIST36
D: [**2115-10-22**] 12:47
T: [**2115-10-22**] 13:12
JOB#: [**Job Number 53475**]
|
[
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] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"51.12",
"87.54",
"96.71",
"54.91",
"51.98",
"97.55",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
1692, 1710
|
7339, 7724
|
2740, 7316
|
7748, 7875
|
1733, 2722
|
7891, 9409
|
162, 1082
|
1347, 1572
|
1104, 1322
|
1589, 1675
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,102
| 126,673
|
44288
|
Discharge summary
|
report
|
Admission Date: [**2190-8-7**] Discharge Date: [**2190-9-5**]
Service: MEDICINE
Allergies:
Penicillins / Heparin Agents
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
Mental status change
Reason for transfer: Status epilepticus
Major Surgical or Invasive Procedure:
Central line placement
Arterial line placement
Lumbar puncture
History of Present Illness:
84 year old woman with atrial fibrillation on coumadin,
diastolic CHF, CRI, and pulmonary hypertension who was admitted
from rehab facility to OSH for increasing somnolence. Pt had
recently been admitted to another OSH s/p and discharged to a
rehab facility. At rehab facility pt became increasing somnolent
and deteriorated to the point of only being responsive to
painful stimuli. She was taken to ED where she was found to be
confused and bradycardic. Digoxin levels found high, u/a with
evidence of UTI. Head CT MRI read as normal. Neurology
consulted; no focal deficits seen on exam but EEG revealed
status epilepticus with R temporal predominance. Loaded with
1400 mg Iv dilantin and transferred to MICU. Pt noted to have
progressively longer periods of apnea; ABG revealed
7.42/48/50/31, pt intubated intially on AC and weaned to
pressure support. Pt has also received vanocmycin, cefepime,
gentamicin and ciprofloxacin for UTI and question of pneumonia.
Pt subsequently transferred to [**Hospital1 18**] for 24 hour EEG monitoring.
Past Medical History:
1) Chronic atrial fibrillation on digoxin and coumadin
2) Diastolic CHF, EF 55%
3) Mild pulm HTN (seen on echo)
4) Chronic renal insufficiency (baseline cr 1.5-3)
5) Diverticulosis
6) ASD, L to R shunt
7) Diverticulosis
8) AAA (3 cm)
9) Chronic dyspnea on exertion
10) Macular degeneration
Social History:
Russian. Used to work as engineer. Lives with husband, had
been able to do basic [**Name (NI) 5669**] prior to this. Son is HCP.
Quit smoking 30 years ago. No tobacco or illicit drug history.
Family History:
Non-contributory
Physical Exam:
T 100 BP 150-160/60-70 P 55-80 R 23 O2 97 on FiO2 40%
Vent: PS 10/5 on rate of 23 TV 375
Gen: Intubated, obtunded
Eyes: PERRL, sclerae anicteric
Mouth: MMM, intubated
Neck: Supple, no lymphadenopathy
Chest: Scattered crackles at bases, fair air movement
Heart: RR, no murmur
Abd: Obese, no bowel sounds.
Ext: No edema
Neurol: Toes mute, some spontaneous movement of lower
extremities. Could not elicit reflexes, no clonus
Skin: No rash.
Pertinent Results:
ABG 7.42/43/120
Phenytoin 6.9 (13 with albumin correction)
WBC 13.7
Cr 1.8
Digoxin from OSH 3.3
.
MRI and CT from OSH no stroke or bleed
.
[**8-8**] MRI/MRA Brain
1. No evidence of acute infarction. Chronic infarcts and small
vessel ischemic change.
2. MRA of the brain within normal limits allowing for flow
artifact as described above.
.
[**8-8**], [**8-9**] EEG
This 24 hour EEG telemetry initially was notable for a burst
suppression
pattern, followed by intermittent predominantly bitemporal
epileptiform
discharges and slowing within these same regions. At times, the
epileptiform discharges acquire a more rhythmic quality,
concerning for
an electrographic seizure. The background reaches a 10 Hz alpha
rhythm
but is remarkable for a generalized delta theta slowing. The
epileptiform activity significantly improves over the later
stages of
the recording. These findings are suggestive of an epileptogenic
focus
in the posterior temporal region, perhaps more so on the right.
Prolonged runs of more rhythmic appearing generalized discharges
are
concerning for limited electrographic seizures early in the
course of
the telemetry.
LP Results
[**2190-8-8**] 03:34AM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-0 Polys-0
Lymphs-24 Monos-75 Atyps-1
[**2190-8-8**] 03:34AM CEREBROSPINAL FLUID (CSF) TotProt-77*
Glucose-68
.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2190-8-12**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
.
**FINAL REPORT [**2190-8-18**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2190-8-18**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
.
**FINAL REPORT [**2190-8-19**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2190-8-19**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
.
[**2190-8-26**] 06:03PM STOOL CLOSTRIDIUM DIFFICILE TOXIN B ASSAY-
detected
Brief Hospital Course:
This 84 year old woman with atrial fib, CHF, HTN in
non-convulsive status epilepticus also with recent digoxin
toxicity and UTI presented to this hospital for management of
her status epilepticus. On presentation, the patient was
intubated (was in hypoxic, hypercarbic respiratory failure
secondary to apnea at OSH) and obtunded. She was started on
propofol and continued on dilantin for presumed status
epilepticus. The cause of seizing was unknown and the
differential included infection, stroke, or organic brain
injury. The patient had been empirically started on meningitic
antibiotics. The regimen was modified on transfer and included
vancomycin and ceftriaxone. She was also started empirically on
acyclovir for possible HSV infection. A lumbar puncture
performed on transfer was unremarkable with no evidence of
infection, all culture data was negative. MRI/MRA brain was not
remarkable for stroke or bleed.
.
The patient was continued on propofol and dilantin. Initial EEG
confirmed the presence of non-convulsive status epilepticus.
Dilantin doses were adjusted and keppra was added on. Propofol
was transitioned to ativan drip as the patients blood pressure
was somewhat labile on propofol. After several days of an EEG
without seizure activity, the Ativan drip was weaned and
eventually discontinued. However, no obvious improvement in her
mental status was noted (despite sedation off for > 1.5 weeks).
The patient remained unresponsive. She was kept on ventilation
until it was decided after several family meetings to move
towards comfort measures only. A morphine drip was started and
the breathing tube was discontinued. Several minutes later, the
patient passed away. Her death was pronounced on [**9-5**] at
1.14pm.
.
The patient's other medical issues were managed as follows. Her
atrial fibrillation was managed with diltiazem or BB if her
blood pressured allowed. Her warfarin was discontinued since the
patient had a decreased hematocrit. She suffered from a GI bleed
and RP bleed. She also had a progressive leukocytosis up to
50.000. C.Diff was negative x 3, and all blood/sputum cultures
no growth. She was empirically started on flagyl, but white
count continued to rise and she did not have any diarrhea. No
definitive source for an infection was found until a colonoscopy
revealed findings consistent with C. diff colitis (vs ischemic
colitis). She improved soon after having started her on PO
vancomycin and IV flagyl. Later, a send out test for C.Diff
toxin B returned positive. With regards to the Digoxin
toxicity, this drug was held throughout her hospital stay and
her acute renal failure was treated with IVF. Her diastolic CHF
was managed with antihypertensive and diuretic medications as
needed.
Medications on Admission:
Medications at home:
Coumadin 1.5 daily
Lasix 160 mg [**Hospital1 **]
Coreg 12.5 [**Hospital1 **]
Digoxin 0.125 daily
Imdur 30 mg PO daily
Lipitor 40 mg daily
Litaman 25 mg PO daily (for buccal dyskinesia)
Zyprexa 1.25 PO dialy
Trazodone 50 PO PRN
Probenecid/Colchicine 1 tab PO daily
Protonix 40 daily
Colace 100 daily
Calcium/vitamin D 600 [**Hospital1 **]
Fosamax 70 q Sunday
Tylenol 750 mg [**Hospital1 **]
MVI
.
Medications on transfer:
MVI
Zyprexa 1.25 qHS
Coumadin 2 mg daily
Protonix 40 IV BID
Lipitor 40 daily
Colace 100 daily
Tylenol prn
Ativan 2 mg IV q3 prn
Morphine 2 mg IV q2 prn agitation
.
All/ADR's: Penicillins (unknown reaction)
Discharge Medications:
not applicable
Discharge Disposition:
Expired
Discharge Diagnosis:
status epilepticus
C.Difficile colitis
retroperitoneal bleed
acute renal failure
thrombocytopenia
atrial fibrillation
Discharge Condition:
expired
Discharge Instructions:
.
Followup Instructions:
.
|
[
"416.8",
"585.9",
"599.0",
"288.62",
"584.9",
"568.81",
"287.5",
"428.30",
"274.0",
"V58.61",
"345.71",
"401.9",
"427.31",
"008.45",
"518.84"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"00.17",
"96.72",
"33.24",
"38.93",
"99.07",
"45.25",
"99.05",
"38.91",
"03.31",
"99.04",
"81.91"
] |
icd9pcs
|
[
[
[]
]
] |
7940, 7949
|
4451, 7203
|
295, 359
|
8110, 8119
|
2463, 4428
|
8169, 8173
|
1972, 1990
|
7901, 7917
|
7970, 8089
|
7229, 7229
|
8143, 8146
|
7250, 7646
|
2005, 2444
|
194, 257
|
387, 1429
|
7671, 7878
|
1451, 1743
|
1759, 1956
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,530
| 137,960
|
51008
|
Discharge summary
|
report
|
Admission Date: [**2191-1-8**] Discharge Date: [**2191-1-21**]
Date of Birth: [**2131-3-19**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 15237**]
Chief Complaint:
Transferred from MICU (admitted with ARF, mental status changes,
pancreatitis, respiratory distress)
Major Surgical or Invasive Procedure:
Central line
Hemodyalisis line
Intubation
History of Present Illness:
59M with HIV on HAART, well controlled CD4 in 400s, who
initially presented with fevers to 102F, with associated chills,
nausea, and dry heaving. Patient initially was seen by his PCP
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 2148**], who gave patient 2L IVF and Pepcid with improvement
in his symptoms. Laboratory studies at that time were
unremarkable.
The next day, patient reported decreased oral intake, nausea,
vomiting, abdominal pain and headaches. Patient also noted
epigastric abdominal pain. Patient has noted no diarrhea, blood
in stool emesis or urine, rash, lymphadenopathy, sore throat,
difficulty swallowing, or weight loss. He was compliant with his
HIV meds. He denied any recent travel, or any unusual foods.
.
Patient does note that his symptoms started immediately after an
arthroscopic knee surgery three weeks prior. Patient noted mild
nausea at the time, but states that symptoms progressed
significantly from then to the point of admission. Patient
states that his only new medication was the addition of Celexa
several weeks prior.
.
On admission, patient had head CT with contrast performed to r/o
toxoplasmosis. Cr subsequently came back at 12.4. Bicarb low,
LFTs abnormal. Had a 7-point Hct drop since last Tuesday. Pt
given fluids, bicarb, mucomyst. Head CT was normal. Mild pulm
edema noted on CXR, MS waxing and [**Doctor Last Name 688**]. In the [**Name (NI) **], pt
reported chest pain and had diffuse ST changes in anterolateral
leads. Rec'd aspirin but no BB at the time, and was also given
amiodarone for runs of SVT vs. VT, which was subsequently
discontinued. Patient had elevated CKs and troponins with
negative MB fractions.
.
Renal, hem/onc, and cards were consulted. A peripheral blood
smear showed spherocytes but no [**Last Name (LF) 21802**], [**First Name3 (LF) **] TTP was felt to
be ruled out. Renal placed a line for CVVHD, and patient was
subsequently dialysed through the catheter for several days,
prior to switch to hemodialysis.
Past Medical History:
HIV - last CD4 ([**2191-12-8**]) - 446, with a VL at that time of 447,
on HAART
Hypertension
Hyperlipidemia
Type II diabetes mellitus
Social History:
Pt denies tobacco, EtOH, or IVDU. Is an architectural designer.
Lives with his partner of 28 years. Lives in wooded areas with
several dogs. No recent travel.
Family History:
Noncontributory
Physical Exam:
T 99.9 HR 83 BP 150/86 RR 24 SaO2 95%
General: WDWN, NAD, breathing comfortably on RA
HEENT: PERRL, EOMi, icteric sclera, conjunctivae pink. No oral
ulcers or lesions.
Neck: supple, trachea midline, no thyromegaly or masses, no LAD
Cardiac: RRR, s1s2 normal, no m/r/g, no JVD
Pulmonary: CTAB
Abdomen: +BS, soft, nontender, nondistended, no HSM. Foley
draining clear yellow urine.
Extremities: warm, 2+ DP pulses, no edema
Skin: No rashes.
Neuro: A&Ox3, speech clear and logical, CNII-XII intact, moves
all extremities
Pertinent Results:
Hematology:
[**2191-1-8**] 10:05AM WBC-5.3 RBC-3.03* HGB-11.9* HCT-32.1*
MCV-106* MCH-39.2* MCHC-37.0* RDW-16.4*
[**2191-1-8**] 10:05AM NEUTS-74* BANDS-2 LYMPHS-21 MONOS-2 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2191-1-8**] 05:10PM PT-13.0 PTT-24.8 INR(PT)-1.1
.
Chemistry:
[**2191-1-8**] 10:05AM ALT(SGPT)-183* AST(SGOT)-273* ALK PHOS-64 TOT
BILI-3.6*
[**2191-1-8**] 10:05AM GLUCOSE-141* UREA N-106* CREAT-12.4*#
SODIUM-127* POTASSIUM-4.9 CHLORIDE-91* TOTAL CO2-15* ANION
GAP-26*
[**2191-1-8**] 03:05PM HAPTOGLOB-469*
[**2191-1-8**] 03:05PM CK-MB-9 cTropnT-0.15*
[**2191-1-8**] 03:05PM LD(LDH)-373* CK(CPK)-1299*
[**2191-1-8**] 05:10PM FIBRINOGE-418*#
[**2191-1-8**] 05:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-5.1
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2191-1-8**] 05:10PM CK-MB-10 MB INDX-0.8
[**2191-1-8**] 05:10PM cTropnT-0.17*
[**2191-1-8**] 05:10PM CK(CPK)-1201* DIR BILI-2.3*
[**2191-1-8**] 05:10PM GLUCOSE-113* UREA N-102* CREAT-12.1*
SODIUM-128* POTASSIUM-4.7 CHLORIDE-95* TOTAL CO2-17* ANION
GAP-21*
[**2191-1-8**] 05:22PM LACTATE-1.3 NA+-130* K+-4.7
[**2191-1-8**] 11:23PM D-DIMER-4135*
[**2191-1-8**] 11:23PM CRP-136.0*
[**2191-1-8**] 11:23PM ANCA-NEGATIVE
[**2191-1-8**] 11:23PM PTH-252*
[**2191-1-8**] 11:23PM CRYO-NO CRYOGLO
[**2191-1-8**] 10:05AM BLOOD ALT-183* AST-273* AlkPhos-64 TotBili-3.6*
[**2191-1-15**] 09:50AM BLOOD ALT-121* AST-108* LD(LDH)-335*
AlkPhos-125* Amylase-290* TotBili-3.9*
[**2191-1-9**] 05:22AM BLOOD Lipase-1396*
[**2191-1-15**] 09:50AM BLOOD Lipase-639*
[**2191-1-9**] 02:59PM BLOOD VitB12-991* Folate-9.0
[**2191-1-10**] 09:37AM BLOOD Cortsol-19.3
[**2191-1-10**] 02:52PM BLOOD Cortsol-27.3*
[**2191-1-10**] 02:52PM BLOOD Cortsol-29.8*
[**2191-1-12**] 05:35AM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE
HBcAb-POSITIVE
[**2191-1-12**] 04:20PM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE
HBcAb-POSITIVE
[**2191-1-9**] 02:59PM BLOOD PEP-NO SPECIFI
[**2191-1-10**] 09:37AM BLOOD C3-122 C4-23
[**2191-1-8**] 11:23PM BLOOD HCV Ab-NEGATIVE
.
CXR ([**1-12**]): REASON FOR EXAMINATION: Evaluation of jugular
venous line placement. Right central venous line double lumen
catheter was inserted with its distal tip pointing at the level
of distal SVC. There is no pneumothorax or pleural effusion.
The left subclavian line tip terminates at the junction of
brachiocephalic vein. The lungs are essentially clear except
for right lower lobe discoid atelectasis. There is no sizeable
pleural effusion. There is no evidence of congestive heart
failure, marked improvement compared to the previous film.
.
Head CT: no intracranial hemorrhage, abscess, or mass
.
Echo:
EF >55%. Preserved biventricular function. No RWMA.
.
CT Abdomen:
1. No abscesses or loculated collections identified.
2. Nonspecific bowel wall thickening with inflammatory changes
seen within the ascending colon. Diagnostic considerations
include colitis (infectious, inflammatory, or ischemic) versus
third spacing of fluid.
3. Appendix not contrast filled, but not dilated. Surrounding
inflammatory changes contiguous with those surrounding the
ascending colon. It is uncertain which inflammatory process is
primary. Discussed with Dr. [**Last Name (STitle) **] following completion of the
study.
4. Again seen is evidence of pancreatic duct and CBD
dilatation, not
significantly changed from prior ultrasound. Findings are
nonspecific, diagnostic considerations including cholangiopathy
or ampullitis.
5. Small bilateral pleural effusions with associated
atelectasis and
consolidation.
Brief Hospital Course:
59M with HIV on HAART presents with F, abd pain, mental status
changes, acute renal failure, hypoxic respiratory failure [**1-21**]
volume overload, now extubated no longer requiring dialysis.
Unclear etiology of his symptoms, but possibities would include
acute chemical pancreatitis, disseminated infection of unclear
etiology, serotonin syndrome in setting of recent initiation of
SSRI, TTP-HUS. Infectious causes have largely been ruled out,
TTP-HUS unlikely in the setting of no hemolysis on smear, and
patient did not exhibit classic signs of serotonin sx (e.g. no
muscle rigidity, clonus) but did initially present with
hyperthermia, nausea, abdominal pain, rhabdo, delta MS, and
renal failure. Likely etiology is pancreatitis, esp with LFT
abnormalities, elevated pancreatic enzymes, jaundice, and
dilatation of pancreatic and CBD seen on ultrasound.
.
# Pancreatitis - Patient had an elevated amylase/lipase, and
elevated LFTs and diffuse abdominal pain leading to this
admission. Cause was unclear. There were no signs of infection
(mycoplasma, CMV, hepatitis, legionella). However, there were
liver enzyme elevation nad CBD dilitation. however, MRI and
ERCP did not demonstrate cholelithiasis. Therefore it was
thought that it may have been secondary to medication side
effects or possibly pancreatitis induced by HIV. AIDS
cholangiopathy seems unlikely given lack of obstruction and
previous CD4 >100. Peak lipase 1396 and amylase 448 prior to
ERCP. However, pt also developed post-ERCP pancreatitis with
abdominal pain and elevation of lipase to 10,000. This quickly
resolved with IV fluids and the patient did not have abdominal
pain and was tolerating food on day of discharge.
.
# Fever. Still with unclear etiology. Patient has negative
cultures to date. Continues to spike low grade fevers. Resolved
without antibiotics. Patient cautioned to take temperature and
call ID fellow or go to the ER.
.
# Acute renal failure. Pt developed severe renal failure and
admission creatinin was 12. Patient was admitted to MICU and
started on CVVH. This was continued only for a few days as the
patient's renal function improved and started urinating.
Evaluation of the urine did not show muddy brown casts, but
given the history and rapid improvement of renal function, cause
was thought to be acute tubular necrosis secondary to
pancreatitis (severe prerenal azotemia) vs. HIV nephropathy vs.
multiple nephrotoxic medications. Negative renal ultrasound.
Appears to be in a diuresis phase currently. Creatinine
continued to decrease throughout hosptial stay and electrolytes
were normal.
.
# HTN: As hospital course progressed, patient's blood pressure
increased and atenolol was increased to [**Hospital1 **]. This should be
reevaluated as an outpatient as atenolol typically a qday
medcation.
.
# Occult blood positive OGT lavages with clots while in ICU.
Did not have persistent bleeding and no episodes concerning for
GI bleeding while on medicine floors. Additionally ERCP was
done with brief exam of upper GI tract and did not have signs of
bleeding.
.
#. Delta MS. Thought to be in setting of uremia and ICU
psychosis. Improved with dialysis and improvement in overall
health. No mental status changes at time of discharge.
.
# ? NSTEMI - ST depressions in inferolateral leads, pt does
have risk factors for CAD including DM2, hyperlipidemia, being
on HAART long-term. Elevated troponin to 0.36 but normal MB
fractions in setting of severe acute renal failure. S/p
amiodarone for SVT currently being medically managed with BB
alone. Echo shows no RWMA. [**Month (only) 116**] need outpatient eval including
stress test.
.
# DM2 - Well-controlled. Check qid fingerstick, ISS coverage.
Was restarted on actos after renal function improve (okayed
with nephrology). Patient was recommended to check fingersticks
as outpatient in the first days after discharge at least [**Hospital1 **].
.
# HIV - holding HAART for now given that ritonavir can cause
acute renal failure as well as the renal and liver side effects
possible from HIV meds. Will need to readdress this with
outpatient dr.
.
# Macrocytic anemia - likely [**1-21**] HAART
- Guaiac all stools, follow Hct per above
.
# Thrombocytopenia - Now resolved. [**Month (only) 116**] represent generalized
bone marrow suppression in the face of systemic inflammatory
illness. No recent heparin so would not send HIT antibody. TTP
has been ruled out as no schistocytes on peripheral smear. DIC
panel did not show signs of DIC. Plts trending up after nadir of
70 and now normalized.
.
# Hyperlipidemia - Will hold statin for now given elevation in
liver enzymes. should restart if liver enzymes normalize.
Medications on Admission:
Actos 30mg daily
acyclovir 400mg [**Hospital1 **]
aspirin 81mg daily
atenolol 100mg daily
celexa 20mg qHS
loratadine 10mg daily
lorazepam prn
percocet prn
univasc 30mg daily
atazanavir 300mg daily
ritonavir 100mg daily
tenofovir 300mg daily
combivir 1 tab [**Hospital1 **]
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
3. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) for 7 days.
Disp:*140 ML(s)* Refills:*0*
5. Actos 30 mg Tablet Sig: One (1) Tablet PO once a day.
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed: Do not exceed 2 grams (6
tablets) in one day.
7. One Touch Test Strip Sig: One (1) Miscellaneous twice a
day: Please call your doctor if your blood sugar is <60 or >300.
Disp:*1 box* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Hypotension
Respiratory failure
Acute renal failure
Sepsis
Pancreatitis
.
Secondary: HIV, Hypertension, type II diabetes, Hyperlipidemia
Discharge Condition:
FAIR
Discharge Instructions:
YOU MUST CALL THE ID SERVICE OR RETURN TO THE ER IF YOU HAVE ANY
FEVER (>101), ABDOMINAL PAIN, NAUSEA, VOMITING, OR ANY
CONCERNING SYMPTOMS.
YOU MUST FOLLOW UP WITH DR. [**Last Name (STitle) **] AT 1PM ON MONDAY.
.
You should have only clear liquids today and if your symptoms
continue to improve, it is ok to transition very bland diet
tomorrow and advance slowly.
.
Please take all medications as prescribed.
.
New medications: Pantoprazole, Nystatin
.
Call your doctor or return to the ED immediately if you
experience worsening chest pain, shortness of breath, nausea,
vomiting, sweating, fevers, chills, bleeding, or other
concerning symptoms.
Followup Instructions:
You are scheduled for the following appointments. Please contact
the [**Name2 (NI) 11686**] provider with any questions or if you need to
reschedule.
.
[**Doctor Last Name 2148**] [**Telephone/Fax (1) 457**]
.
Provider: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2191-1-27**] 1:00 (Nephrology)
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9561**], M.D. Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2191-1-24**] 1:00
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7,567
| 168,328
|
13849
|
Discharge summary
|
report
|
Admission Date: [**2128-10-4**] Discharge Date: [**2128-10-8**]
Date of Birth: [**2071-8-16**] Sex: M
Service: CARDIOTHORACIC.
HISTORY OF THE PRESENT ILLNESS: Mr. [**Known lastname 41563**] is a
postoperative admission. He came to [**Hospital1 190**] for a scheduled aortic valve replacement.
CHIEF COMPLAINT: Increasing chest pressure and occasional
shortness of breath
The patient had a CABG times five in [**2123**] with LIMA to the
LAD and vein grafts. He had cardiac catheterization done in
[**Month (only) 958**] of this year, which showed that all five grafts were
patent with native three-vessel disease, mild pulmonary
hypertension, moderate-to-severe aortic stenosis.
PAST MEDICAL HISTORY: History is significant for the
following:
1. Aortic stenosis.
2. Hypercholesterolemia.
3. Congestive heart failure.
4. Prostate cancer.
5. Anemia.
6. Insulin dependent diabetes mellitus.
7. Hemorrhoids.
PAST SURGICAL HISTORY:
1. History is significant for CABG times five.
2. Transurethral resection of the prostate with
brachytherapy and x-ray radiation treatment of the prostate.
3. Appendectomy as an adolescent.
4. Cataract surgery.
MEDICATIONS: (Medications prior to admission).
1. Aspirin 81 mg q.d.
2. ....................150 mg q.d.
3. Potassium 20 mEq q.d.
4. Lasix 40 mg b.i.d.
5. Lipitor 20 mg q.d.
6. Zestril 5 mg q.d.
7. Actos 15 mg q.d.
8. Calcium tabs q.o.d.
9. Multivitamin one q.d.
10. Vitamin E 400 q.d.
11. Humulin N 33 units q.a.m.
ALLERGIES: The patient has no known drug allergies.
FAMILY HISTORY: History revealed that the patient's mother
is still alive. Father died of diabetes mellitus and
pulmonary embolus; no age declared. Occupation: The patient
is a chef, and he lives with his wife. [**Name (NI) 1139**]: Remote use.
Quit five years ago. Alcohol: Occasional drink one time per
week. The patient denies any other drug use.
PHYSICAL EXAMINATION: Examination revealed the following:
Heart rate 80, blood pressure 132/60, respiratory rate 12,
height 5 feet 9 inches, weight 185 pounds. GENERAL: The
patient is well nourished, fit with good muscle tone. SKIN;
Multiple healed lower extremity bruises. HEENT: Pupils
equal, round, and reactive to light. Pupillary mucosa
intact. No JVD. Positive murmur that radiated bilaterally
to the neck. Chest was clear to auscultation. There is a
well healed sternotomy. HEART: Regular rate and rhythm, S1
and S2 with a 3/6 systolic ejection murmur that radiates to
the neck. ABDOMEN: Soft, nontender, nondistended, with
positive bowel sounds, no hepatosplenomegaly. EXTREMITIES:
Well healed right saphenous vein graft sites, no clubbing,
cyanosis or edema. Cool, but well perfused, no varicosities.
NEUROLOGICAL: Grossly intact cranial nerves II through XII.
Excellent strength and sensation in all four extremities.
The patient has two pulses throughout.
On [**10-4**], the patient was brought to the operating
room, where he underwent an aortic valve replacement. Please
see OR report for full details and summary. The patient had
an AVR with a #23 CE valve placed. The patient tolerated the
operation well. The patient was transferred from the
operating room to the Cardiothoracic Intensive Care Unit. At
the time of transfer, the patient had Neo-Synephrine at 0.5
mcg per kilogram per minute and propofol at 10 mcg per
kilogram per minute. Mean arterial pressure was 76, CVP at
10. The patient was apaced at 83 beats per minute.
The patient did well in the immediate postoperative period.
Upon arrival in the CSRU, the patient's anesthesia was
reversed. He was weaned from the ventilator and successfully
extubated. He remained hemodynamically stable overnight. On
postoperative day #1, he was ready for transfer to the floor,
however, it was found that he was somewhat hyperkalemic, and
he stayed in the ICU just to monitor the electrolytes for an
extra day. On the morning of postoperative day #2, the
patient remained hemodynamically stable. The electrolytes
had come back into order and he was transferred from the
Intensive Care Unit to FAR 2 for continuing postoperative
care and cardiac rehabilitation. Once on the floor, the
patient's postoperative course was uneventful. With the
assistance of the nursing staff and the Department of
Physical Therapy the activity level was gradually increased.
He remained hemodynamically stable. He was gently diuresed
over the next several days and on postoperative day #4, it
was deemed that the patient was stable and ready to be
discharged to home. On the day of discharge, the patient's
physical examination was as follows: VITAL SIGNS:
Temperature 99, heart rate 86 sinus rhythm, blood pressure
130/50, respiratory rate 18, oxygen saturation 93% on room
air. Weight preoperatively was 84.2 kilograms, on discharge
87.6 kilograms.
LABORATORY DATA: Laboratory data revealed the following:
White count 8, hematocrit 23.5, platelet count 131,000,
sodium 130, potassium 4.6, chloride 92, CO2 27, BUN 47,
creatinine 1.2, glucose 136.
PHYSICAL EXAMINATION: Examination revealed that the patient
was alert and oriented times three. The patient moves all
extremities. The patient was conversant. Breath sounds were
clear to auscultation bilaterally. CARDIOVASCULAR: Regular
rate and rhythm, S1 and S2 with no murmurs. Sternum was
stable. Incision with staples, open to air, clear and dry.
ABDOMEN: Soft, nontender, nondistended, normoactive bowel
sounds. EXTREMITIES: Warm, well perfused with 1+ edema.
DISCHARGE MEDICATIONS:
1. Metoprolol 25 b.i.d.
2. Furosemide 20 mg b.i.d. times two weeks.
3. Potassium chloride 20 mEq b.i.d. times two weeks.
4. Atorvastatin 20 mg q.d.
5. Lisinopril 5 mg q.d.
6. Pioglitazone 15 mg q.d. with lunch.,
7. Aspirin 325 mg q.d.
8. Insulin 30 units q.a.m.
9. Niferex 150 mg q.d.
10. Percocet 5/235 one to two tablets q.4h.p.r.n.
11. Ibuprofen 600 mg q.6h.p.r.n.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Aortic stenosis status post aortic valve replacement.
2. Coronary artery disease status post CABG times five.
3. Insulin dependent diabetes mellitus.
4. Hypercholesterolemia.
5. Prostate cancer.
6. Anemia.
7. Status post appendectomy.
8. Status post cataract removal.
9. Status post transurethral resection of the prostate.
FO[**Last Name (STitle) **]P CARE: The patient is to have follow up in the
wound clinic in two weeks. The patient is to have followup
with Dr. [**Last Name (Prefixes) **] in four weeks. The patient is to have
followup with the primary care provider in three to four
weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2128-10-8**] 11:12
T: [**2128-10-8**] 12:15
JOB#: [**Job Number 26732**]
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4,833
| 124,458
|
27763
|
Discharge summary
|
report
|
Admission Date: [**2189-6-16**] Discharge Date: [**2189-6-25**]
Date of Birth: [**2110-4-8**] Sex: M
Service: MEDICINE
Allergies:
Nsaids
Attending:[**First Name3 (LF) 2159**]
Chief Complaint:
Stridor
Major Surgical or Invasive Procedure:
Endotracheal intubation
Fiberoptic bronchoscopy
Central venous line (L subclavian) placement
Transesophageal echocardiography
PICC line placed
History of Present Illness:
79yo spanish speaking M Hx DM2, HTN, Pulm HTN, AF, [**Hospital **]
transferred from [**Hospital 8**] hospital for further
evaluation/management of worsening stridor. Patient was
initially admitted to OSH on [**6-11**]. He presented complaining of
back pain and dysuria, and was found to have a Klebsiella
urinary tract infection, with ? urosepsis as well as ARF (Cr 2.7
from baseline 1.7). He was initially admitted to the ICU. During
his stay, he developed worsening stridor. Per report, he was
started on Solumedrol empirically. He evaluated first with a
chest/neck CT, which showed ? bronchomalacia, but no obvious
parenchymal disease. A laryngoscopy performed by ENT was
negative by report. He had bronchoscopy on the day of transfer,
which demonstrated moderate tracheal occlusion and significant
edema in the proximal [**12-30**] of the trachea (?extrinisc compression
vs malacia), RMSB with 50% circumferential/extrinsic occlusion
at the orfice, and 30% LMSB narrowing. There was moderate
mucous, but no endobronchial lesion or foreign body. He had been
treated with Solumedrol, and nebulizers, but did not tolerate
Heliox by facemask. He was transferred to [**Hospital1 18**] for further
management by interventional pulmonary.
Past Medical History:
CRI- baseline Cr 1.7, Unknown etiology
Paroxysmal A fib
HTN
Pulm HTN
Hypercholesterolemia
DM2
Hepatic steatosis
Osteroarthritis
Social History:
no significant tob use, no drugs. Married.
Family History:
Non-contributory
Physical Exam:
PE - VS 96.0 69 130/58 18 100% FM
GEN - obses man, sitting upright, slight resp distress, audible
stridor, able to speak [**1-30**] words
SKIn- slightly diaphoretic, warm
HEENT - no JVD, PERRL, OP dry
COR - RRR, no m/r/g
PULM - diffuse inspiratory stridor, no audible rales
ABD - obsese, soft, NT, ND
Extr - WWP, no edema
NEURO - grossly intact, MAE x 4
Pertinent Results:
Bronchoscopy at OSH:
50% external compression of left main bronchus
70% external compression of right main bronchus
CT Chest: No evidence of external compression of the bronchi,
evidence of tracheobronchomalacia.
.
Transthoracic ECHO: [**2189-6-17**] Conclusions:
1. The left atrium is dilated.
2. Left ventricular wall thickness, cavity size, and systolic
function are normal (LVEF>55%). Regional left ventricular wall
motion is normal.
3. The ascending aorta is mildly dilated. There are simple
atheroma in the descending thoracic aorta.
4. The aortic valve leaflets are mildly thickened. Mild (1+)
aortic
regurgitation is seen.
5. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**12-29**]+) mitral regurgitation is seen.
6. No evidence for endocarditis seen.
.
[**2189-6-24**]: CT scan chest/abdomen/pelvis with contrast:
IMPRESSION:
1. Multilobulated right pleural-based mass without significant
enhancement, local invasion or associated thoracic
lymphadenopathy. No primary neoplasm identified elsewhere within
the torso. This may represent post- infectious sequelae,
mesothelioma, nerve sheath tumor or metastatic disease from
unknown primary. If clinically indicated, biopsy could be
performed.
2. No significant change in distal sigmoid colonic wall
thickening.
3. Cholelithiasis without evidence of cholecystitis.
.
Labs:
[**2189-6-25**] 05:47AM BLOOD WBC-18.4* RBC-3.38* Hgb-10.3* Hct-29.2*
MCV-86 MCH-30.6 MCHC-35.5* RDW-16.4* Plt Ct-126*
[**2189-6-19**] 03:38AM BLOOD WBC-11.1* RBC-3.04* Hgb-9.1* Hct-27.2*
MCV-89 MCH-29.9 MCHC-33.5 RDW-15.8* Plt Ct-178
[**2189-6-16**] 09:23PM BLOOD WBC-18.0* RBC-3.11* Hgb-9.4* Hct-27.7*
MCV-89 MCH-30.3 MCHC-34.0 RDW-15.8* Plt Ct-180
[**2189-6-21**] 06:30AM BLOOD Neuts-95* Bands-0 Lymphs-2* Monos-1*
Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-1*
[**2189-6-25**] 05:47AM BLOOD PT-13.3* PTT-32.7 INR(PT)-1.2*
[**2189-6-21**] 08:47PM BLOOD PT-14.6* PTT-63.5* INR(PT)-1.3*
[**2189-6-22**] 05:49AM BLOOD FDP-10-40
[**2189-6-22**] 05:49AM BLOOD Fibrino-463*
[**2189-6-25**] 05:47AM BLOOD Glucose-100 UreaN-43* Creat-1.7* Na-135
K-3.7 Cl-98 HCO3-29 AnGap-12
[**2189-6-18**] 03:16AM BLOOD Glucose-143* UreaN-126* Creat-3.5* Na-138
K-3.5 Cl-101 HCO3-22 AnGap-19
[**2189-6-24**] 05:39AM BLOOD ALT-82* AST-158* LD(LDH)-652*
AlkPhos-136* TotBili-1.2
[**2189-6-18**] 03:16AM BLOOD Lipase-172*
[**2189-6-17**] 03:37AM BLOOD CK-MB-17* MB Indx-2.3 cTropnT-0.12*
[**2189-6-16**] 09:23PM BLOOD CK-MB-20* MB Indx-2.4 cTropnT-0.13*
[**2189-6-25**] 05:47AM BLOOD Calcium-7.5* Phos-2.8 Mg-2.3
[**2189-6-22**] 05:49AM BLOOD Hapto-109
[**2189-6-20**] 05:54AM BLOOD calTIBC-191* Ferritn-1826* TRF-147*
[**2189-6-18**] 03:16AM BLOOD Ammonia-41
[**2189-6-17**] 12:13AM BLOOD PTH-182*
[**2189-6-19**] 04:20AM BLOOD Type-ART pO2-109* pCO2-50* pH-7.34*
calHCO3-28 Base XS-0
[**2189-6-23**] 12:29PM BLOOD Lactate-1.0
[**2189-6-18**] 07:40PM BLOOD freeCa-1.12
Brief Hospital Course:
79M initially transferred from OSH for interventional pulmonary
evaluation of worsening inspiratory stridor, which was later
identified as tracheobronchomalacia. Other issues included
renal failure and metabolic derangement, resolving MSSA
bacteremia. His current issues include a pleural based lung
mass, anemia with occult positive stool, infections, hepatitis
and paroxismal Afib.
.
A. Pleural based mass: Please see attached CT reports. This
pleural based mass on the right was stable on his various CT
scans. Radiology was concerned about it being a multilobulated
right pleural-based mass without significant enhancement, local
invasion or associated thoracic lymphadenopathy. No primary
neoplasm identified elsewhere within the torso. This may
represent post- infectious sequelae, mesothelioma, nerve sheath
tumor or metastatic disease from unknown primary. If clinically
indicated, biopsy could be performed. Question as whether this
is an old finding or a more recent one. Of note, his
respiratory status is stable on room air at time of transfer.
.
B. Tracheobronchomalacia/COPD: On initial arrival, patient had
severe stridor concerning for urgent requirement of intubation.
However, continuous bronchodilator treatment overnight induced
near complete resolution of the stridor, and urgent intubation
was not required. On hospital day two, however, pt was
intubated for airway protection given continued poor mental
status and underwent bronchoscopy at that time which revealed no
airway stenosis or external compression without significant
tracheobronchomalacia. Following stabilization, pt was
extubated and again required continuous bronchodilator therapy
(including racemic epinephrine) as well as corticosteroids as
empiric therapy for restrictive airway disease, with ultimate
resolution of stridor. Therefore, it was felt that pt most
likely had bronchospasm as a result of his metabolic derangement
and renal insufficiency/uremia. He has been stable on room air
for several days now with nebulizer treatments written prn. The
steroids are being tapered by 10mg of prednisone per day as his
respiratory status has been stable and there is a concern for
multiple infections including sigmoid colitis. He is currently
on 40mg.
.
C. Infections: His WBC had trended down to about 11 but has
risen back up slowly to 18. This can partly be attributed to
the steroid treatment, but also is concerning for infection.
1. CT scan showed sigmoid colitis (please see attached
reports). We do not think this is ischemic colitis as he was
ruled out with a normal lactate and bicarb. Of note he was
occult blood positive and complained of abdominal pain
especially when defecating. He is being treated empirically for
C Diff (antigen negative x2 thus far) and for gram negative
coverage with levoquin started today [**2189-6-25**]. Given his recent
high doses of steroids and his colitis, would have a low
threshold for examining for free air if his abdominal pain
worsens.
2. MSSA Bacteremia: Per report, 12/12 bottles at OSH and started
on nafcillin on [**2189-6-15**], though no positive surveillance
cultures here. Remained hemodynamically stable, no septic
physiology and afebrile. Both TTE and TEE (performed while
intubated) were negative for endocarditis. No evidence for
septic emboli on complete CT chest/abdomen/pelvis. Pt had
initially complained of back pain on admission to OSH, however
denied this when he arrived here, so no search for epidural or
paraspinal abscesses was made. Therefore, the source remains
unknown for this infection. Would continue the nafcillin for
4-6weeks.
3.Concern about the right pleural based mass is- does it
represent an infectious source or malignancy? See discussion
above.
.
D. Acute on Chronic Renal Failure: Creatinine 2.7, FeNa 1.2%,
no Eos on smear, and bland sediment. From chronic renal
insufficiency (Cr 1.7), but was thought to have developed acute
tubular necrosis, though the etiology was unclear.
Nevertheless, uremia was felt to be the primary etiology of
patient's poor mental status as well as partial contributor to
bronchospasm. Patient did require phos binders. His renal
function has returned to it's original state with a Cr of 1.7.
He was started in epoetin 4000 units SC qMWF.
.
E. Heptatitis: No known Hx liver disease, Hep serologies show
HBsAg HBsAb HBcAb HAV Ab IgM HAV
NEGATIVE POSITIVE POSITIVE POSITIVE
HEPATITIS C SEROLOGY HCV Ab
NEGATIVE
Hep B e antigen/antibodies were not evaluated during inpatient
admission, but should be followed. His liver enzymes are
remaining high at
ALT AST LD(LDH) AlkPhos TotBili
82* 158* 652* 136* 1.2
.
F. Anemia/mild thrombocytopenia: On coumadin, though held
throughout OSH stay. Given FFP for central line placement. No
evidence of DIC. His warfarin is still being held but he has
been continued on aspirin. He had occult blood positive stool.
And GI was consulted and suggested follow up after infection in
colon calms down. His Hct dropped to a low of 23 and he was
transfused two units of packed RBC. Would stop the ASA if his
bleeding continues. Warfarin is still being held.
.
G. UTI: Klebsiella UTI at OSH, however negative UA/UCx here,
felt to be resolved on arrival.
.
H. Coronary artery disease: Not active during this admission,
however continued ASA, lipitor, but held beta blocker for
concern of bronchospasm.
I. Paroxysmal atrial fibrillation: Remained in sinus for most
of MICU course with RBBB and LAFB. On the floor, he was placed
on telemetry and had multiple episodes a day of short lasting
afib with tachycardia. His diltiazem was increased to 120mg
daily to help rate control him. His warfarin is being held
secondary to his bleeding and his occult positive stool. GI
consult here suggeted that he will need GI follow up when the
infection clears. Will need to find out when to restart
warfarin if origin of bleed remains unknown.
.
J. DM2: Glyburide discontinued given renal failure. His sugars
were quite high given the steroids and infections. He is
currently controlled to blood sugars in the 100's with NPH at
5units AM and PM and Humalog 4 units before meals. In addition,
he had a sliding scale of Humalog if needed.
The patient insisted on transfer back to [**Hospital 8**] Hospital for
the remainder of his acute hospitalization and ongoing care.
This request was discussed with his primary care physician, [**Name10 (NameIs) **]
[**Last Name (STitle) 1355**] at [**Hospital 8**] Hospital, who agreed to the transfer.
Although a number of issues remain unresolved at the time of
transfer, they were communicated directly with Dr [**Last Name (STitle) 1355**] to
optimize continuity of care. Although the patient was stable at
the time of transfer, sitting in a chair without complaints,
eating, conversing, and feeling subjectively improved, a number
of diagnostic and therapeutic interventions remain pending in
his clinical care.
Medications on Admission:
Nafcillin 2g q 4h x 4 weeks (start [**6-15**])
Solumedrol 80 tid
Atrovent/albuterol nebs
Heliox
Dilt 30 po tid
Lopressor 50 q6
Morphine
Colace
Senna
ASA 325
Lipitor 80 qd
Tylenol 650 prn
MEDS at home include
coumadin 5mg qd
glyburide 5mg [**Hospital1 **]
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
6. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
8. Albuterol 90 mcg/Actuation Aerosol Sig: 6-8 Puffs Inhalation
Q4-6H (every 4 to 6 hours) as needed.
9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
10. Racepinephrine 2.25 % Solution for Nebulization Sig: One (1)
ML Inhalation Q4H (every 4 hours) as needed.
11. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
12. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
13. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
14. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every
6 hours) as needed.
15. Diltiazem HCl 60 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
16. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Five
(5) units Subcutaneous twice a day.
17. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
18. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
19. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
20. Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: Two (2)
Intravenous Q4H (every 4 hours).
21. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Acute on chronic renal failure
Uremia with mental status changes
Acute bronchospasm, reactive airways
Staphylococcus aureus bacteremia with unknown source
Sigmoid colitis
Pleural based mass on right
Mild thrombocytopenia
Discharge Condition:
Stable. Respiratory status stable on room air.
Discharge Instructions:
Transfer to [**Hospital 8**] Hospital under the care of Dr. [**Last Name (STitle) 1355**].
.
Please see discharge summary for specific instructions.
Patient has Foley cath in place.
Followup Instructions:
He will need follow up with nephrology for his chronic renal
failure.
He will need follow up with Gastroenterology for the occult
blood in his stool and for resolution of his colitis.
Completed by:[**2189-6-25**]
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"416.8",
"493.20",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"88.72",
"99.04",
"38.93",
"96.71",
"96.04",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
14366, 14381
|
5246, 12207
|
274, 418
|
14646, 14696
|
2319, 5223
|
14926, 15141
|
1911, 1929
|
12514, 14343
|
14402, 14625
|
12233, 12491
|
14720, 14903
|
1944, 2300
|
227, 236
|
446, 1683
|
1705, 1835
|
1851, 1895
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,215
| 181,872
|
42924
|
Discharge summary
|
report
|
Admission Date: [**2110-9-4**] Discharge Date: [**2110-9-8**]
Date of Birth: [**2027-11-2**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
pituitary mass
Major Surgical or Invasive Procedure:
[**2110-9-4**] Transphenoidal resection of Pituitary adenoma
[**2110-9-4**] Lumbar Drain
History of Present Illness:
[**Known firstname 92640**] [**Known lastname 1794**] is an 82 yo LH woman with PMHx of DM2, HTN
and HL who represents for reevaluation of a 1.6cm pituitary
mass.
The patient was initially seen in [**6-14**] for experiencing
headaches, nausea and dizziness and went to [**Hospital 1281**] Hospital where
she had an MRI that showed the above mass.
At that time she also began to notice intermittent eye pain and
L
eye blurry vision, which has remained relatively stable. Her
nausea and dizziness improved after her hospitalization and she
was subsequently diagnosed with "vertigo" by a neurologist when
she had a "positive head turning test" that sounds c/[**Initials (NamePattern5) **]
[**Last Name (NamePattern5) **]-Hallpike maneuver. Please see our last OMR note.
Her headaches are annoying and localize tothe L side, pounding
and occasionally sharp and can occur at any time of day. She
treats them with tylenol prn.
Past Medical History:
- HTN
- HL
- DM2
- osteoporosis
- arthritis; needs bilateral shoulder surgery for "bone on bone"
arthritis
- 4.8cm ascneding aortic aneurysm, currently being followed with
Q6 month scans as pt refused surgery
- s/p CCY
- s/p appy
- s/p R knee repair surgery
Social History:
Patient is a home maker, has 1 daughter and 2
grandchildren. She smoked for over 40 years and quit 8 years
ago. She denies EtOH or illicits.
Family History:
mother died at age 78 of asthma, father died at age 85
of pulmonary edema.
Pt with one sister who died at 60 from an MI and a brother who
died in his 70's of a heart attack. Pt's daughter has a heart
valve problem.
Physical Exam:
AF VSS
Gen: WD/WN, comfortable, NAD.
HEENT: OP clear, Snellen Card vision: 20/40 in L eye and 20/20
in
R eye. Fullophtalmology exam in OMR>
Very mild L facial swelling without erythema, throughout cheek
and temple area
Neck: Supple.
Lungs: no SOB bilaterally.
Cardiac: RRR. slight syst murmur
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect. Follows complex commands, but sometimes needs multiple
instructions to complete the task.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils: both briskly reactive, visual fields are full to
confrontation and to finger wiggling.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-7**] throughout although unable to
test trapezius as pt has "too much shoulder pain" because of her
arthritis. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right 2 2 2 0 1
Left 2 2 2 1 1
(of note pt has had R knee repair)
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements
On discharge:
AVVS
NAD
CNII-XII intact
no focal or diffuse nuerologic deficits
normal gate
no drainage from nasal cavity
extremities wwp, 2+ cr
Pertinent Results:
[**9-4**] MRI Brain- IMPRESSION: Similar appearance of the known
pituitary adenoma. Otherwise, no acute intracranial process.
[**9-4**] CT Head- IMPRESSION:
Postoperative changes related to transsphenoidal hypophysectomy,
as described above. Low density material in the resection bed.
High density fluid in the nasopharynx and right maxillary sinus,
likely represents a small hemorrhage. Small amount of
pneumocephalus.
[**2110-9-7**] 05:30AM BLOOD WBC-9.9 RBC-3.74* Hgb-10.8* Hct-33.3*
MCV-89 MCH-28.8 MCHC-32.4 RDW-14.5 Plt Ct-266
[**2110-9-8**] 05:25AM BLOOD Na-137 K-4.2 Cl-103
[**2110-9-7**] 05:30AM BLOOD Glucose-86 UreaN-12 Creat-0.6 Na-141
K-3.6 Cl-106 HCO3-25 AnGap-14
[**2110-9-6**] 09:00PM BLOOD Na-141 K-3.6 Cl-108
[**2110-9-6**] 11:59AM BLOOD Osmolal-293
[**2110-9-6**] 01:10AM BLOOD Osmolal-296
[**2110-9-5**] 08:01PM BLOOD Osmolal-289
[**2110-9-7**] 06:31AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011
[**2110-9-6**] 11:59AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.002
[**2110-9-6**] 06:43AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006
[**2110-9-7**] 06:31AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-7.0 Leuks-NEG
[**2110-9-6**] 11:59AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2110-9-6**] 06:43AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2110-9-7**] 06:31AM URINE Hours-RANDOM Na-144 K-25 Cl-144
[**2110-9-6**] 08:59PM URINE Osmolal-586
[**2110-9-6**] 11:59AM URINE Osmolal-184
[**2110-9-6**] 06:43AM URINE Osmolal-400
Brief Hospital Course:
Pt was admitted for elective transphenoidal resection of a
nonfunctioning pituitary adenoma. ENT assisted in the
transnasal approach and a nasal trumpet and nasal packing were
placed. A lumbar drain was also placed to prevent CSF leak due
to the quality of the dura at closing. Postoperatively she was
extubated and transfered to the PACU. She did well and remained
neurologically intact. Urine output, Urine chemistries and
Serum Sodium were monitored closely for signs of DI.
Endocrinology was consulted. The lumbar drain had a goal
drainage of 30ml Q2hrs and she was kept on bedrest with bathroom
privledges. On [**9-5**] she was neurologically intact and the lumbar
drain was functioning well. All labs remained WNL. On [**9-6**] the
hydrocortisone was discontinued and she was started back on her
home dose of prednisone. In the evening her lumbar drain was
clamped.
On [**9-7**] the patient was again stable and did not have any sign of
drainage from her nose. The lumbar drain was removed without
complication. She was seen by physical therapy who recommended
discharge to acute rehab.
On [**9-8**] she had stable labs and exam. She was cleared for
discharge to home by physicial therapy.
Medications on Admission:
prednisone 17mg, omeprazole, colace, vit d, tylenol, nifedipine,
asa, calcium with vit D
Discharge Medications:
1. Acetaminophen-Caff-Butalbital 2 TAB PO Q4H:PRN headache
RX *Fioricet 50 mg-325 mg-40 mg 2 tablet(s) by mouth Q4HR Disp
#*60 Tablet Refills:*0
2. Bisacodyl 10 mg PO/PR DAILY constipation
3. Docusate Sodium 100 mg PO BID
4. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**2-3**] tablet(s) by mouth q4hr Disp #*60 Tablet
Refills:*0
5. PredniSONE 17 mg PO DAILY
start [**2110-9-6**]
RX *prednisone 10 mg 1.5 tablet(s) by mouth daily Disp #*45
Tablet Refills:*0
RX *prednisone 2.5 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
6. Senna 1 TAB PO BID constipation
7. Famotidine 20 mg PO BID
8. Outpatient Lab Work
Serum Na
Discharge Disposition:
Home With Service
Facility:
Multicultural VNA
Discharge Diagnosis:
Pituitary Adenoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Continue Sinus Precautions for an additional two weeks. This
means, no use of straws, forceful blowing of your nose, or use
of your incentive spirometer.
?????? If you have been discharged on Prednisone, take it daily as
prescribed. If on any day, you are ill, take the prednisone as
you have been instructed by the endocrine team.
?????? If you are required to take Prednisone, an oral steroid, make
sure you are taking a medication to protect your stomach
(Prilosec, Protonix, or Pepcid), as this medication can cause
stomach irritation. Prednisone should also be taken with a
glass of milk or with a meal.
CALL YOUR DOCTOR 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.
?????? It is normal for feel nasal fullness for a few days after
surgery, but if you begin to experience drainage or salty taste
at the back of your throat, that resembles a ??????dripping??????
sensation, or persistent, clear fluid that drains from your nose
that was not present when you were sent home, please call.
?????? Fever greater than or equal to 101?????? F.
?????? If you notice your urine output to be increasing, and/or
excessive, and you are unable to quench your thirst, please call
your endocrinologist.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with your
surgeon, Dr. [**Last Name (STitle) **], to be seen in two months. You will need an
MRI with contrast of the brain prior to this appointment.
?????? You have a couple staples in your back that need to be
removed around [**9-14**]. This can be done at your rehab facility or
by your PCP. [**Name10 (NameIs) **] there are questions or concerns please have them
call [**Telephone/Fax (1) 1669**].
??????Please call ([**Telephone/Fax (1) 5120**] to schedule Formal Visual Field
Testing to be done before you are seen in follow-up with your
surgeon. The Ophthalmology department is located on the [**Hospital Ward Name **] in the [**Hospital Ward Name 23**] building, [**Location (un) 442**].
?????? You have an appointment with Endocrinology scheduled with
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2110-9-15**] 11:20
?????? You will need to have the following labs checked ****
Completed by:[**2110-9-10**]
|
[
"E878.6",
"227.3",
"997.09",
"250.00",
"733.00",
"401.9",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"07.65",
"03.09",
"86.90"
] |
icd9pcs
|
[
[
[]
]
] |
7632, 7680
|
5606, 6808
|
322, 413
|
7742, 7742
|
3908, 5583
|
10065, 11165
|
1827, 2045
|
6947, 7609
|
7701, 7721
|
6834, 6924
|
7893, 10042
|
2060, 2422
|
3757, 3889
|
267, 284
|
441, 1368
|
2764, 3743
|
7757, 7869
|
1390, 1650
|
1666, 1811
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,200
| 199,274
|
21637
|
Discharge summary
|
report
|
Admission Date: [**2136-10-8**] Discharge Date: [**2136-11-4**]
Date of Birth: [**2072-8-23**] Sex: M
Service: HEPATOBILIARY SURGERY SERVICE
HISTORY OF PRESENT ILLNESS: A 64 year old male who underwent
a low anterior resection with coloproctostomy on [**2133-1-16**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for grade 2 adenocarcinoma of the
colon who had free margins of resection free of tumor of 0
out of 12 lymph nodes that were positive, developed sternal
chest pain. On further evaluation including laboratory
studies patient was noted to have an elevated CEA and
abdominal ultrasound performed on [**2136-7-13**] demonstrated
two heterogenous masses in the right lobe of the liver
measuring 7.3 x 6.3 x 5.5 cm and 6.1 x 5.8 x 4.7 cm. Patient
underwent a CT guided liver biopsy that was interpreted as
adenocarcinoma consistent with colonic origin. Patient also
had a PET scan on [**2136-8-6**] that demonstrated two large foci
of a hypermetabolic activity in the right lobe of the liver
consistent with hepatic metastasis. There was also a large
bone metastasis. Patient underwent a CT guided biopsy of the
sternum on [**2136-8-17**] which was read as no adenocarcinoma. On
[**2136-8-22**] patient underwent CT scan of the chest and abdomen.
The chest CT demonstrated one solitary pulmonary nodule in
the superior segment of the right lobe at the level of the
carina approximately 3 to 4 mm in diameter and it was not
determined whether it was granuloma versus metastasis. Three
month follow up was suggested and the CT scan of abdomen
demonstrated a lesion on the dome of the right lobe of the
liver posteriorly. The lesion contained some calcification
and there was some faint enhancement of the more medial
aspect. Directly inferior to this there was almost
inseparable another mass with another poorly marginated area
of irregularly decreased attenuation of the multiple foci of
the peripheral enhancement which measured 4.5 cm in diameter.
A third lesion was seen in the anterior inferior adjacent to
the gallbladder measuring 3.5 cm in diameter. On [**2136-9-11**] a
repeat CT guided biopsy of the sternum was obtained and it
was confirmed the diagnosis of adenocarcinoma consistent with
colonic origin.
PAST MEDICAL HISTORY: Hypertension, subarachnoid hemorrhage,
lung cancer, status post resection.
ALLERGIES: Penicillin.
MEDICATIONS: Zestril 20 mg P.O. q day.
SOCIAL HISTORY: Drinks two beers per day. Does not smoke
cigarettes. No history of intravenous drug use, marijuana
use, blood transfusions, tattoos, hepatitis or piercing.
Patient is married and has two children ages 34 and 36
currently on disability.
FAMILY HISTORY: Father who died at 92 of diabetes. Mother
who died at age 83 of lung cancer.
PHYSICAL EXAMINATION: On presentation patient's vitals were
blood pressure 142/70, pulse 60, respiration of 15,
temperature 96.7. Patient weighed 182 pounds and height was
5 feet, 10 inches. Patient was a well developed, well
nourished male who appeared much younger than his stated age.
Carotids are 2 plus and 4 plus without bruits. Lungs were
clear to auscultation and percussion. Patient with normal
S1, S2, no S3, S4, murmurs or rubs, regular rate and rhythm.
Abdomen was benign. No edema was noted peripherally.
Patient's CEA was 31, AFP was 4.5, creatinine of 0.7, TBA of
0.7. Patient was determined to have a metachronous
metastatic adenocarcinoma of the colon to the liver and
patient was consented for the right hepatic lobectomy as well
as the sternal resection.
HOSPITAL COURSE: The patient underwent both procedures.
Patient remained afebrile with stable vital signs on a drip
of Neo-Synephrine and propofol as well as continuing to be
intubated with CPAP with good gases and postoperative
patient's hematocrit was 33.2 postoperatively with creatinine
of 0.6. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**] [**Last Name (NamePattern1) 12828**] were putting out
serosanguineous fluid and the patient was kept sedated
overnight. The Neo-Synephrine was weaned off and patient was
continued on CPAP to re-extubate in the morning and kept NPO
and managing good urine output overnight night and continuing
levofloxacin and Flagyl. On postoperative day number one
patient was weaned and extubated. Patient's pain was well
controlled. The chest tubes were put to water seal,
continued the levofloxacin and Flagyl and urine output was
continued to be monitored. Patient continued to stay in the
Intensive Care Unit. On postoperative day number two patient
received some bolus for low urine output. The patient's
propofol was completely stopped. Epidural was stopped
because it was not helping. The patient actually failed to
extubate because of fluctuating respiration. However,
patient's gases remained stable and chest tube was continued
on suction. Neo-Synephrine were decreased. Patient was kept
NPO and urine output was continued to be monitored. On
postoperative day number three the patient was extubated
without any difficulty. The day prior patient was weaned off
of Neo-Synephrine and patient was on intermittent intravenous
Dilaudid for pain. Patient's chest physical therapy was
continued. Patient was put on clears to advance to regular.
Patient was started on some Lasix and he was continued on
levofloxacin and Flagyl. On postoperative number four
patient continued to remain afebrile with stable vital signs
and was neb negative about 500 cc but continues to be
edematous. Patient was changed to P.O. pain medication and
was put on a regular diet, out of bed and ambulating and
continues to be diuresed with Lasix and continued on
levofloxacin and Flagyl. On postoperative day number five
the patient continued to do well, was transferred to the
floor, remained afebrile with stable vital signs with a
significant amount of [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] output which are
continued as well as chest tube output. Patient's hematocrit
stabilized at 33 and TBA was at 1.3. AST and ALT were down
to 70 and 119. On postoperative day number six the patient
remained afebrile with stable signs and continued to have a
significant edema and significant output from the chest tube
and the [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 12828**] were draining clear ascitic fluid as
well. Patient's sodium decreased that day but remained
within reasonable range. On postoperative day number 7,
however, the patient had significant drop in the sodium to
124 from 129. The next day they dropped another drop to 119.
The patient was then transferred to the Intensive Care Unit
setting and placed on a 3 percent sodium solution. Patient's
diuresis was stopped and the patient has frequent sodium
checks to ensure that there is no continuation in drop in the
sodium. The patient's chest tubes were removed and [**Initials (NamePattern4) 228**]
[**Last Name (NamePattern4) 1661**] [**Last Name (NamePattern1) 12828**] were continued for high output. On
postoperative day number nine patient's sodium came up slowly
to 128 and postoperative day number 10 came up to 131 and
patient was then transferred back to the floor. Patient
continued to have some drainage from the [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**].
[**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] number two was removed and the area was
stitched and drains number three and one were continued. On
postoperative day 13 the patient remained afebrile with
stable vital signs and taking good P.O. Patient continues to
have [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] output and from one of the areas where the
[**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] was removed there was continual leak where an
ostomy bag was placed which put out approximately 1.3 liters.
Patient was continuously diuresed and continued to be
monitored. On postoperative day 14 patient remained afebrile
with stable vital signs. Patient continued to have
significant output from the drain and there was also an
opening at the sternal wound edges where the thoracic service
recommended placement of VAC dressing which was performed to
allow for good healing of that wound. Patient also had an
ultrasound of the liver to look for portal vein thrombosis
which showed that there is no thrombosis of the portal vein
or superior mesenteric artery. On postoperative day 15
patient remained afebrile with stable vital signs making good
urine. Patient's sodiums continued to be stable. Patient
also had a MR scan which was negative for any signs of
thrombosis of the portal vein. On postoperative day number
17 the patient continued to remain afebrile with stable vital
signs. Two of the [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 12828**] were removed and one
remaining [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] with about 15 cc of drainage which
was later removed. All of the sites were stitches.
Patient's sodium remained stable with stable hematocrit and
creatinine stable around 0.6 and continued to be diuresed.
On postoperative day number 19 patient had good urine output
and remained afebrile with stable vital signs with stable
sodium at 137 and on postoperative day 17 patient remained
afebrile with stable vital signs making good urine.
Patient's sternal wound was healing well. On postoperative
day number 21 patient remained afebrile with stable vital
signs making good urine and improvement in the edema.
Patient's sodiums remained stable at 135, hematocrit of 36
and creatinine of 0.6.
On postoperative day number 22 patient was taken to the
operating room for the removal of the [**Doctor Last Name 4726**]-Tex that was
placed in the original sternal resection and the debridement
of the sternum with pectoral flap advancement. The patient
was continued on VAC. Patient tolerated the procedure well
and was transferred to the floor from the operating room
after a brief stay in the post anesthesia care unit. The
patient remained afebrile with stable vital signs making good
urine. On postoperative day number 24 and postoperative day
2 patient had some drainage from one of the [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**]
sites which put to drain. Then later it was switched back
again. On postoperative day 26 and 4 patient remained
afebrile with stable vital signs. Patient's VAC was
continued and was switched to home VAC and patient had a
stable sodium at 137 and patient was tolerating P.O. without
any difficulties. On postoperative day 27 and 5 patient
remained afebrile with stable vital signs with good urine
output. Patient was continued on Lasix. Patient's sodium
tablet was stopped and patient's sodium remained stable at
138. Patient was then discharged home in good condition with
[**Hospital6 407**].
FINAL DIAGNOSES: Status post colon cancer with metastasis to
liver.
Status post right hepatic lobectomy.
Status post sternal resection with [**Doctor Last Name 4726**]-Tex prosthesis.
SIADH.
Sternal post sternal debridement and pectoralis major flaps.
Hypertension.
DISCHARGE MEDICATIONS: Foley catheter 1 mg P.O. q day,
thiamine 100 mg P.O. q day, multivitamin 1 capsule P.O. q
day, Protonix 40 mg P.O. q day, levofloxacin 500 mg P.O. q
day, Vicodin 1 to 2 tablets q 4 to 6 hours PRN pain, Lasix 40
mg P.O. B.I.D
FOLLOW UP PLANS: Patient will please follow with Dr. [**Last Name (STitle) **]
on [**2136-11-7**] at 1:30 P.M. at [**Hospital Ward Name **] Transplant Center and
please follow up with [**Doctor Last Name **]. Please call for appointment.
DISCHARGE CONDITION: Good.
DISPOSITION: Home with services.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD,PHD[**Numeric Identifier **]
Dictated By:[**Doctor Last Name 6052**]
MEDQUIST36
D: [**2136-11-4**] 20:07:13
T: [**2136-11-4**] 22:20:51
Job#: [**Job Number 56943**]
|
[
"996.67",
"198.5",
"998.32",
"V10.05",
"198.89",
"197.7",
"571.8",
"401.9",
"253.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.79",
"78.41",
"77.81",
"93.59",
"78.61",
"99.04",
"83.82",
"38.93",
"50.3",
"51.22",
"50.22"
] |
icd9pcs
|
[
[
[]
]
] |
11793, 12103
|
2720, 2799
|
11304, 11771
|
3601, 11012
|
11030, 11280
|
2822, 3583
|
191, 2282
|
2305, 2447
|
2464, 2703
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,538
| 195,067
|
45298
|
Discharge summary
|
report
|
Admission Date: [**2185-5-18**] Discharge Date: [**2185-5-25**]
Date of Birth: [**2114-5-27**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
carotid stenosis right.
Major Surgical or Invasive Procedure:
R CEA with stent
History of Present Illness:
70 y.o male with 80 - 99 % r ight carotid stenosis, by doppler
Past Medical History:
HTN,
PAF,
HTN,
COPD,
PE [**3-29**],
CABG 4 vz
Social History:
pos tobacco
pos alcohol
Family History:
non contrib
Physical Exam:
male nad
Right surgical bandage over carotid
supple, farom
DHFT in place
neg lymphandopathy, supra clavicular nodes
cta
rrr
benign
neg c/c/e
palp fem/dp/pt b/l
Pertinent Results:
[**2185-5-25**]
WBC-9.6 RBC-3.64* Hgb-11.9* Hct-34.3* MCV-94 MCH-32.7* MCHC-34.7
RDW-14.5 Plt Ct-236
[**2185-5-25**]
PT-13.2 PTT-47.5* INR(PT)-1.2
[**2185-5-25**]
Glucose-81 UreaN-26* Creat-0.7 Na-141 K-3.6 Cl-105 HCO3-25
AnGap-15
[**2185-5-25**]
Calcium-9.2 Phos-3.3 Mg-2.1
[**2185-5-25**]
VIDEO OROPHARYNGEAL SWALLOW: Study is performed in conjunction
with speech and swallow therapy. Various consistencies of barium
were administered orally. The patient demonstrated a moderate to
large amount of aspiration with both thin and nectar thick
liquids. There was an effective but inconsistent spontaneous
cough response. The aspiration occurred during and following
swallowing. There is premature spillage of liquids to the level
of the valleculae. There is minimally diminished laryngeal
elevation and there is normal epiglottic deflection. There is a
small to moderate amount of residue within the piriform sinuses.
There is a suggestion of narrowing in the region of the
pharyngeal esophageal junction, which was difficult to evaluate
due to patient positioning.
IMPRESSION:
1) Aspiration of liquid consistencies with effective but
inconsistent spontaneous cough response.
2) Possible narrowing in the region of the pharyngoesophageal
junction. This was difficult to evaluate due to patient
positioning. If direct visualization is not being considered,
than AP and lateral soft tissue radiographs of the neck could be
performed for further evaluation.
[**2185-5-20**]
EKG
Atrial fibrillation with rapid ventricular response
Left axis deviation - anterior fascicular block
Old anteroseptal infarct
Possible biventricular hypertrophy
Since previous tracing of [**2177-2-24**], atrial fibrillation is new
Intervals Axes
Rate PR QRS QT/QTc P QRS T
108 0 102 362/[**Telephone/Fax (2) 96774**]
RADIOLOGY Final Report
[**2185-5-19**]
CHEST (PORTABLE AP)
Reason: RESPIRATORY DISTRESS
Portable chest film shows the lungs to be clear without evidence
of pulmonary edema. Post surgical changes with mediastinal wires
and clips.
CONCLUSION: Clear lungs. No evidence for pulmonary edema.
Brief Hospital Course:
pt admitted [**5-18**]
{Pt pre-oped )
pt undergoes rt CEA with stent and selective carotid angiogram.
The stent was placed due to very high bifurcation and plaque
extension. Pt tolerated the procedure well. . Pt transfered to
the PACU in stable condition.
[**2185-5-19**]
Pt found to have hematoma over surgical site. Slight difficulty
breathing It was also found that the pt's tongue deviates to the
right, slightly swollen. Pt started on steroids. Anesthesia
feels that he did not need to reintubated. Pt transfered to the
SICU for observation.
[**2185-5-20**]
Pt feeling better. Pt transfered to th VICU. Still c/o
difficulty swallowing. Nitro weaned off, home meds started.
A-line dc'd.
Pt recieves levonex bridge untill coumadin restarted for PE.
Dr [**Last Name (STitle) 3878**] from ENT to evaluate. Pt remained NPO. Speech and
swallow consult obtained. Likely neuropraxia of cranial nerve
XII and IX
[**2185-5-23**]
Pt fails speech and swallow study.
Coumadin started
[**2185-5-25**]
Pt fails video swallow. Pt recieves DHFT under flouro. Pt
requests to leave hospital with DHFT.
[**Name (NI) **] ENT, pt to follow up.
[**Name (NI) **] GI for PEG placement (pt on lovenox SQ ) would have to
reverse to have PEG tube placed. Recommended to have pt
readmitted under Dr [**Last Name (STitle) **] service, have pt reversed off
coumadin and leovenox. Then Cosult GI for PEG placement.
Medications on Admission:
Gabapentin
Ambien
Cipro
Folic Acid
Discharge Medications:
1. Enoxaparin Sodium 100 mg/mL Syringe Sig: One (1)
Subcutaneous Q12H (every 12 hours): please stop when your INR is
2-2.5.
Disp:*14 100mg/ml* Refills:*1*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Warfarin Sodium 2.5 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)) for 1 doses: please take your usual
dose. Have your PCP [**Name9 (PRE) **] your INR.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
R carotid stenosis
tongue neuropraxia post / op (ix palsy)
difficulty swallowing post / op
Discharge Condition:
Stable
Discharge Instructions:
Please have your INR monitered. Goal is 2-2.5. You may restart
and take at your usual dose. When your INR is at goal, you may
stop your lovenox.
You have a dobbhoff feeding tube. You have to crush your meds
and take as directed.
If your feeding tube becomes clogged please go to the ER.
You also need to have a PEG placement. You have to be readmitted
for this. Call Dr [**Last Name (STitle) **] office and schedulae a date. The
reason for the readmission is that you need to come off your
coumadin and recieve heparin while you in the hospital.
You have a surgical incision. If this incision gets bigger,
becomes red, has discharge. Or if you experience fever and or
chills call Dr [**Last Name (STitle) 27977**] office immediatly.
You are taking lovenox, this is a bridge untill your INR becomes
2-2.5. You may have a tendacy to bleed. If you bleed at the
surgical site or get bruising please notify Dr [**Last Name (STitle) 3407**] or your
PCP.
Followup Instructions:
Please schedule an appointment with Dr [**Last Name (STitle) 3407**] in 1 week. His
number is [**Telephone/Fax (1) 1241**]. He may admit you for PEG placement. When
you call to make the appointment let him know this.
Call ENT. Number given. Make appointment with.
Have PCP [**Name9 (PRE) **] INR.
Completed by:[**2185-5-25**]
|
[
"412",
"401.9",
"496",
"E878.8",
"433.10",
"352.2",
"427.31",
"V45.1",
"998.12",
"997.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.61",
"00.63",
"88.41",
"38.12"
] |
icd9pcs
|
[
[
[]
]
] |
4852, 4909
|
2916, 4318
|
338, 357
|
5044, 5052
|
783, 2893
|
6053, 6383
|
575, 588
|
4403, 4829
|
4930, 5023
|
4344, 4380
|
5076, 6030
|
603, 764
|
275, 300
|
385, 449
|
471, 518
|
534, 559
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,122
| 110,131
|
24467
|
Discharge summary
|
report
|
Admission Date: [**2142-4-17**] Discharge Date: [**2142-4-20**]
Date of Birth: [**2100-6-2**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
41 y/o female, transferred from [**Hospital3 2783**] who fell
backwards off a 5foot stool while at work, striking her head.
+LOC at scene and was noted to be lethargic at [**Hospital1 **]. Patient has a known seizure disorder. At [**Hospital1 2436**], a
head CT was done showing a left occiptal fracture with a ? of an
adjacent small epidural bleed as well as right basilar skull
fractures. She was transferred to [**Hospital1 18**] for further
treatment/evaluation.
Past Medical History:
complex partial seizures--followed by Dr. [**Last Name (STitle) 16077**] @ [**Hospital1 336**].
Social History:
married with 2 children
denies EtOH,/tobacco/IVDU
last seizure [**2141-1-1**] while driving per Dr. [**Last Name (STitle) 16077**]
Family History:
non-contributory
Physical Exam:
on arrival in the trauma bay
Vitals: AF, 144/70 85, 19, 99% on RA
GEN: alert and oriented x 3, GCS 15, NAD, lying on board with
c-collar in place
HEENT: scalp laceration left posterior occiput, PERRL 3->2 mm,
EOMI, OP clear, midface stable, dentition intact
PULM: CTA bilaterally
CHEST: no crepitus
CV: regular, no murmurs
ABD: soft +BS, NTND, prior appendectomy scars
RECTAL: normal tone, guiac negative
PELVIS: stable to AP and lateral compression
BACK: NTTP, no stepoffs
BACK: right hip with ecchymosis, but NT
EXT: moving all 4, no signs of trauma
NEURO: CN II-XII intact, no focal motor or sensory deficits
Pertinent Results:
[**2142-4-17**] 08:00PM BLOOD WBC-14.0* RBC-4.37 Hgb-10.7* Hct-33.3*
MCV-76* MCH-24.4* MCHC-32.0 RDW-14.1 Plt Ct-189
[**2142-4-17**] 08:00PM BLOOD PT-12.7 PTT-25.0 INR(PT)-1.1
[**2142-4-19**] 07:15AM BLOOD Glucose-94 UreaN-7 Creat-0.5 Na-136
K-3.2* Cl-103 HCO3-23 AnGap-13
[**2142-4-19**] 07:15AM BLOOD Calcium-8.3* Phos-2.0* Mg-1.9
[**2142-4-17**] 08:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2142-4-17**] HEAD c-spine CT/CTA FINDINGS: There is no evidence of
intimal flap or intramural hematoma to suggest definite
dissection within both common carotid, internal carotid and
vertebral arteries.
There is a longitudinal fracture of the clivus extending from
the inferomedial clivus adjacent to the dens to the region of
the junction between the clivus and the petrous apex. This
fracture line may extend to foramen lacerum. The fracture line
passes immediately adjacent to the distal right vertebral artery
within the posterior fossa.
There is also a fracture of the right occipital condyle that
extends to the jugular foramen on the right. The fracture line
terminates in the right temporal bone in the region of the right
stylomastoid foramen.
There is also a fracture of the occipital bone that is
nondisplaced, running immediately to the left of midline.
No fractures are seen within the cervical spine vertebral
bodies, within the transverse foramina, and within the posterior
elements of the cervical spine.
CTA HEAD/CIRCLE OF [**Location (un) **]: Both anterior, middle and posterior
cerebral arteries are patent. There is again seen evidence of a
right frontal lobe contusion as well as probable
intraparenchymal hemorrhage within the left frontal lobe.
REFORMATTED IMAGING: Images reformatted in the coronal and
sagittal plane were essential in evaluating the patient's
cervical spine and show no evidence of fracture within the
cervical spine.
IMPRESSION:
1) No intramural hematomas or intimal flaps to suggest
dissection within both internal carotid and vertebral arteries.
Please note that additional reformatted imaging will be
performed at a separate date and an addendum will be issued.
2) Linear fractures of the clivus (with extension to the region
of foramen lacerum), the right occipital condyle, and the left
occipital bone, as described above.
[**2142-4-18**] T-L spine plain films
IMPRESSION: No thoracolumbar fracture identified.
[**2142-4-19**] MR CERVICAL SPINE [**2142-4-19**] 11:42 PM
INTERPRETATION: No definite ligamentous injury identified. The
reliability of this technique for determining ligamentous
integrity is unknown.
Brief Hospital Course:
41 yo F s/p fall off 5 foot stool. After inital stabilization in
the trauma bay and obtaining CT scans the patient was
transferred to the TSICU for Q1h neuro checks and close
monitoring. The patient was stable overnight. A follow up head
CT showed a focal small left frontal contusion or extraaxial
hematoma, and right frontal contusion as well as a left
occipital bone and a fracture through the right side of the
clivus, which extends into the right medial occipital condyle, a
fracture across the right occipital skull base, and a fracture
of the right anterior arch of C1. The patient was kept in a hard
cervical collar and transferred to the step-down unit. The
patient was maintained on logroll precautions until TL spine
films were obtained and read as negative. Ortho spine with
consulted for the patient's C1 fracture. An MRI was obtained
that did not reveal any ligamentous instability. She will remain
in the hard collar for 12 weeks and follow up in 4 weeks with
spine.
ENT was consulted because of the patients temporal bone
fracture. The patient had no evidence of CN 7 involvement or
deficit. The patient will follow up in 3 to 4 weeks for a formal
audiogram.
The patient's outpatient neurologist was contact[**Name (NI) **] the morning
after admission. Dr. [**Last Name (STitle) 16077**] at [**Hospital1 336**] phone [**Telephone/Fax (1) 61877**], states
patient had been seizure free since [**2141-1-1**] when she had
seizure while driving. He described her seizures as partial
complex seizures with secondary generalization. As an outpatient
she was on Lamictal 300mg QAM and 200mg QHS. Initially the
patient was loaded with dilantin here because it was unclear
whether she had a seizure that prompted her fall. Dr. [**Last Name (STitle) 16077**]
advised to d/c dilantin and restart lamictal. She will follow up
with him at discharge.
The patient was evaluated by physical therapy and determined to
be safe for discharge on [**4-20**]. At the time of discharge the
patient was ambulating, eating PO, and using the bathroom
without difficulty.
Medications on Admission:
lamictal
Discharge Medications:
1. Lamotrigine 100 mg Tablet Sig: Three (3) Tablet PO QAM (once
a day (in the morning)).
Disp:*30 Tablet(s)* Refills:*0*
2. Lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO Q4PM ().
Disp:*20 Tablet(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Occipital bone fractures
Temporal bone fracture
C1 fracture
Closed head trauma with contusion
Discharge Condition:
Good
Discharge Instructions:
[**Name8 (MD) **] MD or go to ER if temp >101, persistent pain, nausea or
vomiting, numbness or weakness in arms or legs, or any other
questions. You must wear your neck collar at all times for the
next 12 weeks. You may shower normally despite the sutures in
your scalp.
Followup Instructions:
You should follow up with orthopaedic spine surgery in 4 weeks.
Until your follow up appointment you should keep your collar on
at all times. Call [**Telephone/Fax (1) 3573**] to schedule a follow up
appointment with Dr. [**Last Name (STitle) 363**].
You should follow up with your neurologist, Dr. [**Last Name (STitle) 16077**] at the
[**Hospital1 336**] on Monday. Call today after you are discharged to schedule
an appointment. You should continue taking your lamictal as he
prescribed before.
You should follow up in trauma clinic on Tuesday [**5-1**] to
have your scalp sutures removed. Call [**Telephone/Fax (1) 2359**] to schedule
an appointment.
Follow up with ENT for a hearing test in [**2-2**] weeks. Call the
[**Hospital **] clinic at [**Telephone/Fax (1) 41**] to schedule an
appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
|
[
"805.01",
"801.32",
"780.39",
"873.0",
"E884.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.59"
] |
icd9pcs
|
[
[
[]
]
] |
6896, 6902
|
4403, 6465
|
318, 325
|
7040, 7046
|
1771, 4380
|
7367, 8304
|
1105, 1123
|
6524, 6873
|
6923, 7019
|
6491, 6501
|
7070, 7344
|
1138, 1752
|
274, 280
|
353, 821
|
843, 940
|
956, 1089
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,190
| 178,299
|
23464
|
Discharge summary
|
report
|
Admission Date: [**2150-4-25**] Discharge Date: [**2150-5-15**]
Date of Birth: [**2085-10-25**] Sex: F
Service: MEDICINE
Allergies:
Hydrocodone / Imipenem/Cilastatin Sodium / Zosyn
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
Transferred for management of cryptogenic organizing pneumonia
Major Surgical or Invasive Procedure:
VATS
History of Present Illness:
64 yo female w PMH of bilat pulm emboli in [**2147**] and in [**1-3**],
chronic bronchitis, transfer from [**Hospital1 **] [**Location (un) 620**] to [**Hospital1 18**] with
VATS confirmed cryptogentic organizing pneun on [**4-23**], with
increased FI02 requirments, increased PEEP and concern of
developing ARDS.
.
She initailly presented to OSH on [**4-11**] with c/o SOB/ DOE and
treated presumptively for pneumonia. She was started on
levofloxacin 500mg a day. Repeat x-rays showed increased
bilateral infiltrates. Despite antibiotics and inhalers, she
continued to have worsening shortness ofbreath. Sputum was sent
for culture that was negative. Influenza culturewas also
negative. The patient continued to do worse with saturations
dropping as low as 86% on two liters nasal cannula. By [**2150-4-13**],she was increasingly hypoxic and uncomfortable with
tachypnea. A repeatchest CT scan was done showing interval
development of interstitial consolidation and ground glass
bilaterally as well as bilateral effusions. There was no
evidence of new pulmonary emboli. The patient was transferred to
the intensive care unit for closer monitoring. Later that night,
she developed hypoxic respiratory failure and was intubated.
Repeat cultures were sent and the patient's antibiotic coverage
waschanged to Zosyn. Pulmonary and infectious disease were also
involved atthis point. Azithromycin was started for empiric
coverage of legionella which turned out to be negative. In
addition, human immunodeficiency virus and quantitative IgG were
checked to rule out immunocompromisedstated. Both were within
normal limits. The patient was started on empiric steroids which
did over some improvement. A bronchoscopy was done, cultures
from which remain negative including acid fast bacilli and
Pneumocystis carinii pneumonia. A few days later, steroids
wereabruptly discontinued because of concerns of intraabdominal
process. The patient self-extubated on [**2150-4-17**]. She
initially did well with 97%-98% on two to three liters nasal
cannula. However, over the course of several days, she continued
to have bilateral infiltrates and was not responding to
antibiotics. Ultimately, on [**2150-4-22**], the patient
underwent VATS: notable for an nflammatory process and negative
for an infectious process. Subsequent
to biopsy, the patient was restarted on high-dosed steroids. She
remains intubated with increasing hypoxic failure. Currently,
she is requiringincreasing amounts and PEEP and chest x-rays
show bilateral infiltrates onsistent with bronchiolitis
obliterans with organizing pneumonia,interstitial process, or
adult respiratory distress syndrome. Of note, antibiotics have
been changed from Zosyn to imipenem because of rash. Today, it
was noted that she developed a rash to Imipenum dose at 1:00am
and at 6:00am.
Past Medical History:
Pulmonary embolism [**1-3**]
chronic bronchitis
HTN
ulcerative colitis
chronic bronchitis
pneumonia
degenerative back
depression
Social History:
retired teacher, now runs a daycare center with her daughter;
+15 yr of tobacco hx quit 15 yrs ago
Family History:
breast cancer in aunt, sister,
stomach cancer and lung cancer in mom
Physical Exam:
GEN: lying in bed in NAD
HEENT: no JVD, MMM, ETT in place
CV: RR, no Murmur
Lung: CTAB; minimal crackles diffusely
Abd: soft, NT/ND, +bs
Ext: no C/C/E, +2DP pulses bilat
Pertinent Results:
[**2150-4-25**] 04:14PM WBC-20.2*# RBC-3.67* HGB-10.6* HCT-33.1*
MCV-90 MCH-28.7 MCHC-31.9 RDW-14.5
[**2150-4-25**] 04:14PM PLT COUNT-300
[**2150-4-25**] 04:14PM GLUCOSE-143* UREA N-25* CREAT-0.7 SODIUM-145
POTASSIUM-4.2 CHLORIDE-109* TOTAL CO2-33* ANION GAP-7*
[**2150-4-25**] 04:14PM CALCIUM-8.5 PHOSPHATE-3.9 MAGNESIUM-2.1
[**2150-4-25**] 04:14PM CK-MB-NotDone cTropnT-<0.01
[**2150-4-25**] 04:14PM PT-15.9* PTT-21.5* INR(PT)-1.6
[**2150-4-25**] 04:34PM freeCa-1.23
[**2150-4-25**] 04:34PM GLUCOSE-146* LACTATE-1.0
.
[**2150-4-30**] 11:20 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2150-4-30**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2150-5-2**]):
STAPH AUREUS COAG +. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in MCG/ML
________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
.
CHEST (PORTABLE AP) [**2150-4-26**] 11:16 PM
AP SUPINE VIEW OF THE CHEST: There is a right-sided IJ line
terminating in the distal SVC. There is a right-sided chest tube
terminating in the region overlying the right upper lung zone.
The ET tube is in satisfactory position within the thoracic
inlet. The NG tube terminates in the stomach. There are diffuse
bilateral patchy alveolar opacities. No evidence of
pneumothorax. There is no pleural effusion. Degenerative changes
with scoliotic curvature of the spine are noted.
IMPRESSION: Bilateral diffuse alveolar opacities with an
appearance consistent with ARDS.
.
PORTABLE ABDOMEN [**2150-5-2**] 3:41 PM
SINGLE SUPINE PORTABLE VIEW OF THE ABDOMEN: A feeding tube is
demonstrated overlying the distal second portion of duodenum. A
nonspecific bowel gas pattern is noted. There is a scoliotic
curvature of the spine with degenerative changes, convex to the
right.
.
Brief Hospital Course:
64 year old female with a history of pulmonary embolus, who was
transfered from an OSH after VATS confirmed cryptogenic
organizing pneumonia (COP). Initially, her respiratory failure
was thought to be related to cryptogenic organizing pneumonia
(COP). However, it was likely multifactorial due to a component
of pneumonia and CHF as well. She was continued on prednisone
for COP, and diuresed to a goal negative 1000cc per day. She
was eventually found to have a MRSA pneumonia and empyema for
which antibiotics and chest tube placed for treatment. She was
continued on assist control mechanical ventilation with
increased PEEP and FiO2 requirements. Eventually, it was clear
that she would not be able to wean from the ventilator due to
her deompensated respiratory status. It also became clear that
she could no longer be sustained on the ventilator. Given her
grim prognosis, her family members, including Health Care Proxy,
decided to withdraw care and remove the patient from the
ventilator. She was extubated, made comfortable with narcotics,
and passed away within an hour of ET tube removal.
Medications on Admission:
coumadin, lipitor, pentasa, prozac, cartia, albuterol, flovent,
HCTZ/triamterene, wellbutrin, protonix
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
n/a
Discharge Condition:
deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
[
"263.9",
"482.41",
"995.92",
"785.52",
"999.9",
"518.81",
"038.11",
"510.9",
"401.9",
"484.7",
"V09.0",
"280.0",
"496",
"117.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"38.91",
"31.1",
"96.04",
"33.24",
"96.6",
"96.72",
"99.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7386, 7395
|
6093, 7204
|
372, 378
|
7442, 7452
|
3792, 6070
|
7504, 7510
|
3515, 3586
|
7357, 7363
|
7416, 7421
|
7230, 7334
|
7476, 7481
|
3601, 3773
|
270, 334
|
406, 3230
|
3252, 3383
|
3399, 3499
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,520
| 152,995
|
52996
|
Discharge summary
|
report
|
Admission Date: [**2197-4-20**] Discharge Date: [**2197-4-22**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
laryngoscopy
History of Present Illness:
[**Age over 90 **] F w/ afib, CHF p/w cough. the cough started abt a wk back. it
is not progressive. denies fever, chills, sputum production,
SOb, CP, HA, dizziness, palpitations. no sick contacts. no
recent travel. no voice change. She had a CT of the neck and
chest done one day ago that showed a mass near the larynx with
near complete airway
obstruction. she was sent to the ED
.
Pt evaluated by ENT in the ED: performed laryngoscopy. per ENT
'Retroflexed epiglottis and abnormal positioning may give the
impression of airway compression without clinical disease.'
They recommended decadron 10mg IV x 1,increase PPI to 40 [**Hospital1 **],
cool mist or O2 by humidified face mask rather than nasal
prongs, admit for airway observation, continuous O2 sat
monitoring, consider MRI scan for better delineation of this
soft tissue abnormality
Past Medical History:
1. probable Coronary artery disease
2. Atrial fibrillation
3. Congestive heart failure, systolic and diastolic, chronic
- Echo ([**12-12**]) EF 35%, LVH, moderate MR, severe TR, RV moderate
global free wall hypokinesis, dilated aortic arch and descending
thoracic aorta
4. Valvular disease
- 2+ MR
- 4+ TR
4. Peripheral vascular disease
5. h/o ischemic colitis
6. h/o LGIB
7. Gout/pseudogout: followed by rheum Dr. [**Last Name (STitle) **].
8. Chronic kidney disease: baseline ~2.0
9. h/o PE, s/p IVC filter ([**2185**])
10. h/o h. pylori positive gastritis.
11. s/p TAH/BSO
12. OA/?rheumatoid arthritis
Social History:
remote h/o smoking (Quit tobacco 35 years ago;
15 pack-year history). Denies EtOH ever and illicits.
lives with her niece [**Telephone/Fax (1) 109247**]/NIECE [**Name (NI) **] ALL CALLS HERE
PLEASE
Family History:
non-contributory
Physical Exam:
96.8 99 130/70 18 100/2L by NC
NAD
HEENT: no JVD, no LAD
Chest: R base crackles . no stridor. coughing
Heart: RRR, no m/r/g
Abd: soft, NT, ND, no HSM, BS +
Extr: 2+ edema b/l
Neuro: no focal deficit, AAO x 3
Pertinent Results:
[**2197-4-20**] 03:00PM GLUCOSE-147* UREA N-87* CREAT-2.6* SODIUM-136
POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-25 ANION GAP-19
[**2197-4-20**] 03:00PM estGFR-Using this
[**2197-4-20**] 03:00PM proBNP-[**Numeric Identifier 96125**]*
[**2197-4-20**] 03:00PM NEUTS-62.2 LYMPHS-25.7 MONOS-7.3 EOS-4.4*
BASOS-0.4
[**2197-4-20**] 03:00PM NEUTS-62.2 LYMPHS-25.7 MONOS-7.3 EOS-4.4*
BASOS-0.4
[**2197-4-20**] 03:00PM PLT COUNT-157
MRI of the neck
There is increased T2 signal arising from the posterior wall of
the
supraglottic larynx, with mild thickening of the epiglottic
folds, suggestive of edema within this region. No discrete mass
lesion is identified. The glottic region, and vocal cords appear
grossly normal. The airway does appear patent throughout,
without evidence of occlusion.
There is an incidental note of tortuous carotids approaching
midline in the retropharyngeal region. Additionally, the thyroid
is heterogeneous,
suggestive of possible tiny nodules. Visualized lung apices
reveal left upper lobe nodule, as seen on CT neck and CT chest
from [**2197-4-19**].
IMPRESSION:
1. Edema within the posterior wall of the supraglottic larynx
with mild
epiglottic fold thickening. No discrete mass identified.
2. Left upper lobe pulmonary nodule.
repeat laryngoscopy
[**4-21**] epiglottis normal, inward collapse of soft tissues stable,
vocal cords mobile bilaterally, patent airway. persistant
arytenoid edema.
Brief Hospital Course:
Ms [**Known lastname 109248**] is a [**Age over 90 **] y.o woman with CAD, afib, CHF, PVD, ischemic
colitis, recently admitted for CHF exacerbation who is
presenting with cough and found to have a CT scan of the neck
concerning for near complete tracheal obstruction.
#ENT/airway: Ms. [**Known lastname 109248**] was never dyspneic and had no stridor on
exam. She was admitted to the ICU and treated with IV decadron
10mg x 3 and observed overnight. She did well. She had an MRI
of the neck (reported above) which showed no upper airway
obstruction. She had a repeat fiberoptic exam with no airway
obstruction (exam detailed above). It was felt that her CT scan
was likely either an artifact from her carotid arteries or a
technical problem.
Of note she had a Left upper lobe nodule in her lung on CT and
MRI that should be followed up.
#Acute on chronic renal failure: baseline Cr 2-2.3. now up to
2.6. Likely prerenal
she was gently hydrated and her creatinine returned to 2.4.
#CHF: h/o CHF w/ EF 30-40%.
Initially the team held her diuretics due to her acute on
chronic renal failure. Her chest x-ray did show increased
pulmonary edema. Her diuretics should be continued on discharge
as her creatinine normalized
#Afib: She was given short acting metoprolol; rate was well
controlled on this regimen. Initially warfarin was held as
concern for bleeding during a possible biopsy was raised. Her
warfarin was restarted after her MRI.
#CAD: Initially her aspirin was held as concern for biopsy and
bleeding were raised. After her MRI and second fiberoptic exam
were less concerning her asa was restarted. BB was continued.
#Code: full. d/w pt and HCP
Medications on Admission:
aspirin 81mg daily
vit d 400mg daily
calcium carbonate 500mg qid
allopurinol 100mg every other day
colace [**Hospital1 **]
PPI 40mg daily
senna 8.6 [**Hospital1 **]
lasix 40mg daily
aldactone 25mg daily
acetaminophen 325mg [**12-7**] Q6h prn
bisacodyl 5mg, 2 tabs daily prn
Mag hydroxide 30ml PO q6hrs prn
hep SC TID
warfarin 3mg daily
oxycodone 5mg q6H prn
metoprolol succinate 50mg daily
oxycontin 10mg [**Hospital1 **]
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
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 Hundred (100) mg
PO BID (2 times a day).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY 3 DAYS
(Every 3 Days).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
9. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
10. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
11. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation Q6H (every 6 hours) as needed for
sob/wheeze.
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for sob/wheeze.
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Insulin Lispro 100 unit/mL Solution Sig: as per sliding
scale Subcutaneous ASDIR (AS DIRECTED).
15. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM.
16. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
17. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
18. Aldactone 25 mg Tablet Sig: Two (2) Tablet PO once a day.
19. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
20. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO once a day.
21. [**Doctor First Name **] 60 mg Tablet Sig: One (1) Tablet PO once a day.
22. Outpatient Lab Work
please check INR in two days [**4-24**], and adjust coumadin dose
accordingly
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Edema within the posterior wall of the supraglottic larynx
left upper lobe pulmonary nodule on CT and MRI
coronary artery disease
atrial fibrillation
congestive heart failure
peripheral vascular disease
chronic kidney disase
h/o venous thromboembolic disase
Discharge Condition:
stable, afebrile, no stridor, satting well on room air
Discharge Instructions:
You were admitted to the intensive care unit for monitoring of
your airway after you had a CT scan of your neck and chest that
showed a narrowing. You were seen by ENT specialists who did a
laryngoscopy, and recommended several doses of an
anti-inflammatory medication. You had an MRI that showed some
swelling of part of your airway but no blockage. You were
evaluated again by ENT-they repeated a fiberoptic exam which
showed a normal epiglottis, and stable inward collapse of soft
tissues, and patent airway. You were found to be stable and
ready to go back to [**Hospital1 **]. You will not be on any new
medications. You should follow up with your PCP as outlined
below. Please seek medical attention if you have any shortness
of breath, noisy breathing, increased cough, or any other
concerning symptoms.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:2L
Followup Instructions:
please call Dr. [**First Name8 (NamePattern2) 1528**] [**Last Name (NamePattern1) **] for a follow up appointment
within the next three weeks-you should have follow up imaging of
the left upper lobe mass seen on CT and MRI.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 41**]
Date/Time:[**2197-5-10**] 11:45
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 14465**], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2197-5-18**] 3:00
Completed by:[**2197-4-22**]
|
[
"584.9",
"585.9",
"715.90",
"427.31",
"428.0",
"478.6",
"V45.89",
"424.0",
"397.0",
"518.89",
"428.42",
"275.49",
"443.9",
"414.01",
"712.30",
"V12.51",
"274.9",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.42"
] |
icd9pcs
|
[
[
[]
]
] |
7989, 8068
|
3730, 5401
|
268, 282
|
8370, 8427
|
2279, 3707
|
9416, 10000
|
2017, 2035
|
5874, 7966
|
8089, 8349
|
5427, 5851
|
8451, 9393
|
2050, 2260
|
223, 230
|
310, 1155
|
1177, 1785
|
1801, 2001
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,272
| 137,040
|
3107
|
Discharge summary
|
report
|
Admission Date: [**2188-11-22**] Discharge Date: [**2188-11-27**]
Date of Birth: [**2128-10-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
GI bleeding
Major Surgical or Invasive Procedure:
Esophogastroduodenoscopy
History of Present Illness:
60 yo [**First Name5 (NamePattern1) 4746**] [**Last Name (NamePattern1) 14750**] CAD s/p CABG x6, s/p MI x 2 (IMI, also NQWMI
[**11-3**]), s/p recent SVG ->RCA DES ([**11-13**]), CHF (EF 30%), AVR,
afib, DM2, COPD recently admitted NQWMI ([**2188-11-8**]) was cath 3VD
(LMCA 30%, mid LAD 50%, RCx 80%) so he was stented SVG-PDA.
During that admission EGD performed: gastric mass w/ non
diagnostic Bx, gastric ulcer, gastritis/duodenitis, while pt
taking heparin/integrelin for AVR. Pt was DC home ([**11-16**]) only
to return ([**11-22**]) c/o melena, LH HCT 25 so pt admitted MICU
where pt given 4U PRBC, FFP, and K. Given stable hct, pt was tx
to floor.
Past Medical History:
Cardiac:
CVA x 1
Afib s/p cardioversion (last doc episode [**2181**])
AS s/p mechanical AVR ([**Hospital3 **] AV [**2181**])
CAD s/p CABG x 6 (SVGx4, RIMA, LIMA) w/ SVG to RCA stent([**11-3**])
CHF (EF=30%) w/diffuse hypokinesis
PVD s/p b/l metatarsal amputation
Hyperlipidemia
HTN
NQWMI
.
Pulm:
COPD
Pulm HTN (last echo [**2188-11-10**])
.
Other:
DM2
Iron deficiency anemia
Social History:
smokes 1-3 packs per day; no alcohol
Family History:
[**Name (NI) 12237**] CAD
[**Name (NI) 12238**] COPD
Sister- CAD, DM
Physical Exam:
VS: 98.2 95/50 89 RR=20 O2 sat 96% RA
Gen: lying comfortable in bed, ambulatory, NAD, AAO x 3
HEENT: no icterus, MMM, PERRLA, no LAD palpable
Neck: JVP=7cm
Lungs: Right basilar mild crackles and decreased air entry
CV: RRR, nl S1/S2, 3/6 SEM apex rad to axilla>carotids, no S3,
S4, rubs
Abd: soft, nt/nd, +bs, no rebound or guarding
EXT: trace pedal edema, weak b/l DP/PT/radial pulses, no
clubbing/cyanosis
Neuro: grossly intact and no focal deficit. [**5-5**] motor strength
b/l
Pertinent Results:
EKG: Sinus rhythm with slowing of the rate as compared to the
previous tracing
of [**2189-1-22**]. Intraventricular conduction delay. Diffuse ST-T
wave abnormalities
as previously recorded on [**2188-11-22**] without diagnostic interim
change.
Pan CT ([**2188-11-24**]): Several enlarged pretracheal, paratracheal
LAD + small lesser curvature stomach LAD, small pleural effusion
R>L
Endoscopic US ([**2188-11-25**]): GE jxn mass 2 x 1.5cm in size w/
invasion through muscularis propria, paraesophageal nodes
1-1.7cm size; both mass and LAD bx
EGD ([**2188-11-25**]): 2cm gastric mass extending into esophagus @ GE
jxn.
[**2188-11-26**] 05:15AM BLOOD WBC-4.4 RBC-3.80* Hgb-10.9* Hct-31.7*
MCV-83 MCH-28.6 MCHC-34.3 RDW-15.7* Plt Ct-196
[**2188-11-26**] 05:15AM BLOOD Plt Ct-196
[**2188-11-26**] 05:15AM BLOOD Glucose-124* UreaN-7 Creat-0.7 Na-140
K-4.1 Cl-107 HCO3-27 AnGap-10
[**2188-11-26**] 05:15AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.1
Brief Hospital Course:
A/P: 60M H/O CHF/CAD/CABG/MI S/P Recent Stenting/Plavix w/ GIB
and Gastric Mass awaiting GI imaging and interventions.
1) GI/Heme: EGD repeated, which showed injected mass in distal
esophagus/cardia. CT scan next performed showed pre and
paratracheal enlarged LAD + smaller LAD along lesser curvature
of stomach. Endoscopic u/s next performed which showed non
resectable T3 lesion invading into muscularis propria w/ nodal
involvement, so LAD and mass biopsied for likely Stage III
Esophageal Carcinoma. Pt has minimum of T3N1 (Stage III)
esophageal mass highly suggestive of carcinoma at GE jxn and
path pending. Endoscopic resection not possible given fungating
mass w/ LAD spread; Surgery not actively pursued given increased
operative mortality given cardiac risk factors. Trend Hct TID
reveals hemodynamically stable and no clinical signs of bleeding
x 3 days while pt had 2 large bore IVs, protonix 40mg [**Hospital1 **], and
DC coumadin/heparin per cardiology to minimize potential risk of
GI bleeding. We have arranged pt to F/U w/ med onc on [**2188-12-2**],
rad onc to be determined and [**Doctor First Name **] onc on [**2188-12-8**]. We have
resumed pt's outpt meds including anti-hypertensives. Note path
results will be back on [**2188-11-29**] so please call [**Telephone/Fax (1) 9363**].
Pt to resume regular diet as tolerated, preferably soft diet.
2) CVS: Pt has extensive cardiac hx w/ negative cardiac enzymes
and EKG.
Pt exhibited mildly increased daily weight so lasix was
temporarily held for risk of hypotension. Furthermore, given
the predicament of AVR anticoagulation vs. bleeding GI mass,
cardiology was consulted who recommended DC coumadin/heparin but
maintain on plavix for total 4 weeks given the lower mortality
for stroke vs. bleed. Please continue Plavix for two more
weeks, lipitor, lisinopril, metoprolol, daily weights. We are
currently holding heparin, coumadin, and ASA despite AVR per
cardiology because the risk of mortality from CVA approx 5-10%,
but the mortality from GI bleed is higher(please see above). So
PLEASE HOLD HEPARIN, COUMADIN, AND ASA. PLAVIX FOR TWO MORE
WEEKS ONLY (TOTAL OF 4 WEEKS).
3) DMII: Today advanced pt's diet to regular diet as tolerated
and resume pt's outpt insulin 50U qAM + qHS while RISS.
4) Pulmonary: Clinical right basilar crackles likely secondary
to esophageal mass. Pt oxygenating well during hospitalization.
Resume lasix.
5) Rheum: steroid dependent RA maintained on acetaminophen.
6) PPX: Ambulate & PPI.
7) Code: DNR/DNI
8) Comm: Talked w/ wife and daughter concerning new diagnosis
for pt.
Medications on Admission:
NKDA
Lipitor 40
ASA 325
Metoprolol 100
Plavix 75
Lisinopril 2.5
NPH Insulin, 50 qam, qpm
Coumadin
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
1. GI bleed
2. Esophageal mass
Secondary diagnoses:
1. CAD 3VD s/p cabg
2. Hypercholesterolemia
3. COPD
4. DM2, on insulin
5. HTN
6. s/p MI x2, CVA x1
7. CHF EF=30%
8. AVR
9. PVD s/p b/l metatarsal amputations
10. Iron deficiency anemia
Discharge Condition:
Tolerating POs, HCT stable
Followup Instructions:
Please follow up with your PCP Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 14751**])
on Thursday, [**2188-12-4**] 10:30pm at Health care center at [**Hospital **] Family Center
Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 6568**]) at
[**Hospital1 18**] Thoracic Oncology Center on [**2188-12-2**] at 9:30AM. There, you
will have F/U appt w/ Radiation oncologist.
Please follow up w/ Dr. [**Last Name (STitle) 14752**] ([**Telephone/Fax (1) 2981**]) at [**Hospital1 18**] on
[**2188-12-8**] at noon.
Completed by:[**2188-11-27**]
|
[
"427.31",
"412",
"401.9",
"410.72",
"196.1",
"496",
"578.9",
"714.0",
"280.9",
"151.0",
"428.0",
"530.85",
"V43.3",
"V45.81",
"V58.61",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.33",
"99.07",
"45.16",
"99.04",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
5830, 5836
|
3080, 5681
|
329, 355
|
6136, 6164
|
2117, 3057
|
6187, 6837
|
1510, 1580
|
5857, 5908
|
5707, 5807
|
1595, 2098
|
5929, 6115
|
278, 291
|
383, 1042
|
1064, 1440
|
1456, 1494
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,763
| 153,519
|
28453
|
Discharge summary
|
report
|
Admission Date: [**2106-11-2**] Discharge Date: [**2106-12-3**]
Date of Birth: [**2036-10-2**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7141**]
Chief Complaint:
pelvic mass
Major Surgical or Invasive Procedure:
Exploratory laparotomy, total abdominal hysterectomy, bilateral
salpingo-oophorectomy, tumor debulking, omentectomy, extended
right colectomy, right pelvic peritoneal implant excision,
partial wedge gastrectomy, ileal descending colostomy, and rigid
proctosigmoidoscopy
History of Present Illness:
The patient is a 70-year-old G2, P2 sent by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 468**] for
consultation regarding a possible diagnosis of ovarian cancer.
The patient presented with a several month history of increasing
abdominal distention, diffuse abdominal discomfort, and
exacerbation of heartburn symptoms. She was evaluated with an
upper endoscopy on [**2106-8-27**], at which time a submucosal mass in
the stomach was noted. No biopsy was obtained. She then had a CT
angiography of the abdomen and a CT of the pelvis on [**2106-10-8**].
This revealed the surface of the liver to be studded with
multiple discrete enhancing nodules. There were also nodules in
the region of the fissure for the ligamentum venosum and
ligamentum teres. The pancreas was normal. There was
disseminated peritoneal carcinomatosis, with large omental cakes
seen along the right flank. There was a small amount of
perihepatic ascites. Discrete nodules were identified studding
the surface the liver as previously described, as well as the
surface of the spleen and stomach. There was no significant
retroperitoneal adenopathy. In the pelvis, there was some
suggestion of uterine and bilateral adnexal masses. Given the
nonspecific nature of these findings, a CT guided omental biopsy
was performed on [**2106-10-13**]. This revealed high-grade papillary
carcinoma, consistent with ovarian origin. The patient states
that she has had increasing abdominal girth and has difficulty
fitting into her clothes. She has had about a 12 pound
unintentional weight loss. She has some shortness of breath,
which she attributes to the increasing abdominal distention. She
has diffuse but low-grade abdominal discomfort.
Past Medical History:
GERD and hypothyroidism.
PAST SURGICAL HISTORY: Rotator cuff repair and cholecystectomy.
OB HISTORY: Vaginal delivery x2.
GYN HISTORY: Last Pap smear and mammogram were both recently
normal.
Social History:
The patient does not smoke or drink.
Family History:
Significant for mother with stomach cancer, a brother with
pancreatic cancer, cousin with [**Name2 (NI) 499**] cancer and aunts with
stomach cancer.
Physical Exam:
GENERAL: Well developed and moderately overweight.
HEENT: Sclerae anicteric.
LYMPHATICS: Lymph node survey was negative.
LUNGS: Clear to auscultation.
HEART: Regular without murmurs.
BREASTS: Without masses.
ABDOMEN: Soft and moderately distended. There was no
appreciable ascites. There was a palpable mass extending along
the entire right side of the abdomen. This was quite firm.
EXTREMITIES: Without edema.
PELVIC: The vulva and vagina were normal. The cervix was
normal. Bimanual and rectovaginal examination was limited by
body habitus. No definite pelvic masses were appreciated.
There was no definite cul-de-sac nodularity and the rectal was
intrinsically normal.
Pertinent Results:
[**11-22**] CT Abd/Pelvis:
IMPRESSION:
1. Small-bowel obstruction with candidate transition point in
LLQ
2. Large left pleural effusion with associated compressive
atelectasis.
3. Overall, slight improvement in carcinomatosis and malignant
ascites.
Brief Hospital Course:
On [**2106-11-2**], the patient underwent exploratory laparotomy, total
abdominal hysterectomy, bilateral salpingo-oophorectomy, tumor
debulking, omentectomy, extended right colectomy, right pelvic
peritoneal implant excision, partial wedge gastrectomy, ileal
descending colostomy, and rigid proctosigmoidoscopy, requiring 4
units of packed red blood cells intraoperatively.
Post-operatively, she remained intubated and was transferred to
the SICU, with transfer to regular post-operative floor on
POD#2.
.
The patient's post-operative course was complicated by low
hematocrit, post-operative fever w/ Clostridium perfringens on
blood culture, an intrahepatic IVC thrombus, bilateral upper
lobe opacities and bibasilar effusions L>R with dyspnea/hypoxia
and O2 requirement, lower extremity fungal infection, and small
bowel obstruction.
.
1) Heme:
The pt's low hematocrit stabilized after 2 additional
transfusions of 2 units PRBC's each, and was thought to be
dilutional gvien a fluid excess of 12L. Hcts subsequently
remained stable at ~27, and she had no evidence of bleeding. On
POD #6, the patient underwent a CT of the abdomen for evaluation
of fever, and an intrahepatic IVC thrombus was discovered
incidentally. Per surgery recommendation the patient was
started on heparin for anticoagulation, however this was
discontinued when the pt had another Hct drop. Vascular surgery
recommended no further anticoagulation, and given the location
of the thrombus, filter placement was also not technically
feasible. On repeat CT scan [**11-22**], the thrombus was not
visualized.
.
2) ID: The pt had post-operative fevers, for which blood
cultures were obtained. 1 of 2 bottles from [**11-4**] was positive
for c. perfringens. Infectious disease was consulted and she was
started on vancomycin empirically, with ampicillin-sulbactam
added after identification and sensitivities. Other cultures
from [**11-5**], 13, 14, 15 all showed no growth, therefore the c.
perfringens was thought to be a contaminant. On POD#4, the pt
continued to require 4 L of oxygen by NC. She underwent a CTA of
the chest which showed no pulmonary emboli but did show
bilateral upper lobe opacities concerning for pneumonia. She was
started on levofloxacin, and repeat chest x-ray showed that her
pneumonia improved after 4 days of levofloxacin, and this was
discontinued. Given continued temperatures, CTs of the abdomen
were obtained [**11-8**], [**11-12**] which showed increasing
carcinomatosis and multiple pelvic pockets of free fluid, some
loculated, which were thought to be malignant ascites; none
amenable to percutaneous drainage. The pt remained afebrile on
Vanco/Zosyn from [**11-11**], with decreasing WBC, and V/Z were
discontinued on [**11-23**]. The patient was also noted to have a
bilateral lower extremity and groin rash on [**11-23**]; ID consult
was obtained, and it was felt that this was the result of a
fungal infection, and IV fluconazole was started. The rash
improved on fluconazole, and the patient was switched to PO
fluconazole on [**12-2**], to continue for a 6 week total course.
.
3) Pulm:
In addition to the presumed pneumonia as above, the pt continued
to have subjective dyspnea and O2 requirement. Repeat CTA [**11-12**]
was again negative for PE. CXR's and CTs showed bibasilar
effusions, L>R. An interventional pulm consult was obtained for
possible thoracentesis, but per bedside U/S, the left effusion
was found to be subpulmonic and quite small, and therefore not
likely to account for pt's symptoms; given the location,
thoracentesis would also be at higher risk for adverse events
i.e. PTX, bleeding, per IP. The patient's hypoxia and shortness
of breath resolved spontaneously, and for the last week of
admission she was 96-100% on RA.
.
3) FEN/GI:
Given nausea and poor po intake, the pt was started on TPN, with
diet slowly advanced. However, on CT scan [**11-22**], the patient
was noted to have a small bowel obstruction, associated with
some nausea and vomiting. She was made NPO until passing flatus
and subjective resolution of nausea, and was advanced to clears
[**11-29**], then regular [**12-1**]. As she was tolerating regular PO
without nausea, her TPN was d/c'd [**12-2**].
.
4) Endocrine:
The patient's Levoxyl was briefly increased to 200 mcg qd, but
this was decreased to 150 mcg [**11-17**]. She was covered for
somewhat elevated FSG's with an insulin sliding scale.
.
5) Oncology:
Per discussion with tumor board, medical oncology was consulted
for administration of chemotherapy while in-house. It was
decided to administer first dose of carboplatin alone, given
greater potential toxicity with Taxol. On [**11-23**] the patient
received her 1st carboplatin dose and tolerated this adequately
with only some nausea. She is to follow up with a medical
oncologist at [**Hospital3 3583**] for further chemotherapy cycles.
.
The patient was discharged home on [**2106-12-3**], POD#30.
Medications on Admission:
Levothyroxine alternating 0.112mg and 0.15mg daily, Tricor 145mg
half tab daily, Omeprazole 20mg daily
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
2. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
3. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 weeks.
Disp:*35 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Community VNA
Discharge Diagnosis:
Ovarian cancer
Small bowel obstruction
Lower extremity fungal infection
Discharge Condition:
Good
Discharge Instructions:
No heavy lifting or strenuous exercise. No driving while on
narcotics. Call for worsening pain, nausea/vomiting, fever
>101, other concerns.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] B. [**Telephone/Fax (1) 5777**] Call to schedule
appointment for next week
Completed by:[**2106-12-3**]
|
[
"197.7",
"799.02",
"V16.0",
"453.2",
"530.81",
"198.89",
"197.8",
"285.22",
"486",
"197.6",
"997.4",
"560.9",
"197.4",
"183.0",
"110.3",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"65.61",
"45.93",
"43.89",
"68.49",
"38.93",
"54.4",
"45.73",
"99.04",
"99.15",
"99.25"
] |
icd9pcs
|
[
[
[]
]
] |
9273, 9317
|
3787, 8730
|
340, 611
|
9433, 9440
|
3513, 3764
|
9631, 9796
|
2639, 2790
|
8883, 9250
|
9338, 9412
|
8756, 8860
|
9464, 9608
|
2422, 2569
|
2805, 3494
|
289, 302
|
639, 2351
|
2373, 2398
|
2585, 2623
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,122
| 122,883
|
41935
|
Discharge summary
|
report
|
Admission Date: [**2105-10-7**] Discharge Date: [**2105-10-8**]
Date of Birth: [**2043-8-9**] Sex: M
Service: SURGERY
Allergies:
atorvastatin
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
open laparotomy
History of Present Illness:
Mr. [**Known lastname 91037**] is a 62 year old man with history of alcohol abuse,
presenting from [**Hospital6 12112**] with severe
pancreatitis and acute renal failure, transfered to [**Hospital1 18**] for
further management.
.
Patient presented to [**Last Name (un) 4199**] on [**2105-10-6**] with abdominal pain,
nausea, vomiting. Lipase >600. Abdominal CT non-contrast showed
severe pancreatitis with focal necrosis and possible hemorrhagic
mesentery. Last drink was yesterday. 2L IVF given at OSH, as
well as Dilaudid, Zofran, PPI, Kayexalate, Reglan, Morphine.
.
In the [**Hospital1 18**] ED inital vitals were as follows: 97.1 78 112/71 22
98% 2L nasal cannula. He was noted to have altered mental status
in ED and became tachycardic to 147, so he was intubated upon
arrival for tachypnea and altered MS. [**First Name (Titles) 167**] [**Last Name (Titles) **] CVL was placed
for hypotension, started on Levo and Neo. Lipase 4860. ABG
notable for pH 6.75/51/257 with lactate 13.9. GI was consulted
for pancreatitis. Cardiology was consulted for ECG changes
showing ST elevations in inferior leads when heart rates were in
140s; ST elevations resolved when rates down to 120s. K up to
6.6 with EKG changes, so patient was given calcium gluconate and
insulin. D50 not given because glc 416. Vitals prior to transfer
BP 111/72 HR 122. Access: RIJ CVL, 2PIVs. UOP 120cc over 4 hrs
in the ED. Total 5L IVF in the ED, including 3amps of bicarb in
D5, as well as an amp of bicarb.
Past Medical History:
pancreatitis
HTN
GERD
HLD
Gout
PID
Primary hyperparathyroidism s/p parathyroidectomy
Glaucoma
Social History:
Lives alone. Divorced in [**5-9**]. Two grown children are
estranged.
Tobacco: none
EtOH: heavy EtOH use
drugs: none
Family History:
unknown
Physical Exam:
On admission:
Vitals: T: 97.1 BP: 99/71 P: 121 R: 32 O2: 100%
General: intubated, sedated
HEENT: Sclera anicteric, ETT in place
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation anteriorly
CV: tachycardic, S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: cool, thready pulses, no edema
Neuro: sedated
Pertinent Results:
ADMISSION LABS:
[**2105-10-6**] 11:40PM BLOOD WBC-16.8* RBC-5.18 Hgb-15.6 Hct-53.2*
MCV-103* MCH-30.1 MCHC-29.3* RDW-16.6* Plt Ct-174
[**2105-10-6**] 11:40PM BLOOD PT-15.5* PTT-52.1* INR(PT)-1.4*
[**2105-10-6**] 11:40PM BLOOD Glucose-394* UreaN-49* Creat-3.1* Na-141
K-6.1* Cl-103 HCO3-LESS THAN
[**2105-10-6**] 11:40PM BLOOD ALT-38 AST-153* AlkPhos-94 TotBili-0.9
[**2105-10-6**] 11:40PM BLOOD Lipase-4860*
[**2105-10-6**] 11:40PM BLOOD cTropnT-<0.01
[**2105-10-6**] 11:40PM BLOOD Albumin-3.9 Calcium-8.0* Phos-10.0*
Mg-1.6
[**2105-10-7**] 12:12AM BLOOD Type-ART Temp-36.7 Rates-/14 Tidal V-500
PEEP-5 FiO2-50 pO2-257* pCO2-51* pH-6.75* calTCO2-8* Base XS--31
-ASSIST/CON Intubat-INTUBATED
.
[**10-6**] CXR
1. No acute cardiac or pulmonary process.
2. No pleural effusions.
3. ET tube ends at least 2.5 cm above the level of the carina.
Could
withdraw by 1 cm to prevent self-intubation of the right
mainstem bronchus
during chin flexion.
4. NG tube ends near the GE junction. Recommend advancing.
.
MICRO
Urine cxs:
Blood cxs:
Brief Hospital Course:
Mr. [**Known lastname 91037**] is a 62 year old man with h/o EtOH abuse,
pancreatitis, who was transferred from an OSH with severe acute
pancreatitis, intubated and started on pressors in the [**Hospital1 18**] [**Hospital **]
transferred to the MICU for further manaagement
.
#. Shock: Patient with developed hypotension in the ED, likely
[**12-31**] to severe pancreatitis. Currently on Levo and Neo to
maintain MAP>65. While in the ICU, vasopressin was added for
persistent hypotension. Meropenem was switched to zosyn to
cover GI pathogens. Blood and urine cultures showed:
.
#. Severe acute pancreatitis: Patient admitted with severe acute
pancreatitis (BUN>30, AMS, SIRS, HCT>44, multiorgan failure).
Resuscitated with large amounts of fluid and altered mental
status and tachypnea. No fluid collection seen on OSH CT abd,
however evidence of severe pancreatitis. Bicarb was
administered given severe acidosis, CVVH was started to manage
acidosis, hyperkalemia from renal failure.
.
# Compartment syndrome: pt's bladder pressures increased and UOP
dropped while in the ICU, raising concern for abd compartment
syndrome. He was taken to the OR for open laparotomy and
transferred to the surgical ICU.
.
#. Respiratory distress: Intubated on arrival in the ED for
tachypnea and altered mental status. Currently CXR without signs
of b/l infiltrates, tolerating tidal volume 500. Pt was sedated
with fent/versed
.
#. Acute Renal Failure: Patient with Cr 3.1 on admission, up
from baseline 0.7. He has multiple reasons for urgent dialysis
at this point - acidosis, hyperkalemia with EKG changes.
Dialysis line was placed and CRRT started.
.
#. EKG changes: Patient with STE in inferior leads on initial
EKG, improved on subsequent EKG with slower HR in 120s. Likely
with fixed defect, no intervention for now. CK/MB are flat here
and at OSH, trop elevated in the setting of acute renal failure.
.
#. EtOH abuse: Likely the cause of current pancreatitis. Last
drink 11/7 per OSH records. Unknown if prior withdrawal
seizures/DTs in the past. CIWA? MVI/thiamine/folate?
.
Interim Discharge Summary:
The surgical service (ACS) was consulted regarding elevated
bladder pressures with continued pressor requirements. He was
assessed and initially continued to have urine output with
resuscitation with decreasing pressor requirements, however,
over the course of the 5 hours changed to have increasing
bladder pressures, increasing pressor needs, and decreased urine
output. At this time, West 2a/ pancreaticobiliary surgery was
consulted and he was taken to the operating room for abdominal
decompression for compartment syndrome. In the operating room,
he was found to have a large amount of dark flood with an
extensive amount of ischemic small bowel. The ischmic portions
were resected and he was left in discontinuity. The
retroperitonium was not extsensively expolored at this time,
however, there was a large amount of saponifcation and old blood
in the retroperitonium. The patient's abdomen was closed with a
temporary dressing with plans to return for a second look. He
was taken to the operating room in critical condition on the
same pressor requirements. A family discussion was performed
after the operation and at that time the family wanted to see
him prior to making a decision on his goals of care. However,
in the morning of postoperative day 1 the patient had a sudden
onset of asystole and was pronounced deceased at 0755 with
resuscitation deemed futile given his poor prognosis.
Medications on Admission:
allopurinol 100 mg daily
atenolol 50 mg daily
Fiorinal 1 cap Q6H PRN headache
citalopram 20 mg daily
Topicort gel [**Hospital1 **]
Zetia 10 mg daily
furosemide 20 mg daily
lisinopril 20 mg daily
Prilosec 40 mg [**Hospital1 **]
zolpidem 10 mg daily
Nystatin cream [**Hospital1 **]
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Pancreatitis
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
|
[
"584.5",
"995.92",
"401.9",
"577.1",
"785.52",
"276.2",
"274.9",
"272.4",
"252.01",
"038.9",
"365.9",
"557.0",
"305.00",
"577.0",
"518.52",
"300.4",
"729.73",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"96.71",
"39.95",
"45.62",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
7497, 7506
|
3620, 7137
|
286, 303
|
7562, 7571
|
2565, 2565
|
7624, 7631
|
2084, 2094
|
7468, 7474
|
7527, 7541
|
7163, 7445
|
7595, 7601
|
2109, 2109
|
232, 248
|
331, 1815
|
2582, 3597
|
2123, 2546
|
1837, 1933
|
1949, 2068
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,970
| 111,992
|
33039
|
Discharge summary
|
report
|
Admission Date: [**2166-1-16**] Discharge Date: [**2166-1-20**]
Date of Birth: [**2141-4-18**] Sex: M
Service: MEDICINE
Allergies:
IV Dye, Iodine Containing
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
drug overdose
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 24 year old man with history of prior drug
overdose who was transferred from OSH with altered mental
status. Per report, he initially presented with complaints of
abdominal pain and nausea to [**Hospital3 22765**], then
became non-responsive ("catatonic state") but continued to
protect his airway. He had a metabolic workup, including chem10
(revealing only mildly elevated BUN at 21), CBC, and tox screen
(which was negative for amphetamines and positive for opiates).
He also had a head CT and chest x-ray, which were unremarkable.
Per OSH report, tox screen was positive for opiates. He was
given lorazepam 1mg x 1 and transferred to [**Hospital1 18**] for further
workup.
.
In the ED, his vitals were T98.9F, BP 117/100, HR 148, RR 20,
Sat 100%. He was initially given 5mg haloperidol for agitation,
but a subsequent EKG demonstrated prolonged QT interval. He
continued to be agitated, with visual hallucinations and was
unable to maintain his own safety without physical restraints. A
blood culture was drawn. Urine tox at [**Hospital1 18**] was positive for
both opiates and amphetamines. He received a total of 10mg IV
ativan in the ED prior to transfer to the MICU for further
workup and evaluation.
Past Medical History:
h/o drug overdose requiring dialysis
ORIF, rightleg fracture, Required fasciotomy [**2164**].
s/p recent surgery for tendon lenghtening [**2165-12-6**].
Social History:
Denies any alochol or illicit drug use. He does smoke 1ppd for
6-7 years. Per father has had a problem with percocet abuse in
the past. He has often requested more pain medications and has
made excuses for having percocets stolen.
Family History:
nc
Physical Exam:
VITALS: T98.7F, BP 150/83, HR 140's, RR 18, Sat 99%2L
GENERAL: Agitated, slurring speech, occasional yelling out;
visual hallucinations
HEENT: PERRL, EOMI, mucus membranes dry
CARD: Tachycardic no m/r/g
RESP: CTA bilaterally anteriorly
ABD: Soft, non-distended, non-tender, no HSM, normal active
bowel sounds
RECTAL: Deferred
BACK: Deferred
EXT: RLE in cast, LLE warm, well-perfused, with 2+ DP pulse
NEURO: A&O x 1
PSYCH: Visual hallucinations
Pertinent Results:
Lactate:3.0
.
Na 139 K 3.4 Cl 105 HCO3 23 BUN 18 Creat 1.0 Gluc 99
Ca: 8.7 Mg: 1.9 P: 3.9
.
ALT: 22 AST: 17 AP: 96 LDH: 132 Tbili: 0.2 Alb: 4.3
[**Doctor First Name **]: 29 Lip: 13
Serum Tox: ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Pending
Acetone: Negative
.
Urine Tox: positive for opiates and amphetamine, o/w negative
.
WBC 16.5
N:85.4 L:11.1 M:3.0 E:0.1 Bas:0.4
Hgb 14.4
Hct 41.4
Plt 281
MCV 74
.
PT: 14.2 PTT: 28.0 INR: 1.2
.
U/A: Yellow, Clear, SpecGr 1.027, pH 5.0, Tr prot, Tr ketones,
few bact, otherwise negative
.
STUDIES:
EKG [**2166-1-16**]: Tachycardic at 139bpm, QTc 444ms. No ST elevations
or depressions.
.
CT [**2166-1-16**] (from OSH, reviewed at [**Hospital1 18**] with radiology): ?
slightly enlarged ventricles for age, otherwise unremarkable.
.
CXR [**2166-1-16**] (from OSH): Normal chest x-ray.
Brief Hospital Course:
MICU COURSE:
The patient was admitted to the medical ICU for managment of
altered mental status. His urine studies were posative for
amphetamines and given his clinical picture of agitation,
hallucinations, and irritability he was treated for presumed
aphetamine toxicity along with possible wellbutrin overdose. He
was given IV fluids and IV lorazepam. He required leather
restraints overnight, and despite these suffered a minor fall.
His clinical condition improved over 24 hours and he no longer
required restraints or benzodiazepines for management of
agitation. He was transfered to the floor. QT interval was
initilly prolonged, but resolved. The psychiatry team evaluated
him and found that he had a history of depression, oppositional
defiant disorder, drug abuse, stealing, and suicide attempt.
They recommended in-patient psychiatric stabilization, and the
patient is therefore being transferred to deaconness 4.
Old records and communication with [**Hospital6 **]
showed that his cast on his right foot was from an achilles
release procedure and required the cast for 6 weeks. This is to
be followed up as an outpatient. He has a history in [**2164**] of
compartment syndrome in his right lower extremity,
rhabdomyolysis and renal failure. He had a CK elevation on
admission attributed to being found down. It elevated to 6000
and this was thought secondary to his fall; it trended down to
[**2157**] on the day of transfer. The orthopedics team evaluated him
and removed a cast. He has persistantly asked for escalating
doses of narcotics. We fell that [**1-1**] percocets Q 4 hours is an
adequate dose.
.
#) Microcytosis. normal iron studies. ?thalasemia trait. hct
stable.
.
#) Communication. [**Name (NI) **] father, [**Name (NI) 122**] [**Name (NI) **], [**Telephone/Fax (1) 76829**]
(unable to contact).
Medications on Admission:
percocet prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
2. Phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 3 days.
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 69**] - [**Location (un) 86**]
Discharge Diagnosis:
Drug overdose
Depression
Rhabdomyolysis
Discharge Condition:
Good
Discharge Instructions:
You were admitted to the hospital after a drug overdose and were
monitored in the intensive care unit initially. You were also
seen by psychiatry who recommended inpatient psychiatry unit for
further treatement. You also had some muscle injury from a fall
and received IV fluids. You were also seen by orthopedics who
recommended outpatient follow up with your surgeon.
Please return to the hospital if you fevers, chills, nausea,
vomiting
Followup Instructions:
Please follow up with your PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Telephone/Fax (1) 73578**] in 2
weeks after discharge from psych facility.
You should also follow up with your orthopedic surgeon as
scheduled next week.
Completed by:[**2166-1-21**]
|
[
"E980.3",
"728.88",
"311",
"969.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5749, 5819
|
3351, 5185
|
298, 305
|
5903, 5910
|
2503, 3328
|
6402, 6660
|
2018, 2022
|
5248, 5726
|
5840, 5882
|
5211, 5225
|
5934, 6379
|
2037, 2484
|
245, 260
|
333, 1575
|
1597, 1751
|
1767, 2002
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,806
| 151,587
|
30795
|
Discharge summary
|
report
|
Admission Date: [**2166-3-23**] Discharge Date: [**2166-3-28**]
Date of Birth: [**2115-11-5**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Referred for cardiac catheterization
Major Surgical or Invasive Procedure:
Stenting of the inominate artery intervention and right carotid
stenting
History of Present Illness:
50 year old female smoker with history of hypertension, COPD,
and hypercholesterolemia, who was admitted to an outside
hospital with high grade bilateral ICA stenoses in the setting
of recent TIA symptoms, now transferred from [**Location (un) 11248**]
Hospital for cardiac catheterization.
She was admitted to [**Location (un) 11248**] [**Hospital3 **] after carotid
duplex studies revealed bilateral severe to critical ICA
stenosis, reportedly done for asymptomatic carotid bruits.
However, on further questioning she reported a history of [**3-30**]
minutes of right eye blindness in [**2165-5-25**] which resolved
spontaneously that she didn't tell anyone about. She also
describes several episodes over the ensuing months of diminished
function of her left hand, including episodic numbness as well
as episodic weakness and clumsiness. She had two of these
episodes just 1 week prior to admission. She also tells me that
just yesterday at the outside hospital she had a period of right
eye "blurriness."
At [**Location (un) 11248**] she had a CT of her head which demonstrated an
old right parietofrontal cerebrovascular accident. She was
started on IV heparin. An MRA of the neck demonstrated probable
stenosis in the right brachiocephalic artery, high grade
stenoses in the proximal aspect of both internal carotid
arteries, irregularity in the proximal left subclavian artery,
and narrowing in the proximal right vertebral artery. It was
felt that the patient should have an arch aortogram and
simultaneous cardiac catheterization to evaluate the coronary
anatomy and possible need for coronary artery bypass graft.
Given the complex combination of imaging and possible catheter
based operative interventions, it was felt that the patient
should be transferred to [**Hospital1 18**].
On review of symptoms, she describes the episodes above. She
denies any prior history of stroke, though as above, head CT
demonstrates a chronic versus subacute right parietofrontal
infarct, and she does seem to be having TIAs as above. Denies
history of deep venous thrombosis, pulmonary embolism, bleeding
at the time of surgery, or myalgias. She has chronic joint
pains. She has a chronic cough, but denies hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain, however her
legs do "ache" at the end of the day - she is on her feet all
day at work. All of the other review of systems were negative.
Cardiac review of systems is notable for occasional chest pain
for years, not associated with exertion. She is on her feet all
day at work and never gets chest pain. She does have chronic
dyspnea on exertion but denies paroxysmal nocturnal dyspnea,
orthopnea, ankle edema. She has had intermittent palpitations
for years. Denies syncope or presyncope.
Past Medical History:
1) ICA stenses, bilateral, as above.
2) Hypertension
3) Hypercholesterolemia
4) COPD and chronic bronchitis. Current smoker of [**11-26**] packs per
day.
5) Prior substance abuse, none since [**2155**] when she underwent a
recovery program. She used to abuse various substances
intranasally, and smokes crack.
6) Diverticulosis, status post hemi-colectomy in [**2160**].
7) Urinary frequency
8) Hip pain
9) Recent endometrial thermal ablation for dysfunctional uterine
bleeding. Underwent simultaneous bladder suspension for
incontinence.
Cardiac Risk Factors: (- ) Diabetes, (+) Dyslipidemia, (+)
Hypertension
Cardiac History: None.
Percutaneous coronary intervention, not applicable.
Pacemaker/ICD, not applicable.
Social History:
Social history is significant for the presence of current
tobacco use, 1-2 packs per day. There is no history of alcohol
abuse. She used IV cocaine in the past, but not in more than 10
years. She used to smoke crack frequently, but has been clean
for 10 years. Works at [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] and resides in the
[**Last Name (un) 72904**]-[**Hospital1 6930**] area with a significant other in a monogamous
relationship.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Her parents both had COPD.
Physical Exam:
T 97.1. Blood pressure was 100/80 mm Hg while seated. Pulse
was 78 beats/min and regular, respiratory rate was 18
breaths/min, and she was 98% on room air. Generally the patient
was well developed, well nourished and well groomed. The patient
was oriented to person, place and time. The patient's mood and
affect were not inappropriate.
There was no xanthalesma and conjunctiva were pink with no
pallor or cyanosis of the oral mucosa. The neck was supple with
JVP of 6 cm. The carotid waveform was dminished and she had
bilateral carotid bruits. There was no thyromegaly. The were no
chest wall deformities, scoliosis or kyphosis. The respirations
were not labored and there were no use of accessory muscles. The
lungs were clear to ascultation bilaterally with normal breath
sounds and no adventitial sounds or rubs.
Palpation of the heart revealed the PMI to be located in the 5th
intercostal space, mid clavicular line. There were no thrills,
lifts or palpable S3 or S4. The heart sounds revealed a [**11-30**]
systolic murmur at the LUSB. There were no rubs, clicks or
gallops.
The abdominal aorta was not enlarged by palpation. There was no
hepatosplenomegaly or tenderness. The abdomen was soft nontender
and nondistended. The extremities had no pallor, cyanosis,
clubbing or edema. There were no abdominal or femoral bruits.
Inspection and/or palpation of skin and subcutaneous tissue
showed no stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 1+ Femoral not palpable, DP 2+ PT 2+, radial
not palpable.
Left: Carotid 1+ Femoral not palpable, DP 2+ PT 2+, radial
1+
Pertinent Results:
Cardiac catheterization [**2166-3-24**]: COMMENTS:
1. Coronary angiography of this left dominant system revealed
single
branch vessel coronary artery disease. The left main coronary
artery
had no angiographically apparent flow limiting stenoses. The
LAD had
mild disease and a 70% stenosis in a small diagonal. The LCX
had mild
disease. The RCA was a very small caliber vessel.
2. Limited resting hemodynamics revealed moderately to severely
elevated left sided filling pressures (LVEDP was 26 mm Hg).
Systemic
arterial pressures were mildly elevated (aortic pressure 154/76
mm Hg)
and were approximately 60 mm Hg higher than her cuff pressure.
There
was no significant gradient across the aortic valve upon
pullback of the
catheter from the left ventricle to the ascending aorta.
3. Peripheral angiography revealed severe great vessel disease.
The
right innominate artery had a 90% proximal stenosis and the left
subclavian artery had an 80% stenosis. No right renal artery
was
visualized and the left renal artery had a 30% stenosis. There
was
diffuse aortic atherosclerotic plaquing with a significant
distal aortic
shelf.
FINAL DIAGNOSIS:
1. One vessel branch coronary artery disease.
2. Moderately to severely elevated left sided filling pressures.
3. Severe stenosis of the right innominate artery and left
subclavian
artery.
4. No angiographically apparent right renal artery.
5. Severe aortic atherosclerotic disease with a significant
shelf-like
plaque in the distal segment.
.
MRI/A Abd/pelvis/extr [**2166-3-25**]:
1. Oclusion of the right main renal artery with associated
marked atrophy of the right kidney.
2. Atherosclerotic plaque along the course of the infrarenal
aorta up to the aortic bifurcation, without aneurysm.
3. No evidence of in-flow or out-flow arterial vascular disease
involving the lower extremities.
4. Sludge and/or stones within the gallbladder.
.
CT abd/pelvis [**2166-3-27**]:
1. Hematoma tracking along the left iliacus from the groin to
the iliac crest.
2. Atrophic right kidney and persistent striated nephrogram of
the left kidney along with large amount of vicarious excretion
of contrast in the gallbladder is consistent with ATN and
impaired renal function.
3. 1.8 cm nodule within the medial left anterior subcutaneous
fat may be a breast nodule and clinical correlation with prior
mammograms is recommended.
4. Adnexal asymmetry. If this patient is a postmenopausal woman,
then an ultrasound is recommended. If the patient is not
postmenopausal, then the asymmetry is within normal limits.
Nonetheless the patient has pelvic symptoms, there is no need
for an ultrasound.
.
CT Head [**3-27**]:
No acute intracranial hemorrhage or mass effect is identified.
No interval change from the prior exam. If there is concern for
acute infarction, MRI with diffusion-weighted imaging would be
more sensitive in evaluating this.
.
MRA Abd/Pelvis
IMPRESSION:
1. Oclusion of the right main renal artery with associated
marked atrophy of the right kidney.
2. Atherosclerotic plaque along the course of the infrarenal
aorta up to the aortic bifurcation, without aneurysm.
3. No evidence of in-flow or out-flow arterial vascular disease
involving the lower extremities.
4. Sludge and/or stones within the gallbladder.
.
[**3-26**] carotid U/S
FINDINGS: Duplex evaluation was performed of bilateral carotid
arteries. There is heterogeneous plaque seen in the proximal ICA
bilaterally.
On the right there is a blunted waveform in the proximal and
distal common carotid suggestive of proximal stenosis. Peak
velocities are 104, 51 and 76 cm/sec in the ICA, CCA and ECA
respectively. Normal velocity criteria are invalid in the
presence of the proximal stenosis.
On the left peak velocities are 227, 84 and 31 cm/sec in the
ICA, CCA and ECA respectively. The ICA end-diastolic velocity is
85. The ICA/CCA ratio is 2.7. This is consistent with 60-79%
stenosis.
There is antegrade vertebral flow bilaterally.
IMPRESSION: Likely stenosis in the proximal right CCA or
innominate. 60-79% left ICA stenosis.
Brief Hospital Course:
50 year old female with hypertension, hypercholesterolemia,
COPD, with history of TIA symptoms since last year, found to
have high grade bilateral ICA stenoses, transferred on heparin
and plavix for catheterization with possible catheter based
intervention. Developed L RP bleed after complex right inominate
artery and carotid artery stenting, requiring brief CCU stay for
monitoring but did well and was discharged a day later.
.
1) Severe vascular disease/Bilateral high grade ICA stenoses:
The patient went to the cath lab on the day after arrival, which
demonstrated severe vascular disease in many locations,
including the right innominate artery (90% proximal stenosis),
left subclavian artery (80% stenosis), no right renal artery
visualized, left renal artery with 30% stenosis, and diffuse
aortic atherosclerotic plaquing with a significant distal aortic
shelf. Of note, her coronary arteries were relatively spared,
with an isolated 70% stenosis in a small diagnoal. She had
visual change symptoms and the neuro stroke team recommended an
CT of her head which revealed old stroke. MRA of her
abdomen/pelvis (in setting of CRF and small right kidney) and
lower extremities which revealed an occlusion of the right main
renal artery with associated marked atrophy of the right kidney,
atherosclerotic plaque along the course of the infrarenal aorta
up to the aortic bifurcation, without aneurysm, but no evidence
of in-flow or out-flow arterial vascular disease involving the
lower extremities. She went to the OR on [**3-26**] and had artery
intervention and R carotid stent done by Dr [**Last Name (STitle) **]. She was
continued on heparin drip until she was found to have an RP
bleed (see below) which stabilized quickly. She was continued on
ASA, and clopidogrel and had an otherwise uncomplicated post-op
course and was discharged home on [**3-28**].
.
2) RP bleed: The patient developed a left-sided RP bleed after
endoscopic right inominate artery and carotid artery stenting,
requiring brief CCU stay for monitoring. Her Hct dropped from 39
to 30 but remained stable thereafter not requiring any blood
transfusions. However, her blood pressure dropped briefly,
requiring Phenylephrin transiently. Her BP meds were held. After
having left the CCU, her blood pressure remained stable and her
BP meds were restarted without event. Heparin drip was also
held after the RP bleed was detected.
.
3) Transaminitis: AST/ALT were < 20 at the outside hospital,
however were found to be in the 90s on arrival. Hepatitis
serologies were negative. This was felt to be probably statin
related to her statin which was held. Her transaminases trended
down and she was resumed on Statin prior to discharge
.
4) Hypertension: Systemic pressure on catheterization was found
to be at least 60 mm Hg higher than her cuff pressure.
Continued amlodipine. Benazepril not available here, therefore
started lisinopril 5 mg but switched back to home Lotrel prior
to discharge. Her BB was held during RP bleed and was continued
prior to discharge when her bleeding subsided.
.
5) COPD: She is not on any medications for this, and was
breathing comfortably on room air throughout admission. NEBS
were not necessary.
.
6) Smoking: She was on varenicline at the outside hospital, she
continued her own meds while in house.
.
7) Incontinence: Continued detrol.
.
Medications on Admission:
ASA 325 mg daily
Simvastatin 10 mg daily - hadn't yet started
Detrol
Lotrel (amlodipine and benazepril) 10/40 mg daily
Discharge Disposition:
Home
Discharge Diagnosis:
Vascular stenosis
.
Hyperlipidemia
HTN
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for further evaluation of your occluded
arteries in your chest and neck. You underwent successful
stenting of the inominate artery intervention and right carotid
stenting. Post-procedure you experienced some bleeding and are
now stable and ready for discharge.
.
Seek medical attention immediately if you experience new
symptoms including chest pain, shortness of breath, arm or jaw
pain/numbness, fainting or other concerning symptoms.
.
Please take all medications as prescribed.
.
Follow up as per below
Followup Instructions:
PCP: [**Name10 (NameIs) 72905**],[**Name11 (NameIs) 2053**] please call for an appointment within the
next month
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52,541
| 159,807
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35856
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Discharge summary
|
report
|
Admission Date: [**2188-12-9**] Discharge Date: [**2188-12-19**]
Date of Birth: [**2118-4-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dizziness and dyspnea
Major Surgical or Invasive Procedure:
[**2188-12-12**] Aortic Valve Replacement(23mm St. [**Male First Name (un) 923**] Epic Supra
Porcine) and Single Vessel Coronary Artery Bypass Grafting(vein
graft to ramus intermedius).
History of Present Illness:
Mr. [**Known lastname 81493**] is a 70 year old male with known aortic stenosis. He
admits to a several month history of worsening dyspnea. He
presented to outside hospital with several hours of dizziness.
He ruled out for myocardial infarction. Echocardiogram was
notable for worsening aortic stenosis with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 0.6 cm2
with mild to moderate aortic insufficiency. His ejection
fraction was normal at 65-70%. Cardiac catheterization confirmed
severe aortic stenosis while coronary angiography showed
significant disease in the ramus branch and first obtuse
marginal arteries. Given the above findings, he was transferred
to the [**Hospital1 18**] for cardiac surgical intervention.
Past Medical History:
Aortic Stenosis, Aortic Insufficiency
Coronary Artery Disease
History of Myocardial Infarction [**2182**]
Hypertension
Dyslipidemia
Atrial Fibrillation
Diverticular Disease
Interstitial Lung Disease
Prior Colonic Resection
s/p Appendectomy
Social History:
Retired mechanical engineer. Quit tobacco over 18 years ago.
Admits to only social ETOH. Lives with wife.
Family History:
Two sons died of heart attacks.
Physical Exam:
VS - 114/74, 60, 24
Gen: well developed well nourished elderly male in NAD. Oriented
x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
Neck: Supple, No LAD, no JVP appreciated
CV: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: decreased breath sounds bilaterally
Abd: Soft, NT, ND. No abdominial bruits appreciated.
Ext: Warm. No edema or cyanosis.
Skin: multiple nevi on face and head
Pulses: 1+ bilaterally, no carotid or femoral bruits noted
Pertinent Results:
[**2188-12-10**] Trans-thoracic ECHO: The left atrium is moderately
dilated. The estimated right atrial pressure is 0-5 mmHg. There
is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild regional left ventricular systolic
dysfunction with thinning/akinesis of the inferolateral wall and
hypokinesis of the inferior wall. The remaining segments
contract well (LVEF 45%). Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (area
<0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be quantified. There is an anterior space which most
likely represents a fat pad.
[**2188-12-10**] Carotid US:
1. No significant stenosis of the right ICA.
2. Less than 40% stenosis of the left ICA.
[**2188-12-11**]:
SPIROMETRY 12:43 PM Pre drug Post drug
Actual Pred %Pred Actual %Pred %chg
FVC 4.37 4.23 103 4.30 102 -2
FEV1 2.75 2.85 97 2.70 95 -2
MMF 1.11 2.61 42 1.23 47 +11
FEV1/FVC 63 67 93 63 93 0
LUNG VOLUMES 12:43 PM Pre drug Post drug
Actual Pred %Pred Actual %Pred
TLC 6.55 6.71 98
FRC 2.95 3.82 77
RV 2.17 2.48 88
VC 4.52 4.23 107
IC 3.60 2.89 125
ERV 0.78 1.34 58
RV/TLC 33 37 90
He Mix Time 3.38
DLCO 12:43 PM
Actual Pred %Pred
DSB 15.16 24.79 61
VA(sb) 6.22 6.71 93
HB 15.20
DSB(HB) 14.91 24.79 60
DL/VA 2.40 3.70 65
[**2188-12-12**] Intraop TEE:
Pre Bypass: The left atrium is normal in size. There is mild
symmetric left ventricular hypertrophy. Right ventricular
chamber size and free wall motion are normal. There are complex
(>4mm) atheroma in the aortic arch. The descending thoracic
aorta is mildly dilated. There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets are
severely thickened/deformed. There is severe aortic valve
stenosis (area <0.8cm2). Mild to moderate ([**1-23**]+) aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. Mild to moderate ([**1-23**]+) mitral regurgitation is seen.
There is no pericardial effusion.
Post bypass: Preserved biventricular function LVEF 45%. Mid
inferior hypokinesis is unchanged. MR remains 1+. Aortic
bioprosthesis is insitu (#23 [**Doctor Last Name **]) Peak gradient 17, mean
gradient 5 mm hg. No perivalvular leaks or insufficiency. Aortic
contours intact. Remaining exam is unchanged. All findings
discussed with surgeons at the time of the exam.
[**Known lastname **],[**Known firstname **] C [**Medical Record Number 81494**] M 70 [**2118-4-1**]
Radiology Report CHEST (PA & LAT) Study Date of [**2188-12-15**] 9:05 AM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2188-12-15**] SCHED
CHEST (PA & LAT) Clip # [**0-0-**]
Reason: pleural effusions
Final Report
PA AND LATERAL CHEST RADIOGRAPH
HISTORY: 70-year-old man status post AVR and CABG. Evaluate for
pleural
effusions.
COMPARISON: Chest radiograph from [**12-13**] dating back to
[**2188-12-9**].
FINDINGS: Small bilateral pleural effusions are present and
unchanged.
Bilateral pleural densities may be due to subpleural adipose
tissue or pleural
thickening. In the right apex, there is an ill-defined
spiculated nodule
which is either in the lung parenchyma or abuts the pleura. This
nodule is
unchanged since [**2188-12-9**].
The patient is status post median sternotomy and CABG with
appropriately
positioned cerclage wires. The cardiac silhouette is normal in
size. The
aorta is mildly tortuous but unchanged. The hilar and
mediastinal contours
appear unremarkable. A Swan-Ganz catheter has been removed.
IMPRESSION:
1. Unchanged bilateral pleural effusions with slight improvement
in the left
basilar atelectasis.
2. Right apical spiculated nodule will require further
investigation with
chest CT when the patient is clinically stable.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 13879**] [**Name (STitle) 13880**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: MON [**2188-12-15**] 4:18 PM
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2188-12-17**] 05:15AM 8.2 3.13* 9.6* 27.5* 88 30.8 35.0 14.3
182#
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2188-12-19**] 06:05AM 26* 1.4* 139 3.9
Brief Hospital Course:
Mr. [**Known lastname 81493**] was admitted to the cardiac surgical service and
underwent routine preoperative evaluation which included repeat
echocardiogram, carotid ultrasound and pulmonary function
testing - please see result section for details. He remained
stable on medical therapy. Prior to surgery, he was cleared by
the dental service. His preoperative course was otherwise
uneventful. Given his hospital stay was greater than 24 hours
prior to surgery, Vancomycin was used for perioperative
coverage.
On [**12-12**], Dr. [**Last Name (STitle) **] performed an aortic valve
replacement and coronary artery bypass grafting surgery. For
surgical details, please see separate dictated operative note.
Following the operation, he was brought to the CVICU for
invasive monitoring. Within 24 hours, he awoke neurologically
intact and was extubated without incident. His CVICU course was
uneventful and he transferred to the step down floor on
postoperative day two. Chest tubes and pacing wires were
discontinued without complication. The patient made excellent
progress with physical therapy, showing good strength and
balance prior to discharge. He did require meclizine for
vertigo, which was diagnosed pre-operatively. The patient
required supplemental oxygen throughout his post-operative
course. A blood gas was drawn on room air on [**12-17**] and
reavealed a PO2 of 49. He was diuresed aggressively and treated
with inhalers and his oxygenation improved with room air
saturations above 90% with ambulation. There was a right upper
lobe nodule found on CXR and he had a chest CT which revealed
bullous emphysema and a right upper lobe pleural based mass
which could represent scarring, inflamation, or neoplasm. He
was evaluated by Dr. [**Last Name (STitle) **] from thoracic surgery and will
follow up with him. He should obtain a PET CT and head CT prior
to that visit. He was discharged to home in stable condition on
POD#7.
Medications on Admission:
Aspirin 81 qd, Zocor 20 qd, Metoprolol 150 [**Hospital1 **], Cartia 120 qd,
Zestril 5 qd, Tikosyn 0.5 [**Hospital1 **], Celebrex 200 qd, Protonix 40 qd
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Dofetilide 250 mcg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
Disp:*60 Capsule(s)* Refills:*0*
4. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
5. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for vertigo symptoms.
Disp:*90 Tablet(s)* Refills:*0*
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
7. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
9. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation every six (6) hours.
Disp:*1 vial* Refills:*2*
10. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 vial* Refills:*2*
11. Potassium Chloride 20 mEq Packet Sig: One (1) PO BID (2
times a day) for 10 days.
Disp:*20 tabs* Refills:*0*
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO three times a day
for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
aortic stenosis
emphysema
paroxysmal atrial fibrillation
hypertension
hyperlipidemia
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:
1) Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for
appointment
2) Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] N [**Telephone/Fax (1) 72189**] in 1 week () please call
for appointment *follow up with Dr. [**Last Name (STitle) 70216**] re: right apical
nodule on cxr [**12-15**]*
3) Dr. [**Last Name (STitle) 656**] in [**2-24**] weeks please call for appointment
4) Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3071**])
5)Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks. Obtain
PET CT and head CT prior to visit.
Completed by:[**2188-12-19**]
|
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[
[
[]
]
] |
10512, 10574
|
6837, 8785
|
300, 487
|
10703, 10710
|
2273, 6814
|
11222, 11891
|
1656, 1689
|
8987, 10489
|
10595, 10682
|
8811, 8964
|
10734, 11199
|
1704, 2254
|
239, 262
|
515, 1254
|
1276, 1517
|
1533, 1640
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,447
| 105,153
|
1144
|
Discharge summary
|
report
|
Admission Date: [**2105-12-12**] Discharge Date: [**2105-12-17**]
Date of Birth: [**2061-10-20**] Sex: M
Service: [**Year (4 digits) 662**]
Allergies:
Bactrim
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
benzodiazepine overdose, decreased alertness.
Major Surgical or Invasive Procedure:
intubation for airway protection
History of Present Illness:
44M with hx of AIDS, CD4 84 on HAART, substance abuse, HCV, anal
CA s/p XRT, depression with multiple suicide attempts in the
past who was found down by his mother and admitted for suspected
benzo overdose. Per mother's report, she tried to contact the
pt this morning but after she got no answer she went to his
apartment where she found him unconscious. EMS was called and
they stated that he was periodically apneic. He was given Narcan
and woke up briefly.
In the ED the pt was lethargic, though hemodynamically
stable. He later became agitated and started vomiting. He was
intubated for airway protection. UDS was + for benzos, cocaine,
amphetamines. He received activated charcoal for suspected
overdose and Flagyl to cover for aspiration. The pt was
successfully extubated in the ICU on [**12-13**], with propofol for
sedation stopped at around noon. The pt however remained
somnolent. The pt also was noted to be febrile to 101.5, his t.
bili was noted to be elevated at admission.
Past Medical History:
* AIDS by CD4 (CD4 128, HIV VL<50, [**7-30**], on abacavir,
atazanavir, lamivudine, reports missing 1 dose/week typically)
* HCV not currently treated due to his polysubstance abuse and
depression
* Invasive Anal Carcinoma treated with chemo/XRT; recent high
grade lesion found and treated; followed in Anal dysplasia
clinic
* Substance abuse-last used cocaine and ETOH 2 weeks ago
* L arm amputee secondary to compression injury and ischemia
after drug overdose, [**2096**]
* Depression with multiple suicide attempts
* Bone marrow toxicity secondary to Bactrim/AZT
* Chronic Thrombocytopenia
* MRSA scrotal abscess x2
* h/o testicular cellulitis, [**6-11**]
* COPD (FEV1 83% of predicted on [**4-9**])
* erosive gastritis on EGD, [**2103-2-14**]
* s/p multiple sexual and physical trauma
Social History:
lives alone in section 8 housing, social support from mother in
[**Name (NI) 2251**]
recently lost job as receptionist at [**Hospital 86**] Living Center
cocaine, EtOH abuse, most recently used 2 weeks ago
10 pack year smoking hx
Pt has been in multiple fights, where he has been severely
beaten
and injured.
Family History:
Depression
Substance abuse
Physical Exam:
VS: Tm 101.5 Tc 98.9 BP 107/65(90-125/45-70) p 105(90-105)
rr 22(16-37) rr 22(16-37) 96-99% RA
I/O 3860/1560
Gen: pt responds verbally to questions, follows commands, then
closes his eyes. he responds very slowly.
HEENT: pupils 2mm PERRL, OP clear
Neck: no bruits, no LAD
CV: RRR, 2/6 systolic murmur loudest at LLSB.
Chest: CTA
Abd: soft, NT/ND, NABS
Ext: no edema; left arm amputated below elbow
Pertinent Results:
ABD US [**2105-12-15**]:
IMPRESSION:
1. Stable adherent gallbladder sludge.
2. Small amount of ascites.
3. Splenomegaly.
There is no intra- or extra-hepatic biliary ductal dilatation
.
CXR Pa/Lat [**2105-12-15**]:
Marked improvement of the left lower lobe consolidation probably
indicating improving pneumonia.
.
[**2105-12-12**] 05:10PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-[**4-11**]
[**2105-12-12**] 05:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-50 BILIRUBIN-SM UROBILNGN-8* PH-6.5 LEUK-NEG
[**2105-12-12**] 05:10PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.027
[**2105-12-12**] 05:10PM PT-14.0* PTT-29.9 INR(PT)-1.3
[**2105-12-12**] 05:10PM PLT SMR-VERY LOW PLT COUNT-54*
[**2105-12-12**] 05:10PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2105-12-12**] 05:10PM NEUTS-64 BANDS-0 LYMPHS-28 MONOS-6 EOS-2
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2105-12-12**] 05:10PM WBC-4.6 RBC-5.03 HGB-17.9# HCT-49.8 MCV-99*
MCH-35.6* MCHC-36.0* RDW-14.9
[**2105-12-12**] 05:10PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-POS amphetmn-POS mthdone-NEG
[**2105-12-12**] 05:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2105-12-12**] 05:10PM CALCIUM-7.7* PHOSPHATE-3.8 MAGNESIUM-1.9
[**2105-12-12**] 05:10PM LIPASE-79*
[**2105-12-12**] 05:10PM ALT(SGPT)-224* AST(SGOT)-591* CK(CPK)-2683*
ALK PHOS-102 AMYLASE-76 TOT BILI-6.0*
[**2105-12-12**] 09:57PM GLUCOSE-100 UREA N-26* CREAT-0.7 SODIUM-139
POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-27 ANION GAP-14
[**2105-12-12**] 09:57PM ALT(SGPT)-226* AST(SGOT)-608* LD(LDH)-374*
ALK PHOS-100 TOT BILI-5.5*
Brief Hospital Course:
A/P:
.
44M with hx of AIDS, CD4 of 84, substance abuse, depression and
hx of suicide attempts who presents with benzo overdose,
intubated for airway protection, developed PNA and fever, and
jaundic during ICU stay which quickly resolved.
.
1. benzo overdose/Altered mental status:
Assessed to be [**3-11**] overdose. The urine was pos for benzo,
cocaine and amphetamines.
The pt was intubated in the ED for airway protection and
admitted to [**Hospital Unit Name 153**]. He was ventilated overnight, then successfully
extubated on [**12-13**]. The pt remained somnolent, requiring loud
verbal stimuli to arouse. This was thought [**3-11**] depression as
well as resolving acute illness. The LOC continued to improve.
Given the clear explanations for mental status changes, further
work-up was deferred including LP to rule out meningitis and
head CT. ID consultants agreed with this decision. The pt was
monitored on a CIWA scale as an inpatient for 4 days, and he
demonstrated no clear symptoms of withdrawal.
.
2. PNA:
The pt was noted to be febrile to 101.5 in the ICU, his CXR
showed LLL infiltrate. Levo/flagyl was initially started and the
pt responded well with the infiltrate mostly resolved by CXR on
[**12-15**]. The coverage was narrowed to levoflox alone to continue a
10 day course. Bld Cx were negative. [**Last Name (un) **] Cx showed enterococci
Sensitive to levo, assessed to be colonization by ID. stool
negative for C.diff. Pt was afebrile x48 hours at discharge.
.
3. Elevated LFTs/cholestatic jaundice:
Likely acalculous cholecystitis. On reviewing the pt's previous
labs, he has had elevated AST and ALT in the past, likely [**3-11**]
his HAART regimen or hepatitis. However, his bilirubin has not
been this elevated in the past. AST/ALT peak on [**12-12**] 608/224. T.
bili elevated to 6 at admission. The bilirubin and liver enzymes
continued to trend down over the hospital stay. RUQ US
demonstrated no evidence of stones or ductal dilatation but
showed sludge.
4. HIV/AIDS:
Recent testing done on [**2105-11-12**] at his PCP's visit. CD4 84 (8%)
down from 126 and VL now detectable at 10,800 copies.
Lamivudine/Abacavir/Atazanavir is home regimen. The pt reports
good compliance but according to past notes, misses approx one
dose per week. His HIV genotyping is pending to assess for
resistance mutations. Per ID consultants the ART was held in the
setting of acute illness and will be restarted as an outpt. OI
prophylaxis was continued with atovaquone, biaxin, famvir. The
pt sees Dr. [**First Name (STitle) 3640**] for ID last seen [**2105-7-30**].
.
5. Depression:
s/p suicide attempt. pt is involuntary admit. Outpt Pschiatrist
is Dr. [**Last Name (STitle) 7339**]. The psychiatry team was consulted and followed
along. His psych meds were held for sedation during the
admission per recs, including the effexor, wellbutrin and
trazodone. CIWA scale with diazepam was continued for possible
benzo withdrawal, although the pt demonstrated no clear symptoms
of withdrawal since the admission. 1:1 sitter was continued
because of suicidal intent.
.
6. Thrombocytopenia:
Chronic, baseline between 43-75; follow and transfuse for<10
unless active bleeding
.
7. Rhabdomolysis:
Likely [**3-11**] being down for several hours. CK was trended and
declined without any other symptoms. No renal problems
developed.
8. FEN: NPO until extubated
9. PPx: pneumoboots, PPI, bowel regimen
10. Comm: pt's mother, [**Name (NI) **], [**Telephone/Fax (1) 7340**]
11. Access: PIVx2, RtH 18, RLA 20.
Medications on Admission:
Meds: per OMR
* trazodone 400mg qhs
* Valium 5-10mg qhs prn
* Effexor XR 2 caps qd
* Welbutrin SR 150mg qd
* Abacavir 300mg [**Hospital1 **]
* Atazanavir 400mg qd
* Atovaquione 750mg/5ml, 10cc qd
* Biaxin 500mg qd
* Famvir 250mg [**Hospital1 **]
* Motrin 800mg tid
* Lamivudine 150mg [**Hospital1 **]
* Niferex 50mg qd
* Senna
* Viagra prn
* Androgel qd
* benedryl prn
* compazine prn
* hibiclens qd
* imodium prn
* Nizoral qd
* sarna prn
* Xylocaine q2hrs prn
.
Discharge Medications:
1. Atovaquone 750 mg/5 mL Suspension Sig: Two (2) PO DAILY
(Daily).
2. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Famvir 250 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
6. 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:
[**Hospital1 **] 4
Discharge Diagnosis:
Benzodiazepine drug overdose
Pneumonia
Discharge Condition:
stable, afebrile for 48 hours, breathing comfortably
Discharge Instructions:
Please take all medicines as directed and note that it is very
important to attend all of your follow up appointments.
.
If you have any symtoms of fevers or chills, or coughing that is
severe, please call your doctor.
.
Please note that you are taking a new [**Last Name (LF) **], [**First Name3 (LF) **] antibiotic,
Levofloxacin for six days after you leave the hospital becuase
you had a pneumonia.
Followup Instructions:
You have an apointment to see the Infectious Diseases physician,
[**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2105-12-17**] 11:00.
.
You have an appointment to see your primary care physician, [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7341**] on Thursday, [**12-24**] 1:30. If you have questions,
please call [**Telephone/Fax (1) 250**].
|
[
"042",
"E950.3",
"575.10",
"507.0",
"496",
"070.54",
"728.88",
"287.5",
"294.10",
"305.60",
"305.40",
"296.30",
"518.81",
"969.4",
"530.81",
"305.70",
"V10.06"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
9328, 9373
|
4747, 5013
|
334, 368
|
9456, 9511
|
3015, 4724
|
9961, 10402
|
2549, 2577
|
8774, 9305
|
9394, 9435
|
8287, 8751
|
9535, 9938
|
2592, 2996
|
249, 296
|
396, 1392
|
5028, 8261
|
1414, 2206
|
2222, 2533
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,463
| 126,932
|
37561
|
Discharge summary
|
report
|
Admission Date: [**2150-12-17**] Discharge Date: [**2150-12-21**]
Date of Birth: [**2082-7-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
mild exertional chest
discomfort and shortness of breath
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting x3 with a left
internal mammary artery to left anterior descending artery
and reverse saphenous vein graft to the first obtuse marginal
artery and right coronary artery.
History of Present Illness:
68-year-old male with a complaint of some mild exertional chest
discomfort and shortness of breath who recently had an abnormal
ETT. He subsequently underwent a cardiac catheterization, which
showed left main and three-vessel coronary artery disease.
Specifics of his diagnostic studies are as follows: Cardiac
catheterization at [**Hospital3 **] on [**2150-10-15**], which showed a
left main 50% lesion, LAD 50%, left circumflex 80%, OM1 80%, RCA
60%, and PLV of 50%. Cardiac echocardiogram on [**2150-9-28**]
revealed EF of 60%, trace MR [**First Name (Titles) **] [**Last Name (Titles) **], mild MAC, mild AS, no AI
and
he had LVH.
Past Medical History:
HTN, CAD s/p myocardial infarction in [**2138**], hyperlipidemia,
IDDM, gastric ulcer, anemia, Lyme disease treated in [**9-/2149**],
s/p
tonsillectomy
Social History:
His occupation, he is retired. His last dental examination was
years ago. He lives with his wife. His race is Caucasian.
Tobacco, he quit 12 years ago after one pack per day times 30
plus years. He denies any alcohol use.
Family History:
non-contributory
Physical Exam:
PE:
98.2 70 170/74 18 97/RA
NAD, EOMI
CTAB
RRR, III/VI SEM @ LUSB
soft/NT/ND
radial pulses 2+ bilaterally
Pertinent Results:
[**2150-12-21**] 07:30AM BLOOD WBC-6.2 RBC-3.07* Hgb-8.8* Hct-26.3*
MCV-86 MCH-28.6 MCHC-33.4 RDW-14.7 Plt Ct-196
[**2150-12-21**] 07:30AM BLOOD Glucose-145* UreaN-27* Creat-1.2 Na-136
K-4.2 Cl-94* HCO3-32 AnGap-14
[**2150-12-21**] 07:30AM BLOOD Mg-1.9
Pre-bypass:
The left atrium is normal in size. No mass/thrombus is seen in
the left atrium or left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler.
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) appear mildly thickened, with good
leaflet excursion and no aortic regurgitation. The mitral valve
leaflets are mildly thickened.. Mild (1+) mitral regurgitation
is seen.
There is an anterior space which most likely represents a fat
pad.
Post-bypass:
The patient is receiving no inotropic support post-CPB.
Biventricular systolic function is preserved and all findings
are consistent with pre-bypass findings. The aorta is intact
post-decannulation. All findings communicated to the surgeon.
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2150-12-17**] where he underwent cabgx3 with Dr. [**Last Name (STitle) **].
Please see op report for further details. Overall the patient
tolerated the procedure well and post-operatively was
transferred in stable condition to the CVICU for further
observation and invasive monitoring. POD 1 found the patient
extubated, alert and oriented and breathing comfortably. He was
neurologically intact and hemodynamically stable on no
vasoactive support. At this time he was found suitable for
transfer to telemetry. Chest tubes and pacing wires were
discontinued without complication. Physical therapy was
consulted for assistance with post-operative strength and
mobility. The patient progressed as planned through the cardiac
surgery pathway. By POD 4 he was ambulating freely, the wound
was healing and pain was controlled with oral analgesics. Beta
blockade and diuresis were initiated. He was discharged home on
POD 4 with VNA services.
Medications on Admission:
Lisinopril, Metformin, Atenolol, Zocor, Omeprazole, Aspirin,
Insulin, Byetta, Glyburide, Magnesium Oxide.
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
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:*0*
6. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
7. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
8. Byetta 5 mcg/0.02 mL Pen Injector Sig: One (1) Subcutaneous
twice a day.
Disp:*qs 1 month * Refills:*0*
9. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
10. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day
for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
11. Insulin Asp Prt-Insulin Aspart 100 unit/mL (70-30) Solution
Sig: One (1) Subcutaneous twice a day: 20 units in am, 10 units
in pm as you were taking before surgery.
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Hospital1 1559**]
Discharge Diagnosis:
coronary artery disease
hypertension
diabetes
hyperlipidemia
myocardial infarction [**2138**]
gastric ulcer
anemia
lyme disease
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**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Primary Care Dr. [**Last Name (STitle) 57464**] [**Telephone/Fax (1) 14888**] in [**12-12**] weeks
Cardiologist Dr. [**Last Name (STitle) **] in [**12-12**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Completed by:[**2150-12-21**]
|
[
"285.9",
"414.01",
"250.00",
"531.90",
"412",
"272.4",
"780.62",
"V58.67",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.12",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
5706, 5779
|
3099, 4129
|
380, 584
|
5953, 6049
|
1856, 3076
|
6673, 7098
|
1688, 1706
|
4286, 5683
|
5800, 5932
|
4155, 4263
|
6073, 6650
|
1721, 1837
|
284, 342
|
612, 1252
|
1274, 1428
|
1444, 1672
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,811
| 158,768
|
44085
|
Discharge summary
|
report
|
Admission Date: [**2187-12-12**] Discharge Date: [**2187-12-29**]
Date of Birth: [**2111-6-6**] Sex: M
Service: Medicine
NOTE: The following is an admission History and Physical as
observed by Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **].
CHIEF COMPLAINT: Hematemesis.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 94633**] is a Russian-speaking
gentleman with a long past medical history including coronary
artery disease, status post coronary artery bypass graft in
[**2181**], myocardial infarction in [**2173**], congestive heart failure
with an ejection fraction of 40% and 3+ mitral regurgitation,
status post dual-mode, dual-pacing, dual-sensing pacer
placement for sick sinus syndrome, history of atrial
fibrillation, hypertension, hyperlipidemia, and chronic renal
insufficiency (at baseline creatinine between 1.6 and 2.1),
interstitial lung disease, osteoarthritis, and
insulin-requiring type 2 diabetes who presents to the [**Hospital1 1444**] Emergency Department with
bloody diarrhea and hematemesis. History is taken from his
wife who is the translator and the Emergency Department
charts.
One day prior to admission the patient had nausea, vomiting,
and bloody diarrhea with bright red blood per rectum and a
large volume of hematemesis times two. He felt lightheaded
and short of breath when going to the bathroom. He never had
gastrointestinal bleeding in the past. The patient denies
chest pain, lower extremity edema, cough, fever, or chills.
He called his primary care physician who advised him to go to
the Emergency Department.
In the Emergency Department he had continued epigastric pain
and received nasogastric lavage with 1 liter without
clearing. He was seen by Gastrointestinal who deferred
endoscopy for an INR of 4. The patient was given blood
transfusions, fresh frozen plasma, and vitamin K in the
Emergency Department. He was subsequently assessed by the
Medical Intensive Care Unit team and admitted to the unit.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post coronary artery
bypass graft in [**2181**] with 3-vessel disease.
2. Myocardial infarction in [**2173**].
3. Congestive heart failure with an echocardiogram of [**2187-5-1**] revealing diffuse hypokinesis and an ejection
fraction of 40% with moderate-to-severe mitral
regurgitation,, mild pulmonary hypertension.
4. Sick sinus syndrome, status post dual-mode, dual-pacing,
dual-sensing pacer placement in [**2179**].
5. Atrial fibrillation, currently in sinus rhythm.
6. Hypertension.
7. Hyperlipidemia.
8. Peripheral vascular disease.
9. History of peptic ulcer disease.
10. Chronic renal insufficiency with a creatinine between
1.6 and 2.1.
11. Interstitial lung disease; pulmonary function tests in
[**2187-11-1**] with a FVC of 3.05, an FEV1 of 2.57, the
ratio 128%.
12. Diabetes mellitus.
13. Osteoarthritis.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Aspirin 81 mg p.o. q.d.
2. Procainamide 1000 mg p.o. q.i.d.
3. Digoxin 250 mcg p.o. q.a.m.
4. Lasix 80 mg p.o. q.d.
5. Diovan 80 mg p.o. q.d.
6. Coumadin 3.75 mg p.o. q.d.
7. Captopril 50 mg p.o. t.i.d.
8. Zocor 20 mg p.o. q.d.
9. Nitro-Dur patch 0.8 mg per hour q.d.
10. Humulin and Humalog.
11. Celebrex.
SOCIAL HISTORY: The patient lives with his wife and rarely
uses ethanol. The patient quit using tobacco in [**2173**].
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs were
temperature of 98.6, heart rate lying down 94, heart rate
sitting up 109, blood pressure 109/75, respirations 20,
oxygen saturation 99% on room air. In general, an elderly
gentleman, alert in bed, in minimal distress. Head, ears,
nose, eyes and throat was normocephalic and atraumatic.
Right sclerae with erythema. Mucous membranes were moist.
Oropharynx without lesions. Neck was supple, neck veins
flat. No lymphadenopathy. Chest was clear to auscultation
bilaterally. Cardiovascular was regular. No murmurs, rubs
or gallops appreciated. Abdomen had normal active bowel
sounds, obese, soft nontender, nondistended, guaiac-positive.
Extremities had no clubbing, cyanosis or edema.
LABORATORY DATA ON PRESENTATION: White count 12.9,
hematocrit 34.6, platelets 350. PT 24.1, INR 4, PTT 37.5.
Sodium 139, potassium 5.6, chloride 105, bicarbonate 19,
blood urea nitrogen 45, creatinine 1.7, glucose 352.
Creatine kinase 100, MB 4, troponin of less than 0.3.
RADIOLOGY/IMAGING: Electrocardiogram with sinus rhythm
at 88 beats per minute, normal axis and intervals, Q wave in
II, III, and aVF, ST segment depressions in V2 through V5.
HOSPITAL COURSE: Mr. [**Known lastname 94633**] was admitted to the [**Hospital1 346**] Medical Intensive Care Unit for
further treatment of his acute bleeding. He was intubated
for impending esophagogastroduodenoscopy and hemodynamic
instability which included tachycardia and increased blood
pressure. The patient received 5 units of packed red blood
cells, 5 units of fresh frozen plasma, and vitamin K, along
with intravenous fluids. The patient's INR went from 4
to 1.3.
Subsequently esophagogastroduodenoscopy was performed which
revealed diffuse nodularity, a clot in the fundus, and some
small polys, and erosions, but there was no active source of
bleeding. No biopsies were done at that time.
1. CARDIOVASCULAR: Cardiology was asked to evaluate the
patient, and they recommended short-acting beta blocker to
maintain systolic blood pressure below 200 and heart rate
below the 150s. The patient was started on an esmolol drip
withe good affect. However, during the hospitalization, the
patient's cardiac enzymes revealed an elevated troponin which
initially was less than 0.3 and rising to 2.8 on [**2187-12-13**] and decreasing to 0.5 by [**2187-12-20**]. This was
thought to be demand ischemia. Given the patient's acute
problems, his cardiologist Dr. [**Last Name (STitle) **] recommended a stress
test as an outpatient at a later date when other issues have
stabilized.
The patient has a history of atrial fibrillation well
controlled on procainamide and anticoagulation with Coumadin.
Given his acute gastrointestinal bleed Cardiology recommended
discontinuation of Coumadin, and because the patient has been
in sinus rhythm for over seven years it was thought that the
patient can also stop procainamide. However, the patient
went into atrial fibrillation on [**12-17**] and was quickly
cardioverted chemically with intravenous procainamide.
Because of the patient's chronic renal insufficiency he was
started on maintenance amiodarone. Initially, the patient
received 400 mg of amiodarone t.i.d. for one week, and
currently is taking 400 mg of amiodarone q.d. for three
months, and thereafter he will take 200 mg p.o. q.d. The
patient has been in stable normal sinus rhythm since
cardioversion on [**12-18**].
2. GASTROINTESTINAL: The patient was admitted to the
Medical Intensive Care Unit with a brisk upper
gastrointestinal bleed and was transfusion, in total, 9 units
of blood and 5 units of fresh frozen plasma. The patient's
INR was rapidly corrected and endoscopy was emergently done.
It showed no evidence of active bleeding but there was
diffuse and continuous erythema, congestion, nodularity, and
mosaic of the mucosa of the stomach without bleeding
especially at the antrum, stomach body, and pylorus. There
was blood in the whole stomach and erosions at the antrum.
However, there was no active bleeding noted. The patient was
started on Protonix 40 mg intravenously b.i.d.
Over the course of the hospitalization the patient's
hematocrit remained stable above 30, and his stools became
guaiac-negative toward the end of the hospitalization.
Furthermore, the patient was found to be Helicobacter pylori
positive during this admission, and he was begun on triple
therapy for the treatment of Helicobacter pylori which
included clarithromycin, amoxicillin, and Prevacid.
3. PULMONARY: The patient was aggressively transfused to
maintain a hematocrit of 30, and over the course of the
hospital developed worsening congestive heart failure which
was treated with Lasix successfully. He was extubated on
[**12-17**] without problems.
4. RENAL: The patient has a history of chronic renal
insufficiency with a creatinine between 1.6 and 2.1. Because
of the patient's congestive heart failure he was treated with
Lasix aggressively and found to have an increasing creatinine
with a maximum of 2.9. At the time his urine was spun and
found to have muddy brown casts consistent with acute tubular
necrosis. At that time, the patient's lung examination was
clear and his ACE inhibitor and Lasix were held for the
remainder of the hospitalization. This resulted in
improvement in the patient's creatinine. At the time of this
dictation the creatinine was at 2.1 and trending downward.
We will restart the patient's ACE inhibitor and Lasix after
his renal function level is down to baseline.
5. NUTRITION: After extubation bedside examination revealed
that the patient was at risk for aspiration as he would cough
with thin liquids. More formal testing with video swallow
revealed that the patient indeed frankly aspirated thin
liquids and also thick liquids, and with regard to intake of
soft solids the patient had residual in the vallecula which
was concerning for aspiration. Based on this it was
recommended for the patient to be kept strictly n.p.o. and
his swallowing reassessed at a later date.
The etiology of the patient's inability to swallow remains
unclear. It is possible this may be neurologic; however,
there are no other neurologic findings suggestive of a
hypoxic hit to the brain. At this time we feel that it is
most likely trauma during the intubation process or
extubation process coupled with deconditioning resulting in a
weak swallowing musculature. It will likely take some time
for this to recover, and out best sense is that it may take
weeks to months. Given this assessment it was recommended
that the patient undergo a percutaneous gastrotomy tube for
nutrition and medications. This was placed without issue one
day prior to discharge and the patient was started on
Ultra-Cal tube feeding with a goal of 80 cc an hour, giving
2035 kilocalories and 85 g of protein. This assessment was
made based upon this patient's basal metabolic needs as
calculated by the [**First Name8 (NamePattern2) 6164**] [**Last Name (NamePattern1) **] equation. Furthermore, the
patient will need free-water boluses q.i.d. at 300 cc to
400 cc each.
6. ENDOCRINOLOGY: The patient has a history of type 2
diabetes now requiring insulin. He reports the use of NPH at
home, although the doses are unclear. We would therefore
recommend that fingersticks blood glucoses be checked q.i.d.
and the patient's insulin regimen adjusted accordingly.
At the time of discharge the patient's NPH insulin was at
20 q.a.m. and 20 q.p.m. with a regular insulin sliding-scale
to maintain a blood glucose between 150 and 200. In order to
do this close monitoring of blood glucose and adjustments to
the patient's NPH insulin will be necessary.
7. INFECTIOUS DISEASE: As mentioned above the patient was
Helicobacter pylori positive and a course of treatment was
initiated. In addition, the patient was also found to have
Moraxella pneumonia which was treated with a course of
levofloxacin. Several days prior to discharge the patient
was noted to have a right upper lobe infiltrate which, given
the patient's aspiration risks, we felt that it was
reasonable to extend his levofloxacin coverage for an
additional five days. The patient remained afebrile
throughout the hospitalization with a normal white count.
8. REHABILITATION: Having been in the hospital for a
relatively extended period the patient's strength and ability
to ambulate progressively worsened during this
hospitalization. Therefore, we feel that the patient would
benefit from a course of physical rehabilitation to increase
his strength, and as his nutrition increases his swallowing
may also improve with increased physical mobility and
reconditioning.
At the time of this dictation the patient was stable from a
medical perspective for transfer to a rehabilitation facility
with the goal of sending the patient home in the near future.
CONDITION AT DISCHARGE: Markedly improved.
DISCHARGE STATUS: Discharged to [**Hospital3 105**] in
[**Location (un) 583**], [**State 350**] (telephone number [**Telephone/Fax (1) 26091**]).
DISCHARGE DIAGNOSES: (As in Past Medical History and
include)
1. Gastrointestinal bleed.
2. Acute myocardial infarction.
3. Swallowing difficulty leading to the placement of a PEG
tube.
MEDICATIONS ON DISCHARGE:
1. Lopressor 50 mg p.o. b.i.d.
2. Tums 2 tablets p.o. t.i.d.
3. Ultram 50 mg p.o. q.i.d.
4. Amiodarone 400 mg p.o. q.d. for three months and
then 200 mg p.o. q.d. maintenance.
5. Nitroglycerin transdermal patch 0.8 mg per her
transdermally q.d.
6. Prevacid 30 mg p.o. b.i.d.
7. Glipizide 10 mg p.o. q.d.
8. NPH insulin 20 units subcutaneous q.a.m. and 20 units
subcutaneous q.p.m.
9. Regular insulin sliding-scale; blood glucose 0 to 60
give 1 amp D-50, 61 to 150 give nothing, 151 to 200 give
1 unit regular insulin, 201 to 250 give 3 units, 251 to 300
give 5 units, 301 to 350 give 7 units, 351 to 400 give
9 units, greater than 400 give 11 units and call medical
doctor.
10. Clarithromycin 250 mg p.o. t.i.d. for three more days,
amoxicillin 500 mg p.o. b.i.d. for three more days, and
continue Prevacid indefinitely for treatment of Helicobacter
pylori.
11. Hydralazine 20 mg per PEG tube q.i.d.
12. Free-water bolus 300-cc bolus q.i.d.
13. Levofloxacin for four more days.
14. Trazodone 100 mg p.o. q.h.s. p.r.n. for sleep.
15. Morphine sulfate p.r.n. for breakthrough pain.
16. Zocor 20 mg p.o. q.d.
17. Dulcolax 10 mg b.i.d. p.r.n. for constipation.
18. Colace 100 mg p.o. b.i.d.
Note: Please note that the patient's digoxin has been
discontinued, and currently Lopressor is being used.
Furthermore, because of the patient's acute tubular necrosis
his ACE inhibitor has been held; however, this should be
restarted in the next couple of days to provide afterload
reduction in this patient with severe mitral regurgitation
and congestive heart failure. We would favor the addition of
lisinopril. With regard to the patient's furosemide, he
takes 80 mg p.o. q.d. at home. This may need to be restarted
based upon the patient's pulmonary examination. If he goes
into congestive heart failure and pulmonary edema it will be
necessary to restart his Lasix regimen.
DISCHARGE FOLLOWUP:
1. The patient was to follow up with his cardiologist,
Dr. [**Last Name (STitle) **], for outpatient stress test and further
management of his cardiac condition.
2. Follow up at the [**Hospital 6283**] Clinic with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 17185**] (telephone number [**Telephone/Fax (1) 1954**]).
3. The patient should also have a repeat video study in
about one month's time. This can be scheduled either with
Dr. [**First Name (STitle) 17185**] in Gastrointestinal or the patient's primary
physician.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Last Name (NamePattern1) 94634**]
MEDQUIST36
D: [**2187-12-29**] 04:39
T: [**2187-12-29**] 05:28
JOB#: [**Job Number 94635**]
|
[
"428.0",
"276.2",
"584.5",
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"250.40",
"578.9",
"486",
"707.0",
"410.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"99.69",
"96.71",
"99.29",
"96.6",
"43.11",
"96.34",
"96.04",
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icd9pcs
|
[
[
[]
]
] |
12516, 12685
|
12712, 14612
|
2968, 3298
|
4640, 12311
|
12326, 12494
|
297, 311
|
14632, 15461
|
340, 2005
|
2028, 2941
|
3315, 4622
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,882
| 114,463
|
19769
|
Discharge summary
|
report
|
Admission Date: [**2101-11-30**] Discharge Date: [**2101-12-6**]
Date of Birth: [**2023-6-28**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 78 year old
gentleman with a past medical history of syringomyelia with
residual left hemi-diaphragmatic paralysis and chronic
obstructive pulmonary disease on home oxygen. He presents
from an outside hospital after two days of worsening
shortness of breath. By report, the patient had stopped his
Lasix two weeks prior to admission to the outside hospital
and had begun home oxygen around the clock instead of at
night only.
On admission to the outside hospital, he was found to have a
collapse of the left lung, initially thought secondary to
mucus plugging, since he did improve with suctioning at that
time. On [**2101-11-17**], the patient was diagnosed with a right
lower lobe pneumonia at the outside hospital and started
empirically on Vancomycin and Zosyn. The patient was
transferred to the Intensive Care Unit there for respiratory
failure on [**2101-11-21**] and intubated at that time. Bronchoscopy
was performed on [**11-22**] which found a mass in the left medial
basilar lobe, with intrinsic compression of other bronchi.
Biopsy done on that lesion came back as collagen, with a
question of possible chondroma or bronchial cartilage. The
patient was transferred to our hospital for a possible
endobronchial intervention by Dr. [**Last Name (STitle) **].
On receiving the patient from the outside hospital, he was
alert and responsive to voice. He was in restraints but
denied any pain or discomfort. He was resting comfortably on
the vent.
PAST MEDICAL HISTORY: Other past medical history of peptic
ulcer disease, complicated by gastrointestinal bleeds. He
has no known drug allergies.
MEDICATIONS ON TRANSFER:
Zosyn 3.375 grams q. 8 hours, day 15.
Prevacid 30 mg p.o. q. day.
Theophylline 50 mg p.o. four times a day.
Albuterol.
Reglan.
Celexa 20 mg p.o. q. day.
Timolol eye drops.
Xalatan eye drops.
Dulcolax.
Milk of Magnesia prn.
SOCIAL HISTORY: Lives at home with his wife.
PHYSICAL EXAMINATION: On admission, the patient was
afebrile; blood pressure 101/65; heart rate of 65;
respirations of 20; saturating 93% on the vent. In general,
he was alert and appeared comfortable. He had dry oral
membranes. His neck was supple. Cardiovascular examination
noted a normal S1 and S2, with no murmurs. His lungs were
clear on the right. He had decreased breath sounds at the
left base. Abdomen had positive bowel sounds, was soft and
nontender. Extremities: Warm and without edema. Left upper
extremity was somewhat atrophic with 1/5 strength.
LABORATORY DATA: White count was 9.9; hematocrit was 29.8;
platelets were 392. Sodium was 139; potassium was 4.1;
chloride 100; bicarbonate was 35; BUN was 9; creatinine .6;
glucose 115. Liver function tests were all within normal
limits. Calcium, magnesium and phosphorus were all normal.
Chest x-ray showed complete white-out of the left lung.
Electrocardiogram showed sinus rhythm with frequent premature
atrial contractions. Rate was 65. He had a left axis
deviation and early R wave progression but no acute ST or T
wave changes.
HOSPITAL COURSE: 78 year old gentleman with left
hemi-diaphragmatic paralysis secondary to syringomyelia and
chronic obstructive pulmonary disease, transferred from an
outside hospital for further work-up and management of
possible endobronchial lesion and left lung collapse.
On hospital day number three, a rigid bronchoscopy was
performed in the operating room which showed a distal lesion
with granulation; question of a possible foreign body. An
attempt at biopsy was aborted secondary to heavy bleeding.
A rigid bronchoscopy was repeated on hospital day number five
and a successful biopsy of the lesion was obtained and sent
to pathology for further review. In terms of the patient's
questionable pneumonia status, the patient had received 15
days of Zosyn at the outside hospital and it was felt that
the patient did not currently have a pneumonia; thus, the
Zosyn was discontinued on admission to our hospital.
In terms of his chronic obstructive pulmonary disease, the
patient was on a vent and got nebs and inhalers as needed. In
terms of his hematologic status, the patient received two
units of packed red blood cells on hospital day number six,
after he had dropped his hematocrit. This was after the
second bronchoscopy and he dropped his hematocrit to 20. His
hematocrit following the two units increased to 35. He
remained stable.
In terms of his cardiovascular status, he had no known heart
dysfunction and that remained stable.
DISCHARGE CONDITION: The patient had a tracheostomy
performed on hospital day number six, along with a second
rigid bronchoscopy. The patient was weaned off the
ventilator for approximately two hours on hospital day number
seven. He tolerated that well. The patient was placed back
onto the ventilator, secondary to some desaturations into the
high 80's, however, his respiratory rate remained at around
20.
DISCHARGE STATUS: Back to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 805**] Hospital.
DISCHARGE DIAGNOSES:
Left endobronchial lesion, not otherwise specified.
Left upper lobe collapse.
Chronic obstructive pulmonary disease.
Anemia.
DISCHARGE MEDICATIONS:
Acetaminophen 650 mg p.o. q. four to six hours as needed.
Albuterol neb, one neb q. six hours as needed.
Albuterol inhaler, two to four puffs every six hours as
needed.
Celexa 20 mg p.o. q. day.
Docusate 100 mg p.o. twice a day.
Ipratropium bromide four puffs inhaled four times a day as
needed.
Lantonoprost eye drops.
Lansoprazole oral solution, 30 mg p.o. q. day.
Lorazepam .5 to 2 mg p.o. every six hours prn.
Oxycodone 5 mg p.o. q. six hours prn.
Senna one tablet p.o. twice a day prn.
Theophylline 100 mg p.o. q. 8 hours.
Heparin 5000 units subcutaneous q. 8 hours.
Timolol eye drops.
Ipratropium bromide nebs, one neb q. six hours.
FOLLOW-UP PLANS: The patient should follow-up with his
primary care physician following his discharge from [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 805**] Hospital.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
MEDQUIST36
D: [**2101-12-6**] 04:07
T: [**2101-12-6**] 17:41
JOB#: [**Job Number 53448**]
|
[
"533.90",
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"496",
"518.81",
"515",
"518.0",
"336.0"
] |
icd9cm
|
[
[
[]
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] |
[
"99.04",
"96.72",
"31.1",
"96.04",
"33.24",
"32.01"
] |
icd9pcs
|
[
[
[]
]
] |
4683, 5180
|
5201, 5327
|
5350, 5990
|
3223, 4661
|
2111, 3205
|
6008, 6454
|
161, 1644
|
1818, 2042
|
1667, 1793
|
2058, 2088
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,311
| 102,959
|
28260
|
Discharge summary
|
report
|
Admission Date: [**2166-1-2**] Discharge Date: [**2166-1-19**]
Date of Birth: [**2088-12-7**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
ICD placement, dyspnea
Major Surgical or Invasive Procedure:
ICD implantation
History of Present Illness:
This is a 77 year old gentleman with a history of known coronary
artery disease, s/p stent to the left circumflex in [**2144**] and
CABG in [**2160**] with a LIMA to the LAD, SVG to diagonal, sequential
SVG to the ramus/OM, SVG to the PDA. He also has a history of
hypertension, hyperlipidemia, diabetes, systolic and diastolic
CHF (EF 35-40%) and atrial fibrillation on coumadin, and
presented for placement of ICD for primary prevention of sudden
cardiac death. Patient noted several weeks of worsening dyspnea
on exertion, in that previously he was able to walk around the
mall without getting symptomatic, but lately cannot ascend a
flight of stairs without having to stop to catch his breath. He
also had not been sleeping well and is occasionally waking with
dyspnea. He admitted to two-pillow orthopnea, which is not new.
There had also been worsening lower extremity edema over the
last few weeks. He had gone a week or two without taking many
of his medications, including Plavix, Lasix, and metoprolol, due
to him not sending away for his supply of pills.
.
Patient went for ICD placement on the day of admission, and
patient appeared fluid overloaded on presentation. He received
80 mg IV Lasix x 1 after ICD placement, and was transferred to
the floor. He was on 3 liters of O2 upon presenting to the
cardiology floor.
.
On review of systems, he denied any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, black stools or
red stools. He denied recent fevers, chills or rigors. He
denied exertional buttock or calf pain. All of the other review
of systems are negative.
.
Cardiac review of systems was notable for absence of chest pain,
palpitations, syncope or presyncope.
.
At the time of arrival to the floor, patient complained of
dyspnea mostly when he dozes off and falls asleep. He reported
no chest pain, palpitations, or syncope.
.
Past Medical History:
Cardiac Risk Factors: +Diabetes +Dyslipidemia +Hypertension
.
Cardiac History: CAD s/p PTCA to LCx and CABG in [**2161-10-8**] -
CABGx5 (LIMA->LAD, Vein->Diagonal, Vein->Ramus sequentialed to
Obtuse marginal, Vein->Posterior descending artery)
.
Other Past History:
Hypertension
Hyperlipidemia
Aortic stenosis
Diabetes mellitus type 2
Hx of pleural effusions, s/p left thoracentesis
Chronic renal insufficiency
Atrial fibrillation s/p treatment with Amiodarone and
cardioversion in [**2164**]
Colon Cancer s/p resection in [**2157**]
Probable GERD
Tonsillectomy
Social History:
He is a widower with six adult children. He lives with his
daughter and grandson. [**Name (NI) **] is retired. Prior to retiring he
worked as a design draftsman. He quit smoking over 20 years
ago, reports social alcohol use and denies illicit drug use.
Family History:
Father reportedly died of a myocardial infarction at the age of
39.
Physical Exam:
On admission:
VS: T= 96.9 BP= 137/100 HR= 104 RR= 18 O2 sat= 97%3L O2 BS=
191
GENERAL: WDWN obese male in NAD. Oriented x 3. Mood, affect
appropriate. Pleasant and cooperative
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva are
pink, MM slightly dry, no pallor or cyanosis of the oral mucosa.
No xanthalesma.
NECK: Supple with JVP of 6 cm above the clavicle.
CARDIAC: Tachycardic, regular rhythm, normal S1, S2. No m/r/g
audible. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, moderate kyphosis.
Respirations are unlabored, no accessory muscle use. CTAB,
bibasilar rales, no wheezes or rhonchi audible.
ABDOMEN: Soft NT, obese and distended, + shifting dullness.
Mild pitting edema present. No HSM.
EXTREMITIES: 3+ pitting edema up to above the knee, warm and
well-perfused.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
On discharge:
VS: Tm/Tc 98.7/97.8 BP 119/72 (111-139/67-86) P 88 (82-94) R
18 Sat 96%RA BS 166-196
I/O: 1715/1800
Wt: 87.9-->79.8 kg
GENERAL: WDWN obese male in NAD. Oriented x 3. Mood, affect
appropriate. Pleasant and cooperative.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva are
pink, MM slightly dry, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP elevated to 4 cm above clavicle.
CARDIAC: Irregularly irregular, normal S1, S2. II/VI SEM
indicative of TR, III/VI blowing holosystolic murmur at apex
indicative of MR.
CHEST: no swelling of ICD placement site, no erythema, no pain
to palpation around site.
LUNGS: No chest wall deformities, moderate kyphosis.
Respirations are unlabored, no accessory muscle use. CTAB, no
rales present, no wheezes or rhonchi audible.
ABDOMEN: Soft NT, obese, less distended than previous. No HSM.
EXTREMITIES: WWP, no c/c/e present.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS
--------------
[**2166-1-2**] 07:15AM BLOOD WBC-8.9 RBC-4.97 Hgb-11.6* Hct-37.8*
MCV-76* MCH-23.3* MCHC-30.7* RDW-20.3* Plt Ct-373
[**2166-1-2**] 07:15AM BLOOD Neuts-84.1* Lymphs-8.3* Monos-5.1 Eos-1.3
Baso-1.1
[**2166-1-2**] 07:15AM BLOOD PT-21.3* INR(PT)-2.0*
[**2166-1-2**] 07:15AM BLOOD Glucose-164* UreaN-34* Creat-2.0* Na-143
K-4.4 Cl-103 HCO3-27 AnGap-17
[**2166-1-3**] 07:10AM BLOOD Calcium-8.8 Phos-4.4 Mg-2.4
DISCHARGE LABS
--------------
[**2166-1-19**] 07:31AM BLOOD WBC-8.4 RBC-3.47* Hgb-8.8* Hct-26.7*
MCV-77* MCH-25.4* MCHC-32.9 RDW-19.7* Plt Ct-237
[**2166-1-19**] 07:31AM BLOOD PT-18.2* PTT-78.9* INR(PT)-1.6*
[**2166-1-19**] 07:31AM BLOOD Glucose-132* UreaN-72* Creat-3.2* Na-140
K-4.6 Cl-103 HCO3-27 AnGap-15
[**2166-1-19**] 07:31AM BLOOD Calcium-9.5 Phos-4.0 Mg-2.1
MICROBIOLOGY
------------
[**2166-1-3**] 07:14PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009
[**2166-1-3**] 07:14PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2166-1-3**] 01:03PM URINE Hours-RANDOM UreaN-389 Creat-54 Na-53
K-50 Cl-59
[**2166-1-17**] 10:51AM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
IMAGING
-------
ECG on admission:
Artifact is present. Probable sinus tachycardia, although
baseline abnormality precludes definitive assessment of the
rhythm. Left axis deviation. Non-specific intraventricular
conduction delay. There is a late transition with Q waves in the
anterior leads consistent with prior myocardial infarction.
Non-specific ST-T wave changes. Compared to the previous tracing
of [**2165-4-10**] the rhythm has probably changed.
CXR on admission:
Current study demonstrates mild degree of pulmonary edema,
significantly
improved when compared to the [**Month (only) 547**] radiograph. The pacemaker
defibrillator
was newly inserted with its lead terminating in the expected
location of the right ventricle. There is no evidence of
pneumothorax. There are still
present bibasilar areas of atelectasis and right basal
interstitial changes
that potentially might represent interstitial lung disease
underlying
pulmonary congestion. If clinically warranted, further
evaluation of the
patient with HRCT at some point may be reasonable for precise
characterization of the lung findings to differentiate between
the interstitial lung disease and superimposed part of pulmonary
edema.
TTE [**2166-1-7**]:
The left atrium is dilated. The right atrium is moderately
dilated. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. Overall left
ventricular systolic function is severely depressed (LVEF= 25 %)
secondary to severe hypokinesis of the inferior free wall,
interventricular septum and anterior free wall, extensive apical
akinesis with focal dyskinesis. [Intrinsic left ventricular
systolic function is likely more depressed given the severity of
valvular regurgitation, and relatively preserved function of the
basal posterior and lateral walls.] A large apical thrombus is
seen in the left ventricle. Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). There
is no ventricular septal defect. The right ventricular free wall
thickness is normal. The right ventricular cavity is dilated
with depressed free wall contractility. [Intrinsic right
ventricular systolic function is likely more depressed given the
severity of tricuspid regurgitation.] There are focal
calcifications in the aortic arch. There are three aortic valve
leaflets. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis (valve area 1.2-1.9cm2). The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Moderate to severe (3+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. Severe
[4+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. [In the setting of at
least moderate to severe tricuspid regurgitation, the estimated
pulmonary artery systolic pressure may be underestimated due to
a very high right atrial pressure.] The main pulmonary artery is
dilated. The branch pulmonary arteries are dilated. The
pulmonary artery is not well visualized. There is no pericardial
effusion.
Compared with the findings of the prior study (images reviewed)
of [**2165-4-1**], there has been a major further reduction of
left ventricular ejection fraction as well as significant
increase in the mitral and tricuspid regurgitation. A large
apical thrombus is now present in the left ventricle. The right
ventricle is now dilated and hypocontractile.
.
Renal ultrasound [**2166-1-12**]:
IMPRESSION: Normal renal son[**Name (NI) **]
.
Cardiac catheterization [**2166-1-14**]:
COMMENTS:
1. Coronary angiography in this right dominant system
demonstrated three
vessel disease. The LMCA had no angiographically apparent
disease. The
LAD was occluded in its mid-portion. The LCx was occluded at
OM1. The
RCA was not engaged as it was known to be occluded.
2. Resting hemodynamics revealed normal right sided filling
pressures
with RVEDP 8mmHg and a normal pulmonary capillary wedge pressure
of
13mmHg. There was mild pulmonary arterial systolic hypertension
with
PASP 35mmHg. The cardiac index was preserved at 3 L/min/m2. The
systemic
and pulmonary vascular resistances were normal at 973
dynes-sec/cm5 and
80 dynes-sec/cm5 respectively. The systemic arterial blood
pressure was
normal with SBP 100mmHg and DBP 61mmHg.
3. Arterial conduit angiography revealed the LIMA-LAD, SVG-OM,
SVG-Diag,
and SVG-PDA to be patent.
4. Supravalvular aortography revealed no significant aortic
regurgitation.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Patent bypass grafts.
3. Normal filling pressures.
.
TTE [**2166-1-15**]:
The left atrium is mildly dilated. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. There is mild to moderate regional left ventricular
systolic dysfunction with severe hypokinesis of the distal third
of the left ventricle, mid to distal inferior wall, and true
apex. large thrombus is seen in the left ventricle. The right
ventricular cavity is mildly dilated with normal free wall
contractility. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets (3) are mildly thickened. There
is mild aortic valve stenosis (valve area 1.2-1.9cm2). No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. Significant
pulmonic regurgitation is seen. The end-diastolic pulmonic
regurgitation velocity is increased suggesting pulmonary artery
diastolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2166-1-7**],
left ventricular systolic function has improved. The severity of
mitral and tricuspid regurgitation is reduced.
Brief Hospital Course:
77 year-old man with ischemic cardiomyopathy and an LVEF of 30%
referred for ICD implantation, presenting with weeks of
worsening dyspnea on exertion secondary to medication
noncompliance.
.
[**Hospital1 **] COURSE
-------------
# Systolic congestive heart failure, acute on chronic: patient
presented with symptoms of worsening dyspnea on exertion and at
rest, and peripheral and pulmonary edema, in the setting of
medication noncompliance. Initially, patient received boluses
of IV furosemide, but urine output was not optimal, so he was
switched to an IV furosemide drip. Urine output was still not
optimal and metolazone was added. His home dose of
spironolactone and lisinopril were initially continued, but then
the medication was discontinued due to worsening renal function.
He was continued on his home dose of metoprolol.
Echocardiography was initially performed, showing an ejection
fraction of 25% and worsening mitral and tricuspid
regurgitation. Patient was started on milrinone drip, and
initially required pressor support but was quickly weaned. He
was able to maintain good urine output, achieving net -1.5 - 2.0
L fluid balance per day. He was restarted on home spironalactone
25 mg qd, kept on milrinone gtt, and transferred back to [**Hospital1 1516**]
service. Diuresis was continued upon coming back to the
cardiology service, but was stopped when he was found to be
euvolemic and his creatinine started to rise. Prior to
catheterization on [**2166-1-14**], all diuresis was discontinued,
patient was given intravenous hydration, but milrinone was
continued. Fluid restriction and a low sodium diet were
employed and strict ins and outs and daily weights were
recorded. Diuresis was resumed with torsemide after returning
from catheterization, and milrinone was discontinued. His
creatinine continued to rise, so torsemide was discontinued upon
discharge and more IV fluid was given, to which his creatinine
downtrended. He is being discharged without further diuresis at
this time. He will likely need torsemide dosing in the future
as an outpatient.n Echocardiography was performed again after
diuresis, and showed improvement in ejection fraction and
valvular function. He is scheduled to follow up with Dr. [**First Name (STitle) 437**],
his new heart failure doctor on the day after discharge, who
will determine when to resume diuresis. He is being discharged
on metoprolol for therapy. His lisinopril and spironolactone
are currently being held due to elevated creatinine level.
.
# Status post ICD placement: patient initially presented for the
placement of an ICD, for primary prevention due to low ejection
fraction. He underwent the procedure without complication. He
is scheduled for follow-up at the device clinic for
post-procedure evaluation.
.
# Left ventricular thrombus: patient was noted on echocardiogram
to have a left ventricular thrombus present. He was started on
a heparin drip and also started on coumadin. At the time of his
discharge, his INR was 1.6. He will continue coumadin therapy
and see Dr. [**First Name (STitle) 437**] on the day after discharge for further
management of anticoagulation.
.
# Acute kidney injury on chronic kidney disease: baseline
creatinine approximately 1.7, in the setting of likely diabetic
nephropathy. On admission, patient creatinine was 2.0 compared
to baseline of 1.7, which peaked at 3.5 after initiation of
milrinone drip. Urine lytes showed FeUrea 37.5%, which was not
consistent with prerenal etiology. Etiology was likely from the
milrinone drip and fluid overload. It was subsequently
exacerbated by likely overdiuresis and dye load during
catheterization. Creatinine should continue to be monitored as
outpatient. Patient's medications were renally dosed and
nephrotoxins were avoided. Due to patient's creatinine levels,
his home doses of lisinopril and spironolactone were
discontinued. They may be added back in the future if his
creatinine returns towards baseline. Patient should have his
creatinine checked three times per week at rehab to evaluate
status of kidney function. His discharge creatinine was 3.2.
.
# Microcytic anemia, acute on chronic: patient's hematocrit
slowly trended down during his hospital stay. He was provided
with one unit blood transfusion on the day before discharge.
Patient has had a colonoscopy within the last two years that was
reported to be free of polyps or cancer, reported by the
patient, but this is not in our records system. He was noted to
be guaiac positive while admitted and on heparin IV. Patient
should have his CBC checked three times per week at rehab to
evaluate status of anemia. His discharge hematocrit level was
26.
.
INACTIVE ISSUES
---------------
# Coronary artery disease: s/p CABG, patient reported no chest
pain during his hospitalization. He was continued on his home
dose of clopidogrel as well as low-dose aspirin. He was also
continued on his home dose of metoprolol. Since patient is on
amiodarone, his rosuvastatin dose was decreased to 10 mg daily.
He was continued on his home dose of Plavix. He is being
discharged on metoprolol for therapy. His lisinopril is
currently being held due to elevated creatinine level.
Catheterization was performed during his stay and showed no new
lesions in the coronary arteries. Patient will follow up with
both his general cardiologist and heart failure specialist upon
discharge.
.
# Atrial fibrillation/flutter: patient is on coumadin and
amiodarone, as well as metoprolol for rate control, all of which
were given during his hospitalization. His coumadin was held
prior to admission for ICD placement, and then later for
catheterization. It was restarted after the procedures and INR
trended up until the time of discharge. He was monitored on
telemetry during this admission. He stayed in normal sinus
rhythm during his hospital stay. He is being discharged on his
home dose of warfarin, metoprolol and amiodarone. Patient
should have his INR checked two times per week at rehab to
evaluate status of therapeutic coumadin dosing.
.
# Hypertension: patient remained normotensive on his home
medications. His metoprolol succinate was continued, and he
will continue taking this as an outpatient. His Imdur was
discontinued since he was normotensive during his stay. His
lisinopril and spironolactone was held when his potassium and
creatinine level rose above 2.5.
.
# Hyperlipidemia: patient's statin dose was decreased to
rosuvastatin 10 mg daily due to being on amiodarone, and he will
continue this dosage upon discharge.
.
# Diabetes mellitus type 2: patient has a history of diabetic
retionopathy with likely nephropathy as well. Patient's
glyburide was held and sliding scale insulin was begun. Blood
sugar levels were well controlled throughout this
hospitalization. Patient is being discharged on glipizide for
further diabetic management instead of glyburide due to his
renal function.
.
# GERD: patient was continued on his home dose pantoprazole
during hospitalization.
.
TRANSITION OF CARE
----------------
# Code status: patient is confirmed full code.
.
# Follow-up: patient will follow up with his general
cardiologist and a heart failure specialist. He needs follow-up
of his INR levels due to being subtherapeutic on coumadin upon
discharge. He also needs follow-up of his kidney function and
anemia, since both were active issues upon discharge. He may
need a colonoscopy due to noted guaiac positive stools. His
INR, CBC and Chem7 should be checked at rehab as described
above.
Medications on Admission:
Furosemide 80 mg PO BID
Imdur 60 mg PO daily
Warfarin 3 mg PO daily
Plavix 75 mg PO daily
Lisinopril 20 mg PO daily
Metoprolol succinate 200 mg PO daily
Amiodarone 200 mg PO daily
Spironolactone 25 mg PO BID
Rosuvastatin 20 mg PO daily
Allopurinol 200 mg PO daily
Ventolin aerosol 2 puffs IH qid PRN
Protonix 40 mg PO daily
Spiriva 18 mcg IH daily
Glyburide 5 mg PO BID
Coenzyme Q10 200 mg PO daily
Multivitamin PO daily
Fish oil - dose uncertain
Discharge Medications:
1. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual Q5MIN () as needed for chest pain.
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
wheeze.
4. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. metoprolol succinate 200 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
10. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
11. glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
12. coenzyme Q10 200 mg Capsule Sig: One (1) Capsule PO once a
day. Capsule(s)
13. multivitamin Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
14. Fish Oil Oral
15. rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
16. Outpatient Lab Work
Please perform INR check twice per week starting on [**2165-1-21**] and
17. Outpatient Lab Work
Please perform Chem7 and CBC three times a week and fax results
to MD on call
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary diagnosis:
Systolic congestive heart failure, acute on chronic
Acute on chronic renal insufficiency
Left ventricular thrombus
Microcytic anemia, acute on chronic
Secondary diagnosis:
Coronary artery disease
Atrial fibrillation
Hypertension
Hyperlipidemia
Diabetes mellitus type 2
Gastroesophageal reflux disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 68637**],
It was a pleasure taking care of you at the [**Hospital1 18**]. You came for
placement of a defibrillator (ICD), but were found to have
increased fluid and decompensation of your heart failure.
Further tests showed that you had worsening heart function on
echocardiogram, and you were given medications to help take this
fluid off. Your kidneys were also found to not be working
optimally. A cardiac catheterization showed no problems with
the blood vessels of your heart. Your kidneys are still not
working like they used to, and this will need follow-up. It is
important that you continue to take your medications and follow
up with the appointments listed below, one of which is with Dr.
[**First Name (STitle) 437**] on the day after your discharge, Monday [**1-20**]. Weigh
more than 3 lbs.
The following changes have been made to your medications:
We STOPPED your furosemide, lisinopril and spironolactone
We STOPPED your glyburide, which is given for diabetes, and
ADDED glipizide, which is better for this condition given your
kidney function.
We DECREASED your rosuvastatin dose due to your kidney function
We STOPPED your isosorbide mononitrate (Imdur), since your blood
pressure appears to be controlled.
We DECREASED your dose of allopurinol, to adjust for your kidney
function
Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2166-1-20**] at 9:00 AM
With: DR. [**Known firstname **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) **],[**First Name3 (LF) **] W.
Location: [**Hospital3 **] INTERNAL MEDICINE ASSOCIATES
Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 4475**]
Appt: Please call Dr [**Last Name (STitle) 68638**] office to book a follow up appt
from your hospital stay in the next two weeks.
|
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"428.0",
"250.40",
"414.01",
"530.81",
"280.9",
"424.1",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.94",
"38.93",
"88.56",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
21983, 22054
|
12368, 19926
|
334, 352
|
22421, 22421
|
5162, 6432
|
23932, 24627
|
3138, 3207
|
20423, 21960
|
22075, 22075
|
19952, 20400
|
10922, 12345
|
22572, 23909
|
3222, 3222
|
4149, 5143
|
272, 296
|
380, 2266
|
22269, 22400
|
22095, 22247
|
6884, 10905
|
22436, 22548
|
2288, 2851
|
2867, 3122
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,634
| 109,863
|
24651
|
Discharge summary
|
report
|
Admission Date: [**2133-8-3**] Discharge Date: [**2133-8-15**]
Date of Birth: [**2085-6-19**] Sex: M
Service: [**Last Name (un) **]
PRESENT ILLNESS: The patient is a 48 year old male who
presented [**7-24**], at which time the patient had a
laparoscopic cholecystectomy, a laparoscopic intraoperative
ultrasound, and attempted laparoscopic segment 5 resection
converted to open segment 5 resection adjacent to the
gallbladder. The operative note is dictated in detail by Dr.
[**First Name (STitle) **]. At that point the patient was transferred to the
intensive care unit and eventually transferred to the floor
and discharged home. The patient re-presented to the
emergency room on [**2133-8-3**] with lethargy and severe
dehydration. His [**Location (un) 1661**]-[**Location (un) 1662**] drain which he was sent home
with was putting out approximately 1800 cc per day. His
admission creatinine was 4.1. His admission white blood cell
count was 30.6. His AST was 233. His ALT was 142. His
alkaline phosphatase was 131. Bilirubin was 1.4. Blood
cultures were sent upon admission and revealed 4 out of 4
positive vials of methicillin sensitive staph aureus. Fluids
sent from the JP also revealed methicillin sensitivity staph
aureus.
PAST MEDICAL HISTORY: Morbid obesity, hypertension, NIDDM,
sleep apnea.
PAST SURGICAL HISTORY: Left knee surgery.
MEDICATIONS: Admission medications of Metformin, Lisinopril,
Hydrochlorothiazide, Nifedipine, Reglan and Glipizide.
HOSPITAL COURSE: The patient was admitted to the transplant
surgery service and hydrated. Over the course of the next 5
days his creatinine improved back to his baseline of 1.0. The
[**Location (un) 1661**]-[**Location (un) 1662**] drain was removed on hospital day 4. However,
on hospital day 8 the patient had a bump in creatinine to 1.8
and a guaiac positive stool. An NG tube was placed which
revealed a significant amount of blood. A significant drop in
hematocrit was also seen. The patient was transferred to the
intensive care unit and had an endoscopy performed. Three
collapsed varices were banded by Dr. [**Last Name (STitle) **],
gastrointestinal service. The patient became rapidly
unstable, was intubated in the intensive care unit. His
hemodynamics were completely off and they were requiring
pressors. His LFTs significantly increased to an AST of 4567
and an ALT of 923, alkaline phosphatase of 653 and a
bilirubin of 8.7. His INR at that time was also significantly
elevated at 2.5. Mr. [**Known lastname **] at that point was requiring a
significant amount of support. He was paralyzed with a Swan
Ganz catheter in place. He had maximum pressors with Levophed
and Octreotide, as well as Vasopressin. He was on maximum
ventilation support which was eventually switched to pressure
control ventilation with continued maximal oxygenation. He
was also started on CVH for significant acidosis and volume
overload. He was placed on broad spectrum antibiotics, which
included Vancomycin, Zosyn, Fluconazole and Flagyl.
The patient's status continued to deteriorate despite the
maximal support. On [**8-14**] the patient had multiple coding
episodes with V-tach, asystole, pulseless electrical activity
in which ACLS protocol was initiated. This happened 4 times.
After discussion with the family and the intensive care unit
attending, as well as the surgical attending, it was decided
the patient should be made DNR.
The morning of [**8-15**] at 7:20 a.m. the patient expired.
CONDITION ON DISCHARGE: Expired.
DISCHARGE DIAGNOSES:
1. Status post segment 5 liver resection.
2. Morbid obesity.
3. Hypertension.
4. Non-insulin dependent diabetes mellitus.
5. Sleep apnea.
The patient's family agreed to postmortem, which was
performed.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**], M.D. [**MD Number(2) 6727**]
Dictated By:[**Name8 (MD) 368**]
MEDQUIST36
D: [**2133-8-15**] 17:11:35
T: [**2133-8-15**] 18:39:21
Job#: [**Job Number 62223**]
|
[
"572.0",
"038.11",
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"285.1",
"155.2",
"278.01",
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"456.20",
"427.5",
"286.7",
"995.92",
"250.00",
"570",
"572.4",
"998.59",
"571.5",
"707.8",
"785.52",
"518.81",
"567.2",
"276.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"39.95",
"93.90",
"99.60",
"99.05",
"42.33",
"96.04",
"99.04",
"00.17",
"99.15",
"96.72",
"99.06",
"38.93",
"89.64",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
3541, 4003
|
1510, 3485
|
1354, 1492
|
1279, 1330
|
3510, 3520
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,079
| 194,948
|
2104+55348+55349
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2145-10-8**] Discharge Date: [**2145-10-19**]
Date of Birth: [**2090-5-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Iodine
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
decreased exercise tolerance
Major Surgical or Invasive Procedure:
Aortic valve replacement with a Mechanical St.[**Male First Name (un) 923**] size 23-mm
valve [**2145-10-8**]
History of Present Illness:
55 year old male with progressive intolerance for activity over
the previous
12-18 months. He was found to have a murmur on exam with his
PCP. [**Name10 (NameIs) **] revealed severe AI. He was referred for TEE which
confirmed severe AI and showed flail right coronary cusp. He is
referred for surgical evaluation.
Past Medical History:
Colon CA s/p anastomotic reconstruction followed by
chemotherapy/radiation
Port-a-Cath discontinued in [**2134**]
Erectile Dysfunction
Fecal stress incontinence
Chronic right sided sinus pressure
Decreased auditory acuity
Tonsillectomy
Colon resection as above
Social History:
Mr. [**Known lastname 957**] lives in [**Location 11269**] with his wife. One daughter lives at
home with him. His occupation is teaching video data networks.
He has never smoked or used illicit drugs and drinks two beers
per week.
Family History:
His father had an unknown cancer diagnosed at age 70.
Physical Exam:
Pulse: 76 Resp: 14 O2 sat: 97%RA
B/P Right: Left: 180/71
Height: 5'[**43**]" Weight: 195lb
General: NAD, WGWN, appears stated age
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade _3/6 diastolic_
Abdomen: Soft [x] non-distended [x] non-tender [] +BS [x]
Extremities: Warm [x], well-perfused [x] Edema [] none
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right: 2+ Left:2+
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
LEFT ATRIUM: Dilated LA. Mild spontaneous [**Hospital1 113**] contrast in the
body of the LA. No mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Mild symmetric LVH. Moderately dilated
LV cavity. Normal regional LV systolic function. Moderately
depressed LVEF.
RIGHT VENTRICLE: Normal RV systolic function.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. Simple
atheroma in aortic arch. Normal descending aorta diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No
masses or vegetations on aortic valve. No aortic valve abscess.
No AS. Severe (4+) AR. Eccentric AR jet directed toward the
anterior mitral leaflet.
MITRAL VALVE: Mildly thickened mitral valve leaflets.
Physiologic MR
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
Conclusions
PRE-BYPASS: The left atrium is dilated. Mild spontaneous [**Last Name (Prefixes) 113**]
contrast is seen in the body of the left atrium. No
mass/thrombus is seen in the left atrium or left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity is moderately to severely dilated.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is globally, moderately depressed
(LVEF= 30-35 %). The right ventricle displays normal free wall
contractility. There are simple atheroma in the aortic arch.
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) are mildly thickened. No masses or
vegetations are seen on the aortic valve. No aortic valve
abscess is seen. There is no aortic valve stenosis. There is
severe prolapse of right coronary cusp and also some prolapse of
one of the other leaflets. Severe (4+) aortic regurgitation is
seen. The aortic regurgitation jet is eccentric, directed toward
the anterior mitral leaflet. The mitral valve leaflets are
mildly thickened. Physiologic mitral regurgitation is seen
(within normal limits). There is a trivial/physiologic
pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person
of the results in the operating room at the time of the study.
POST-BYPASS: The patient is receiving epinephrine by infusion.
The patient was AV paced. There is normal right ventricular
systolic function. The left ventricle displasia new septal
dyskinesis that may be secondary to pacemaking vs. new
intraventricular conduction delay vs. ischemia. The rest of the
left ventricular segments display improved function relative to
the pre-bypass exam. Overall ejection fraction is likely
marginally improved to the 35-40% range. There is a bileaflet
prosthesis in the aortic position. It appears well seated and
displays normal leaflet motion. At a cardiac output of 6.5
liters/minute, the maximum gradient across the valve was 28 mmHg
woith a mean gradient of 13 mmHg and an effective area of about
1.9 cm2. There is trace aortic regurgitation as consistent with
this prosthesis. The thoracic aorta is intact after
decannulation. No other significant changes from the pre-bypass
findings.
PA and lateral chest compared to [**10-8**]:
Left lower lobe atelectasis nearly resolved. Small residual
pleural effusions and stable normal-appearing postoperative
cardiomediastinal silhouette, heart size increased since the
last preoperative study on [**9-30**]. No pulmonary edema. No
pneumothorax.
EKG
Normal sinus rhythm. Left bundle-branch block with secondary
ST-T wave
abnormalities. Compared to the previous tracing of [**2145-9-29**] the
left
bundle-branch block is new.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
87 158 138 416/463 70 -52 107
Admission Labs:
[**2145-10-8**] 08:05AM HGB-13.4* calcHCT-40
[**2145-10-8**] 11:11AM HGB-10.4* calcHCT-31
[**2145-10-8**] 11:57AM FIBRINOGE-174
[**2145-10-8**] 11:57AM PT-14.9* PTT-28.4 INR(PT)-1.3*
[**2145-10-8**] 11:57AM PLT COUNT-176
[**2145-10-8**] 12:01PM GLUCOSE-183* LACTATE-2.3* NA+-136 K+-5.1
CL--107
[**2145-10-8**] 01:12PM UREA N-19 CREAT-1.2 SODIUM-142 POTASSIUM-4.0
CHLORIDE-110* TOTAL CO2-23 ANION GAP-13
Discharge Labs:
[**2145-10-13**] 06:00AM BLOOD WBC-5.4 RBC-3.97* Hgb-11.8* Hct-34.3*
MCV-86 MCH-29.6 MCHC-34.3 RDW-13.6 Plt Ct-193
[**2145-10-14**] 05:32AM BLOOD PT-29.2* INR(PT)-2.8*
[**2145-10-13**] 06:00AM BLOOD Glucose-105* UreaN-18 Creat-0.9 Na-140
K-3.8 Cl-107 HCO3-28 AnGap-9
[**2145-10-12**] 03:45PM BLOOD ALT-14 AST-23 LD(LDH)-350* AlkPhos-44
TotBili-0.5
[**2145-10-13**] 06:00AM BLOOD Calcium-8.3* Phos-3.2 Mg-2.0
Brief Hospital Course:
55-year-old patient with progressive intolerance for activity
over the previous several months was found to have a cardiac
murmur. A subsequent investigation showed severe aortic valve
regurgitation with some dilatation of the left ventricle with an
ejection fraction about 35%. A`coronary angiogram had non
obstructive coronary artery disease.
The patient was admitted for elective aortic valve replacement
on [**2145-10-8**]. He was taken to the operating room and had Aortic
valve replacement with a mechanical St. [**Male First Name (un) 923**] size 23-mm valve,
his bypass time was 145 minutes with a crossclamp of 132
minutes. Please see operative report for further details. He
tolerated the procedure well and was transferred to the CVICU
intubated and sedated in stable condition. He weaned off pressor
support, awoke neurologically intact and was extubated without
incident. Anticoagulation was initiated with Coumadin for his
mechanical valve. Beta-blocker and diuresis were initiated. All
tubes, lines and drains were discontinued per cardiac surgery
protocol. On POD1 he was transferred to the step down unit for
further monitoring. Physical Therapy was consulted for
evaluation of strength and mobility. An ACE-I was started for
hypertension management. He continued with issues with
hypertension so he was transitioned to HCTZ and lasix was
stopped, additionally he was taken off lopressor and placed on
carvedilol for chronic sytolic heart failure and hypertension
with good response. The remainder of his hospital stay was
uneventful, he continued to progress and was cleared for
discharge to home on POD 6
His INR is to be followed by Dr.[**Last Name (STitle) 838**] [**Telephone/Fax (1) 4775**]
Medications on Admission:
ZYRTEC 10 mg once a day
ASPIRIN 325 mg once a day
Discharge Medications:
1. Outpatient Lab Work
Labs: PT/INR for Coumadin ?????? indication :Mechanical AVR
Goal INR 2.5-3
First draw [**2145-10-13**]
Results to phone
Primary Care Dr.[**Last Name (STitle) **],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 4775**]
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-20**] Sprays Nasal
QID (4 times a day) as needed for dry nares .
4. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Outpatient Lab Work
LFT in 1 month - results to PCP [**Name Initial (PRE) **] [**Name10 (NameIs) **] statin
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
7. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
8. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
Disp:*qs qs* Refills:*1*
9. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. Outpatient Lab Work
LFT 1 month result to PCP [**Name Initial (PRE) **] [**Name10 (NameIs) **] statin
12. lisinopril 20 mg Tablet Sig: One (1) Tablet PO twice a day:
start [**10-15**] am.
Disp:*60 Tablet(s)* Refills:*1*
13. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
Disp:*30 Tablet, ER Particles/Crystals(s)* Refills:*1*
14. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*1*
15. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*1*
16. warfarin 2 mg Tablet Sig: Goal INR 2.5-3 Tablets PO once a
day: dose to be adjusted based on INR .
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
aortic insufficiency s/p AVR
Hypertension
Chronic systolic heart failure
Colon CA s/p anastomotic reconstruction followed by
chemotherapy/radiation
Erectile Dysfunction
Fecal stress incontinence
Chronic right sided sinus pressure
Decreased auditory acuity
Tonsillectomy
Colon resection
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Tramadol/Tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Labs: PT/INR ?????? indication :Mechanical AVR
Goal INR 2.5-3
First draw - [**10-15**]
Results to phone
Primary Care Dr.[**Last Name (STitle) 838**] [**Telephone/Fax (1) 4775**]
Please check PT/INR Monday and Wednesday and Friday for first
two weeks then decrease as directed by PCP
You are scheduled for the following appointments
Surgeon: Dr [**First Name (STitle) **] [**Telephone/Fax (1) 170**] on [**2145-11-15**] at 1:30
Wound check - [**Telephone/Fax (1) 170**] on [**2145-10-19**] at 10:30 cardiac surgery
office [**Hospital Unit Name **] [**Hospital Unit Name **].
Cardiologist: Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 62**] on [**2145-10-25**] 4:00
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) 838**] [**Telephone/Fax (1) 4775**] in [**3-23**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2145-10-14**] Name: [**Known lastname **],[**Known firstname 116**] Unit No: [**Numeric Identifier 1591**]
Admission Date: [**2145-10-8**] Discharge Date: [**2145-10-19**]
Date of Birth: [**2090-5-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Iodine
Attending:[**First Name3 (LF) 265**]
Addendum:
NP was called to patient's room on day of discharge due to
dizziness while showering. As patient was being held sitting up
in the bathroom he became unresponsive and stopped breathing
with no pulse. Code was called and compressions were initiated.
After ~ 6 compressions, patient regained consciousness, then
became unresponsive once again had 5 subsequent compressions.
He once again regained consciousness and BP systolic was in the
70's. He remained hemodynamically stable but dizzy with sitting
up. Echo done showed EF 30% (unchanged) and no pericaridal
effusion. He was transferred to CVICU. The following day he was
hypotensive and lightheaded after receiving Coreg, HCTZ and
Lisinopril and these were titrated down. He was transferred back
to the floor. His Coreg and Lisinopril were gradually decreased
and then stopped due to hypotension and lightheadedness after
taking medications, especially Coreg . Per Dr [**First Name (STitle) **], he is to
go home on no antihypertensives, including no Ace-I, due to
hypotension. Follow up caridology appointment in 1 week for
titration/reinstituion of medications. He continued to on
anticoagulation for mechanical AVR with INR 2.5-3.5 goal. On
the day of discharge he was hemodynamically stable with BP
118/78 with no symptoms of dizziness. He was be discharged home
in stable condition with visiting nurse services. INR 2.6 on
day of discharge.
Major Surgical or Invasive Procedure:
Aortic valve replacement (Mechanical St.[**Male First Name (un) 744**] 23-mm)[**2145-10-8**]
Past Medical History:
Colon CA s/p anastomotic reconstruction followed by
chemotherapy/radiation
Port-a-Cath discontinued in [**2134**]
Erectile Dysfunction
Fecal stress incontinence
Chronic right sided sinus pressure
Decreased auditory acuity
Tonsillectomy
Colon resection as above
Pertinent Results:
[**2145-10-18**] 06:00AM BLOOD WBC-6.2 RBC-4.01* Hgb-12.1* Hct-34.3*
MCV-86 MCH-30.0 MCHC-35.2* RDW-13.3 Plt Ct-301
[**2145-10-16**] 04:20AM BLOOD WBC-8.1 RBC-4.37* Hgb-13.3* Hct-38.2*
MCV-88 MCH-30.5 MCHC-34.9 RDW-13.4 Plt Ct-280
[**2145-10-15**] 05:14AM BLOOD WBC-6.6 RBC-4.11* Hgb-12.5* Hct-36.0*
MCV-88 MCH-30.4 MCHC-34.7 RDW-13.6 Plt Ct-230
[**2145-10-14**] 09:38AM BLOOD WBC-5.9 RBC-4.02* Hgb-12.4* Hct-35.3*
MCV-88 MCH-30.9 MCHC-35.2* RDW-13.6 Plt Ct-242
[**2145-10-18**] 06:00AM BLOOD Glucose-92 UreaN-23* Creat-1.1 Na-142
K-4.2 Cl-106 HCO3-28 AnGap-12
[**2145-10-16**] 04:20AM BLOOD Glucose-108* UreaN-19 Creat-1.0 Na-142
K-4.3 Cl-105 HCO3-26 AnGap-15
[**2145-10-15**] 05:14AM BLOOD Glucose-102* UreaN-18 Creat-1.0 Na-140
K-4.0 Cl-105 HCO3-26 AnGap-13
[**2145-10-14**] 09:38AM BLOOD Glucose-111* UreaN-17 Creat-1.1 Na-141
K-4.0 Cl-107 HCO3-24 AnGap-14
[**2145-10-14**] TTE
Left Atrium - Long Axis Dimension: *5.3 cm <= 4.0 cm
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *5.8 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 5.3 cm
Left Ventricle - Fractional Shortening: *0.09 >= 0.29
Left Ventricle - Ejection Fraction: 30% >= 55%
Aorta - Sinus Level: 3.4 cm <= 3.6 cm
Aortic Valve - Peak Velocity: *2.3 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *23 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 11 mm Hg
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A ratio: 0.88
Mitral Valve - E Wave deceleration time: *98 ms 140-250 ms
Findings
LEFT ATRIUM: Moderate LA enlargement.
LEFT VENTRICLE: Mild symmetric LVH. Mildly dilated LV cavity.
Depressed LVEF. No resting LVOT gradient.
RIGHT VENTRICLE: RV not well seen.
AORTA: Normal aortic diameter at the sinus level.
AORTIC VALVE: Bileaflet aortic valve prosthesis (AVR). AVR well
seated, normal leaflet/disc motion and transvalvular gradients.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No
MVP. Normal mitral valve supporting structures. No MS.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal tricuspid valve supporting structures. No TS.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity is
mildly dilated. LV systolic function appears depressed (ejection
fraction 30 percent), at least partly due to marked mechanical
dyssynchrony (pacing vs left bundle branch block). A bileaflet
aortic valve prosthesis is present. The aortic valve prosthesis
appears well seated, with normal leaflet/disc motion and
transvalvular gradients. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. There is no pericardial effusion.
Discharge Medications:
1. Outpatient Lab Work
Labs: PT/INR for Coumadin ?????? indication :Mechanical AVR
Goal INR 2.5-3
First draw [**2145-10-13**]
Results to phone
Primary Care Dr.[**Last Name (STitle) **],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 702**]
2. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-20**] Sprays Nasal
QID (4 times a day) as needed for dry nares .
3. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
Disp:*qs qs* Refills:*1*
6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Outpatient Lab Work
LFT 1 month result to PCP [**Name Initial (PRE) **] [**Name10 (NameIs) **] statin
9. warfarin 2 mg Tablet Sig: Goal INR 2.5-3 Tablets PO once a
day: dose to be adjusted based on INR .
Disp:*90 Tablet(s)* Refills:*2*
10. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 720**]
Discharge Diagnosis:
aortic insufficiency
s/p aortic valve replacement
Hypertension
Chronic systolic heart failure
Colon CA (s/p resection,chemotherapty & radiation)
Erectile Dysfunction
Fecal stress incontinence
Chronic right sided sinus pressure
Decreased auditory acuity
Tonsillectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
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) 1477**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 1477**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Labs: PT/INR ?????? indication :Mechanical AVR
Goal INR 2.5-3.5
First draw - [**2145-10-19**]
Results to phone
Primary Care Dr.[**Last Name (STitle) **] [**Telephone/Fax (1) 702**] Fax [**Telephone/Fax (1) 1592**]
Please check PT/INR Monday and Wednesday and Friday for first
two weeks then decrease as directed by PCP
You are scheduled for the following appointments
Surgeon: Dr [**First Name (STitle) **] ([**Telephone/Fax (1) 1477**]) on [**2145-11-15**] at 1:30
Wound check - [**Telephone/Fax (1) 1477**] on [**2145-10-19**] at 10:30 cardiac surgery
office [**Hospital Unit Name **] [**Hospital Unit Name 1593**].
Cardiologist: Dr. [**Last Name (STitle) 1594**] ([**Telephone/Fax (1) 337**]) on [**2145-10-25**] 4:00
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) **] ([**Telephone/Fax (1) 702**]) in [**3-23**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 1477**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2145-10-18**] Name: [**Known lastname **],[**Known firstname 116**] Unit No: [**Numeric Identifier 1591**]
Admission Date: [**2145-10-8**] Discharge Date: [**2145-10-19**]
Date of Birth: [**2090-5-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Iodine
Attending:[**First Name3 (LF) 265**]
Addendum:
Patient was kept an additional day due to episode of
lightheadedness and diaphoresis. No arryhthmia was noted at the
time, BP 123/79 HR 80's and BS 149. Percocet was discontinued
and he was observed for an additional 24 hrs without any further
episodes. He was hemodynamically stable at the time of
discharge - BP 120/70's, HR 80's. He was discharged home with
VNA services on POD 11 on no antihypertensive agents - Tylenol
only for pain. He is to follow up with his cardiologist in 1
week for further adjustment in medications.
Discharge Disposition:
Home With Service
Facility:
[**Company 720**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2145-10-19**]
|
[
"780.4",
"424.1",
"478.19",
"E942.9",
"V58.61",
"428.22",
"780.2",
"E941.3",
"401.9",
"V10.05",
"458.29",
"428.0",
"V45.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.22",
"39.61",
"99.60"
] |
icd9pcs
|
[
[
[]
]
] |
23250, 23419
|
7099, 8817
|
15156, 15251
|
20199, 20357
|
15555, 18444
|
21199, 23227
|
1309, 1365
|
18467, 19817
|
19909, 20178
|
8843, 8895
|
20381, 21176
|
6667, 7076
|
1380, 2020
|
233, 263
|
441, 758
|
6233, 6651
|
15273, 15536
|
1059, 1293
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,251
| 123,791
|
44348
|
Discharge summary
|
report
|
Admission Date: [**2143-3-2**] Discharge Date: [**2143-3-6**]
Date of Birth: [**2103-6-18**] Sex: F
Service: [**Location (un) 259**]
HISTORY OF PRESENT ILLNESS: Patient is a 39-year-old African-
American female with history of HIV, whose last CD4 count is
approximately 260 with a viral load of less than 50, end-stage
renal disease secondary to HIV nephropathy, who presents with
fever and hypotension. The patient was recently admitted to [**Hospital1 1444**] for right middle lobe pneumonia
several weeks prior to admission. She was discharged on a 10 day
course of levofloxacin followed by a five day course of
azithromycin.
Several days prior to admission, patient also experienced a
seizure. A lumbar puncture and MRI were both negative at this
time. She states that she has not felt well since having a
seizure. The patient was noted to be febrile in hemodialysis on
day of admission. Patient presents to the Emergency Department
with complaints of increased generalized pain, dry cough, and
fever to 105.
Patient denies headaches, chest pains, sore throat, shortness of
breath, abdominal pain, rigors, lightheadedness, or sick contacts
at this time. The patient does complain of pain in her left knee
and thigh.
PAST MEDICAL HISTORY:
1. Depression.
2. Anemia.
3. End-stage renal disease secondary to HIV nephropathy.
4. HIV.
5. Hypertension.
6. Secondary hyperparathyroidism.
7. Severe mitral regurgitation per echocardiogram in [**2141**].
MEDICATIONS:
1. Nephrocaps.
2. Acyclovir 200 mg po q day.
3. Taxol 30 mg po q day.
4. Celexa 50 mg po q day.
5. Abacavir 300 mg po bid.
6. Gabapentin 300 mg po q day.
7. Tramadol 50 mg po q4-6h.
8. Tylenol.
9. Activella one q day.
10. Didanosine 125 mg po q day.
11. Efavirenz 600 mg po q day.
12. Calcitriol 0.75 mg po q day.
13. Trazodone.
14. Calcium acetate [**Hospital1 **] with meals.
15. Estradiol.
SOCIAL HISTORY: Not recorded per MICU admission note.
ALLERGIES:
1. Percocet.
2. Amphotericin.
3. Morphine.
4. Dilaudid.
5. Amoxicillin.
PHYSICAL EXAM ON ADMISSION: Systolic blood pressure is 65,
heart rate in the 120s, temperature 101.5, oxygen saturation
of 100% on 2 liters nasal cannula. In general, the patient
was alert, oriented, appearing fatigued, appropriately
conversing. HEENT exam revealed pupils are equal, round, and
reactive to light. Extraocular movements are intact.
Sclerae were anicteric. The neck was supple with full range
of motion. There is no lymphadenopathy noted. Pulmonary
examination was clear to auscultation bilaterally. Cardiac
examination revealed a normal S1, S2, the rate was
tachycardic, there was a [**2-14**] holosystolic ejection murmur
throughout the precordium. Abdomen was almost soft,
nontender, nondistended with positive reactive bowel sounds
in all four quadrants. The back was negative. There was no
costovertebral angle tenderness appreciated. Extremities
were notable for 2+ distal pulses, were warm to touch. There
is a failed A-V fistula in her left forearm with a working
fistula on the right side. Neurologically, cranial nerves
were intact. There are no focal deficits and the patient is
moving all extremities.
LABORATORIES: White count was 9.3, hematocrit 36.8,
platelets of 136 with 86.5% polys, no bands, 9.2%
lymphocytes, 3.3% monocytes. Chem-7 revealed a sodium of
139, potassium 4.2, chloride of 95, bicarb of 24, BUN 25,
creatinine of 6.3, and glucose of 120. Blood cultures drawn
from [**3-1**] showed no growth to date. CSF fluid from
[**2-28**] also was negative.
CHEST X-RAY: Was clear.
ASSESSMENT: Patient is a 39-year-old female with HIV, end-stage
renal disease, recent pneumonia, and new onset seizure, who
presents with fever, dry cough, and hypotension without
alteration in mental status. Given patient's hypotension and
concern for sepsis: The patient was transferred to the Medical
Intensive Care Unit for further monitoring.
HOSPITAL COURSE:
1. Hypotension: Within three days of admission, the patient had
resolution of her hypotension. Although the initial etiology was
thought to be secondary to sepsis, patient failed to develop
fever, white count, and all culture data remained negative. Thus,
it was thought that patient's presentation of hypotension was
indeed secondary to a clonidine patch that was unbeknownst at
time of admission. Upon initial admission to the Medical
Intensive Care Unit, she required Neo-Synephrine. The Neo-
Synephrine was weaned off within the first 24 hours of admission.
By hospital day #3, patient's hypotension resolved completely,
and she was transferred to the General Medicine floor. The
patient remained hemodynamically throughout the remainder of her
hospital stay.
2. Infectious disease: Given patient's immunocompromised status,
history of recurrent pneumonia and complaints of pleuritic chest
pain. The patient was initially started on broad-spectrum
antibiotics to cover for possible sources of recurrent pneumonia.
The patient was initially treated with Vancomycin, ceftazidime,
and gentamicin for broad-spectrum coverage.
Given that patient's culture data remained negative, though with
continued right middle lobe consolidation on chest x-ray,
antibiotic therapy was adjusted to include only ceftazidime.
Thus, the Pulmonary Service was consulted for bronch.
Status post bronch, the patient did well and was discharged to
home on day after procedure. The patient is to followup with PCP
with results of bronch.
Given persistent right middle lobe infiltrate on CT scan with
slight hemoptysis, Pulmonary was consulted.
3. HIV: Patient was continued on HAART therapy throughout
this hospital stay without complication.
4. End-stage renal disease: Patient continued to receive
hemodialysis as scheduled. She is followed by Renal service
throughout this admission without any complications. Given
negative blood cultures, there is no concern that her
presentation could be consistent of that of a line infection that
would possibly compromise her hemodialysis.
5. History of seizures: Patient remained asymptomatic throughout
this hospital stay.
DISCHARGE DIAGNOSES:
1. Hypotension.
2. Human immunodeficiency virus.
3. End-stage renal disease.
MEDICATIONS UPON DISCHARGE:
1. Nephrocaps.
2. Acyclovir 200 mg po q day.
3. Taxol 30 mg po q day.
4. Celexa 50 mg po q day.
5. Abacavir 300 mg po bid.
6. Gabapentin 300 mg po q day.
7. Tramadol 50 mg po q4-6h.
8. Tylenol.
9. Activella one q day.
10. Didanosine 125 mg po q day.
11. Efavirenz 600 mg po q day.
12. Calcitriol 0.75 mg po q day.
13. Trazodone.
14. Calcium acetate [**Hospital1 **] with meals.
15. Estradiol.
16. Levofloxacin for 10 day course of therapy.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To home.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Last Name (NamePattern1) 7944**]
MEDQUIST36
D: [**2143-7-22**] 17:30
T: [**2143-7-25**] 09:33
JOB#: [**Job Number 95097**]
|
[
"276.7",
"403.91",
"486",
"276.5",
"423.9",
"275.41",
"780.39",
"042"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.93",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
6689, 6969
|
6120, 6210
|
3932, 6099
|
6226, 6667
|
179, 1247
|
2053, 3915
|
1269, 1884
|
1901, 2038
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,666
| 154,442
|
3412
|
Discharge summary
|
report
|
Admission Date: [**2147-6-15**] Discharge Date: [**2147-6-25**]
Date of Birth: [**2083-1-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
Sepsis: Cholangitis
Major Surgical or Invasive Procedure:
ERCP [**2147-6-16**] no complications
Central line placement and removal
History of Present Illness:
Pt is a 64 yo female with h/o of DM, HTN, anemia, who initailly
presented to Bodowin St health ctr on [**2147-6-13**] b/c of 1d h/o N/V/D
after having eaten out in NY. She was treated w/ Compazine and
Imodium.
.
On [**2147-6-15**] the pt presented to [**Hospital **] hospital w/ jaundice,
chills, N/V. In the [**Name (NI) **] [**Name (NI) **] pt was noted to have fever (106.4
in ED), abd. pain, vomiting, tachycardia 180's, and hypotension
(130-->74). She was notably dehydrated and was treated with IVF.
She was then xferred to ICU at OSH for delta MS and concern for
sepsis. She was empirically treated with Amp/Gent. Labs were
initially notable for %10 bandemia, Na134, K+3.9, cl 97, HCO
23.5, Ca++9.4, TB 5.5, AP 205, AST116, ALT 82, alb 3.3, TP 6.4.
INR 1.2. Pt started c/o RUQ and epigastric pain. An US of Abd
found to have CBD dil., CBD 1.1cm. She was dx w/ acute
cholangitis and was referred to [**Hospital1 18**] for urgent
evaluation/decompression of CBD.
.
ROS: abdominal pain, denied weight changes
Past Medical History:
PMH:
-HTN
-DM (dx 1 week prior to admission)
-Pernicious anemia
-Abnormal mammogram ([**2142**]-?abnormality)
.
Medications on transfer: (incomplete)
Tylenol 625mg PR, Amp 2g Q4H, Gent x1
.
Medications on admission to OSH:
-Compazine 5-10mg Q6H PRN
-Motrin 100mg Q8H PRN
-Ferrous sulfate 325mg QD
-Lisinopril 20mg QD
-B12 500mg Qmonthly
-Metformin (not started yet)
Social History:
Social Hx: Native of [**Country 15800**]. Mother of 6 children. Lives with
daughter. [**Name (NI) 1403**] as a cafeteria monitor. No ETOH, no smoking.
Family History:
NC
Physical Exam:
Vitals: T:100.1 P:133 RR:33 BP:104/32 SaO2:100% 6L
General: Awake, alert, agitated
HEENT: NC/AT, PERRL, EOMI without nystagmus, bilateral scleral
icterus, MMdry, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: Lungs CTA bilaterally with mild expiratory wheezing
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, mild RUQ tenderness, ND, normoactive bowel
sounds, liver margin palpable 1cm below costal margin
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Neurologic: alert, not oriented x3, no focal neurologic deficits
Pertinent Results:
[**2147-6-16**] 12:01AM BLOOD WBC-6.6 Hct-10.0*# Plt Ct-52*#
[**2147-6-16**] 03:00AM BLOOD WBC-25.4*# RBC-3.44*# Hgb-9.6* Hct-28.8*#
MCV-84 MCH-27.9 MCHC-33.4 RDW-14.1 Plt Ct-154
[**2147-6-16**] 05:55AM BLOOD WBC-23.3* RBC-3.50* Hgb-9.8* Hct-29.4*
MCV-84 MCH-28.0 MCHC-33.3 RDW-14.4 Plt Ct-156
[**2147-6-21**] 06:40AM BLOOD WBC-20.0* RBC-4.19* Hgb-10.9* Hct-33.8*
MCV-81* MCH-26.0* MCHC-32.2 RDW-14.5 Plt Ct-237
[**2147-6-23**] 06:50AM BLOOD WBC-13.6* RBC-3.84* Hgb-10.9* Hct-29.9*
MCV-78* MCH-28.3 MCHC-36.4* RDW-15.0 Plt Ct-331
[**2147-6-24**] 07:05AM BLOOD WBC-12.3* RBC-3.90* Hgb-10.1* Hct-30.7*
MCV-79* MCH-25.9* MCHC-33.0 RDW-15.6* Plt Ct-354
[**2147-6-25**] 06:55AM BLOOD WBC-9.6 RBC-3.89* Hgb-10.1* Hct-30.7*
MCV-79* MCH-26.1* MCHC-33.0 RDW-15.6* Plt Ct-422
[**2147-6-16**] 12:01AM BLOOD Glucose-199* UreaN-25* Creat-1.2* Na-142
K-4.1 Cl-117* HCO3-13* AnGap-16
[**2147-6-16**] 02:55PM BLOOD Glucose-108* UreaN-22* Creat-1.0 Na-143
K-4.1 Cl-119* HCO3-14* AnGap-14
[**2147-6-17**] 04:37AM BLOOD Glucose-107* UreaN-21* Creat-0.8 Na-143
K-3.5 Cl-114* HCO3-19* AnGap-14
[**2147-6-20**] 06:00AM BLOOD Glucose-135* UreaN-24* Creat-0.6 Na-138
K-3.8 Cl-103 HCO3-26 AnGap-13
[**2147-6-23**] 06:50AM BLOOD Glucose-129* UreaN-11 Creat-0.7 Na-137
K-3.4 Cl-103 HCO3-22 AnGap-15
[**2147-6-25**] 06:55AM BLOOD Glucose-141* UreaN-14 Creat-0.8 Na-137
K-3.8 Cl-104 HCO3-20* AnGap-17
[**2147-6-16**] 12:01AM BLOOD ALT-69* AST-88* LD(LDH)-277* AlkPhos-133*
Amylase-89 TotBili-4.5*
[**2147-6-16**] 02:55PM BLOOD ALT-73* AST-87* AlkPhos-126* TotBili-3.8*
DirBili-3.2* IndBili-0.6
[**2147-6-17**] 04:37AM BLOOD ALT-74* AST-92* AlkPhos-125* TotBili-3.6*
[**2147-6-18**] 03:51AM BLOOD ALT-67* AST-56* AlkPhos-140* TotBili-2.3*
[**2147-6-19**] 03:48AM BLOOD ALT-53* AST-32 AlkPhos-142* TotBili-1.7*
[**2147-6-20**] 06:00AM BLOOD ALT-41* AST-23 AlkPhos-154* TotBili-1.4
[**2147-6-21**] 06:40AM BLOOD ALT-36 AST-25 AlkPhos-142* TotBili-1.4
[**2147-6-22**] 06:45AM BLOOD ALT-32 AST-22 AlkPhos-121* TotBili-1.1
[**2147-6-23**] 06:50AM BLOOD Free T4-1.9*
[**2147-6-23**] 06:50AM BLOOD TSH-1.4
[**2147-6-16**] 05:55AM BLOOD Cortsol-23.3*
[**2147-6-16**] 10:45AM BLOOD Cortsol-20.1*
[**2147-6-16**] 12:19PM BLOOD Cortsol-25.9*
[**2147-6-16**] 12:19PM BLOOD Cortsol-28.6*
.
[**2147-6-23**] CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The lung
bases are grossly clear. The liver is unremarkable. The
gallbladder contains multiple small dependent gallstones. There
is also contrast material within the gallbladder lumen. The
gallbladder wall is thickened measuring 5 mm. No pericholecystic
fluid is seen. The gallbladder is moderately distended. A common
bile duct stent is seen. At the superior aspect of the body of
the pancreas, there is a 1.5 x 1.9 x 1.7 cm enhancing cystic
mass lesion. Comparison to old outside studies if available is
recommended. Otherwise, if this is not available, an MRI would
be necessary for further evaluation. Both kidneys contain
several hypoattenuating lesions, too small to characterize. The
adrenal glands are unremarkable. There is no mesenteric or
retroperitoneal lymphadenopathy. No ascites is seen.
CT OF THE PELVIS WITH INTRAVENOUS AND ORAL CONTRAST: The rectum
and sigmoid colon are unremarkable. The uterus contains some
fluid within the uterine cavity. The bladder is normal. No
ascites is seen. No pelvic lymphadenopathy is seen.
BONE WINDOWS: No suspicious lytic or sclerotic lesions are seen.
IMPRESSION:
1. 1.7 x 1.9 x 1.5 cm enhancing cystic lesion at the superior
aspect of the pancreatic body. Comparison to prior outside study
if available is recommended. Otherwise, an MRI would be
necessary for further evaluation. Dr. [**Last Name (STitle) **] has been paged to
communicate this finding. The finding has also been communicated
to her via email.
2. Cholelithiasis with gallbladder wall thickening. The
gallbladder wall thickening may be related to known patient's
history of cholangitis. However, the presence of cholecystitis
cannot be excluded.
3. Multiple hypoattenuating lesions in both kidneys too small to
characterize.
.
[**2147-6-23**] BILATERAL LOWER EXTREMITY ULTRASOUND: [**Doctor Last Name **] scale and
color son[**Name (NI) 1417**] of the right and left common femoral,
superficial femoral, and popliteal veins were performed. These
demonstrate normal flow, waveforms, augmentation, and
compressibility. No intraluminal thrombus is identified.
IMPRESSION: No evidence of bilateral lower extremity DVT.
.
[**2147-6-24**] MRCP FINDINGS: As demonstrated in the recent CT exam,
there is a 2.0 x 1.7x 1.4 cm complex mass arising from the body
of the pancreas. This mass is exophytic, arising from the
superior aspect of the pancreas. Post- gadolinium imaging
demonstrates nodular, soft tissue enhancement within the
periphery of this lesion. Findings are most consistent with a
mucinous cystadenoma/cystadenocarcinoma. No additional
pancreatic lesions are identified. There is no pancreatic duct
dilatation.
Conventional arterial anatomy is noted. No replaced hepatic
arteries are identified. The mass is in close proximity to the
splenic artery.
No focal liver lesions are identified. There is no intra - or
extrahepatic biliary dilatation. Note is made of a common bile
duct stent. There is diffuse gallbladder wall thickening and
enhancement and the gallbladder contains multiple tiny stones.
These findings can be seen in chronic cholecystitis.
Spleen and adrenal glands are unremarkable. Within the mid right
kidney, there is a 12 mm solid lesion which demonstrates
enhancement on post- gadolinium imaging. Findings are most
consistent with a low-grade papillary renal cell carcinoma. A
few simple cysts are noted within both kidneys.
There is no significant lymphadenopathy or free fluid. The
visualized bowel is unremarkable.
IMPRESSION:
1) 2.0 x 1.4x 1.7 cm complex, exophytic mass arising from the
body of the pancreas. Findings are most consistent with a
mucinous cystadenoma/cystadenocarcinoma. The mass appears
exophytic and enucleation may be a consideration.
2) 12 mm solid right renal lesion, as described above. Findings
are concerning for a low-grade papillary renal cell carcinoma.
3) CBD stent. Gallstones with gallbladder wall thickening and
enhancement. Findings can be seen with chronic cholecystitis.
Clinical correlation is suggested.
Brief Hospital Course:
# Respiratory Distress:
The pt was noted to be tachypneic on arrival to the floor. She
was placed on 6L face mask and was noted to have evidence of
metabolic acidosis on ABGs. She was intubated for airway
protection during her emergent ERCP and to improve her
ventilatory status. She remained on the vent until [**6-18**], when
she was extubated without complication. She maintained her O2
sats on minimal oxygen supplemetation by NC and her CXR remained
clear without any evidence of consolidation or infiltrates.
.
# Acute Cholangitis/E.coli sepsis:
The triad of RUQ pain, fever and jaundice in the presence of
dilated CBD and + stones was suggestive of acute cholangitis.
The pt appeared to be in acute septc shock, requiring pressors
and aggresive fluid resuscitation. Pt had an emergent ERCP on
arrival to the [**Hospital Unit Name 153**] which showed copius expulsion of pus when
CBD stent was placed. She was started on Ampicillin,
Levofloxacin, Flagyl for broad coverage. Blood cultures from
[**Hospital Unit Name **] grew out gram negative rods. Blood cultures were also
sent from our ED and showed pansensitive E.coli. Pt was to
complete a 14 day course of Levaquin for her E.Coli bacteremia.
Per GI recs, patient will require stent extraction in 1 month
with sphincterotomy and CBD clearance. Gen [**Doctor First Name **] was consulted
during this admission who recommended outpatient f/u with a
general surgeon post-stent removal to have her cholecystectomy.
Because of her persistent low grade temps, CT abdomen/pelvis was
obtained which showed a cystic lesion in pancreatic body. This
finding led to MRCP which confirmed a lesion as above and also a
R renal lesion. Her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 8499**] was notified of these
findings, and pt will follow-up with Dr. [**Last Name (STitle) 8499**] for
follow-up for cholangitis as well as above pancreatic and renal
findings. Pt defervesced without any intervention and was sent
home to finish 14 day course levofloxacin. The MRCP findings
were not available prior to the patient's discharge. They were
communicated to Dr. [**Last Name (STitle) 8499**], Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **]
for a multidisciplinary approach to further diagnosis and
treatment. The patient was notified of the findings by her
outpatient providers.
.
# Hypotension:
Pt was noted to be hypotensive to SBP 50s in the setting of
sepsis. A foley catheter was placed and the patient was
aggressively resuscitated with IVF but her blood pressure
remained low. Norepinephrine was started with good response.
She continued to recive fluid resuscitation and was weaned off
norepi on [**6-16**]. Her blood pressure remained stable and patient
became somewhat hypertensive. Lisinopril was titrated up to her
usual home dose.
.
# DM: Patient is a newly diagnosed diabetic who was prescribed
Metformin but has not started taking it. Metformin held duing
this admission. Patient was started on an insulin drip, then
transitioned to ISS once she was taking POs. At discharge, pt
was rx with metformin to take at home.
.
# Pernicious Anemia: Stbale. Patient on monthly Vitamin B12
and folic acid.
.
# Prophylaxis: PPI, sc heparin, bowel regimen
.
# FEN: Patient was NPO while intubated. She was restarted on
PO's once she was extubated and diet was advanced to ADAT as
tolerated. She experienced some nausea and 2-3 episodes of
emesis after extubation so she was treated with anzamet PRN.
Nausea resolved.
Medications on Admission:
Medications on transfer: (incomplete)
Tylenol 625mg PR, Amp 2g Q4H, Gent x1
.
Medications on admission to OSH:
-Compazine 5-10mg Q6H PRN
-Motrin 100mg Q8H PRN
-Ferrous sulfate 325mg QD
-Lisinopril 20mg QD
-B12 500mg Qmonthly
-Metformin (not started yet)
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO QD () for 5
days.
Disp:*5 Tablet(s)* Refills:*0*
3. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
4. Ferrous Sulfate 325 (65) mg Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Ascending cholangitis s/p ERCP, stent placement
E. Coli sepsis
Secondary diagnoses:
Diabetes mellitus
Anemia
Hypertension
Discharge Condition:
Stable, afebrile
Discharge Instructions:
Return to emergency department or call your doctor if you
develop fevers, chills, abdominal pain, worsening nausea,
vomiting, shortness of breath, diarrhea, or any other worrisome
symptoms. Take medications as instructed and keep your follow-up
appointments. Please call ERCP office ([**Telephone/Fax (1) 2360**] to schedule
an appointment for stent removal in one month.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2147-6-28**] 4:45
Please call Dr. [**Last Name (STitle) **] (general surgeon) to schedule a follow
up appointment after stent removal. Office number: [**Telephone/Fax (1) 1864**]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15801**], RN Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2147-6-30**] 9:30
Provider: [**Name10 (NameIs) **] MAMMOGRAM [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2147-9-5**] 1:00
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
|
[
"250.00",
"276.2",
"574.30",
"281.0",
"785.52",
"577.8",
"287.5",
"576.1",
"995.92",
"518.81",
"038.42",
"401.9"
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
"51.87",
"96.71",
"96.04"
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icd9pcs
|
[
[
[]
]
] |
13286, 13292
|
8977, 12495
|
334, 409
|
13478, 13497
|
2649, 8954
|
13917, 14642
|
2027, 2031
|
12799, 13263
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13313, 13396
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12521, 12521
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2046, 2630
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13417, 13457
|
275, 296
|
437, 1452
|
12546, 12776
|
1474, 1586
|
1858, 2011
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,655
| 143,688
|
17204
|
Discharge summary
|
report
|
Admission Date: [**2195-4-9**] Discharge Date: [**2195-4-22**]
Date of Birth: [**2109-4-7**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
ERCP [**2195-4-10**]
ERCP [**2195-4-20**]
History of Present Illness:
86F w gallstone pancreatitis transferred from [**Location (un) 620**]. Pain
started 1 week ago associated with N/V and decreased PO intake
since that time. Pain sharp in epigastric region radiating to
the back. Emesis is recent PO contents. No bowel movement in 4
days. Denies fevers/chills, [**Location (un) **] in stool, jaundice, darkening
of urine or other complaints.
Past Medical History:
PMH: HTN, insomnia, mitral regurg, osteoporosis, renal
insufficiency, cataracts, DVT, spondylosis, hyperlipidemia,
carpal tunnel
PSH: unknown back surgery, appendectomy, TAH,BSO
Social History:
lives in [**Location **], -tobacco, -EtOH, -illict
Family History:
unknown
Physical Exam:
PHYSICAL EXAMINATION upon admission: [**2195-4-9**]
Temp:97.6 HR:150 BP:172/95 Resp:16 O(2)Sat:98
Constitutional: Comfortable
HEENT: Pupils equal, round and reactive to light,
Extraocular muscles intact
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: mild tenderness to palpation right upper
quadrant
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Neuro: Speech fluent, neuro intact
Physical examination:upon discharge:
Vital signs: bp=108/56, hr=72, 18, room air 98%
General: Pale, sitting in chair, mild scleral icterus
CV: Ns1, s2, -s3, -s4
LUNGS: Diminshed BS, crackles right base
ABDOMEN: Soft, non-tender
EXT: Cool, + dp bil, no pedal edema, bony lesions fingers, left
fifth finger swollen, bony lesion, left foot, 2nd digit, adaptic
dressing
Pertinent Results:
Admission Labs (from [**Location (un) 620**]):
22.7 > 38.6 < 410
145 104 91
--------------< 100
3.8 23 3
[**4-9**]//11: EKG:
Atrial fibrillation. Intraventricular conduction delay. No
previous tracing
available for comparison.
TRACING #1
[**2195-4-9**]: chest x-ray:
IMPRESSION: Bibasilar atelectasis
[**2195-4-10**]: EKG:
Sinus rhythm. Possible old anterior myocardial infarction.
Compared to the
previous tracing ectopy is resolved.
[**2195-4-10**]: ERCP:
Impression: Peri-ampullary diverticula
A moderate diffuse dilation was seen at the main duct with the
CBD measuring 12 mm.
There were at least 3 -4 round stones from 8 mm to 10 mm that
were causing partial obstruction were seen.
Successful sphincterotomy
Successful plastic stent placement to bypass CBD stones.
[**2195-4-22**] 06:15AM [**Month/Day/Year 3143**] WBC-10.7 RBC-2.19* Hgb-7.2* Hct-22.3*
MCV-102* MCH-33.1* MCHC-32.5 RDW-19.7* Plt Ct-333
[**2195-4-21**] 06:35AM [**Month/Day/Year 3143**] WBC-11.3* RBC-2.22* Hgb-7.3* Hct-22.7*
MCV-102* MCH-32.7* MCHC-32.1 RDW-19.4* Plt Ct-347
[**2195-4-20**] 05:50AM [**Month/Day/Year 3143**] WBC-13.1* RBC-2.35* Hgb-7.6* Hct-23.6*
MCV-101* MCH-32.4* MCHC-32.2 RDW-18.2* Plt Ct-389
[**2195-4-19**] 07:25AM [**Month/Day/Year 3143**] WBC-11.5* RBC-2.45* Hgb-8.2* Hct-24.5*
MCV-100* MCH-33.7* MCHC-33.7 RDW-17.5* Plt Ct-387
[**2195-4-18**] 07:00AM [**Year/Month/Day 3143**] WBC-12.3* RBC-2.52* Hgb-8.1* Hct-25.3*
MCV-100* MCH-32.0 MCHC-31.9 RDW-16.7* Plt Ct-391
[**2195-4-17**] 06:10AM [**Year/Month/Day 3143**] WBC-12.6* RBC-2.41* Hgb-7.7* Hct-23.8*
MCV-99* MCH-31.9 MCHC-32.3 RDW-16.2* Plt Ct-371
[**2195-4-16**] 09:55AM [**Year/Month/Day 3143**] WBC-17.2* RBC-2.77* Hgb-8.9* Hct-27.4*
MCV-99* MCH-32.0 MCHC-32.4 RDW-15.8* Plt Ct-450*
[**2195-4-22**] 06:15AM [**Month/Day/Year 3143**] WBC-10.7 RBC-2.19* Hgb-7.2* Hct-22.3*
MCV-102* MCH-33.1* MCHC-32.5 RDW-19.7* Plt Ct-333
[**2195-4-21**] 06:35AM [**Month/Day/Year 3143**] WBC-11.3* RBC-2.22* Hgb-7.3* Hct-22.7*
MCV-102* MCH-32.7* MCHC-32.1 RDW-19.4* Plt Ct-347
[**2195-4-20**] 05:50AM [**Month/Day/Year 3143**] WBC-13.1* RBC-2.35* Hgb-7.6* Hct-23.6*
MCV-101* MCH-32.4* MCHC-32.2 RDW-18.2* Plt Ct-389
[**2195-4-19**] 07:25AM [**Month/Day/Year 3143**] WBC-11.5* RBC-2.45* Hgb-8.2* Hct-24.5*
MCV-100* MCH-33.7* MCHC-33.7 RDW-17.5* Plt Ct-387
[**2195-4-18**] 07:00AM [**Year/Month/Day 3143**] WBC-12.3* RBC-2.52* Hgb-8.1* Hct-25.3*
MCV-100* MCH-32.0 MCHC-31.9 RDW-16.7* Plt Ct-391
[**2195-4-17**] 06:10AM [**Year/Month/Day 3143**] WBC-12.6* RBC-2.41* Hgb-7.7* Hct-23.8*
MCV-99* MCH-31.9 MCHC-32.3 RDW-16.2* Plt Ct-371
[**2195-4-16**] 09:55AM [**Year/Month/Day 3143**] WBC-17.2* RBC-2.77* Hgb-8.9* Hct-27.4*
MCV-99* MCH-32.0 MCHC-32.4 RDW-15.8* Plt Ct-450*
[**2195-4-14**] 06:45AM [**Year/Month/Day 3143**] WBC-17.0* RBC-2.91* Hgb-9.2* Hct-29.4*
MCV-101* MCH-31.7 MCHC-31.3 RDW-15.2 Plt Ct-379
[**2195-4-13**] 05:00AM [**Year/Month/Day 3143**] WBC-16.3* RBC-2.87* Hgb-9.1* Hct-29.2*
MCV-102* MCH-31.7 MCHC-31.1 RDW-15.0 Plt Ct-386
[**2195-4-12**] 03:20PM [**Year/Month/Day 3143**] WBC-25.4*# RBC-3.33* Hgb-10.5* Hct-34.2*
MCV-103* MCH-31.7 MCHC-30.8* RDW-14.9 Plt Ct-423
[**2195-4-15**] 06:30AM [**Year/Month/Day 3143**] Neuts-89* Bands-1 Lymphs-5* Monos-2 Eos-0
Baso-1 Atyps-0 Metas-2* Myelos-0
[**2195-4-22**] 06:15AM [**Month/Day/Year 3143**] Plt Ct-333
[**2195-4-22**] 06:15AM [**Month/Day/Year 3143**] Plt Ct-333
[**2195-4-21**] 06:35AM [**Month/Day/Year 3143**] Plt Ct-347
[**2195-4-22**] 06:15AM [**Month/Day/Year 3143**] Glucose-93 UreaN-16 Creat-1.1 Na-140
K-3.9 Cl-108 HCO3-25 AnGap-11
[**2195-4-21**] 06:35AM [**Month/Day/Year 3143**] Glucose-78 UreaN-18 Creat-1.1 Na-141
K-4.2 Cl-110* HCO3-24 AnGap-11
[**2195-4-20**] 05:50AM [**Month/Day/Year 3143**] Glucose-75 UreaN-22* Creat-1.1 Na-140
K-3.9 Cl-108 HCO3-24 AnGap-12
[**2195-4-19**] 07:25AM [**Month/Day/Year 3143**] Glucose-74 UreaN-24* Creat-1.3* Na-138
K-3.9 Cl-108 HCO3-25 AnGap-9
[**2195-4-17**] 06:10AM [**Year/Month/Day 3143**] Glucose-78 UreaN-30* Creat-1.5* Na-140
K-3.5 Cl-109* HCO3-20* AnGap-15
[**2195-4-16**] 06:40AM [**Year/Month/Day 3143**] Glucose-86 UreaN-39* Creat-2.2* Na-141
K-3.9 Cl-111* HCO3-19* AnGap-15
[**2195-4-15**] 06:30AM [**Year/Month/Day 3143**] Glucose-81 UreaN-36* Creat-2.0* Na-143
K-4.0 Cl-109* HCO3-24 AnGap-14
[**2195-4-14**] 06:45AM [**Year/Month/Day 3143**] Glucose-75 UreaN-24* Creat-1.1 Na-145
K-3.9 Cl-111* HCO3-25 AnGap-13
[**2195-4-22**] 06:15AM [**Month/Day/Year 3143**] ALT-42* AST-40 AlkPhos-240* Amylase-105*
TotBili-0.6
[**2195-4-21**] 06:35AM [**Month/Day/Year 3143**] ALT-49* AST-57* AlkPhos-263* Amylase-107*
TotBili-0.7
[**2195-4-20**] 05:50AM [**Month/Day/Year 3143**] ALT-59* AST-53* LD(LDH)-278* AlkPhos-279*
Amylase-123* TotBili-0.7
[**2195-4-19**] 07:25AM [**Month/Day/Year 3143**] ALT-71* AST-67* LD(LDH)-263* AlkPhos-283*
TotBili-0.6
[**2195-4-18**] 07:00AM [**Year/Month/Day 3143**] ALT-97* AST-119* AlkPhos-327*
Amylase-121* TotBili-0.6
[**2195-4-17**] 06:10AM [**Year/Month/Day 3143**] ALT-101* AST-182* AlkPhos-253*
Amylase-111* TotBili-0.8
[**2195-4-12**] 04:00AM [**Year/Month/Day 3143**] ALT-45* AST-45* AlkPhos-176* TotBili-1.0
[**2195-4-11**] 02:06AM [**Year/Month/Day 3143**] ALT-42* AST-56* AlkPhos-148* Amylase-260*
TotBili-0.8
[**2195-4-10**] 09:46AM [**Year/Month/Day 3143**] ALT-48* AST-48* AlkPhos-159* TotBili-1.0
DirBili-0.6* IndBili-0.4
[**2195-4-21**] 06:35AM [**Month/Day/Year 3143**] Lipase-48
[**2195-4-20**] 05:50AM [**Month/Day/Year 3143**] Lipase-88*
[**2195-4-19**] 07:25AM [**Month/Day/Year 3143**] Lipase-76*
[**2195-4-18**] 07:00AM [**Year/Month/Day 3143**] Lipase-90*
[**2195-4-17**] 06:10AM [**Year/Month/Day 3143**] Lipase-58
[**2195-4-11**] 02:06AM [**Year/Month/Day 3143**] Lipase-198*
[**2195-4-10**] 09:46AM [**Year/Month/Day 3143**] Lipase-76*
[**2195-4-22**] 06:15AM [**Month/Day/Year 3143**] Calcium-7.7* Phos-2.9 Mg-1.9
[**2195-4-21**] 06:35AM [**Month/Day/Year 3143**] Calcium-8.2* Phos-3.5 Mg-2.1
[**2195-4-20**] 05:50AM [**Month/Day/Year 3143**] Calcium-7.9* Phos-2.9 Mg-1.7
[**2195-4-14**]: x-ray hands:
IMPRESSION: Severe multi-joint osteoarthritis. Findings
consistent with
tophaceous gout. No comparison exams at this facility.
[**2195-4-17**]: Ultra-sound of the liver:
1. Biliary sludge and [**Doctor Last Name 5691**] seen within the gallbladder
without any evidence
of cholecystitis. The biliary stent is not visualized.
[**2195-4-17**]: Abdominal US:
FINDINGS: Single abdominal radiograph is obtained. A plastic
stent is seen
in the region of the common bile duct. The patient is status
post surgical
fusion of L1 through L5. A dual-lead nerve stimulator projects
over the lower
lumbar spine with leads coursing cranially. Air is seen in small
and large
bowel. There is bilateral acetabular degenerative change.
IMPRESSION: Plastic common bile duct stent seen in appropriate
location.
[**2195-4-20**]: ERCP:
Bile duct was dilated to 15mm with multiple large stones.
Intrahepatic biliary ducts were normal.
Balloon shincteroplasty with a 12mm balloon.
Multiple small stones were extracted with balloon catheter.
Lithotripsy of larger stones was performed.
About 80% of stones were removed.
A 5cm by 10FR double pigtail plastic biliary stent was placed
successfully.
Of note:
DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Ms [**Known lastname 48243**] has a new
diagnosis
of anti-Dantu alloantibody and warm and cold autoantibodies.
Dantu is a low frequency antigen and is a member of the MNS
[**Known lastname **] group
system. Anti-Dantu antibody has uncertain clinical significance.
Most
ABO compatible [**Known lastname **] will be Dantu-antigen negative and we will
perform
a full crossmatch.
Ms [**Known lastname 48243**] also has a diagnosis of warm and cold autoantibodies.
These
autoantibodies may or may not be associated with hemolysis and
serologic
results should be correlated with clinical findings.
Regardless of cinical significance, warm and cold autoantibodies
may
complicate [**Known lastname **] bank testing. Please contact the [**Name2 (NI) **] bank as
soon as
possible when transfusion is being considered.
To faciliate future serologic testing, we will provide, when
available,
[**Name2 (NI) **] matched to the patient for major Rh and [**Doctor Last Name **] antigens.
Approximately 63% of ABO compatible [**Doctor Last Name **] will be E and K
negative.
Brief Hospital Course:
The patient was admitted to the ACS service with nausea, back
pain, and vomitting. Upon admission was made NPO, given
intravenous fluids, and had [**Doctor Last Name **] work done which showed an
elevated lipase and white [**Doctor Last Name **] cell count. Imaging studies of
the abdomen showed common bile duct stone. Prior to her arrival
to the hospital, she had an episode of atrial fibrillation which
resolved with intravenous metoprolol. Because of the new onset
of atrial fibrillaton, she was admitted to the intensive care
unit for monitoring.
She underwent an ERCP on [**4-10**] where she had a sphincterotomy and
placement of a stent. She did develop confusion and delirium
post-procedure. She was placed on unasyn as coverage for her
cholangitis. Her foley catheter was discontinued on HD #4 and
she has been voiding without difficulty.
She did have another episode of atrial fibrillation prior to
her transfer to the floor on [**4-12**], this resovled with intravenous
metoprolol. Her atrial fibrillation did resolve with medication.
She was started on clear liquids on HD#5 with advancement to a
regular diet. She has been evaluated by physical therapy and
recommendations have been made for rehabilitation related to her
deconditioning. She has resumed her pre-hospital medications.
Of note, she did develop a swollen 5th left finger. She did have
anx-ray taken of her hands which did show osteo-arthitis and
lesions suggestive of tophaceous gout. [**Month/Day (4) 2225**] was
consulted and recommendations were made for her management with
subsequent follow-up.
During the course of her hospitalization, she did have an
elevation in her creatinine up to 2-2.2 and her medications were
reviewed as a potential source. She did require additional
intravenous fluids for additional hydration. In order to
monitor her urine output, her foley catheter was re-insterted.
On HOD #8, she reported flank pain and was found to have a
worsening of her liver function tests and a elevation in her
white [**Month/Day (4) **] cell count. GI was consulted and recommended a
repeat ERCP. On HOD # 12 she underwent an ERCP which showed
multiple large stones and a biliary stent was placed. Over the
last few days, her liver function tests have improved and her
white [**Month/Day (4) **] cell count has normalized. Her foley catheter was
discontinued on HOD #12. She did have difficulty voiding and it
was replaced. A urine culture did show yeast and she was
started on a 4 day course of fluconazole.
Her vital signs are stable and she is afebrile. Her hematocrit
is 22.3 and her creatinine has decreased to 1.1. Her appetite
is diminished and she continues to need encourageement to eat.
She has been out of bed. Because of her difficulty voiding, her
foley catheter will remain in place.
She is preparing for discharge to a rehabilitation facility
with subsequent follow-up with her Primary care provider,
[**Name10 (NameIs) 2225**], GI, and with the acute care service.
Of note: her HCTZ, k-lor, and atacand have not been resumed
related to her gout occurrence and normalized [**Name10 (NameIs) **] pressure.
She does need to have a follow-up appointment with her primary
care provider.
T&C sent to red cross (very reactive). If needs [**Name10 (NameIs) **] will have
to
have emergency release and will be high risk for hemolysis.
Medications on Admission:
atenolol 75mg [**Hospital1 **], klor-10 daily, lansoprazole 30mg QD,
vitamin D 400U daily, atacand 16mg [**Hospital1 **], folic acid 1mg daily,
felodipine ER 5mg daily, ASA 325mg daily, HCTZ 25mg daily,
lipitor 10mg daily, ambien 10mg daily
Discharge Medications:
1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. ipratropium bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed for Wheezing.
3. atenolol 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a
day): hold for [**Hospital1 **] pressure <110, hr <60.
4. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
6. felodipine 5 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day: hold for [**Hospital1 **]
pressure <110, hr <60.
7. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for diarrhea.
9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) cc
Injection TID (3 times a day).
10. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
11. fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
12. naproxen 250 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours: as needed for gout pain.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Doctor Last Name 5749**] [**Doctor Last Name **] Village - [**Location (un) **]
Discharge Diagnosis:
Gallstone pancreatitis
Atrial fibrillation
Gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with upper abdomimal pain.
You were found to have a gallstone in the common bile duct. You
underwent ERCP where you had a sphincterotomy and a stent placed
in the common bile duct. Despite this, you continued to have
elevated liver function tests and went for another ERCP in which
you had multiple stones removed from the bile duct and placment
of a stent. Your liver function tests have improved. You are
now preparing for discharge home with the following
instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see [**Location (un) **] or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have [**Location (un) **] in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest
Followup Instructions:
Please follow up with the Acute Care service in 2 weeks. You
can schedule this appointment by calling # [**Telephone/Fax (1) 600**]
Please follow up with Dr. [**Last Name (STitle) **] about repeat ERCP in [**3-13**]
weeks. You can schedule this appointment by callling
#[**Telephone/Fax (1) 13246**]
Please follow up with your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5873**], in
1 week to discuss the new onset of atrial fibrillation. The
telephone number is #[**Telephone/Fax (1) 5878**]
Completed by:[**2195-4-22**]
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icd9cm
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64,700
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5029+55629
|
Discharge summary
|
report+addendum
|
Admission Date: [**2117-11-7**] Discharge Date: [**2117-11-17**]
Date of Birth: [**2067-12-26**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Worsening headache
Major Surgical or Invasive Procedure:
[**2117-11-9**]: Left craniotomy with hematoma evacuation
History of Present Illness:
This is a pleasant, Russian 49 y/o female who is well known to
the Neurosurgery service. She first presented to us on [**2117-10-28**]
after sustaining a fall down [**2-25**]
steps, the date of admission, which resulted in a left subdural
hematoma and was
discharged from the neurosurgery service on [**2117-10-30**]. She then
returned to the ER on [**2117-11-4**] with worsening headache and new
right lower extremity weakness. She was admitted to our service
and was given mannitol and her extremity weakness resolved and
she was discharged home on [**2117-11-5**] with an appointment to see
Dr. [**Last Name (STitle) 739**] again on [**2117-11-10**]. On the date of this
admission ([**2117-11-7**]), she had been experiencing worsening
headaches and the right lower extremity weakness had returned.
EMS had responded and she was brought to [**Hospital3 7362**] where
repeat CT imaging was performed. She was then transfered to
[**Hospital1 18**].
Past Medical History:
Grade I parasagital meningioma s/p subtotal resection and IMRT
radiation; now with recurrence and on protocol drug,
hysterectomy for fibroids, gastritis, hiatal hernia
Social History:
Lives with boyfriend. [**Name (NI) 1403**] as beautician. Occasional alcohol
use (drinks wine). No smoking or illicit drug use.
Family History:
Mother died at 44 of stomach cancer, father died
at 68 of a heart attack. She has no brothers or sisters
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
O: T: 98.0 BP: 114/73 HR: 69 R 18 O2Sats 99% RA
Gen: WD/WN, comfortable, NAD, sleepy as pt just received
narcotics for headache.
HEENT: normocephalic
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 1.5 to 1
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 [**4-28**] throughout except R
Hem/AT/G/[**Last Name (un) 938**]
-[**4-28**]. No pronator drift
Sensation: Intact to light touch
Coordination: dysmetria R>L
Exam on Discharge: Left craniectomy defect. PERRLA, face
symmerical. wound clean and dry. No drift. No motor or sensory
deficit. No dysphasia
Pertinent Results:
CT Head w/o contrast obtained at the OSH shows a stable
appearance of L SDH with MLS. Known Meningioma is also noted.
CT HEAD W/O CONTRAST [**2117-11-7**]: Redemonstration of left subdural
hematoma, which is stable in size from one day prior, without
evidence for new hemorrhage. However, there is progressively
increased mass effect over multiple prior studies, with now up
to 9 mm rightward midline shift, and clear enlargement of the
right temporal [**Doctor Last Name 534**], compatible with trapping. There is slight
effacement of the left aspect of the suprasellar cistern.
Known extra-axial mass at the vertex, compatible with known
residual
meningioma. Prior right craniotomy, with underlying
encephalomalacia noted.
MR IMAGING BRAIN W/WO CONTRAST [**2117-11-8**]:
1. Left subdural hematoma with mass effect and midline shift of
approximately 11 mm towards the right. There is also enlargement
of the temporal [**Doctor Last Name 534**] of right lateral ventricle compatible with
trapping.
2. Stable meningiomas as described above.
CT head [**11-9**]
Expected post-surgical changes after left frontoparietal
craniectomy. Slightly increased shift of normally-midline
structures to the right, with entrapped right lateral
ventricular temporal [**Doctor Last Name 534**], as before.
NOTE ADDED IN ATTENDING REVIEW: The degree of rightward shift of
the normally- midline structures is, in fact, stable or slightly
improved from the MR study of [**11-8**], when it measured 11.5 mm.
CT head [**11-11**]
1. Persistent left-sided subdural hematoma with a transverse
dimension of 9.3 mm, with significant mass effect on the left
cerebral hemisphere and the left lateral ventricle and rightward
shift of the midline structures by approximately 1.3 cm, not
significantly changed from prior. Correlate
clinically and consider close followup as clinically indicated.
Increase in the previously noted left frontal subdural fluid
collection, which measures 7.6 mm compared to the prior of 0.6
mm, with decrease in attenuation. Mass effect is also noted on
the upper midbrain structures along with a component of cerebral
edema. To correlate clinically.
2. Two dense areas noted in the left vertex, one parafalcine and
one along
the convexity, likely representing meningiomas, not
significantly changed,
however, inadequately assessed on the present study. The lesions
noted in the right side of the vertex are inadequately assessed
on the present study.
3. Left temporal extra-axial fluid collection with increased
density (series 2, image 7) is more conspicuous than prior.
Attention on close followup to be considered.
[**2117-11-14**] EEG
This video EEG telemetry captured a normal waking
background but nearly continuous delta frequency slowing over
the left
hemisphere which improved over the course of the day's
recording.
These findings suggest the presence of significant cortical and
subcortical dysfunction over the left side although with gradual
improvement over the course of the day. There appeared to be a
right
central breach rhythm, as could be seen after a skull defect. No
epileptiform activity was seen.
[**11-15**] Brain MRI/MRV
1. No obvious acute infarction.
2. Left-sided extra-axial fluid collection with blood products
and overlying soft tissue fluid collection with blood products,
with shift of the midline structures to the right side by 1 cm
and mass effect on the left lateral ventricle, not significantly
changed from the recent study of CT head of [**2117-11-14**],
attention on close followup as clinically indicated.
3. Known multiple meningiomas in the brain at the vertex, with
the left
parasagittal lesion, seen to extend into the superior sagittal
sinus as
before. While there is no significant change in size compared to
the recent study of [**2117-11-8**], the left parasagittal meningioma
has increased compared to the study of [**2110**]. Accurate assessment
being limited due to the technical differences. Follow up as
clinically indicated if no intervention is contemplated. Other
details as above.
4. Nonvisualization of the mid portion of the superior sagittal
sinus, related to the invasion by the known left frontal
parasagittal meningioma, as seen on the prior study as well.
Patent other major venous sinuses; diminutive caliber of the
left transverse and sigmoid sinuses is likely related to
hypoplasia, the appearance is not significantly changed from the
prior study.
Obliquie Chest X-ray [**2117-11-16**]
Nodular opacity in the right mid lung that appears to be
intrapulmonary. Recommend CT of the chest for further
characterization.
CT head [**2117-11-17**]
Little change from [**2117-11-14**]. Post-operative changes are
again noted from left craniectomy. Residual subdural collection
is again identified, without acute hemorrhagic component. Mass
effect upon the left cerebral hemisphere is stable, with
persistent rightward shift of midline structures by 8 mm.
Trapping of the right lateral ventricle is slightly decreased.
No new parenchymal edema, no evidence of territorial infarction.
Brief Hospital Course:
Ms. [**Known lastname 20780**] was admitted to the neurosurgical service for
observation and frequent neuro checks. She was relatively
stable, but developed significant lethargy, otherwise with
stable vitals signs, on [**2117-11-8**], requiring transfer to the ICU.
She was admitted to the SICU, administered mannitol 50 g IV x 1
then 25 g IV Q6 hours with frequent electrolyte monitoring. A
Dilantin bolus of 300 mg IV was also administered upon transfer.
Repeat CT head imaging was performed on [**2117-11-7**] showing
redemonstration of a left subdural hematoma, which was stable in
size from prior, without evidence for new hemorrhage. However,
there was progressively increased mass effect over multiple
prior studies, with up to 9 mm rightward midline shift and clear
enlargement of the right temporal [**Doctor Last Name 534**], compatible with
trapping. For this reason, operative intervention was planned
and on [**2117-11-9**] she underwent left craniotomy with subdural
hematoma evacuation. Post -op CT showed less midline shift and
expected post-op changes. She was still lethargic on [**11-10**] and
her Mannitol was increased and Decadron was re-started. Her
dilantin was bloused. A cranial helmet was ordered.
On [**11-11**], the patient had a repeat CT head which showed evidence
of improving midline shift and her neurologic exam seemed to be
steadily improving; the patient was more responsive and alert,
following commands for favorably. She passed a bedside
speech/swallow evaluation and PO medications and a regular diet
was initiated.
On [**11-12**] Ms [**Known lastname 20780**] was much more awake, her Decadron was stopped
and Mannitol started to be weaned. Her sodium level started
increasing. Orders were written for her to transfer to the step
down. On [**11-14**], patient became aphasic, suspected seizure
activity and Keppra increased to 1000mg [**Hospital1 **]. EEG was started and
mannitol was kept at 25g [**Hospital1 **]. She was also placed on Decadron
for edema.
On [**11-15**] patient's speech improved and exam nonfocal. EEG showed
R central and temporal activity consistent with seizure activity
and Keppra was increased to 1250 [**Hospital1 **]. Neurology was consulted
and MRI/MRV ordered for further evaluation. There was no
infarct.
On [**11-16**], her oblique chest x-ray was done. She was without
seizures. She walked with PT. Dr. [**Last Name (STitle) 724**] from Neurooncology met
with her and wanted her Decadron to be at 4Q8. He felt that the
edema was due to tumor invading the sagittal sinus. Her
requested a LUQ US and lab work as per the protocol for
termination of her chemotherapy trial.
She was being screened for rehab and was transferred on
[**2117-11-17**].
** During this hospitalization it was found that the patient had
an incidental pulmonary nodule. This was confirmed on oblique
chest radiography. It is recommended that you undergo CT imaging
of the chest to evaluate this nodule as an outpatient. **
Medications on Admission:
Phenytoin 100 mg PO TID, Tylenol 325 mg PO Q6 hours PRN,
Guaifenesin 600 mg PO daily
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. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**12-26**]
Tablets PO Q4H (every 4 hours) as needed for pain.
3. insulin regular human 100 unit/mL Solution Sig: Two (2) units
Injection ASDIR (AS DIRECTED): see scale.
4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
5. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain/fever: max 4g/24hrs.
7. levetiracetam 250 mg Tablet Sig: Five (5) Tablet PO BID (2
times a day).
8. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY
(Daily) as needed for prn no BM 48hrs.
10. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours): do not taper.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Left Subdural Hematoma
Brain Compression
Cerebral Edema
Lung Nodule
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:
GENERAL INSTRUCTIONS
WOUND CARE
?????? You or a family member should inspect your wound every
day and report any of the following problems to your physician.
?????? Keep your incision clean and dry.
?????? You may wash your hair with a mild shampoo 24 hours
after your sutures are removed.
?????? Do NOT apply any lotions, ointments or other products to
your incision.
?????? DO NOT DRIVE until you are seen at the first follow up
appointment.
?????? Do not lift objects over 10 pounds until approved by
your physician.
DIET
Usually no special diet is prescribed after a craniotomy. A
normal well balanced diet is recommended for recovery, and you
should resume any specially prescribed diet you were eating
before your surgery.
MEDICATIONS
?????? Take all of your medications as ordered. You do not
have to take pain medication unless it is needed. It is
important that you are able to cough, breathe deeply, and is
comfortable enough to walk.
?????? Do not use alcohol while taking pain medication.
?????? Medications that may be prescribed include:
o Narcotic pain medication such as Dilaudid
(hydromorphone).
o An over the counter stool softener for constipation
(Colace or Docusate). If you become constipated, try products
such as Dulcolax, Milk of Magnesia, first, and then Magnesium
Citrate or Fleets enema if needed). Often times, pain medication
and anesthesia can cause constipation.
?????? You have been prescribed Keppra for anti-seizure
medicine, take it as prescribed.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc, as this can increase your chances of bleeding.
ACTIVITY
The first few weeks after you are discharged you may feel tired
or fatigued. This is normal. You should become a little stronger
every day. Activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. In general:
?????? Walk for exercise with your helmet on. You must wear the
helmet at all times when OOB and with PT. Do not lay on left
side of head.
?????? DO NOT DRIVE until you speak with your physician.
?????? Do not lift objects over 10 pounds until approved by
your physician.
?????? Avoid any activity that causes you to hold your breath
and push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
?????? Do your breathing exercises every two hours.
?????? Use your incentive spirometer 10 times every hour,
that you are awake.
WHEN TO CALL YOUR SURGEON:
With any surgery there are risks of complications. Although your
surgery is over, there is the possibility of some of these
complications developing. These complications include:
infection, blood clots, or neurological changes. Call your
Physician Immediately if you Experience:
?????? Confusion, fainting, blacking out, extreme fatigue,
memory loss, or difficulty speaking.
?????? Double, or blurred vision. Loss of vision, either
partial or total.
?????? Hallucinations
?????? Numbness, tingling, or weakness in your extremities or
face.
?????? Stiff neck, and/or a fever of 101.5F or more.
?????? Severe sensitivity to light. (Photophobia)
?????? Severe headache or change in headache.
?????? Seizure
?????? Problems controlling your bowels or bladder.
?????? Productive cough with yellow or green sputum.
?????? Swelling, redness, or tenderness in your calf or thigh.
Call 911 or go to the Nearest Emergency Room if you Experience:
?????? Sudden difficulty in breathing.
?????? New onset of seizure or change in seizure, or seizure
from which you wake up confused.
?????? A seizure that lasts more than 5 minutes.
** You were found to have a pulmonary nodule on Chest X-ray
during your hospitalization which was NOT causing any symptoms.
It is recommended that you undergo CT imaging of the chest as an
outpatient to evaluate this incidental pulmonary nodule. **
Followup Instructions:
Follow-Up Appointment Instructions
?????? Please return to the office on [**11-23**] for removal of your
staples and a wound check. You may also have them removed at
rehab.
?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment
with Dr. [**Last Name (STitle) 739**], to be seen in 4 weeks.
?????? You will need a CT scan of the brain with contrast.
Provider: [**Name10 (NameIs) 640**] [**Name11 (NameIs) 747**] [**Name12 (NameIs) **], M.D. Phone:[**Telephone/Fax (1) 1844**]
Date/Time:[**2117-11-30**] 10:30
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2117-11-17**] Name: [**Known lastname 3462**],[**Known firstname 3463**] Unit No: [**Numeric Identifier 3464**]
Admission Date: [**2117-11-7**] Discharge Date: [**2117-11-17**]
Date of Birth: [**2067-12-26**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1698**]
Addendum:
Please perform the following labs for Ms.[**Known lastname **] before [**2117-11-22**]
per the request of her oncologist Dr. [**First Name8 (NamePattern2) 55**] [**Last Name (NamePattern1) 25**]:
3.) Labs: fasting if possible
1 PT, PTT
2 bicarbonate
3 Glycosylated hemoglobin
4 Free T4/TSH
5 Albumin
6 alkaline phosphatase
7 total bilirubin
8 direct bili
9 indirect bili
10 calcium
11 chloride
12 creatinine
13 CPK
14 γ-GT (GGT)
15 glucose
16 LDH
17 phosphate
18 lipase
19 amylase
20 potassium
21 Total protein
22 AST
23 ALT
24 sodium
25 total cholesterol
26 LDL cholesterol
27 HDL cholesterol
28 triglycerides
29 BUN
30 uric acid
31 CBC and Dif
32 HCG
34 Urinalysis
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 3465**] - [**Location (un) 824**]
[**Name6 (MD) **] [**Name8 (MD) 1041**] MD [**MD Number(2) 1709**]
Completed by:[**2117-11-17**]
|
[
"518.89",
"287.5",
"041.10",
"300.00",
"852.20",
"348.5",
"225.2",
"E880.9",
"599.0",
"348.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.31",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
18862, 19061
|
8289, 11264
|
340, 399
|
12604, 12604
|
3208, 8266
|
16918, 18839
|
1732, 1840
|
11399, 12397
|
12513, 12583
|
11290, 11376
|
12780, 15409
|
1855, 1869
|
15436, 16892
|
282, 302
|
427, 1378
|
2335, 3045
|
3064, 3189
|
1883, 2083
|
12619, 12756
|
1400, 1570
|
1586, 1716
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,770
| 113,704
|
9758
|
Discharge summary
|
report
|
Admission Date: [**2146-6-4**] Discharge Date: [**2146-7-11**]
Date of Birth: [**2066-7-17**] Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Perforated duodenum s/p laparoscopic cholecystectomy in OSH
Major Surgical or Invasive Procedure:
[**2146-6-4**]:
1. Exploratory laparotomy with repair of enterotomy in the
jejunum.
2. Placement of lateral duodenostomy tube for duodenal
perforation.
3. Placement of feeding jejunostomy tube and drainage.
.
[**2146-6-10**]: Placement of a 10Fr internal-external biliary drain
through the right posterior biliary tree.
.
[**2146-6-16**]: Replacement of 10 French internal-external biliary
drainage catheter.
History of Present Illness:
79yM s/p laparoscopic cholecystectomy [**2146-6-2**] @ [**Hospital3 **]
with intraoperative drain placement for bleeding and mild bile
spillage who developed bilious drainage on POD1. He was sent to
[**Hospital1 18**] from [**Hospital1 392**] for ERCP and was found to have a duct of
Luschka leak and is now s/p CBD stent. He returned to [**Hospital1 **] [**2146-6-3**] in the evening and began to develop some
vague abdominal pain. He also became distended. He was
tachycardic to HR: 130's overnight. A CXR this AM showed free
air and a subsequent CTscan showed free extravasation of
contrast into the gallbladder fossa likely from the duodenal
stump as well as a large amount of free air, pneumomediastinum
and subcutaneous emphysema.
Upon transfer to the ICU, he continued to complain of diffuse
abdominal pain. He was tachycardic upon presentation to the
TSICU and his BP was stable from 107-110 systolic without
vasopressors. He had an NGT in place with bilious output and a
foley in place with 40cc over 2 hours.
Past Medical History:
Past Medical History: HTN, prostate CA, duodenal ulcer
Past Surgical History: partial gastrectomy with BII
reconstruction, prostatectomy with bilateral inguinal node
dissection, laparoscopic cholecystectomy
Social History:
Lives at home with wife who has alzheimer's, and is retired. No
EtOH, no tobacco x 20yrs
Family History:
non-contributory
Physical Exam:
At time of discharge:
Vitals: T 98.2, HR 68, BP 112/55, RR 26, O2sat 96%RA
General: Appears well, in no acute distress, alert and oriented
to person and place but not to time. Obeys simple commands,
awakens and responds to voice and touch.
Cardiac: RRR, holosystolic murmur.
Pulmonary: Diminished breath sounds in the bilateral lung bases,
no rales or rhonchi appreciated. Otherwise, the rest of the lung
fields were CTAB.
Abdomen: 3 drains in place: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] tube connected to a JP bulb,
a T-tube draining the duodenum connected to a JP bulb, and a
PTBD drain. All three drains are putting out green, billous
appearing discharge. Abdomen was soft, non-tender,
non-distended. Drain sites appeared C/D/I, no erythema or
discharge. Patient has a small wound open to air inferior to the
umbilicus which is healing well. There is no erythema,
discharge, or warmth surrounding the wound. Patient has +BS.
Skin: Multiple areas of skin breakdown due to tape on abdomen
and neck
Ext: No lower extremity edema
Pertinent Results:
[**2146-6-13**] ABD CT:
IMPRESSION:
1. Small 1.4 x 3.7 cm focus of peri-hepatic fluid along the
course of the
duodenostomy tube.
2. Small 2 x 2 x 3cm fluid collection interposed between colon
and duodenal stump.
3. Small bilateral pleural effusions and atelectasis.
4. Mild wall thickening of pelvic loops of ileum, cannot exclude
enteritis.
5. Subcentimeter left thyroid lobe hypodensities. Consider
thyroid
ultrasound if clinically appropriate.
6. Indeterminate left renal lesion
[**2146-6-15**] PA/LAT:
Interval resolution of pulmonary edema with mild persistent
bibasilar atelectasis and small right pleural effusion.
[**2146-6-15**] LENI: No evidence of deep vein thrombosis in either the
right or left lower extremity.
[**2146-6-15**] CTA CHEST:
IMPRESSION:
1. Apart from an equivocal filling defect in the left lower lobe
superior
segmental branch there are no filling defects in the main, lobar
or segmental branches concerning for pulmonary embolism.
2. Mild paraseptal emphysema.
3. Mild-to-moderate non-serous right pleural effusion
accompanying adjacent atelectasis.
4. Bilateral pleural plaques with small nodular calcification
suggest prior asbestos exposure.
5. Extensive esophagotracheal aspiration or retained
tracheobronchial
secretion.
[**2146-6-20**] G/GJ/GI TUBE CHECK:
1. Contrast filling the [**Doctor Last Name 406**] drain is worrisome for a leak from
the
duodenum.
2. Duodenostomy tube appears to be in satisfactory position and
unchanged
from prior.
[**2146-6-21**] ECHO:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is small.
Left ventricular systolic function is hyperdynamic (EF 80%).
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). The right ventricular free wall
is hypertrophied. The right ventricular cavity is dilated with
depressed free wall contractility. The aortic valve is not well
seen. There is no aortic valve stenosis. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. There is severe mitral annular calcification. Mitral
stenosis is present, most likely secondary to severe annular
calcification. Tricuspid regurgitation is present but cannot be
quantified. There is no pericardial effusion.
MICRO:
[**2146-6-20**] PERITONEAL FLUID
ENTEROBACTER CLOACAE COMPLEX - Resistent to Zosyn, sensitive to
cipro
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA - Sensitive to Zosyn
ACINETOBACTER BAUMANNII - Sensitive to Zosyn, sensitive to cipro
[**2146-6-25**] Sputum Cx
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
GRAM NEGATIVE ROD #2. SPARSE GROWTH.
GRAM NEGATIVE ROD #3. RARE GROWTH.
YEAST. SPARSE GROWTH.
Diagnostic:
TTE [**6-21**]- LVEF 80%, mild symmetric LVH, PCWP>18mmHg, RV dilation
with depressed free wall contractility, mitral stenosis present
& is most likely secondary to severe annular calcification.
[**2146-6-25**] CT Abdomen
IMPRESSION:
1. Interval decrease in size of the right upper quadrant fluid
loculation
adjacent to the duodenostomy tube; no discrete wall seen
surrounding this
fluid.
2. Bilateral pleural effusions, slightly increased on the left.
3. Multiple small calculi in the right kidney, the largest
measures 6 mm.
4. Extensive atherosclerotic calcification in the abdominal
aorta and
calcification of the mitral valve.
5. Bilateral pleural plaques consistent with prior asbestos
exposure.
[**2146-6-25**] CT Head
FINDINGS:
There is no evidence of acute intracranial hemorrhage, edema,
large
vessel territorial infarction, shift of normally midline
structures. The
ventricles and sulci are prominent, likely representing
age-related cortical atrophy. Mild bilateral periventricular
white matter hypodensities are identified and likely sequela of
chronic small vessel ischemic disease. No acute fractures are
identified. Mucosal thickening is noted in bilateral maxillary
sinuses as well as the sphenoidal sinuses. Mucosal thickening is
also noted in the right mastoid air cells.
[**2146-7-6**] EEG
IMPRESSION: This is an abnormal continuous ICU monitoring study
because of moderate diffuse background slowing and frequent runs
of frontal intermittent rhythmic delta activity. These findings
are indicative of moderate diffuse cerebral dysfunction which is
etiologically non-specific. There is focal slowing over the left
hemisphere indicative of more prominent focal dysfunction in
this region. No epileptiform discharges or electrographic
seizures are present. Compared to the prior day's recording,
there is no significant change.
[**2146-7-8**] CXR
As compared to the previous radiograph, there is no relevant
change. Mild elevation of the right hemidiaphragm, borderline
size of the
cardiac silhouette without pulmonary edema. Unchanged left PICC
line. No
larger pleural effusions. No pneumothorax. No evidence of
pneumonia.
Brief Hospital Course:
The patient was transferred emergently from [**Hospital3 5365**] on
[**2146-6-4**] for duodenal perforation and bile leak s/p laparoscopic
cholecystectomy. He was taken immediately to the OR where he
underwent exploratory laparotomy with placement of lateral
duodenostomy tube for duodenal perforation, repair of enterotomy
in the jejunum, and placement of feeding J-tube. He also had an
NG tube in place, as well as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] drain placed
intraoperatively and a JP drain from his cholecystectomy at the
outside hospital. He was transferred back to the ICU intubated
and sedated. In the morning he was weaned from the ventilator
and extubated on [**2146-6-5**]. His pain was initially controlled with
IV dilaudid, however he had confusion and agitation and all
narcotics and benzos were stopped. He required restraints and
intermittent haldol to protect his lines. He remained agitated
the next night and pulled out his NG tube, which was replaced on
[**2146-6-6**]. He remained in the ICU for close monitoring. Tube feeds
were started through his J-tube and advanced to goal. Overnight
he had an episode of tachypnea and respiratory distress for
which he received IV lasix with appropriate diuresis. He also
received nebulizer treatments and with improved respiration.
During this time his creatinine increased to 1.3 and no further
diuresis was performed at this time. He continued to be
intermittently confused and on [**6-8**] the geriatric surgery service
was consulted and felt he was having delirium. He was changed to
seroquel as necessary for agitation given his history of
possible Parkinson's disease. His respiratory status was stable
and he was transferred to a regular floor bed.
On [**6-9**] increased biliary drainage was noted from the [**Doctor Last Name **] drain
near the duodenostomy tube, while decreased drainage was
observed from the duodenostomy tube. It was felt there was a
continued bile leak and on [**6-10**] he underwent placement of
percutaneous transhepatic biliary drainage catheter by IR. This
was performed under general anesthesia and the patient tolerated
it well. He was returned to the floor. His foley catheter was
removed and a condom cath was placed.
on [**6-11**] the NG tube was removed and the patient was out of bed to
chair with assistance. He continued to have intermittent
confusion but was not agitated. His creatinine increased to 1.3
with an eventual maximum of 1.5 and his lisinopril was held due
to concern for kidney injury. He was seen by PT who recommended
rehab when ready for discharge.
on [**6-13**] the patient was afebrile but had a rising WBC. He had a
CT torso with IV and po contrast that showed several small fluid
collections believed to be consistent with normal post-operative
changes.
on [**6-14**] he had a speech and swallow evaluation in which he was
cleared for nectar thick liquids and pureed solids, although he
was unable to take in much by mouth. His labs were checked and
his WBC was noted to be increasing.
on [**6-15**] he continued to be tachypneic with respiratory rate in
the high 20s-30s. A blood gas showed respiratory alkalosis. He
underwent lower extremity ultrasound studies which were negative
for DVT, and a CTA was negative for pulmonary embolism. He
remained hemodynamically stable.
on [**6-16**] the patient's T-tube continued to have low output while
the [**Doctor Last Name **] drain output had increased. The PTC drain output
continued to be appropriate. He underwent a repeat cholangiogram
which again showed a bile leak from an accessory bile duct. No
leak was observed from the cystic duct stump.
on [**6-17**] the patient had longer periods of clarity. His labs were
checked and his WBC decreased.
on [**6-18**] the bilious output from the PTC drain was returned to
the patient via the J-tube feeds. He continued to have a weak
voice which had not improved significantly over the past several
days. ENT was consulted and reported that his vocal cords moved
symmetrically, but were atrophic. It was felt that his
difficulty with phonation could be due to deconditioning.
[**6-19**] the patient was noticed to have dicreased urine output,
and his Cre increased to 1.8 (1.3 day before). He received 500
cc LR boluses x 2 and his free H2O was increased via J-tube.
Patient was started on 1 to 1 fluid repletions, and his PTBD
output was given back via J-tube.
[**6-20**] Cre up to 2.1, patient was given IV Bicarb. His
respiratory rate remained within 30-36. The patient underwent
T-tube study, which demonstrated leak around t-tube captured by
[**Doctor Last Name 406**] drain.
[**6-21**] Nephrology was consulted for climbing Cre (3.0) and
metabolic acidosis, ATN most like s/t recent contrast
administration. Nephrology recommendations were followed. The
patient underwent cardiac echo, which revealed LVEF 80% and
depressed RV function.
[**6-22**] Pulmonary was consulted for persisent tachypnea, which
thought to be compensatory for metabolic acidosis. The patient's
urine output improved, Cre 3.5. The patient received one unit of
RBC for HCT 22.6. [**Doctor Last Name 406**] fluid gram stain positive for GNRs,
continued Zosyn, Vanc and Fluconazole (renal dose).
[**6-24**] Neurology was consulted for altered mental status,
tachypnea, and new onset acidosis. Patient was transferred to
the ICU and intubated. CT scan of head without contrast revealed
no acute process. CT scan of abdomen revealed interval decrease
in RUQ fluid loculation, seen on previous CT scan.
[**6-27**] His creatinine improved to 2.6, from peak value of 3.8.
Patient was taken off of zosyn and cipro and switched to
levofloxacin instead, as all three speciated organisms from
[**Doctor Last Name **]-tube fluid were shown to be sensitive to levofloxacin.
[**6-30**] Patient was extubated.
[**7-1**] Patient's stool output remained high (~2L) a day, lomotil,
tincture of opium, and imodium were initiated.
[**7-2**] Patient received a PICC line.
[**7-3**] Due to high stool output, rather than re-feed his bile
output through his J-tube, he was replenished with 1cc LR per IV
per cc bile output. The patient received [**Hospital1 **] BMP's to monitor
his electrolyte status. His stool output responded to this
change, resulting in a daily stool output of <300cc.
[**7-4**] His CXR's suggested that he might be fluid overloaded, and
he continued to be tachypneic. Thus, he was gently diuresed to
decrease his net fluid balance.
[**7-7**] Patient had a 48-hour EEG which revealed that he was not
suffering from seizures. Patient remained on chest physical
therapy, but nebulized saline and guaifenisin were added to his
regimen in an attempt to improve his respiratory status. He had
a bedside swallow evaluation performed by speech language
pathology - patient failed to pass the swallow test. His
creatinine plateaued at 1.4.
[**7-8**] Patient was weaned off of supplemental oxygen.
[**7-10**] Patient's stool output has decreased to 200cc/day.
[**7-11**] Patient had a high potassium of 5.7 and was given a dose of
kayexelate. The patient's potassium decreased to 5.4. His
tubefeeds were changed to Nepro@55cc/hr due to concern regarding
the high potassium. He was also given a second dose of
kayexelate. Patient was deemed stable and ready for discharge to
a long term care facility.
Medications on Admission:
lisinopril 20 mg
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB., wheeze
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 neb every six (6)
hours Disp #*120 Unit Refills:*1
2. Aspirin 324 mg PO DAILY
crush 4 81mg tablets administer through j tube
RX *aspirin 81 mg 4 Tablet(s) Jtube once a day Disp #*120 Tablet
Refills:*1
3. Culturelle *NF* (lactobacillus rham.
GG-inulin;<br>lactobacillus rhamnosus GG) 10 billion cell Oral
qd Reason for Ordering: increased stool output despite
modifications of tube feeding, addition of opium, lomotil
RX *Probiotic 10 billion cell 1 Capsule(s) Jtube once a day Disp
#*30 Capsule Refills:*1
4. Guaifenesin 5 mL PO Q6H
RX *guaifenesin 100 mg/5 mL 5 mL Jtube every six (6) hours Disp
#*60 Milliliter Refills:*1
5. 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.
RX *heparin lock flush 10 unit/mL every six (6) hours Disp #*30
Syringe Refills:*1
6. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
RX *dextrose 50% in water (D50W) 50 % q15min Disp #*30 Syringe
Refills:*1
7. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
RX *glucagon (human recombinant) 1 mg q15min Disp #*3 Syringe
Refills:*1
8. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
RX *lansoprazole 30 mg 1 Capsule(s) Jtube once a day Disp #*30
Capsule Refills:*1
9. Metoprolol Tartrate 25 mg PO TID
Hold for SBP < 95, HR < 55
RX *metoprolol tartrate 25 mg 1 Tablet(s) J tube three times a
day Disp #*90 Tablet Refills:*1
10. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
11. Heparin 5000 UNIT SC TID
12. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
RX *Humalog KwikPen 100 unit/mL Up to 8 Units per sliding scale
four times a day Disp #*80 Unit Refills:*2
RX *Humalog KwikPen 100 unit/mL Up to 8 Units per sliding scale
four times a day Disp #*60 Unit Refills:*1
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
1. Perforated duodenum.
2. Bile leak after laparoscopic cholecystectomy
3. Acute renal failure
4. Persistent tachypena with respiratory alkalosis
5. Post op delirium
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:
You were admitted to the surgery service at [**Hospital1 18**] for perforated
duodenum and bile leak following a laparoscopic cholecystectomy
at an outside hospital. You are now safe to complete your
recovery at an extended care facility with the following
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 [**5-12**] 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.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. You have an
appointment scheduled on [**2146-8-5**], 9:30 AM. Location:
[**Hospital Ward Name 23**] building, [**Location (un) 470**], [**Hospital Ward Name 516**]. [**Location (un) **],
[**Location (un) 86**], MA. Phone: [**Telephone/Fax (1) 2998**]
|
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icd9cm
|
[
[
[]
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] |
[
"38.97",
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"46.39",
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icd9pcs
|
[
[
[]
]
] |
17626, 17698
|
8193, 15535
|
351, 762
|
17908, 17911
|
3283, 8170
|
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|
2172, 2190
|
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|
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|
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|
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|
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|
2205, 3264
|
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|
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|
17926, 18067
|
1862, 1896
|
2065, 2156
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,356
| 126,146
|
3474
|
Discharge summary
|
report
|
Admission Date: [**2118-7-29**] Discharge Date: [**2118-8-4**]
Date of Birth: [**2060-3-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Diarrhea, BRBPR
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
58 yo M with ESRD on HD, DM, PVD s/p BKA on [**First Name3 (LF) **] and [**First Name3 (LF) 4532**], dCHF
admitted today from the ED with BRBPR and ongoing diarrhea. He
was recently here at [**Hospital1 18**] for N/V/D and CT A/P that showed
cecal inflammation. In [**Month (only) 116**], he had been admitted with a L foot
infection and was on broad spectrum abx at that time. During his
most recent admission in [**Month (only) **] was treated for colitis initially
with cipro/flagyl and po vancomycin and was ultimately
discharged on po vancomycin, last does was yesterday. C. diff
was negative x3 but he was treated given his leukocytosis of 27
and left shift. Patient was discharged to rehab on [**7-21**].
This morning, patient reports he had an episode of BRBPR without
any pain and he came to the ED. He states his diarrhea has not
resolved - [**4-19**] stools/day. No N/V, and he is taking PO without
difficulty. He has no fever, chills, or associated abdominal
pain. Per NH documentation, has not had blood stools previously.
.
In the ED, Initial vitals: 98.8 90 115/55 18 91%RA. CT A/P again
ischemia vs infectious. A RIJ was placed. Hct was 29 down from
32 on last d/c. No blood was given. He received a dose of cipro
and flagyl. He was seen by GI who felt that he was stable for
the medical floor given his stable bp/hr. VS prior to transfer
to floor: 99.1 79 126/47 96% on RA.
.
Upon arrival to the floor, patient had 2 large bloody bowel
movements and the ICU was consulted for transfer per GI request.
Upon evaluation on the floor bp was 130/65 hr 89. Patient
reports he is very fatigued and sleepy. He denies abdominal
pain, fever/chills, chest pain, or SOB.
Past Medical History:
DMII
HTN
ESRD on HD TThSa
Peripheral neuropathy
Secondary hyperparathyroidism
Nephrotic syndrome
Hyperlipidemia
PAD s/p bypass, angioplasty [**2117-12-16**]
Diastolic Heart Failure
Preserved EF, Persantine stress wnl in [**2117-1-14**]
Psoriasis
MRSA wound infection
s/p CFA endarterectomy + fem-post tib insitu saphenous vein
bypass
Balloon angioplasty [**2116-12-21**], R 2+3
s/p Toe amputations [**2117-1-18**]
Social History:
Unemployed, came in from skilled nursing facility ([**Location (un) 582**]), no
pets. No cigs, EtOH, drugs.
Family History:
Diabetes
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric
Neck: supple
Lungs: clear to ascultation
CV: Normal S1 and S2 no S3 or S4. No mumurs or rubs.
Abdomen: Soft, non-tender, non-distended, bowel sounds present.
No rebound or guarding.
Ext: Warm, no cyanosis or edema
Pertinent Results:
[**2118-7-29**] 08:15PM WBC-6.8 RBC-2.46* HGB-8.5* HCT-25.9* MCV-105*
MCH-34.4* MCHC-32.7 RDW-16.3*
[**2118-7-29**] 05:13PM LACTATE-0.9
[**2118-7-29**] 05:10PM GLUCOSE-58* UREA N-25* CREAT-5.3* SODIUM-137
POTASSIUM-4.3 CHLORIDE-96 TOTAL CO2-32 ANION GAP-13
[**2118-7-29**] 05:10PM WBC-6.9 RBC-2.50* HGB-8.7* HCT-26.2* MCV-105*
MCH-34.8* MCHC-33.3 RDW-16.1*
[**2118-7-29**] 05:10PM PLT COUNT-438
[**2118-7-29**] 05:10PM PT-14.1* PTT-28.9 INR(PT)-1.2*
[**2118-7-29**] 10:30AM ALT(SGPT)-9 AST(SGOT)-40 ALK PHOS-61 TOT
BILI-0.2
CT ABDOMEN:
1. Stable appearance of the ascending colon with mild bowel wall
thickening and pericolonic fat stranding with apparent
hypoenhancement of the mucosa along the cecum. No definite signs
for pneumatosis or free air. Please note, given the appearance
of the colon, the possibility of ischemic colitis is a also a
consideration, though the possibility of infectious or
inflammatory colitis cannot be excluded.
2. Cholelithiasis without CT evidence for cholecystitis.
3. Atrophic and cystic kidneys compatible with diagnosis of
end-stage renal disease in this patient on hemodialysis.
Colonoscopy:
Colonic mucosa appeared grossly normal upon insertion through
the anal canal. At the hepatic flexure there was abrupt severe
changes consistent with colitis characterized by exudate,
ulcerations, and areas that appeared to be denuded mucosa. At
the hepatic flexure there was a circumferential area of mucosa
that had an adenomatous appearance that was biopsied separately.
In the cecum was 1.5 cm well circumscribed punched out
ulceration with exudate. This was adjacent to what was clearly
identified as the appendiceal orifice. In the jar labeled cecum,
biopsies of the edge of the ulcer and the surrounding mucosa
were obtained. (biopsy, biopsy)
Otherwise normal colonoscopy to cecum and distal 6 cm of ileum
Recommendations: Differential diagnosis includes ischemic
colitis, less likely CMV or C-diff colitis and even lower on the
differential inflammatory bowel disease. Of note, the distal 6
cm of the ileum appeared normal.
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2118-8-4**] 04:14 6.6 3.01* 10.1* 31.4* 104* 33.4* 32.1 17.1*
423
[**2118-8-4**] 04:14 14.5* 27.4 1.3*
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2118-8-4**] 04:14 1001 21* 5.8* 142 4.7 99 36* 12
.
Brief Hospital Course:
# ACUTE BLOOD LOSS ANEMIA: He had bright red blood per rectum,
and his hematocrit drop to mid twenties, but he remained
hemodynamically stable. He was taken to colonoscopy where he was
found to have ulcerations in the colon most prominent along the
hepatic flexure. There was a high suspicion that this was due
to ischemic disease due a watershed infarct. Other etiologies
considered were infectious (CMV biopsy) and inflammatory bowel
disease. The final path report suggested his bleeding was
secondary to ischemia. He was transfused two units of blood in
the MICU, and he continued to have intermittent episodes of
bloody bowel movements. His hematocrit remained stable. He was
transferred to the floor where he had brown stool that was quiac
positive. Since his transfer, he has not any bloody bowel
movements.
.
# COLITIS: He was found to have evidence of colitis on imaging
and was started on ciprofloxacin and Flagyl for 10 days. He
will be discharged to an extended care facility where he will
take an additional 5 day course of antibiotics (Finishes
[**2118-8-9**]).
.
# Peripheral [**Year (4 digits) **] Disease: Due to his bloody bowel movment,
we held his aspirin and [**Year (4 digits) **] until he could discuss restarting
his medications at follow up appointments with GI and [**Year (4 digits) **]
surgery.
.
# Passive Suicide Ideation: The patient made passive comments
about not wanting to live while in the hospital. He was seen by
psychiatry and cleared to return to the nursing home. They
recommended Seroquel at bed time to help improve his sleep.
.
# ESRD: Dialysis while in the hospital (Tu/[**Last Name (un) **]/Sat).
.
# Diastolic CHF: He was started on a low dose ace inhibitor. He
will need electrolytes checked in one week.
.
Communication with Family: Sister, [**Name (NI) **]
[**Telephone/Fax (1) 15996**] (c)
[**Telephone/Fax (1) 15997**] (h)
[**Telephone/Fax (1) 15998**] (w)
Medications on Admission:
Medications:
Per recent d/c summary:
Atorvastatin 10 mg
Nephrocaps 1 qd
Calcitriol 0.25 mcg qd
Calcium Acetate 1334 mg tid
Clopidogrel 75 mg qd
Epoetin Alfa
Fluoxetine 20 mg qd
Folic Acid 1 mg qd
Gabapentin 100 mg tid
Glipizide 5 mg qd
Hydromorphone 2-4 mg q 3h as needed for pain
Lactulose 15 ml daily
Metoprolol Tartrate 12.5 mg Tablet [**Hospital1 **]
Ranitidine 150 mg qd
Sevelamer Carbonate 800 mg tid
Zolpidem 5 mg qd
Acetaminophen 325 mg qh6 prn
[**Hospital1 **] 325 mg qd
B Complex Vitamins
Docusate Sodium 100 mg Capsule [**Hospital1 **]
Multivitamin qd
Senna 8.6 mg [**Hospital1 **] prn
Discharge Medications:
1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours).
2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
11. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
12. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for sore throat.
13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Insluin Sliding Scale
Please see attached sliding scale.
15. Epogen
Epogen Alfa 10,000 U as directed at dialysis
16. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
17. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO three
times a day.
18. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
19. Lactulose 10 gram/15 mL Solution Sig: Ten (10) gram PO three
times a day as needed for constipation.
20. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO QHS as needed
for insomnia.
21. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day: hold for loose or multiple stools.
22. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
23. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day:
hold for loose or multiple stools.
24. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every four (4)
hours as needed for pain.
25. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day.
26. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) enema Rectal
once a day as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] at [**Location (un) 620**]
Discharge Diagnosis:
Primary Diagnosis:
Ischemic colitis
Secondary Diagnosis:
Infectious diagnosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. [**Known lastname 15994**],
Thank you for receiving your care at [**Hospital3 **] Hospital.
You were admitted to the hospital for a painless lower
gastrointestinal bleed, and diarrhea. You were sent to the ICU
for continued bleeding and given blood. A colonscopy was done
to evaluate the source of your bleeding from your colon. The
bleeding could have been from decreased blood flow to the region
versus an active infection. A small sample of the colon was
sent to pathology. You were being treated with antibiotics
throughout your hospital stay. You will take a 10 day course of
antibiotics and five more days of antibiotics once discharged
from the hospital. Because you had bleeding from the
gastrointestinal tract, we will hold your aspirin and [**Hospital3 4532**].
These medications can be restarted when you discuss your
treatment options at your follow up appointments with the
gastrointestinal doctors [**Name5 (PTitle) **] the [**Name5 (PTitle) 1106**] surgeons.
While you were here the following medications were STOPPED:
Aspirin
[**Name5 (PTitle) **]
oral Vancomycin
Dilaudid
The following medications were STARTED:
Flagyl
Cipro
Lisinopril
Followup Instructions:
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2118-8-24**] at 1 PM
With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 11716**] [**Name8 (MD) 11717**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: [**Location (un) **] SURGERY
When: TUESDAY [**2118-9-6**] at 3:15 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2118-8-9**]
|
[
"557.1",
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"440.20",
"569.82",
"588.81",
"357.2",
"578.9",
"285.1",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.25",
"39.95",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10478, 10555
|
5808, 7729
|
330, 343
|
10678, 10678
|
3438, 5785
|
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|
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|
2071, 2486
|
2502, 2611
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,739
| 147,621
|
34645
|
Discharge summary
|
report
|
Admission Date: [**2186-8-12**] Discharge Date: [**2186-9-9**]
Date of Birth: [**2133-5-29**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
VT storm, hypotension
Major Surgical or Invasive Procedure:
ICD/Pacemaker interrogation
AV nodal ablation
History of Present Illness:
This is a 53yoM w/h/o CAD s/p MI c/b ischemic CM w/PPM placement
for EF 10-15% in [**4-7**], recently had LV lead placement [**6-11**] who
is txed from OSH for VT/VF storm s/p 14 appropriate shocks. He
initially presented earlier today w/ICD firing x 2 at 12:20am
and then at 2:40 AM per medical records. He presented to the OSH
where he was found to be in VT.
.
At [**Hospital1 **], BP initially 92/61 w/initial O2 sat 9%2LNC,
dropped to 88/68 sat 99%5LNC after episode of Vfib. Amio IV load
and drip were started at 340AM which terminated Vfib, he had
repeat episode at 0805AM and another Amio bolus was administered
at 9:50AM. Mag was repleted. Cardiac enzymes were negative x 1
at OSH
.
In our ED, he arrived in VT, he was shocked 100 joules then 150
joules for VT c/b BP in 50s/20s and pt w/ dizzyness. VT
persisted and he was started on Lido IV; he was sedated and
intubated and started on dopamine gtt. Neo was started and dopa
d/ed after cardiology input.
.
Upon arrival to the CCU, he is on Neo and dobutamine. His BP is
in the 90's/70s. He is V-paced in NSR. EP was consulted and
interrogated his ICD which revealed 14 appropriate shocks for
VT/VF.
Past Medical History:
CAD, s/p AMI in [**2164**] failed streptokinase thearpy ->salvage
angioplasty of proximally occluded LAD c/b dissecton of left
main and cardiac arrest-> emergent 2V CABG surgery w/SVGs to LAD
and LCx-OM
Cath [**2180**] (no interventions per patient)
CHF (EF 10-15% in [**3-6**])
Dry weight ~135 lbs
AFib
Severe MR
ICD (for EF 10-15%) [**4-7**], Implantation of LV lead and changed
ICD to BIV ICD [**2186-6-21**]
.
Cardiac Risk Factors: + Diabetes, + Dyslipidemia, - Hypertension
.
Cardiac History: CABG, in [**2164**] anatomy as follows:
SVG-LAD, SVG LCx
.
Percutaneous coronary intervention, in '[**64**] anatomy as follows:
angioplasty of LAD as above, no stents
.
Pacemaker/ICD placed in [**4-7**]
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
HEENT: JVD 3cm above clavicle
Heart: RRR, No MRG
Lungs: Crackles to midlung bilaterally
Abd: Soft, NT, ND, BS+
Ext: 3+ pitting edema of lower extremities, 1+ of upper
extremities. 2+ pedal pulses.
Neuro: A/OX3
Pertinent Results:
[**2186-9-8**] CXR Since yesterday, bilateral pleural effusion with
associated atelectasis slightly decreased. Cardiomegaly is
unchanged. There is no residual vascular congestion. ICD is in
unchanged position.
[**2186-9-6**] Head CT w/o contrast
1. No acute intracranial abnormality.
2. Small low-attenuation lesion, superficially located in the
right
frontovertex cortex; while this may represent focal
encephalomalacia related to a past ischemic event, a "cortical
dimple" associated with underlying focal cortical dysplasia may
also have this appearance.
[**2186-8-22**] Cardiac cath
1. One vessel coronary artery disease.
2. Patent SVG to LAD with 90% stenosis distal to touch down.
3. Elevated left and right sided filling pressures.
4. Normal cardiac index.
5. Pulmonary hypertension related to hypoxic vasoconstriction
and V/Q
mismatch
[**2186-8-12**] 11:20AM BLOOD WBC-7.7 RBC-3.64* Hgb-11.6* Hct-35.0*
MCV-96 MCH-31.8 MCHC-33.1 RDW-13.5 Plt Ct-127*
[**2186-9-9**] 07:40AM BLOOD WBC-8.1 RBC-3.45* Hgb-10.9* Hct-32.9*
MCV-95 MCH-31.4 MCHC-33.0 RDW-15.4 Plt Ct-253
[**2186-8-13**] 05:29AM BLOOD Neuts-93.8* Bands-0 Lymphs-2.8* Monos-3.4
Eos-0.1 Baso-0.1
[**2186-8-28**] 06:13AM BLOOD Neuts-81.8* Lymphs-12.7* Monos-3.1
Eos-2.1 Baso-0.3
[**2186-8-28**] 06:13AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+
Macrocy-2+ Microcy-NORMAL Polychr-2+ Ovalocy-1+
[**2186-8-12**] 11:20AM BLOOD PT-32.3* PTT-45.2* INR(PT)-3.3*
[**2186-9-9**] 07:40AM BLOOD PT-16.1* PTT-40.2* INR(PT)-1.4*
[**2186-8-12**] 11:20AM BLOOD Glucose-297* UreaN-34* Creat-1.8* Na-134
K-4.5 Cl-103 HCO3-21* AnGap-15
[**2186-9-9**] 07:40AM BLOOD Glucose-92 UreaN-17 Creat-1.4* Na-138
K-4.6 Cl-100 HCO3-29 AnGap-14
[**2186-8-12**] 08:39PM BLOOD ALT-47* AST-63* LD(LDH)-232 AlkPhos-19*
TotBili-1.0
[**2186-9-9**] 07:40AM BLOOD ALT-143* AST-56* LD(LDH)-394* AlkPhos-74
TotBili-0.8
[**2186-8-12**] 11:20AM BLOOD cTropnT-0.03*
[**2186-8-12**] 04:26PM BLOOD CK-MB-5 cTropnT-0.07*
[**2186-8-13**] 12:02AM BLOOD CK-MB-6 cTropnT-0.10*
[**2186-9-5**] 04:13AM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2186-8-12**] 04:26PM BLOOD Calcium-7.3* Phos-2.4* Mg-2.3
[**2186-9-9**] 07:40AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.7
[**2186-8-23**] 03:45AM BLOOD VitB12-1140* Folate-10.4
[**2186-8-28**] 06:13AM BLOOD Hapto-169
[**2186-8-28**] 06:13AM BLOOD TSH-7.3*
[**2186-8-28**] 06:13AM BLOOD T4-8.3 T3-60* Free T4-1.8*
[**2186-8-12**] 08:39PM BLOOD Cortsol-20.6*
[**2186-8-17**] 05:45PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2186-8-17**] 05:45PM BLOOD PSA-5.7*
[**2186-8-18**] 12:49PM BLOOD HIV Ab-NEGATIVE
[**2186-8-19**] 06:30AM BLOOD Vanco-20.6*
[**2186-9-4**] 05:55AM BLOOD Digoxin-1.0
[**2186-8-12**] 11:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
This is a 53yo male with past medical history of coronary artery
disease with ischemic cardiomyopathy status post pacemaker
placement with recent LV lead placement [**5-11**], who was
transferred from outside hospital for VT/VF storm and presented
in shock.
.
Problem:
# Shock: Cardiogenic in the setting of VT/VF vs. distributive.
Presented to our ED w/hypotensions and started on pressors, was
weaned off vent and pressors and transferred to floor where he
had another episode of VT w/ hypotension and was intubated and
transferred back to CCU where he was completely weaned off at
time of discharge. No source of infection at this time. He has
very poor pump function at baseline (EF of [**10-18**] percent),
arrhythmia.
.
# Arrhythmia: V-tach/Afib w/RVR -- ICD in place, VT/VF storm
upon presentation, received 14 appropriate shocks over 24 hours.
He was shocked externally x 2 in our ED. Pt. had 3 separate
episodes of VT, the first requiring a shock (200J) along with a
bolus of lidocaine and restarting of the lidocaine drip which
converted him back to NSR. The second episode of VT resulted in
another bolus of lidocaine, intubation due to altered mentation
and hypotension, and EP reconfiguring his pacemaker to act at a
lower heart rate. He was started on an amiodarone and
lodocaine drip and required pressors to maintain blood pressure.
His pressors were weaned off and the lidocaine was also weaned
off. He remained on an Amiodarone drip. He then went into
V-tach again and required a shock to go back into sinus rhythm.
He was again started on a lidocaine drip and remained on the
amiodarone drip. The patient then remained arrhythmia free for
a few days, at which point the patient was successfully
extubated. His amiodarone drip was discontinued due to
elevations in liver enzymes, and the patient was summarily sent
to the floor. On the floor, the patient had one instance where
he was shocked inappropriately for Afib, and then subsequently
developed Afib with RVR, whereupon he was placed on Digoxin. He
then developed VT again and was given lidocaine and developed
several minutes of tonic/clonic seizures. His rhythm was
converted with shock and neuro was consulted for his siezure and
said to avoid lidocaine.
.
# CAD/Ischemia: s/p CABG; cardiac enzymes have been negative and
EKG is relatively unchanged from baseline. Unclear etiology of
cardiac disease. Placed on aspirin and statin.
.
# Left iliopsoas bleed: s/p ecmo catheter placement on thursday
[**8-17**]. Pt recieved total of 4 units of blood for unsable HCT;
Hct has been rising since, and has been stable at low 30's.
.
# CHF: severe ischemic CM EF 10-15%, h/o arrest, severe MR.
Currently, appears to be euvolemic/hypovolemic. Is on heart
transplant list since [**Month (only) 1096**]. Due to HIT positive test, the
patient had a Serotonin reactive assay done in order to clear
him for surgery. The test returned back negative -- however, it
was unclear if this meant that he was never HIT positive or if
he simply was not currently HIT positive. In either event, the
sugery (LV aneurysmectomy with possible heart transplant) was
planned -- however, the patient had an INR in the low 2.0's, and
it was decided that the patient could not have surgery unless
his INR was decreased to 1.0 to 1.2. Despite daily vitamin K
both IV and PO, and the discontinuing of amiodarone to eliminate
a possible source of injury to his liver, the patient remained
with an INR between 1.4 to 1.6. As a result, it was decided to
push his surgery back a few weeks and allow the patient to go to
rehab in the interim.
.
# Renal failure: in the setting of hypotension, shock; unknown
baseline Cr. Likely from hypoperfusion from shock due to heart
failure. Patient was autodiuresing fairly well throughout his
stay, Cr. came down to baseline at hospital of 1.3-1.4 prior to
discharge.
.
#Seizure: Pt. had episode of tonic clonic seizure after
recieving lidocaine and this did not recurr after lidocaine was
D/C'd. Per neuro pt. did not recieve any more lidocaine and had
a noncontrast head CT to evaluate for a possible nidus for
seizure activity which showed a right frontovertex cortex lesion
possibly representing a "cortical dimple". Radiology recommended
a dedicated MRI to evaluate further, but pt. has PPM. Neuro did
not recommend prophylactic antiepileptic as thought that seizure
likely due to hypoxia or lidocaine.
Medications on Admission:
Coumadin
lisinopril 10mg daily
ASA 81 mg daily
Zocor 20 mg daily
spironolactone 12.5mg daily
fenofibrate 500 daily
lasix 20mg daily
digoxin 0.125 mg daily
Discharge Medications:
1. Mexiletine 200 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
Disp:*90 Capsule(s)* Refills:*1*
2. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-4**]
Drops Ophthalmic PRN (as needed).
3. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
Acute on Chronic Congestive Heart Failure
Ventricular Tachycardia
Atrial Fibrillation with Rapid Ventricular Response
Secondary:
Coronary Artery Disease
Severe Mitral Regurgitation
Discharge Condition:
Stable, ambulating, eating, drinking, voiding, and having bowel
movements with no complaints.
Discharge Instructions:
You were admitted for having an acute onset of an arrhythmia
called ventricular tachycardia that was not being adequately
taken care of by your pacemaker/internal defibrillator. As a
result, you came here where you had many runs of this
arrhythmia. The doctors [**Name5 (PTitle) 65386**] in the pacemaker attempted
to alter your device so that it would prevent you from both
being shocked inappropriately and from having problems from
arrhythmias. You had to be intubated several times for these
arrhythmias/shocks. Also, a surgery to help correct the defects
in your heart, called an aneurysmectomy, was scheduled, along
with a possible transplant, but had to be postponed because some
of the coagulation levels in your blood were too high. The
surgery is now scheduled in a few weeks. In the meantime,
please attend both of your appointments, one with Dr. [**Last Name (STitle) 1295**],
and the other with Dr. [**First Name (STitle) 437**]. Please reschedule your
appointment with Dr. [**Last Name (STitle) 1295**] due to it now being on the same
day with Dr. [**First Name (STitle) 437**]. Additionally, please weigh yourself every
morning, [**Name8 (MD) 138**] MD if weight > 3 lbs and adhere to 2 gm sodium
diet.
Followup Instructions:
1. Dr. [**Last Name (STitle) 1295**], Monday, [**2189-9-10**]:00 AM
2. Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2186-9-11**] 9:00
Completed by:[**2186-9-9**]
|
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icd9cm
|
[
[
[]
]
] |
[
"39.32",
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"37.27",
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icd9pcs
|
[
[
[]
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11120, 11199
|
5548, 9956
|
304, 351
|
11433, 11529
|
2733, 5525
|
12804, 13070
|
2406, 2488
|
10162, 11097
|
11220, 11412
|
9982, 10139
|
11553, 12781
|
2503, 2714
|
243, 266
|
379, 1539
|
1561, 2265
|
2281, 2390
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,660
| 177,641
|
41744+58469
|
Discharge summary
|
report+addendum
|
Admission Date: [**2152-10-2**] Discharge Date: [**2152-10-8**]
Date of Birth: [**2090-3-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
ProAir HFA
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Aymptomatic Aortic Insufficency
Major Surgical or Invasive Procedure:
[**2152-10-4**]: Resection of the ascending aortic aneurysm and aortic
valve replacement with a Bentall procedure with a [**Street Address(2) 11688**]. [**Hospital 923**]
Medical mechanical valve conduit.
History of Present Illness:
62M was treated for bronchitis in [**Month (only) 205**] and found to have
moderate
to severe AI on echo as well as ascending aortic aneurysm of
5.3cm. He is asymptomatic, able to climb stairs and walk
distances without difficulty. Cardiac cath revealed clean
coronary arteries. The patient presents today for PAT. He had
dental extractions last week and will see his dentist in
follow-up for letter of clearance.
Past Medical History:
Aortic insufficiency
Ascending Aortic Aneurysm
History of hyponatremia
Hypertension
High Cholesterol
Cataract
Glaucoma
Depression
Anxiety
Tobacco use 1ppd x 40 years
Vitamin D deficiency
S/P skin tag removal
Mild varicose veins
S/P left patellar fracture [**2147**]
Left foot crush injury [**2147**]
Past Surgical History
S/P left knee surgery [**2147**] with titanium wires in place
Tonsillectomy
Social History:
Lives with: Lives alone. High stress due to laid off [**12-23**] from
job at [**Location (un) 6692**] in cargo.
Cigarettes: Tob: 1 ppd x 40+ yrs-- **quit [**2152-9-19**]
ETOH: Daily [**4-18**] 12 oz beers most days. **quit [**2152-9-19**]
Substance abuse: Past marijuana
Contact upon discharge: [**Name (NI) 449**] [**Name (NI) 90689**], brother-in-law
Family History:
Premature coronary artery disease - none
Physical Exam:
Pulse:71 Resp:15 O2 sat:100% RA
B/P Right: 149/82 Left: 148/96
Height: 5'[**51**]" Weight:203#
General: AAO x 3 in NAD
Skin: Dry [x] intact [x] left knee well healed scar
HEENT: PERRLA [x] EOMI [x] Several missing teeth with remaining
teeth in poor repair
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] grade I/VI
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] None
Varicosities: + right lower extremity
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:none Left:none
Pertinent Results:
Admission Labs:
[**2152-10-2**] 07:15AM HGB-13.4* calcHCT-40
[**2152-10-2**] 07:15AM GLUCOSE-108* LACTATE-0.9 NA+-137 K+-4.0
CL--102
[**2152-10-2**] 12:32PM FIBRINOGE-188
[**2152-10-2**] 12:32PM PT-17.5* PTT-43.9* INR(PT)-1.6*
[**2152-10-2**] 12:32PM PLT COUNT-242
[**2152-10-2**] 12:32PM WBC-6.5 RBC-2.58*# HGB-7.7*# HCT-22.6*#
MCV-88 MCH-30.0 MCHC-34.2 RDW-13.7
[**2152-10-2**] 02:03PM UREA N-15 CREAT-0.8 SODIUM-137 POTASSIUM-4.7
CHLORIDE-110* TOTAL CO2-23 ANION GAP-9
Echo [**10-4**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2152-10-3**] 8:10
AM
Final Report: The patient is status post cardiac surgery.
sternal wires are intact. The cardiomediastinal silhouette,
small left pleural effusion, and minimal pneumopericardium are
all stable. There is no pneumothorax. The right internal jugular
line ends in the upper SVC. Minimal left lung base atelectasis
is unchanged. There are no new lung opacities of concern.
[**2152-10-7**] 07:15AM BLOOD WBC-6.9 RBC-3.03* Hgb-8.8* Hct-27.3*
MCV-90 MCH-29.1 MCHC-32.3 RDW-13.7 Plt Ct-387
[**2152-10-7**] 07:15AM BLOOD UreaN-12 Creat-0.9 Na-133 K-4.5 Cl-99
[**2152-10-7**] 07:15AM BLOOD PT-24.9* INR(PT)-2.4*
Brief Hospital Course:
Mr. [**Known lastname 90690**] was brought to the operating room on [**2152-10-2**] where
the he underwent a Bentall procedure with a 23mm mechanical
valved conduit and ascending aorta/hemiarch replacement with Dr.
[**Last Name (STitle) **]. Cardiopulmonary bypass time was 174 minutes, cross
clamp time 126 minutes and circulatory arrest 19 minutes.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. Post operative
day one found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
Coumadin was initiated for the mechanical valve. He did develop
acute kidney injury with a rise in creatinine from 0.8 to 1.6.
Lasix and Lisinopril were discontinued and urine output was
monitored very closely. By the end of his stay his renal
function returned to baseline. Chest tubes and pacing wires
were discontinued without complication. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on
post-operative day five the patient was ambulating freely, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged in good condition with appropriate
follow up instructions.
Medications on Admission:
BRINZOLAMIDE [AZOPT] - (Prescribed by Other Provider) - 1 %
Drops, Suspension - 1 drop each eye two times daily
LATANOPROST - (Prescribed by Other Provider) - 0.005 % Drops -
1
drop each eye at bedtime
METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 25 mg
Tablet Extended Release 24 hr - 1 Tablet(s) by mouth once a day
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet,
Delayed
Release (E.C.) - 1 Tablet(s) by mouth once a day
MULTIVITAMIN - (Prescribed by Other Provider) - Capsule - 1
Capsule(s) by mouth once a day
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. brinzolamide 1 % Drops, Suspension Sig: One (1) Ophthalmic
[**Hospital1 **] ().
3. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
4. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2*
5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*2*
7. potassium chloride 10 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 7 days.
Disp:*7 Tablet, ER Particles/Crystals(s)* Refills:*2*
8. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
9. Coumadin 1 mg Tablet Sig: Two (2) Tablet PO once a day: take
2mg nightly or as directed by the office of Dr. [**Last Name (STitle) **].
Disp:*60 Tablet(s)* Refills:*2*
10. Outpatient Lab Work
INR to be drawn on [**10-9**] with results called to the office of Dr.
[**Last Name (STitle) **]. INR goal for mechanical aortic valve is 2.5-3
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
s/p Bental,AVR(23mm St. [**Male First Name (un) 923**] mechanical valved conduit)
PMH: Aortic insufficiency, Ascending Aortic Aneurysm, History of
hyponatremia, Hypertension, High Cholesterol, Cataract,
Glaucoma, Depression, Anxiety, Tobacco use 1ppd x 40 years,
Vitamin D deficiency, S/P skin tag removal, Mild varicose veins,
S/P left patellar fracture [**2147**], Left foot crush injury [**2147**],
S/P left knee surgery [**2147**] with titanium wires in place,
Tonsillectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD :[**Telephone/Fax (1) 170**] :[**2152-11-8**] @1:00P
[**Hospital 409**] Clinic: [**Telephone/Fax (1) 170**] :[**2152-10-17**] @10:30A
Cardiologist: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5686**], MD on [**10-26**] at 10:45A
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) 11006**],[**First Name3 (LF) 640**] W [**Telephone/Fax (1) 23874**] in [**4-18**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication -Mechanical aortic valve
Goal INR 2.5-3
First draw [**10-9**] with results to the office of Dr. [**Last Name (STitle) **]
Results to phone ([**Telephone/Fax (1) 1504**]
Completed by:[**2152-10-7**] Name: [**Known lastname 14310**],[**Known firstname **] Unit No: [**Numeric Identifier 14311**]
Admission Date: [**2152-10-2**] Discharge Date: [**2152-10-8**]
Date of Birth: [**2090-3-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
ProAir HFA
Attending:[**First Name3 (LF) 741**]
Addendum:
revised med list:
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*
brinzolamide 1 % Drops, Suspension Sig: One (1) Ophthalmic
[**Hospital1 **] ().
latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2*
metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
furosemide 20 mg Tablet Sig: [**1-16**] Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*2*
potassium chloride 10 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 7 days.
Disp:*7 Tablet, ER Particles/Crystals(s)* Refills:*2*
oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Coumadin 1 mg Tablet Sig: Two (2) Tablet PO once a day:
take 2mg nightly or as directed by the office of Dr. [**Last Name (STitle) **].
Disp:*60 Tablet(s)* Refills:*2*
Outpatient Lab Work
INR to be drawn on [**10-9**] with results called to the office of Dr.
[**Last Name (STitle) **]. INR goal for mechanical aortic valve is 2.5-3
Discharge Disposition:
Home With Service
Facility:
[**Hospital 136**] Homecare
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2152-10-8**]
|
[
"272.0",
"584.9",
"V70.7",
"305.1",
"401.9",
"268.9",
"424.1",
"300.4",
"441.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.45",
"39.59",
"35.22",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
11700, 11881
|
3832, 5416
|
310, 517
|
7991, 8148
|
2627, 2627
|
8989, 11677
|
1778, 1821
|
6024, 7386
|
7488, 7970
|
5442, 6001
|
8172, 8966
|
1836, 2608
|
238, 272
|
1703, 1762
|
545, 964
|
2643, 3809
|
986, 1386
|
1402, 1686
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,042
| 148,562
|
20354
|
Discharge summary
|
report
|
Admission Date: [**2147-2-6**] Discharge Date: [**2147-2-17**]
Date of Birth: [**2076-5-6**] Sex: M
Service: CARD [**Doctor First Name 147**]
HISTORY OF PRESENT ILLNESS: This is a 70 year old gentleman
who was admitted to [**Hospital6 33**] on [**2147-2-5**]
with a one week history of increasing shortness of breath and
generalized edema with associated symptoms of bilateral arm
pain. The patient underwent cardiac catheterization which
showed left main severe three vessel coronary artery disease
and he was transferred to [**Hospital1 188**] for coronary artery bypass grafting.
PAST MEDICAL HISTORY:
1. Chronic atrial fibrillation.
2. Status post cardiac arrest ten years ago.
3. History of rheumatic fever.
4. Rheumatoid arthritis.
5. Anxiety.
6. Psoriasis.
7. Hypercholesterolemia.
8. Obesity.
9. Hypertension.
10. Congestive heart failure, pulmonary hypertension.
SOCIAL HISTORY: The patient is retired and lives with wife.
Denies tobacco use and admits to rare ETOH use.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Corgard 20 mg p.o. q. day.
2. Lasix 10 mg p.o. q. day.
3. Lipitor.
4. Norvasc.
5. Coumadin.
6. Aspirin.
LABORATORY: Preoperative laboratory data significant for a
hematocrit of 38.7, a BUN of 15 and a creatinine of 0.5.
HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] preoperatively for his coronary
artery bypass graft. The patient underwent an ultrasound of
the carotids which showed a 60% right internal carotid artery
stenosis, an occluded left common and left internal carotid
artery.
The patient was taken to the Operating Room on [**2-7**] with
Dr. [**Last Name (STitle) **] for a coronary artery bypass graft times three,
[**Doctor First Name 4796**] to left anterior descending, saphenous vein graft to
obtuse marginal; saphenous vein graft to PDA. In the
Operating Room, an intra-aortic balloon pump was placed
perioperatively due to the patient's low ejection fraction.
Please see operative note for further details.
The patient was transferred to the Intensive Care Unit on
Milrinone and Levophed infusion. The patient was weaned and
extubated from mechanical ventilation on postoperative day
zero, continuing on Levophed and Milrinone with adequate
cardiac output.
On postoperative day number one, the Milrinone was weaned,
however, the patient's cardiac output decreased and it was
felt that he was not tolerating the weaning of the
medication. The patient was returned to previous dose and on
postoperative day number two, the Milrinone was again weaned
and successfully discontinued by evening of postoperative day
number two the patient maintained adequate cardiac output and
index. The Levophed was weaned to off.
On postoperative day number three, the patient was started on
Lasix. The pulmonary artery catheter was removed. Chest
tubes were removed without incident.
On the evening of postoperative day number three, the patient
had a 42 beat run of ventricular tachycardia. At the time
the patient was asymptomatic with a stable blood pressure.
The patient was given two grams of magnesium and an
Electrophysiology Service consultation was obtained.
Recommendations were made to start the patient on low dose
beta blocker and plans were made for an Electrophysiology
Service study due to the patient's low ejection fraction and
ventricular ectopy.
The patient had an echocardiogram which showed an ejection
fraction of 30%, dilated right and left atrium, moderate
regional left ventricular systolic dysfunction, one to two
plus mitral regurgitation and one to two plus tricuspid
regurgitation.
The patient remained in the Intensive Care Unit and continued
without any further ventricular tachycardia. The patient
tolerated his low dose beta blocker, however, the patient
occasionally had episodes of bradycardia with rates in the
30s to 40s while asleep. The patient was asymptomatic from
this. This seemed to improve over the course of the next few
days.
On postoperative day number six, the patient's pacing wires
were removed without incident. The patient was taken to the
Electrophysiology Laboratory for Electrophysiology studies
which were negative for any inducible ventricular
tachycardia. It was felt at this time that the patient was
not a candidate for an AICD. The patient's hematocrit was
noted to be 25; he was transfused one unit of packed red
blood cells.
On postoperative day number seven, the patient was
transferred from the Intensive Care Unit to the regular part
of the hospital. He began working with Physical Therapy. In
the evening of postoperative day number seven, while the
patient was asleep, the patient was noted to have a period of
bradycardia with an approximately 4.5 second pause.
Electrophysiology Service was again re-consulted and it was
felt that the patient was asymptomatic and that the episodes
were only happening while the patient was asleep and there
was no further intervention required.
The patient continued on a heparin infusion for
anticoagulation for his atrial fibrillation. Coumadin was
restarted. By postoperative day number nine, the patient was
cleared from Physical Therapy and was able to ambulate 500
feet and climb one flight of stairs without difficulty. By
postoperative day number ten, the patient's INR still
remained low in spite of three doses of Coumadin.
Discussions with Dr. [**Last Name (STitle) **] were had and it was decided to
discharge the patient to home on subcutaneous injections of
Lovenox with continued Coumadin therapy until the patient's
INR was therapeutic.
Of note, the patient had a TSH checked during his arrhythmia
work-up. TSH was noted to be elevated at 7.4 and it was felt
that no therapy was needed but it would be recommended that
the patient have his TSH rechecked again in one month.
CONDITION AT DISCHARGE: Temperature maximum 98.6 F.; pulse
84 in atrial fibrillation; blood pressure 104/62; respiratory
rate 16; room air oxygen saturation of 98%. White blood cell
count 5.7, hematocrit 26.1, platelet count 378.
Sodium 140, potassium 4.9, chloride 106, bicarbonate 25, BUN
13, creatinine 0.8, glucose 89. The patient's PT is 14.1 and
INR 1.3.
Neurologically, the patient is alert and oriented times
three. Cardiovascular is irregularly irregular; no rub or
murmur. Respiratory: Breath sounds are clear, decreased at
bilateral bases. Abdomen is soft, nontender, nondistended,
with positive bowel sounds, tolerating a regular diet.
Sternal incision: The staples are intact, open to air.
There is mild erythema; no drainage. Sternum is stable.
Lower extremity vein harvest site is clean, dry and intact;
no erythema or drainage.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Status post coronary artery bypass graft.
3. Chronic atrial fibrillation.
4. Postoperative ventricular tachycardia.
5. Postoperative bradycardia.
6. Congestive heart failure, pulmonary hypertension.
DISCHARGE MEDICATIONS:
1. Lopressor 25 mg p.o. twice a day.
2. Lasix 20 mg p.o. twice a day times seven days.
3. Potassium chloride 10 meq p.o. twice a day times seven
days.
4. Zantac 150 mg p.o. twice a day.
5. Colace 100 mg p.o. twice a day.
6. Enteric coated aspirin 81 mg p.o. q. day.
7. Percocet 5/325, one to two p.o. q. four to six hours
p.r.n.
8. Xanax 0.25 mg p.o. three times a day p.r.n.
9. Lovenox 60 mg subcutaneously twice a day until INR
greater than 2.0.
10. Coumadin 5 mg on [**3-19**] and [**2-19**]. The patient's
INR is to be checked on [**2-20**] and further Coumadin dosing is
to be per Dr.[**Name (NI) 54594**] office.
DISPOSITION: The patient is to be discharged to home.
CONDITION AT DISCHARGE: Stable.
DISCHARGE INSTRUCTIONS:
1. The patient is to follow-up with Dr.[**Name (NI) 54594**] office and
[**Hospital 197**] clinic by phone on [**2-20**], for a Coumadin dose and
the patient should see Dr. [**Last Name (STitle) 4541**] in person in one to two
weeks.
2. The patient should follow-up with Dr. [**Last Name (STitle) **] in three to
four weeks.
3. The patient should follow-up with Dr. [**Last Name (STitle) **] on [**3-21**] at 12:30 p.m.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 1541**]
MEDQUIST36
D: [**2147-2-17**] 16:03
T: [**2147-2-17**] 16:54
JOB#: [**Job Number 54595**]
|
[
"424.0",
"997.1",
"443.9",
"427.1",
"414.01",
"428.0",
"427.31",
"410.71",
"416.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"37.26",
"39.61",
"99.04",
"38.91",
"37.61",
"88.72",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
6707, 6943
|
6966, 7662
|
1317, 5839
|
7711, 8414
|
7678, 7687
|
192, 607
|
629, 905
|
922, 1299
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,432
| 190,083
|
29401
|
Discharge summary
|
report
|
Admission Date: [**2125-4-29**] Discharge Date: [**2125-5-4**]
Date of Birth: [**2063-1-11**] Sex: M
Service: NEUROLOGY
Allergies:
Aspirin / IV Dye, Iodine Containing Contrast Media
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Cerebral angiogram
History of Present Illness:
62RHM with a PMH of right parietal IPH in [**2119**] no microbleeds to
suggest amyloid on recent MRI [**8-/2124**] and felt to be related to
hypertension, 1x GTC seizure in [**2120**] on lamotrigine, lung cancer
s/p right lobectomy 3 years ago with chemotherapy with radiation
and radiation pneumonitis and periodic bronchospasm now
seemingly
in remission, Paroxysmal AF not on anticoagulation, CRF, HTN,
COPD presented with a 2 day history of right temporal headache
followed by acute onset on ED evaluation [**2125-4-29**] of left
hemiparesis and difficulty speaking at 7pm with head CT at
[**Hospital 27217**] Hospital showing a roughly 3.2x2.9cm right temporal IPH
with minimal edema and mass effect and is being admitted to the
neuro-ICU.
Patient notes being previously assessed at [**Hospital 27217**] Hospital [**4-15**]
weesk ago where he apparently had a 4 day hospitalisation for
headaches where CT head was normal and discharged. He was then
at
his baseline until 2 days ago when he noted a relatively sudden
onset of right temporal headache which was sharp and at times
severe.He hadno nausea, vomiting and no visual changes. Thsi
worsened ovver this time but the patient was stoical. He was
visiting [**Hospital 27217**] Hospital for an unrelated reason where his
wife
felt he did not look himself. She then took him to the ED to
evaluate his headaches where at just after 6pm he had a CT which
showed a right temporal IPH as above. Importantly, per his wife,
apparently AFTER this at roughly 7pm he then had onset of left
weakness and speech difficulties where initilly he could not
move
the right side at all. Unfortunately we do not have notes of his
current admission from [**Hospital 27217**] Hospital but perreport given to
ED, he was loaded with fosphenytoin and given IV ondansetron and
fentanyl and transferred to BIDMV for further evaluation.
Since transfer his symptoms have improved. He is now antigravity
in both left arm and leg although the arm is weaker than the
leg.
He also described some numbness and tingling in his left hand
and
this seemingly subsided. He also felt light-headed and noted
cough, SOB and some chest tightness with wheezing while in
[**First Name4 (NamePattern1) 27217**] [**Last Name (NamePattern1) **] (has COPD).
He still has a fairly significant headache and was given
morphine
for this in the ED. He is somewhat inattentive and has a right
gaze preference but is verbalising well and shows insight into
his situation.
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysphagia, vertigo, tinnitus or hearing difficulty.
Denies difficulties producing or comprehending speech. No bowel
or bladder incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
chest pain or tightness, palpitations. Denies nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denies arthralgias or
myalgias. Denies rash.
Past Medical History:
PMH:
- Lung cancer s/p right lobectomy 3 years ago with chemotherapy
with radiation and radiation pneumonitis and
periodicbronchospasm
now seemingly in remission
- Right parietal IPH in [**2119**] in [**12/2119**] admitted to the ICU and
started on phenytoin for seizure prophylaxis and treated for a
week with mannitol as well and went to rehab. Felt to be
hypertensive in origin.
- Paroxysmal AF not on anticoagulation
- CRF - OSH documentation shows previous Cr 1.8
- Seizure disorder since [**2120**] apparently 1x GTC seizure and
started on lamotrigine for this
- HTN
- GERD
- Squamous cell carcinoma
- COPD and ? asthma
PSurgHx:
Other than right lobectomy above had an appendectomy
Social History:
The patient lives with his wife.
Occupation: retired heavy equipment operator worked for the city
of [**Last Name (un) 27217**] for 36 years
Mobility: Unaided
Smoking: Ex-smoker quit [**2119**] previously 40/day
Alcohol: 2 beers/month
Illicits: Denies
Family History:
Mother - died 82 of ICH no associated dementia
Father - CAD s/p CABGx3 died 70 after 3xMIs
Sibs - brother and sister are well
Children - None
There is no history of seizures, developmental disability,
learning disorders, migraine headaches, strokes less than 50,
neuromuscular disorders, or movement disorders.
Physical Exam:
ADMISSION Physical Exam:
Vitals: T:97.4 P:74 R:18 BP:152/87 SaO2:92% 2L
General: Awake, some difficulties following commands but
generally does well, complains of headache.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Some decreased BS right base and otherwise with
prolonged expiratory phase and wheeze
Cardiac: RRR, nl. S1S2, no M/R/G noted. Regular also on monitor.
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: [**2-12**]+ pitting edema to upper shin on left and lower
shin on right which is less significant, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
NIH Stroke Scale score was [**9-20**]
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 1 but mild right gaze preference
3. Visual fields: 1
4. Facial palsy: 2
5a. Motor arm, left: 1
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 1
9. Language: 0
10. Dysarthria: 1
11. Extinction and Neglect: [**2-12**] - essentially 2 modalities
(visual and sensory inattention) but not severe
-Mental Status:
ORIENTATION - Alert, oriented x 3 but had to think about the
month at length
The pt. had good knowledge of current events knew current
president is [**Last Name (un) 2753**] and previous was [**Last Name (un) 2450**].
SPEECH
Able to relate history with some difficulty but helped by wife.
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors.
Speech was dysarthric but easily able to understand.
NAMING Pt. was able to name both high and low frequency objects
on stroke card.
[**Location (un) **] - Able to read without difficulty on stroke card
examples.
ATTENTION - Inattentive, able to name DOW forward with pauses
and
significant difficulty.
REGISTRATION and RECALL
Pt. was able to register 3 objects and recall 0/ 3 at 5
minutes.
COMPREHENSION
Able to follow both midline and appendicular commands including
2
step commands.
There was no evidence of apraxia but had visual and sensory
neglect which was not profound.
Patient had intermittent chewing motion which was interruptable
and very brief right mentalis twitching with 3-5s episode of
left
UE low amplitude jerking.
-Cranial Nerves:
I: Olfaction not tested.
II: Mild anisocoria right pupil1.5mm and left 2mm and brisk.
VFF
show possible left incongrous homonymous hemianopia essentially
in the left eye field to confrontation but may be related to
neglect and did not seem to have a field defect on assessment of
the right eye field. Funduscopic exam revealed no papilledema,
exudates, or hemorrhages but technically challenging and only
got
brife glimpses of disc.
III, IV, VI: Full range of eye movement but non-sustained
nystagmus 10 beats on left gaze and 3 beats on right gaze.
Saccadic intrusions. Left gaze preference but coyld fully [**Last Name (un) **] to
the left and this was subtle.
V: Facial sensation intact to light touch.
VII: Left lower facial weakness. Dysarthria.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM on right and 4+/5 on left.
XII: Tongue protrudes in midline with noraml movement.
-Motor: Normal bulk reduced tone left arm>leg. Left pronator
drift.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**]
L 4 4 4- 3 4+ 3 5 4+ 4+ 4 5 4+ 4+
R 5 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
proprioception on right. On left seemingly normal light touch
but
noted decreased pinprick whole left side. Decreased vibration to
knee on left and ankle on right and decreased proprioception to
ankle on left. Left sensory inattention.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 1 1 1 2+ 2
R 1 1 1 2+ 0
Plantar response was flexor on right extensor on left.
-Coordination: No intention tremor noted. No dysmetria on FNF or
HKS bilaterally in context of significant weakness on left.
-Gait: Deferred
Pertinent Results:
ON ADMISSION:
-------------
[**2125-4-29**] 08:10PM BLOOD WBC-7.7 RBC-4.88 Hgb-13.9* Hct-42.7
MCV-88 MCH-28.5 MCHC-32.6 RDW-14.4 Plt Ct-206
[**2125-4-29**] 08:10PM BLOOD Neuts-75.4* Lymphs-19.4 Monos-3.6 Eos-1.1
Baso-0.5
[**2125-4-29**] 08:10PM BLOOD PT-10.6 PTT-31.2 INR(PT)-1.0
[**2125-4-29**] 08:10PM BLOOD Glucose-123* UreaN-23* Creat-1.7* Na-140
K-4.3 Cl-103 HCO3-29 AnGap-12
[**2125-4-29**] 08:10PM BLOOD ALT-17 AST-16 AlkPhos-74 TotBili-0.2
[**2125-4-29**] 08:10PM BLOOD Albumin-4.9
[**2125-4-29**] 08:10PM BLOOD Phenyto-13.5
IMAGING & STUDIES:
-----------------
CT HEAD [**2125-4-29**] New right temporoparietal intraparenchymal
hemorrhage with no clear subarachnoid or intraventricular
extension. Minimal associated mass effect without evidence of
herniation or shift of midline structures. Encephalomalacia
related to prior right frontoparietal intraparenchymal
hemorrhage.
CT HEAD [**2125-4-30**] Unchanged exam with stable right
temporoparietal intraparenchymal hemorrhage with surrounding
vasogenic edema and minimally associated mass effect. Further
workup to exclude underlying vascular/neopalstic etiology;
correlate clinically for coagulopathy/amyloid angiopathy.
MR HEAD [**2125-5-1**] Noncontrast study Right parietal
intraparenchymal hemorrhage with no significant change compared
to same day CT. Underlying lesion cannot be excluded. Followup
is recommended.
CXR [**2125-4-30**] Status post right thoracic surgery, most likely
lobectomy,
recording rib defects and clips in situ. Elevation of the right
hemidiaphragm. The cardiac silhouette is of normal size. The
left hemithorax is normal. At the site of resection on the
right, there is no evidence of recurrence. However, CT should be
performed given the substantially higher sensitivity of this
technique.
EKG [**2125-4-30**] Sinus rhythm. Non-specific ST-T wave changes,
probably normal variant. Compared to the previous tracing of
[**2125-4-29**] no change.
Rate PR QRS QT/QTc P QRS T
76 176 88 364/392 58 12 55
Cerebral angiogram [**2125-5-2**]: [**Known firstname **] [**Known lastname 23147**] underwent cerebral
angiography which revealed that there were no vascular sources
for his right hemispheric hemorrhages, specifically no AVM,
arteriovenous fistula or vasculitis was identified. He does have
an occlusion of his right common iliac artery just beyond the
aortic bifurcation.
Hip Film [**2125-5-1**] Three views show the bony structures and joint
spaces to be within normal limits and symmetric with the
opposite side. If there is serious clinical concern for occult
fracture, cross-sectional imaging could be considered.
MRI L Spine [**2125-5-2**]: There is normal lumbar vertebral body
height and alignment. There is a small hemangioma at L1
vertebral body. The conus medullaris is normal in morphology and
intrinsic signal intensity and terminates at the L1-2 level.
There is a normal distribution of cauda equine nerve roots. The
paravertebral and limited included retroperitoneal soft tissues
are grossly unremarkable. At L1-L2 and L2-3 there are mild disc
bulges but no spinal canal stenosis or neuroforaminal narrowing.
At L3-L4, there is a disc bulge with a left annular tear
touching the left L3
nerve root in the left neural foramen. At L4-L5, there is a disc
bulge with an annular tear on the left. There is also bilateral
facet arthrosis which in combination with the disc bulge is
causing compression of the right L4 nerve root and also
contacting the left [**Name (NI) 5774**] nerve root. There is ligamentum flavum
thickening but no spinal canal stenosis. At L5-S1, there is a
disc bulge with an annular tear but no spinal canal stenosis or
neural foraminal narrowing.
Brief Hospital Course:
The patient is a 62 yo RHM h/o prior right parietal IPH ([**2119**])
c/b seizures, lung cancer (s/p right lobectomy, chemotherapy,
radiation), PAF, CKD, HTN, COPD p/w severe right
periorbital/temporal headache and subsequently sudden onset
aphasia and left hemiparesis. He was transferred from an OSH
with a finding of a 3.2 x 2.9 cm right temporal IPH and was
admitted to the Neuro ICU for close monitoring and blood
pressure control. His deficits quickly improved but overnight on
[**2125-4-29**] he did have some worsening of LLE weakness which had
resolved by the morning. Repeat NCHCTs showed no change in size
or extent of the hemorrhage. He was continued on lamotrigine at
a slightly higher dose (175 mg/150 mg from 150 mg [**Hospital1 **])
concerning the possibility of increased seizure activity related
to the hemorrhage. Given concerns regarding the nature of his
hemorrhage, he had an MRI Brain with contrast which (other than
the hemorrhage) showed no underlying obvious mass or vascular
malformation. Given his stable neurological examinations and
hemodynamic stability, he was transferred to the floor wards of
the Neurology unit.
Neurosurgery was consulted to perform a diagnostic cerebral
angiogram to identify a possible arteriovenous dural fistula or
other cerebral vascular malformation as a possible etiology of
his two hemorrhages. This was done following the administration
of steroids, H1 and H2 blockers as well as a bicarbonate
preparation given his 1) chronic kidney disease with Cr 1.7-1.8,
and 2) history of iodine contrast allergy. This also
unfortunately did not identify an etiology of his
intraparenchymal hemorrhages. This procedure was complicated a
small groin hematoma that was not noticeable the next day. His
peripheral pulses remained constant.
He did complain of some local right sided hip pain which was
limiting motion of his right lower extremity. We obtained hip
films and a lumbar spine MRI which showed no acute injury,
fracture or radicular/plexus lesion, which was reassuring. He
also reassured us that he has had problems with hip pain in the
past.
On the day of his discharge, he was able to ambulate with one
assist. His foley catheter was discontinued. His pain was well
controlled with PO analgesics and he obtained good relief from
his pain following one dose of IV toradol.
TRANSITIONAL ISSUES:
- Please be sure to have Mr. [**Known lastname 23147**] follow up with Dr. [**Last Name (STitle) **] and
Dr. [**Last Name (STitle) 3291**] at the dates/times listed below. He has been
ordered for an outpatient MRI/MRA for follow up. The date for
this test has not been [**Last Name (STitle) 1988**]. Please call [**Telephone/Fax (1) 70598**] to
clarify date/time of this appointment.
Medications on Admission:
Lamotrigine 150mg [**Hospital1 **]
Metoprolol 50mg [**Hospital1 **]
Simvastatin 10mg HS
Omeprazole 40mg qd
Lisinopril 10mg qd
Combivent inhaler qid
Acetaminophen 650mg qid PRN
Discharge Medications:
1. lamotrigine 150 mg Tablet [**Hospital1 **]: One (1) Tablet PO QAM (once a
day (in the morning)).
Disp:*30 Tablet(s)* Refills:*2*
2. lamotrigine 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO QAM.
Disp:*30 Tablet(s)* Refills:*2*
3. lamotrigine 150 mg Tablet [**Hospital1 **]: One (1) Tablet PO QPM (once a
day (in the evening)).
Disp:*30 Tablet(s)* Refills:*2*
4. lisinopril 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. metoprolol tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
7. oxycodone 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q3H (every 3
hours) as needed for headache.
Disp:*40 Tablet(s)* Refills:*0*
8. benzonatate 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO TID (3
times a day) as needed for cough.
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Main Diagnosis: Intraparenchymal hemorrhage
Paroxysmal atrial fibrillation
History of lung cancer s/p pneumonectomy
Chronic kidney disease
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
.
Neuro exam on discharge: Normal mental status without focal
weakness or sensory deficits. No cranial nerve findings save for
mild old left ptosis.
Discharge Instructions:
Dear Mr. [**Known lastname 23147**],
It was a pleasure taking care of you during this
hospitalization. You were admitted to the ICU after you were
found to have an area of bleeding in your brain. We performed a
number of neuroimaging tests as well as an angiogram to
understand the cause for this bleeding. These tests all showed
that the size of your bleed remained stable, which is
reassuring. We were able to organize a rehabilitation location
for you so that you can spend a few days/weeks building your
strength and balance. We have set up follow up appointments for
you to see your primary care physician as well as Dr. [**Last Name (STitle) **]
from the division of Stroke Neurology.
- We ask that you take all your medications as prescribed below.
- Please see the doctors [**Name5 (PTitle) 1988**] below for follow-up.
- Do not hesitate to contact us should you have any questions or
concerns.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] from Neurology
Tuesday [**2125-6-19**] at 3:00pm
[**Location (un) 830**], [**Location (un) 86**], MA: [**Numeric Identifier **]
[**Hospital Ward Name 23**] Building, [**Location (un) 858**]
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3291**]
[**2125-5-17**] at 10:30AM
Location: [**Hospital3 **] OF [**Hospital1 420**]
Address: [**Street Address(2) 70599**], [**Hospital1 420**],[**Numeric Identifier 15489**]
Phone: [**0-0-**]
Fax: [**Telephone/Fax (1) 70600**]
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2125-5-4**]
|
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icd9cm
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[
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[
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icd9pcs
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319, 340
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17121, 17121
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,423
| 167,819
|
22695
|
Discharge summary
|
report
|
Admission Date: [**2122-1-5**] Discharge Date: [**2122-1-28**]
Date of Birth: [**2074-2-6**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 2159**]
Chief Complaint:
Multilobar pneumonia
Major Surgical or Invasive Procedure:
Intubation
Transesophageal echocaardiogram
Temporary Hemodialysis catheter placement
History of Present Illness:
HPI: On [**2122-1-4**] Pt awoke with sob, cough (blood tinged), and
intermittently confused. In in ED at OSH, reported that CT chest
showed right mid and upper lobe and left lower lobe infiltrates.
Pt was started on cetriaxone and azithromycin. He also received
Lasix 80 mg x1. Pt was noted to be in atrial fibrillation and
was placed on a diltiazem gtt.
.
Vitals taken on arrival at OSH were T=103, HR=145, SBP=140s,
O2sat=91-93% 3L NC. LABS were Gluc=50 (received D50), Cr=2.6,
ph=7.39, pCO2=40, pO2=50 on NRB. Intubated and ventilated. BCxs
and UCx sent. Influenza A and B negative. Transferred to [**Hospital1 18**]
for further management.
Past Medical History:
-DM2 c/b diabetic nephropathy, retinopathy and neuropathy.
-kidney transplant [**2107**]
-prosthetic mitral valve after endocarditis
-hypertension
-hypercholesterolemia
-chronic L ankle pain
Social History:
Married, lives with wife and two stepchildren. Moved to [**Location (un) 86**]
from [**Location (un) 9012**] 3y ago. Unemployed since foot fracture. Denies
tobacco, alcohol, other illicits.
.
Family History:
Non-contributory.
Physical Exam:
97.5 130/60 66 20 95 RA
GEN: sitting at edge of bed with foley, nad, pleasant,
interactive, oriented.
HEENT: no lad
CV: rrr, s1/s2 mechanical click, 3/6 systolic murmur at LLSB
PULMO: Rhonchi RLL, otherwise CTA
ABD: bs+, soft, slightly distended, no masses
EXT: warm, 3+ edema lt. upper and bt. lower extremities
distally, no c/c, palp DP pulses
.
Pertinent Results:
[**2122-1-5**] 08:31PM PT-29.6* PTT-100.2* INR(PT)-3.1*
[**2122-1-5**] 04:14PM TYPE-ART PEEP-8 PO2-123* PCO2-41 PH-7.42
TOTAL CO2-28 BASE XS-2 INTUBATED-INTUBATED VENT-SPONTANEOU
[**2122-1-5**] 04:14PM GLUCOSE-215*
[**2122-1-5**] 04:14PM O2 SAT-97
[**2122-1-5**] 12:45PM URINE HOURS-RANDOM CREAT-19 TOT PROT-25
PROT/CREA-1.3* albumin-13.9 alb/CREA-731.6*
[**2122-1-5**] 12:45PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2122-1-5**] 12:45PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
[**2122-1-5**] 12:45PM URINE RBC-0-2 WBC-[**5-3**]* BACTERIA-RARE
YEAST-NONE EPI-0-2
[**2122-1-5**] 04:37AM TYPE-ART PO2-145* PCO2-38 PH-7.38 TOTAL
CO2-23 BASE XS--1
[**2122-1-5**] 04:37AM LACTATE-1.3
[**2122-1-5**] 04:37AM O2 SAT-97
[**2122-1-5**] 04:37AM freeCa-1.14
[**2122-1-5**] 04:15AM GLUCOSE-156* UREA N-80* CREAT-2.1* SODIUM-140
POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-22 ANION GAP-15
[**2122-1-5**] 04:15AM estGFR-Using this
[**2122-1-5**] 04:15AM CK(CPK)-27*
[**2122-1-5**] 04:15AM CK-MB-NotDone cTropnT-0.09*
[**2122-1-5**] 04:15AM CALCIUM-8.2* PHOSPHATE-3.8 MAGNESIUM-1.7
[**2122-1-5**] 04:15AM WBC-17.8*# RBC-3.94* HGB-10.9* HCT-36.0*
MCV-91 MCH-27.7 MCHC-30.3* RDW-20.7*
[**2122-1-5**] 04:15AM NEUTS-88.4* BANDS-0 LYMPHS-7.8* MONOS-3.0
EOS-0.5 BASOS-0.3
[**2122-1-5**] 04:15AM PLT COUNT-475*
[**2122-1-5**] 04:15AM PT-26.0* PTT-86.0* INR(PT)-2.6*
Brief Hospital Course:
A/P: 47 M w/ DM2, ESRD s/p renal transplant (chronic rejection),
mechanical mitral valve p/w respiratory failure requiring
intubation for acute decompensation, likely secondary to
multilobar pneumonia, now extubated and on floor.
.
RESPIRATORY FAILURE: The patient was admitted for respiratory
failure secondary to multilobar pneumonia. A bronchoscopy was
done which showed no bacteria but did grow yeast. He was
successfully extubated in the ICU and transferred to the floor
for further care. He received a 14 day course of antibiotics
intially started on zosyn, flagyl and vancomycin but was
converted to levaquin. He received albuterol and ipratropium
nebs as needed. Blood cultures from the referring hospital were
negative. In the ICU, blood cultures were drawn which grew
[**Female First Name (un) **] albicans. ID was consulted. He was treated with a 14
day course of antifungals begining with ambisome, then
caspofungin and finally diflucan when the sensitivities
returned. He had no further issues with his respiratory status.
.
RENAL TRANSPLANT: The patient had rising creatinine levels
throughout the hospital stay and had decreased urine output
despite lasix challenges and IV fluids. The cellcept was
discontinued and all medications were renally dosed. Renal was
consulted and recommended placement of an hemodialysis catheter
and [**Female First Name (un) 2286**] was started. He has continued on a tuesday,
thursday, saturday [**Female First Name (un) 2286**] schedule and has improved his volume
status. He was discharged to home on prednisone, EPO, iron, and
sevelamer. He will have outpatient [**Female First Name (un) 2286**] continuing on
tuesday, thursday, saturday.
.
FEVER: Pt spiked temp to 101 on [**1-26**] and was restarted on
vancomycin, cultures are pending. Likely source is a lower
extremity cellulitis (RLE) noted. His fevers cleared on
vancomycin and he was discharged to complete a course of 10 days
of vancomycin, to be dosed at HD. Blood cultures were pending at
the time of discharge and will need to be followed up by his
primary care provider. [**Name10 (NameIs) **] vancomycin will be dosed at his
[**Name10 (NameIs) 2286**] pending vancomycin levels to be drawn at dialysisl. Of
note, lower extremity ultrasound studies and Xrays of the RLE
were negative for clot, fracture, or effusion.
.
DM2: The patient's diabetes was difficult to manage because of
his poor clearance of medications including drugs such as
insulin. He had rapidly fluctuating finger sticks glucose
levels requiring large boluses of insulin or D50W twice. [**Last Name (un) **]
was consulted regarding his diabetes and he was treated with
standing and sliding scale insulin. Compliance was occasionally
an issue, as the patient had frequent concerns about taking his
insulin when his po intake was less than ideal. He will need
[**Last Name (un) **] follow up after discharge.
.
AFIB: Although the patient has a history atrial fibrillation, he
was in a sinus rhythm during his hosptial stay. He was
continued on his diltiazem for rate control.
.
MECHANICAL VALVE: The patient was initially supratherapuetic for
his INR and his coumadin was held while hospitalized. He was
then subtherapuetic and started on heparin for a bridge. He was
restarted on coumadin but again became supratherapuetic. His
coumadin was again held and finally restarted prior to discharge
at a lower dose. His goal INR is 2.5-3.5 for his valve. He is
usually followed in the coumadin clinic and will continue to
follow-up there. His INR will be drawn at [**Last Name (un) 2286**] and the
result faxed to the [**Hospital3 **]. INR 4.0 at the time
of dishcharge with no evidence of bleeding and planned INR check
at HD the following day.
.
L HUMERUS FX: The patient had an old impacted L humerus fracture
with no change in alignment. Occupational therapy worked with
the patient. He had edema in the LUE but and ultrasound was
negative for DVT. Orthopaedics was aware of the patient's
condition but said he should be treated non-operatively. He will
follow up with his primary care provider upon discharge.
.
R FLANK PAIN: The patient was found to have an 11th rib fracture
on plain films. He was treated with tylenol, oxycontin and
oxycodone for pain control.
.
HTN: The patient was restarted Procardia 60 mg daily and
Labetalol 800 mg t.i.d. His blood pressure was well-controlled
while hospitalized.
.
GOUT: The patient was started on allopurinol every other day
given his renal function.
Mr. [**Known lastname 58784**] was discharged to home with services (home PT, lab
draws: INR, and antibiotics). Outpatient [**Known lastname 2286**] was arranged
to continue tuesdays, thursdays, and saturdays.
Medications on Admission:
MEDS (as per PCP ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) note [**2121-12-24**]):
--Diltiazem 240 mg extended release
--Procardia 60 mg daily
--Labetalol 800 mg t.i.d.
--Coumadin as per [**Hospital3 **] with INR 2.5-3.5
--Procrit (Monday-Wednesday-Friday)
--CellCept [**Pager number **] mg b.i.d.
--Prednisone 10 mg daily
--Furosemide 40 mg daily
--Allopurinol 100 mg daily
--Protonix 40 mg b.i.d.
--Zyprexa 5 mg b.i.d.
--Lantus 14 units daily with sliding scale
--Acetominophen prn
--Oxycodone prn
--Ativan prn
--calcium carbonate
--thiamine
.
MEDS (on transfer to [**Hospital1 **]):
--cefepime 1 g q8h
--linezolid 600 q12h
--prednisone 10 mg daily
--cellcept [**Pager number **] mg [**Hospital1 **]
--diltiazem gtt
--versed gtt
--fentanyl gtt
--heparin gtt
Discharge Disposition:
Home
Discharge Diagnosis:
Multilobar pneumonia.
Sepsis.
Respiratory failure.
Renal failure.
Discharge Condition:
Stable, ambulating with assistance, afebrile, O2 sat mid- to
high-90s on room air
Discharge Instructions:
You were hospitalized for respiratory failure related to severe
pneumonia and kidney failure. Your pneumonia was treated with
antibiotics and you were started on hemodialysis. You are being
discharged on multiple new medications. Please take all of your
medications as directed. If you have questions or concerns
regarding your medications, please call your primary care
provider or the hospital team.
You are being discharged with a continued need for hemodialysis.
Appointments have been made for you at your [**Hospital1 2286**] center. It
is imperative that you keep these appointments. If you are
unable to keep an appointment, you must call your doctor or come
to the hospital.
You are being discharged with vancomycin to complete a ten-day
course; you will receive vancomycin at hemodialysis dosed
through [**2-5**]. Your nephrologist will decide when you will
receive doses of this antibiotic based on your blood levels that
will be drawn at [**Month/Year (2) 2286**]. A vancomycin level drawn before your
discharge is pending and will be reviewed by your nephrologist
at [**Month/Year (2) 2286**] tomorrow ([**2122-1-29**]).
If you experience fever, shortness or breath or difficulty
breathing, chest pain, nausea, vomiting, or inability to eat or
drink, you should call your doctor or come to the emergency
department immediately.
If you notice that your hemodialysis line site is becoming red,
or has foul-appearing or -smelling discharge from the site, or
is painful to touch, please alert your doctors [**First Name (Titles) **] [**Last Name (Titles) 2286**] [**Name5 (PTitle) **]
call your doctor to have it evaluated.
If you have any new or concerning symptoms, call your doctor or
return to the emergency department immediately.
Home skilled nursing has been arranged for you. A representative
from the company has been in touch with you regarding this care
and will come to your home starting Friday, [**2122-1-30**].
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 30147**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2122-2-2**] 3:30
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2122-2-17**] 2:00
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2122-5-1**]
9:00
You will need to continue your [**Month/Day/Year 2286**] on tuesday, thursdays,
and saturdays as directed. Your [**Month/Day/Year 2286**] will be done at [**Last Name (un) 4029**]
[**Last Name (un) 2286**] and the information (address, phone number) has been
given to you. Your first appointment is thursday, [**1-29**] at
3:45 pm.
|
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icd9cm
|
[
[
[]
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[
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8930, 8936
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3379, 8094
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287, 373
|
9046, 9130
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|
227, 249
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401, 1046
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1276, 1469
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,846
| 159,316
|
37008
|
Discharge summary
|
report
|
Admission Date: [**2195-9-10**] Discharge Date: [**2195-9-13**]
Date of Birth: [**2112-8-3**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is an 83 year-old female transferred from
[**Hospital3 **] after a fall from 3 steps approximately 2
hours ago. Per report, she was carrying her laundry up the
stairs and was on the 3rd step when she fell posteriorly and hit
her occiput. She sustained a 7cm laceration which was sutured
at
[**Hospital3 **] ED. She received a head CT at [**Hospital1 3494**]
with
reports of bilateral occiput SDH and was then transferred to
[**Hospital1 18**] for further neurosurgical workup.
Past Medical History:
thyroidectomy, mastectomy, cyst on spine, and arthritis
Social History:
Lives at home with daughter
Family History:
NC
Physical Exam:
PHYSICAL EXAM:
O: T: 97.7 BP: 123/64 HR:83 RR:16 O2Sats:97% on 2LNC
Gen: WD/WN, comfortable, NAD.
HEENT: PERLA, EOMs intact, left forehead abrasion, nasal bridge
abrasion, left maxillary abrasion
Neck: Supple.
Lungs: CTA bilaterally, left posterior shoulder abrasion
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: [**4-14**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to 3-5mm
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 [**6-16**] throughout. No pronator drift
Sensation: Intact to light touch, proprioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right 2+ 2+ 2+ 2+ 2+
Left 2+ 2+ 2+ 2+ 2+
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Physical exam on discharge:
A&OX3
PERRL
face symmetrical
tongue midline
no pronator drift
Motor B T D IP QUAD HAM AT [**Last Name (un) **] [**Last Name (un) 938**]
L 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5
Pertinent Results:
CT of head [**2195-9-10**]:
*2mm R frontal acute SDH, 6MM acute L SDH
*L frontal and temporal SAH
*Bilateral parafalcine SDH
*No interventricular hemorrhage, midlines shift, or herniation.
*R posterior subgaleal hematoma with laceration, no fx.
CT c-spine [**2195-9-10**]
No dislocation or fracture. Dengenerative chages at C5/6 and
C6/7.
Brief Hospital Course:
Patient was transferred to [**Hospital1 18**] s/p fall with CT of the heading
showing bilateral SDH. She was also found to have a SAH.
Neurologically, patient has been stable, repeat CT scan of the
head was also stable with initial scan. On [**9-11**], patient was
found to have a fever of 101.2. She was pancultured. Uranialysis
was negative and blood cultures are pending. Patient will be
discharged today, blood culture results pending at time of
discharge and patient is nonfebrible, follow up as outpatient.
Medications on Admission:
Fosamax, thyroid med, Sudafed for post nasal drip
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Hydralazine 20 mg/mL Solution Sig: One (1) Injection Q4H
(every 4 hours) as needed for SBP >160.
4. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*2*
5. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO Q6H PRN as needed
for pain.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Traumatic brain injury, right SDH, left SDH, left SAH, SDH along
falx
Discharge Condition:
Neurologically stable
Discharge Instructions:
General Instructions
?????? Take your 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.
?????? Do not take any anti-inflammatory medicines such as Motrin,
Aspirin, Advil, or Ibuprofen etc. for one month.
?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week. This can be drawn at your PCP??????s
office, but please have the results faxed to [**Telephone/Fax (1) 87**].
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 2726**] to schedule an appointment with Dr.
[**Last Name (STitle) 548**], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
.Visiting RN can removed sutures in [**8-21**] days from placement.
*Patient will have 24 hour continuous care at home with family
supervision.*
Completed by:[**2195-9-17**]
|
[
"873.0",
"244.0",
"780.60",
"733.90",
"716.90",
"E880.9",
"852.21",
"V45.71"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4214, 4272
|
3136, 3650
|
323, 330
|
4386, 4410
|
2772, 3113
|
5649, 6161
|
992, 996
|
3751, 4191
|
4293, 4365
|
3676, 3728
|
4434, 5626
|
1026, 1362
|
2539, 2753
|
279, 285
|
358, 852
|
1655, 2511
|
1377, 1639
|
874, 931
|
947, 976
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,552
| 126,247
|
1407
|
Discharge summary
|
report
|
Admission Date: [**2109-9-27**] Discharge Date: [**2109-10-5**]
Date of Birth: [**2039-3-29**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
cad
Major Surgical or Invasive Procedure:
off-pump coronary artery bypass graft x2,
left saphenous vein graft to left anterior descending artery
and obtuse marginal artery
History of Present Illness:
70 year old patient of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 8446**] with a prior history of CABG, now with exertional chest
discomfort and an abnormal stress test, referred for outpatient
cardiac catheterization to further evaluate.
Needs BPG
Past Medical History:
PMH: CAD, HTN, ^chole, L subclavian stenosis, Renal calculi, GI
bleed, polypectomy, stress incontinence
PSH: CABGx3 '[**96**] (LIMA->LAD, SVG->LPDA, SVG->OMI) w/ Dr [**Last Name (STitle) 1537**], L
carotid to L Subclavian bypass w/ dacron graft, R/L CEA '[**97**]
Social History:
non smoker
non drinker
Family History:
FH: Father (died at age 42 of an MI) and multiple siblings with
premature CAD, brother s/p CABG last week in [**Location (un) 8447**]
Physical Exam:
AFVSS
a/o x3
nad
grossly intact
supple
farom
cta
rrr
abd - beingn
surgival inc c/d/i
palp distal pulses
Pertinent Results:
[**2109-10-5**] 04:40AM BLOOD WBC-14.2* RBC-3.58* Hgb-10.5* Hct-31.2*
MCV-87 MCH-29.4 MCHC-33.7 RDW-14.3 Plt Ct-401
[**2109-10-5**] 04:40AM BLOOD PT-12.9 PTT-26.3 INR(PT)-1.1
[**2109-10-5**] 04:40AM BLOOD Glucose-133* UreaN-26* Creat-1.0 Na-136
K-3.6 Cl-98 HCO3-27 AnGap-15
[**2109-10-5**] 04:40AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.6
[**2109-10-3**] 08:51PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
[**2109-10-3**] 08:51PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2109-9-29**] 09:22AM URINE RBC-5* WBC-0 Bacteri-RARE Yeast-NONE
Epi-5
Brief Hospital Course:
As mentioned in the HPI Mrs [**Last Name (STitle) 8448**] had a cardiac
catherization. This prompted her for a redo BP. She underwent
usual pre-operative work-up including labs and diagnostics. On
[**9-30**] she was brought to the operating room where he underwent a
Redo off-pump coronary artery bypass graft x2,left saphenous
vein graft to left anterior descending artery and obtuse
marginal artery . Please see operative report for surgical
details. Following surgery she was transferred to the CSRU for
invasive monitoring in stable condition. Within 48 hours she was
weaned from sedation, awoke neurologically intact and extubated.
On post-op day day she was started on beta blockers and
diuretics and gently diuresed towards his pre-op weight. Chest
tubes were removed on this day and he was transferred to the SDU
for further management. On post-op day three her epicardial
pacing wires were removed. she remained stable post-operatively
and worked with physical therapy for strength and mobility. On
post-op day eight she was dischqarge to rehab and the
appropriate follow-up appointments.
Pt did experience atrail fibrillation. She was converted with BB
and amiodorone. She will leave on a taper
Medications on Admission:
[**Last Name (un) 1724**]: ASA 325', Metoprolol 200', Quinapril 20', Lipitor 40',
Omeprazole20', Amlodipine 5', Detrol LA 4'
Discharge Medications:
1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
7. Furosemide 10 mg/mL Solution Sig: One (1) Injection Q12H
(every 12 hours) for 5 days.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for 7 days: prn. Tablet(s)
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
13. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): TAPER # 1
x 7 days.
14. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days: TAPER # 2
x 7 days
after 400 [**Hospital1 **] .
15. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
TAPER # 3
AFTER 200 [**Hospital1 **].
Discharge Disposition:
Extended Care
Facility:
The [**Doctor Last Name **] Nursing and Rehabilitation Center
Discharge Diagnosis:
CAD
CAD, HTN, ^chole, stress incontinence
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. 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.
Followup Instructions:
Call Dr [**Last Name (STitle) **]. Schedule an appointment for 2 weeks. He
can be reached at ([**Telephone/Fax (1) 1504**]
Should followup with PCP [**Name Initial (PRE) **]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2109-10-5**]
|
[
"V13.01",
"414.04",
"401.9",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"36.12",
"88.56",
"88.57"
] |
icd9pcs
|
[
[
[]
]
] |
4887, 4975
|
2046, 3253
|
277, 409
|
5062, 5069
|
1403, 2023
|
5784, 6081
|
1129, 1264
|
3428, 4864
|
4996, 5041
|
3279, 3405
|
5093, 5761
|
1279, 1384
|
234, 239
|
437, 785
|
807, 1073
|
1089, 1113
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,251
| 176,105
|
25508
|
Discharge summary
|
report
|
Admission Date: [**2118-2-2**] Discharge Date: [**2118-2-4**]
Service: MEDICINE
Allergies:
Levaquin
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Neck mass
Major Surgical or Invasive Procedure:
none
History of Present Illness:
81 y.o. woman with recent neck trauma, now on ventilator,
presents with right neck mass noted at [**Hospital3 **]. The
mass was noted yesterday and noted to bulge out during cough or
Valsalva. There was concern for a tracheo-subcutaneous fistula
so she was sent to ED for evaluation. A neck CT did not show
evidence of subc air. It was concerning for either jugular vein
dilatation or a mass in the supraclavicular fossa. However,
further characterization could not be made based on a
non-contrast CT so further imaging would be required. Pt is
otherwise at her baseline. There are no acute resp issues and
she is hemodynamically stable. She denies pain or dyspnea.
Past Medical History:
1) s/p fall with neck trauma
2) central cord syndrome
3) Respiratory failure secondary to cord involvement with
psuedomonas, serratia and MRSA VAP.
4) HTN
5) Asthma
6) CAD s/o CABG, PAF
7) s/p thyroidectomy in teens
8) s/p hysterectomy
Social History:
No history of tobacco or recent EtOH.
Did not obtain history on former occupation.
Currently resides at [**Hospital3 **].
Has multiple children involved in care.
Family History:
Non-contributory
Physical Exam:
Gen arousable, responsive to commands, communicates
nonverbally, in NAD
HEENT NCAT, PERRL, anicteric. OP clear with dry MM.
Neck: 5x2cm area above right clavicle that bulges with
straining, no fluctuance, crepitus, erythema, tenderness,
palpable mass.
Lungs coarse BS b/l
CV: RRR, nml S1S2, 3/6 systolic murmur.
Abd: G-tube. soft, NT, ND, naBS
Ext: no edema, warm/well perfused.
Neuro: moves both upper extrem minimally to command, does not
move LE to command (chronic)
Pertinent Results:
[**2118-2-2**] 02:23AM WBC-15.2* RBC-3.03*# HGB-9.8*# HCT-28.0*
MCV-92#
PLT COUNT-480*
NEUTS-82.9* LYMPHS-9.9* MONOS-3.5 EOS-3.6 BASOS-0.2
.
GLUCOSE-98 UREA N-41* CREAT-0.7 SODIUM-137 POTASSIUM-4.0
CHLORIDE-98 TOTAL CO2-28 ANION GAP-11
.
PT-12.5 PTT-23.2 INR(PT)-1.0
.
Neck CT:
1. There is no air within the subcutaneous tissues of the right
supraclavicular fossa to suggest a tracheal subcutaneous
fistula. There is likely an enlarged right internal jugular vein
v. a mass in the supraclavicular fossa on the right, though IV
contrast could not be administered for confirmation. This
finding could be confirmed with ultrasound.
2. Small lymph nodes within the neck and superior mediastinum.
3. Heavily calcified aorta.
4. Intralobular septal thickening and possible scarring at the
lung apices.
5. Status post anterior fixation of the cervical spine.
.
Ultrasound: Right supraclavicular lesion represents the bulb of
the right internal jugular vein.
Brief Hospital Course:
81 y.o. woman with recent neck trauma, now on ventilator without
failure to wean, presenting with new neck deformity. Pt is
asymptomatic, and there does not appear to be any compromise of
airway or circulation.
..
1) Neck Mass: Imaging findings were consistent with a
dilatation/aneurysm of the R internal jugular vein. Vascular
surgery evaluated the patient and determined no need for
intervention at this time. They recommended a repeat ultrasound
to evaluate the mass in 1 week. They also suggested a CT with
venous phase contrast in 1 week to evaluate for any progression
of the aneurysm.
..
2) Respiratory Failure: Pt has reportedly not been able to be
weaned at [**Hospital1 **]. We continued her on current vent settings
and did not attempt further weaning. She was stable on her
current vent settings.
..
3) Ventilator associated pneumonia: She is on meropenem,
colistin, and linezolid, which we contined as at rehab. She had
a low-grade fever on arrival here, but otherwise showed no
evidence of active infection and was afebrile thereafter.
Antibiotics should be continued for the planned course
(linezolid to be continued until [**2-9**], meropenem until [**2-10**],
and colistin until [**2-7**], per the medication list from [**Hospital1 **]).
..
4) CAD: We continued lopressor at her usual dose. It is not
clear why she is not on ASA.
..
5) Asthma: Continue spiriva, salmeterol, albuterol, and
flovent. We held her mucomyst.
.
6) F/E/N: Tube feeds were continued. Electrolytes were
repleted as needed.
..
7) PPx: SC heparin for DVT ppx and PPI.
Medications on Admission:
Linezolid 600mg [**Hospital1 **]
Meropenem 1g q8h
Diflucan 400mg qd (to complete [**2-3**])
Digoxin 125mcg every other day
Lopressor 12.5 mg PO q6h
Spiriva
Flovent 220 2 puffs [**Hospital1 **]
Albuterol prn
Mucomyst nebs
Ativan
Prevacid
Neurontin 300mg tid
Questran 4g tid
Fragmin 5000U daily
Discharge Medications:
1. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
2. Digoxin 50 mcg/mL Elixir Sig: 0.125 mg PO EVERY OTHER DAY
(Every Other Day).
3. Bacitracin Zinc Topical
4. Feosol 220 mg/5mL Elixir Sig: Three [**Age over 90 **]y Five (325)
mg PO once a day.
5. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) cap Inhalation once a day.
6. Xenaderm Ointment Topical
7. Foradil Aerolizer 12 mcg Capsule, w/Inhalation Device Sig:
One (1) Inhalation twice a day.
8. Flovent 220 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
9. Proventil 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
10. Mycostatin 100,000 unit/g Powder Sig: One (1) application
Topical twice a day.
11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO Q6H
(every 6 hours).
12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO q2h as needed
for agitation.
13. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig:
Thirty (30) mg PO DAILY (Daily).
14. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO three
times a day.
15. Fragmin 5,000 anti-Xa u/0.2mL Syringe Sig: 5000 (5000) units
Subcutaneous once a day.
16. Cholestyramine-Sucrose 4 g Packet Sig: One (1) Packet PO TID
(3 times a day).
17. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: 10-15 MLs
Mucous membrane [**Hospital1 **] (2 times a day).
18. Citracal 950 mg Tablet Sig: Two (2) Tablet PO q8h ().
19. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
20. Acetaminophen 500 mg/5 mL Liquid Sig: Six [**Age over 90 1230**]y
(650) mg PO every four (4) hours as needed for fever or pain.
21. Meropenem 1 g Recon Soln Sig: 1000 (1000) mg Intravenous
Q8H (every 8 hours) for 7 days: End date is 12/2905.
22. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 6 days: End date is [**2118-2-9**].
23. Colistimethate Sodium 150 mg Recon Soln Sig: One (1) Recon
Soln Injection [**Hospital1 **] (2 times a day) for 4 days: End date is
[**2118-2-7**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnosis:
right internal jugular aneurysm
Discharge Condition:
stable
Discharge Instructions:
1. For new or concerning symptoms, please call your doctor or
return to the emergency room for evaluation.
2. Please continue all medications as prescribed, we have not
made any changes to your medications.
3. You will need a repeat ultrasound to evaluate your neck mass
in about 1 week. A CT with venous phase contrast in 1 week may
also be useful to evaluate the extent of the mass.
Followup Instructions:
Please obtain repeat ultrasound of neck mass in 1 week. CT with
venous phase contrast in 1 week may also be useful.
|
[
"V44.0",
"518.83",
"453.8",
"427.31",
"V44.1",
"344.01",
"486",
"V46.11",
"V45.81",
"285.9",
"401.9",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
6897, 6967
|
2900, 4476
|
224, 231
|
7062, 7071
|
1921, 2877
|
7507, 7627
|
1388, 1406
|
4819, 6874
|
6988, 6988
|
4502, 4796
|
7095, 7484
|
1421, 1902
|
175, 186
|
259, 934
|
7007, 7041
|
956, 1193
|
1209, 1372
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,192
| 147,130
|
49574+49592+49593+59187
|
Discharge summary
|
report+report+report+addendum
|
Admission Date: [**2128-7-20**] Discharge Date: [**2128-7-26**]
Service:
CONTINUATION
HOSPITAL COURSE: Issue #2: Aspiration pneumonia. She was
also started on Flagyl 500 mg t.i.d.
$3: Hypoxia. Patient had oxygen requirement of
approximately 4 to 5 liters nasal cannula. This was felt to
be related to her pneumonia and/or volume overload related to
fluid rehydration in the Emergency Room. Patient was gently
diuresed. On the day prior to discharge she was saturating
in the upper 90s on 2 liters nasal cannula.
#4: Mental status changes. Patient had brief episode of one
to two days of mental status change with increased agitation
and some confusion. This related to orientation to place.
Likely etiologies include medication error, hypotension,
hypoxia. Neurology was consulted secondary to concerns about
questionable history of slurred speech and some weakness.
They felt her changes were most likely related to
encephalopathy due to prior mentioned etiologies and not
related to ischemic infarct. She was started on Seroquel
12.5 mg q.h.s. At the time of discharge the patient was
alert and oriented times three and by best accounts felt to
be at her baseline mental status.
#5: Acute renal failure. Most likely prerenal secondary to
her hypercontinent episode. Her creatinine and CK trended
down throughout her stay. Her ACE inhibitor and
non-steroidal anti-inflammatory drugs were held initially
until her creatinine function returned to baseline at which
time her Actoprel was restarted.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Patient likely to rehabilitation. Will be
addended at time of discharge.
DISCHARGE DIAGNOSIS:
1. Hypotension.
2. Bradycardia.
3. Aspiration pneumonia.
4. Acute renal failure.
5. Mental status changes.
6. Hypertension.
7. History of paroxysmal atrial fibrillation.
8. Coronary artery disease, status post three vessel
stents.
9. Breast cancer.
10. Anemia.
11. Hypercholesterolemia.
12. Dysuria and urinary frequency.
13. Chronic abdominal pain.
DISCHARGE MEDICATIONS: Cefpodoxime 200 mg p.o. q 24 hours
for a total of a 14 day course, Flagyl 500 mg p.o. t.i.d.,
also for a total of a 14 day course, aspirin 325 mg q day,
Plavix 75 mg q day, tamoxifen 10 mg b.i.d., ranitidine 150 mg
b.i.d., Colace 100 mg b.i.d., Neurontin 600 mg b.i.d., Zoloft
25 mg q A.M., 50 mg q h.s., Simvastatin 10 mg q day,
Seroquel12.5 mg q h.s., Sotalol 20 mg q.A.M., 40 40 mg q
h.s., hydrochlorothiazide 25 mg p.o. q day, Imdur 15 mg q.
day, clonazepam 1 mg q h.s., losartan 25 mg b.i.d.
FOLLOW UP PLANS: Patient is likely to be discharged to an
extended care facility. she should follow with her primary
care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], in one to two weeks.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**]
Dictated By:[**Last Name (NamePattern1) 8478**]
MEDQUIST36
D: [**2128-7-25**] 15:57
T: [**2128-7-25**] 16:30
JOB#: [**Job Number 103686**]
Admission Date: [**2128-7-20**] Discharge Date: [**2128-7-25**]
Service:
CHIEF COMPLAINT: Lethargy and weakness.
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
female with a significant past medical history of coronary
artery disease status post three stents in [**8-20**],
hypertension, paroxysmal atrial fibrillation and anemia who
was brought to the emergency department by a friend with
complaint of weakness and fatigue and lightheadedness times
approximately three days plus a questionable report of
slurred speech on the day of admission.
The patient states she went on vacation approximately one
week ago and forgot some meds. She had a replacement called
in to a Pharmacy but she states they were different and that
they gave her diarrhea times approximately 5 days.
Apparently she also took a few extra pills once she got back
home to make up the difference. In the emergency department
the patient was hypotensive to the 70's with a heart rate in
the 50 or 60's. Initially she responded to intravenous fluid
boluses but after three liters her systolic blood pressure
remained in the low 80's. She was started on Dopamine drip
at 50 mcs per kg per minute and her systolic blood pressure
increased to the 140's with a heart rate in the 80's. Also
in the emergency department the patient had one episode of
vomiting after drinking water and complained of mild chronic
abdominal pain but denies fever, chills, cough, chest pain or
short of breath.
PAST MEDICAL HISTORY:
1. Coronary artery disease. Status post three vessel
stents, distal right coronary artery. The proximal
descending artery and the circumflex. Echo in [**2119**] showed
mild AI and MR with a normal EF, catheterization [**8-20**] showed
patent stents and [**8-21**] stress test showed an EF of 50% with a
mild fixed inferior wall deficits.
2. Hypertension.
3. Hypercholesterolemia.
4. Paroxysmal atrial fibrillation.
5. Breast cancer.
6. Questionable chronic renal insufficiency.
7. Anemia.
8. Spinal stenosis.
9. Total knee replacement of the right knee.
10. Dysuria and urinary frequency.
11. Gastroesophageal reflux disease.
12. Chronic abdominal pain.
13. Status post Epi.
ALLERGIES: Penicillin, Macrodantin, Amiodarone exact
reactions unknown.
MEDICATIONS ON ADMISSION: The patient is unsure of exact
medications. The following are derived from a letter from
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], the patient's cardiologist which is dated
[**2128-6-29**]. Includes.
1. Hydrochlorothiazide 25 mg per day.
2. Zantac 150 mg twice per day.
3. Neurontin 600 mg twice per day.
4. Klonopin, question 0.5 q AM and 1.0 mg at bedtime.
4. Betapace 20 mg q AM, 40 mg q PM.
5. Nitroglycerin p.r.n.
6. Zoloft 25 mg q AM, 50 mg q PM.
7. Imdur 15 mg per day.
8. Tamoxifen
9. Aspirin 325 mg per day.
10. Plavix 75 mg per day.
11. Zocor 25 mg per day.
12. Lactulose.
13. Accupril 10 mg twice per day.
14. Naprosyn.
15. Claritin.
16. Colace.
17. Prilosec.
18. Urocid.
19. Tylenol with Codeine
20. Imodium p.r.n.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient lives alone at home, no tobacco
or alcohol use. She walks to the store once per day and is
independent in her activities of daily living. She works in
the antique business.
PHYSICAL EXAMINATION: Temperature 99.9, blood pressure
95/52, heart rate 62, respiratory rate 15, sating 96% on four
liters. Those vitals were on 5 mcs of Dopamine drip. Urine
output 60 cc's per hour.
General: An elderly female in no acute distress, speaking in
full sentences. Head, eyes, ears, nose and throat: Mucous
membranes dry, oropharynx clear. Extraocular movements
intact. Jugular venous distention elevated to approximately
14 cm, non lymphadenopathy. Neck supple. Heart: Normal S1
and S2. Bradycardiac. Holosystolic murmur [**2-26**] at apex
radiating to the axilla. Lungs: Limited exam, rales [**2-23**] way
up on the right with decreased breath sounds at right base.
Abdomen: Slightly distended, decreased bowel sounds,
nontender. Extremities: 1+ pitting edema left greater than
right. Neurological: Speaking in full sentences, tangential
in thought. Cranial nerves 2 through 12 intact. Speech is
intact.
PERTINENT DATA ON ADMISSION: White count 12.1, 79%
neutrophils, 16% lymphocytes, hematocrit 29.9, MCV 94.
Platelets 164. Chem 7: Sodium 137, potassium 4.5, chloride
99, bicarbonate 29, BUN 52, creatinine 2.6, glucose 124. CK
was 1492, MB 35, MB index of 2.3 and a Troponin of less than
0.1. Head CT showed no bleed or mass, no infarct. Chest
x-ray showed right middle lobe infiltrate, old interstitial
markings and a small right effusion.
Electrocardiogram demonstrated sinus bradycardia, prolonged
QT, possible old lateral infarction, borderline Q-waves in 1
and AVL. There were o ST segment changes. No significant
changes since previous echocardiogram [**8-21**].
HOSPITAL COURSE:
1. Hypotension. Etiology felt to be related to
polypharmacy/medication error. On further discussion with
the patient's family they reported the patient has a history
of prior medication errors and had been making errors more
frequently with her medications. She was admitted to the
Intensive Care Unit on Dopamine drip but was called out to
the floor the next day off pressors.
[**Name6 (MD) 251**] [**Last Name (NamePattern4) 6366**], M.D. [**MD Number(1) 6367**]
Dictated By:[**First Name3 (LF) 103724**]
MEDQUIST36
D: [**2128-7-25**] 15:17
T: [**2128-7-25**] 15:23
JOB#: [**Job Number 103725**]
Admission Date: [**2128-7-20**] Discharge Date: [**2128-7-26**]
Service:
CONTINUATION OF PREVIOUS REPORT:
HOSPITAL COURSE:
1. Hypotension likely related to polypharmacy and/or
medication error. Report from patient's family indication
that she has made medication errors in the past and that
these have become increasingly more frequent. She was
initially admitted to the Intensive Care Unit on dopamine
drip but was called out to the floor the next day off
pressors with a stable blood pressure. Over the remainder of
the course of her hospital stay she became hypertensive and
was gradually restarted on her antihypertensive. At time of
discharge, her home dose of Accupril 10 b.i.d. was changed to
Losartan 25 b.i.d. secondary to a chronic nonproductive cough
that was felt possibly to be secondary to her ACE inhibitor.
2. Her history of atrial fibrillation and initial
bradycardia. At the request of Dr. [**Last Name (STitle) 1537**], the patient's
cardiologist, the aim was to restart her sotalol at half her
home dose with a goal of titrating to her home dose of 20 q.
a.m. and 40 q. p.m. which was adjusted accordingly for her
creatinine clearance which was initially decreased on
admission. This was done without incident and patient was
discharged on prior mentioned home dose of 20 q. a.m. and 40
q. p.m. She was monitored on telemetry with frequent 12 lead
electrocardiograms. She remained in normal sinus rhythm
throughout her stay and her initial QT prolongation corrected
and remained within normal limits through the rest of her
stay.
3. Right middle lobe infiltrate. Felt to be aspiration
pneumonia related to episode of emesis in the Emergency
Department. She was initially started on levofloxacin which
was later changed to cefpodoxime, an oral third generation
cephalosporin. This change was made secondary to
levofloxacin's association with prolonged QT. With regard to
patient's prior stated allergy to penicillin, further
questioning revealed that the reaction was greater than 30
years ago and patient did not recall and specific symptoms of
an anaphylactic type reaction. She was monitored throughout
her stay and did not have any complications related to the
cephalosporin therapy. She was also started.........
DR.[**Last Name (STitle) 903**],[**First Name3 (LF) 251**] 11-431
Dictated By:[**Last Name (NamePattern1) 8478**]
MEDQUIST36
D: [**2128-7-25**] 15:37
T: [**2128-7-25**] 15:42
JOB#: [**Job Number 103726**]
Name: [**Known lastname **], [**Known firstname 1715**] Unit No: [**Numeric Identifier 16793**]
Admission Date: [**2128-7-20**] Discharge Date: [**2128-7-28**]
Date of Birth: [**2036-3-23**] Sex: F
Service:
ADDENDUM: The patient's remaining hospital stay since prior
dictation was without incident. Of note, the patient had
repeat chest x-ray [**7-26**] showing interval improvement, right
middle lobe and right lower lobe infiltrates. Also had
echocardiogram [**7-26**] showing no significant from prior study
[**2-/2119**] and normal EF and moderate risk for endocarditis
prophylaxis recommended. At the time of discharge she was
C-diff toxin negative times two and she was ambulating
without desaturation.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) 304**], M.D. [**MD Number(1) 594**]
Dictated By:[**Last Name (NamePattern1) 16794**]
MEDQUIST36
D: [**2128-7-28**] 08:12
T: [**2128-7-28**] 08:19
JOB#: [**Job Number 16795**]
|
[
"276.5",
"427.31",
"427.89",
"401.9",
"507.0",
"584.9",
"414.01",
"272.0",
"458.2"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6170, 6188
|
2076, 3166
|
1679, 2052
|
5395, 6153
|
8810, 12232
|
6416, 7351
|
3184, 3208
|
3237, 4584
|
7366, 8013
|
4606, 5368
|
6205, 6393
|
1555, 1658
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,716
| 122,999
|
46494
|
Discharge summary
|
report
|
Admission Date: [**2169-12-23**] Discharge Date: [**2170-1-4**]
Date of Birth: [**2113-2-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
cellulitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 56 yo man with PMH hodgkins, colon ca, sarcoma, who p/w
LLE edema and erythema. First noted on Thursday to have banged
on his inner left ankle. That night he noted subjective fevers,
chills with +/- rigors. The next day he felt better but noticed
increased pain in left leg beyond his baseline. That night he
again had chills, and the next day morning, he noticed erythema
and swelling. At that pt, he decided to come in to hospital. Of
note, in [**7-/2169**], he was discharged from ED for LLE cellulitis
and treated with Unasyn at the time. In addition, in [**2168**], he
had an episode of cellulitis in his RUE after undergoing XRT
after excision of his sarcoma. Of note, he had been travelling
(plane trip from [**Location (un) 86**] to [**Hospital1 **] and back) while his
symptoms developed.
.
ROS positive for new ulcer at the tip of his left toe which is
new as of 1 day PTA, baseline numbness along lateral left leg
which is old, frequent cracks in heels and dark grey toenails.
He denies any hx of tinea pedis. He denies and h/o DVT, denies
SOB, chest pain, palpitations.
.
In ED, vitals: T 103 oral, 110/53, 71, 22, 98%RA. Initially
concern for DVT given travel hx and swelling, but LENIs neg for
DVT. He was then given vanc 1gm IV x 1, tylenol, percocet for
pain, and admitted to medicine.
Past Medical History:
1. Hodgkin's disease, treated with ABVD cycles by Dr. [**First Name8 (NamePattern2) 189**]
[**Last Name (NamePattern1) **] in complete remission for twelve years.
2. Colon cancer stage II adeno Ca in [**2163**], treated with a
subtotal colectomy, tumor was T2, N0, no mets. Last colonoscopy
fall of [**2167**], next one [**2170**].
3. Sarcoma, diagnosed spring [**2168**], removed by Dr. [**Last Name (STitle) 519**] and found
to have a high-grade fibro sarcoma. Wide resection and radiation
followed. He remains on Trental for better healing as he still
has an open ulcer in that region.
4. History of cholecystectomy, Dr. [**Last Name (STitle) 52120**].
5. History of right knee replacement, Dr. [**First Name (STitle) **] done this
winter.
6. Atrial fibrillation.
7. osteochondritis
8. HTN
9. hyperlipidemia
Social History:
He is married and works in fund raising as a consultant. He
works with the JCP. He lives in [**Location 745**]. He has a 5-1/2-year-old
child and two older children ages 22 and 27. He smoked
cigarettes from his teenage years till [**2145**]. He occasionally has
some wine but not on a regular basis.
Family History:
His mother died at 47 of coronary artery disease, his father
died at 55 of multiple issues, both of them smoked.
Physical Exam:
PE: % O2 Sats
Gen: pleasant, NAD
HEENT: EOM intact, Clear OP, MM dry
NECK: Supple, No LAD
CV: irregularly irregular, NL S1, S2. No murmurs, rubs or
gallops
LUNGS: CTAB
ABD: Soft, NT, ND
EXT: LLE is warm to touch, erythema extending around ankle, up
inner calf and up inner thigh; tense edema around ankles; no
crepitus; 2+ DP pulses BL
SKIN: Numerous seborrheic keratosis on back; one on left
upper/mid back which has reddish component: per pt, he gets them
checked regularly; 1cm round lipoma on right upper back
NEURO: A&Ox3. decreased sensation along left upper thigh
compared to R (per pt, this is old)5/5 strength throughout.
Pertinent Results:
.
.
.
.
.
.
.
Micro:
[**2169-12-23**] blood cxs - NGTD
.
Imaging:
[**2169-12-23**] Left ankle film: IMPRESSION: Soft tissue swelling with
no evidence of fracture.
.
[**2169-12-23**] Left LE duplex:
IMPRESSION:
1) No DVT.
2) Left calf cellulitis.
3) Left groin and medial thigh lymphadenopathy.
Brief Hospital Course:
Assessment/Plan: Pt is a 56 yo man with hx of Hodgkins, colon
ca, sarcoma, who p/w LLE cellulitis.
.
# Cellulitis: Patient presents with signs/sx suggestive of
serious cellulitis. Given bandemia and extremely elevated
leukocytosis, there is additional concern for a more serious
infection and possibly bacteremia. This is his second episode of
cellulitis in this leg in several months. Wound bx revealed
MSSA, and he was started on IV nafcillin. Wound nursing
continued debridement with wet to dry dressing changes daily.
Given hx of soft-tissue sarcoma and hx of HD, dermatology
evaluated patient and felt biospy was of low utility. He will
be treated with 7 more days of IV nafcillin 2grams q6hour then
switch to oral dicloxacillin 500mg q6 hour for 7 more days.
.
# ARF: baseline 1.0, now 1.7. Most likely [**2-9**] prerenal azotemia.
ATN also possible. Improved with hydration.
# Pneumonia: AM [**12-24**] patient was noted to have worsening
hypoxia requiring nonrebreather on the floor. He also was in a.
fib with HR in the 100-110s since admission on the floor, and he
was transferred to the MICU. In the MICu patient continued to
be hypoxic with a-a gradient and high O2 requirement. Patient's
oxygen requirement was new this admission, ddx included
bilateral PNA as seen on chest ct, ARDS due to p/f ratio,
pcwp<12, underlying infection, heartfailure (although no
evidence on cxr or ct), PE (less likely as patient is
therapeutic on coumadin), Cardiac etiology and MI less likely as
pt without any chest pain. He was maintained on supplemental O2.
Echo with bubble study was done to evaluate for shunt and was
negative for PFO. He was treated with vanc/zosyn/clinda for PNA
and was monitored with serial ABGs, was given CPAP briefly. He
was treated with 10 total days antibiotics, 9 of which w/
meropenem. He was discharged on room air, no consolidations on
CXR and breathing comfortably.
.
# Sarcoma: Currently no active issues following wide resection.
He received radiation to upper arm only at the time.
.
# Malignancies: Currently no active issues. He is follow-up
regularly. It is curious why he has had so many malignancies.
?Li-Fraumeni syndrome, which may predispose him to sarcomas and
colon cancer. No active issues, but may be interesting to
pursue w/u as outpatient for genetic testing purposes
.
# Atrial Fibrillation: chronic on coumadin. He had rapid
ventricular response in house presumed to be [**2-9**] his infections.
He will be discharged on incresaed doses of nodal blockers
including dilt XR 360 daily and metoprolol 100mg TID.
.
Medications on Admission:
Lipitor 5mg
Aspirin 81 mg
atenolol 50 mg
cartia (diltiazem) 180 mg
ambien 5mg
coumadin 5mg
Discharge Disposition:
Home With Service
Facility:
Centrus Home Care
Discharge Diagnosis:
Cellulitis
Multifocal Pneumonia
Rapid Atrial Fibrillation
Discharge Condition:
Good
Discharge Instructions:
If you have these symptoms, call your doctor:
fever, chills, rash, nausea, vomiting, palpitations, weakness,
belly pain, shortness of breath, chest pain
Make sure you take your IV nafcillin 4 times a day for the next
7 days. Thereafter, take oral dicloxacillin 500mg 4 times a day
for the following 7 days.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4286**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2170-1-12**] 1:00
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/ONCOLOGY-CC9
Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2170-1-12**] 1:00
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 5500**], M.D. Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2170-5-4**] 9:05
Completed by:[**2170-1-3**]
|
[
"V10.89",
"V10.00",
"785.6",
"459.81",
"584.9",
"041.11",
"427.31",
"401.9",
"379.91",
"682.6",
"707.12",
"V43.65",
"707.13",
"286.9",
"038.9",
"V10.79",
"707.15",
"995.92",
"272.4",
"518.81",
"486",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"93.90",
"86.28",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6658, 6706
|
3940, 6516
|
325, 332
|
6808, 6815
|
3621, 3917
|
7172, 7714
|
2840, 2954
|
6727, 6787
|
6542, 6635
|
6839, 7149
|
2969, 3602
|
275, 287
|
360, 1672
|
1694, 2507
|
2523, 2824
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,172
| 182,640
|
29326+57635
|
Discharge summary
|
report+addendum
|
Admission Date: [**2145-12-1**] Discharge Date: [**2145-12-6**]
Date of Birth: [**2061-4-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Bactrim Ds
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest tightness and Shortness of breath with exertion
Major Surgical or Invasive Procedure:
[**2145-12-1**]
1. Coronary artery bypass graft x4: Left internal mammary
artery to left anterior descending artery and saphenous
vein grafts to obtuse marginal, diagonal and distal
right coronary artery.
2. Endoscopic harvesting of the long saphenous vein.
3. Aortic valve replacement with a size 23 St. [**Male First Name (un) 923**] Epic
tissue valve.
History of Present Illness:
84-year-old man with a history of aortic stenosis and coronary
artery disease status post a stent in [**2138**]. Pt admitted for
chest
pain and cardiac catheterization. Cardiac surgery consulted for
coronary revascularization/ valve replacement.
Cardiac Catheterization: Date: [**2145-11-9**] Place:[**Hospital1 18**]
PROXIMAL RCA DISCRETE 40-50%
LEFT MAIN TUBULAR 50%
PROXIMAL LAD DISCRETE 50%
DIAGONAL-1 DISCRETE 70%
PROXIMAL CX DISCRETE 80%
LAD stent patent
Cardiac Echocardiogram: [**2145-11-9**] [**Hospital1 18**]
The left atrium is mildly dilated. The right atrial pressure is
indeterminate. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
Regional
left ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The right ventricular cavity is mildly dilated
with normal free wall contractility. The aortic root is mildly
dilated at the sinus level. The ascending aorta is mildly
dilated. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. There is mild aortic valve
stenosis (valve area 1.2-1.9cm2). Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no
mitral valve prolapse. Moderate (2+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened.
Moderate
[2+] tricuspid regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. Significant pulmonic
regurgitation is seen. There is a trivial/physiologic
pericardial
effusion.
Past Medical History:
1. CARDIAC RISK FACTORS: Hypertension, hyperlipidemia
2. CARDIAC HISTORY:
-PERCUTANEOUS CORONARY INTERVENTIONS: [**Hospital1 112**] [**2142**] or [**2143**]
-PACING/ICD: [**Company 1543**] Kappa Implanted: [**2140-11-1**] ? indication
3. OTHER PAST MEDICAL HISTORY:
-[**2143**] back surgery for spinal stenosis- course c/b GIB
-benign cystic lesion of pancreas
-BPH s/p TURP approx [**2135**]
- h/o BPPV treated with intermittent meclizine
-chronic tinnitus [**2-16**] sonic trauma in military
- h/o cataract surgery
-OA of knees s/p steroid injection by [**Hospital1 112**] ortho 10 days ago
Social History:
Pt is a former [**University/College **] design and land development professor.
Lives in [**Location 4288**] with grandson and 2 other students and a
friend. Pt is still active in planning an intergenerational apt
complex in [**Hospital1 8**].
-Tobacco history: never
-ETOH: never
-Illicit drugs: never
Family History:
Father died at [**Age over 90 **] yo of CHF. Mother had a "[**Last Name **] problem" since
her youth but died at [**Age over 90 **] yo of complications after hip fx. 2
Sisters both 80 and 82 yo with hx of colon cancer.
Physical Exam:
Pulse:61 Resp:18 O2 sat:98/RA
B/P Right: 184/83 Left:
Height: 5'7" Weight:190 lbs
General:A&Ox3, NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI []
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur SEM III/VI
Abdomen: Soft [x] non-distended [x] non-tender []x bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: Left:
DP Right: 1+ Left:1+
PT [**Name (NI) 167**]: Left:
Radial Right:2+ Left:2+
Carotid Bruit (B)->likely murmur transmission
carotid pulses Right:2+ Left:2+
Pertinent Results:
[**2145-12-6**] 06:06AM BLOOD WBC-6.3 RBC-2.79* Hgb-8.7* Hct-24.6*
MCV-88 MCH-31.1 MCHC-35.3* RDW-15.4 Plt Ct-145*
[**2145-12-6**] 06:06AM BLOOD Glucose-115* UreaN-45* Creat-2.1* Na-139
K-4.1 Cl-106 HCO3-25 AnGap-12
[**2145-12-5**] 05:45AM BLOOD Glucose-113* UreaN-45* Creat-2.3* Na-137
K-4.3 Cl-105 HCO3-24 AnGap-12
[**2145-12-5**] 05:45AM BLOOD WBC-8.7 RBC-2.88* Hgb-9.0* Hct-25.3*
MCV-88 MCH-31.3 MCHC-35.6* RDW-15.7* Plt Ct-131*
Echo: [**2145-12-1**]:
Pulse:61 Resp:18 O2 sat:98/RA
B/P Right: 184/83 Left:
Height: 5'7" Weight:190 lbs
General:A&Ox3, NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI []
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur SEM III/VI
Abdomen: Soft [x] non-distended [x] non-tender []x bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: Left:
DP Right: 1+ Left:1+
PT [**Name (NI) 167**]: Left:
Radial Right:2+ Left:2+
Carotid Bruit (B)->likely murmur transmission
carotid pulses Right:2+ Left:2+
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2145-12-1**] where the patient underwent coronary
artery bypass graft x4 with left internal mammary artery to left
anterior descending artery and saphenous vein grafts to obtuse
marginal, diagonal and distal right coronary artery and aortic
valve replacement with a size 23 St. [**Male First Name (un) 923**] Epic tissue valve.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
The patient was neurologically intact and hemodynamically
stable on no inotropic or vasopressor support. Beta blocker was
initiated and the patient was gently diuresed toward the
preoperative weight. He did have an increased creatinine to a
peak of 2.3 with a baseline of 1.4. He continued to diurese
well and creatinine was stable at the time of discharge. The
patient was transferred to the telemetry floor for further
recovery. Chest tubes and pacing wires were discontinued
without complication. He did fail to void after the foley was
discontinued initally and he was subsequently started on Flomax
and voided after foley was removed the second time. He should
follow up with Urology as an outpatients. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD 5 the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics. The patient was discharged
to [**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) **] at [**Hospital 1821**] rehab in good condition with
appropriate follow up instructions.
Medications on Admission:
ATENOLOL - 25 mg Tablet - one and one half Tablet(s) by mouth
once a day
MECLIZINE - 25 mg Tablet - 1 Tablet(s) by mouth every eight (8)
hours as needed for prn dizziness
SIMVASTATIN [ZOCOR] - 40 mg Tablet - 1 Tablet(s) by mouth once a
day
ASPIRIN - 325 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by
mouth once a day
CALCIUM CARBONATE - (Prescribed by Other Provider) - Dosage
uncertain
MULTIVITAMIN,TX-MINERALS [MULTI-VITAMIN HP/MINERALS] -
(Prescribed by Other Provider) - Dosage uncertain'
Fish Oil
Vitamin D
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet 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. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
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. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
8. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. meclizine 12.5 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed for dizziness.
10. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for fever/pain.
12. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7
days.
13. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
coronary artery disease
aortic stenosis
PMH:
Hypertension
coronary artery disease status post a stent (LAD) in [**2138**]
s/p Pacemaker- [**Company **] [**2137**]
s/p Lead revision [**2141**]
Spinal Stenosis
Vertigo
Carpal Tunnel
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**First Name (STitle) **] on Mon [**12-20**] at 1:45 PM [**Telephone/Fax (1) 170**]
Cardiologist Dr. [**First Name (STitle) **]
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 250**] in [**4-19**] weeks
**PLEASE CHECK BUN/CREA/POTASSIUM/CBC in next 2-3 days***
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2145-12-6**] Name: [**Known lastname 749**],[**Known firstname **] Unit No: [**Numeric Identifier 11927**]
Admission Date: [**2145-12-1**] Discharge Date: [**2145-12-6**]
Date of Birth: [**2061-4-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Bactrim Ds
Attending:[**First Name3 (LF) 265**]
Addendum:
You are scheduled for the following appointments:
Surgeon Dr. [**First Name (STitle) **] on Mon [**12-20**] at 1:45 PM [**Telephone/Fax (1) 1477**]
Cardiologist Dr. [**Last Name (STitle) 1594**] [**2146-1-3**] at 11:20 AM
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 23**] in [**4-19**] weeks
**PLEASE CHECK BUN/CREA/POTASSIUM/CBC in next 2-3 days***
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 1477**]. Answering service will contact on call
person during off hours**
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 2324**] [**Last Name (NamePattern1) **] @ [**Location (un) 2325**]
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**First Name (STitle) **] on Mon [**12-20**] at 1:45 PM [**Telephone/Fax (1) 1477**]
Cardiologist Dr. [**Last Name (STitle) 1594**] [**2146-1-3**] at 11:20 AM
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 23**] in [**4-19**] weeks
**PLEASE CHECK BUN/CREA/POTASSIUM/CBC in next 2-3 days***
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 1477**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2145-12-6**]
|
[
"424.1",
"753.10",
"V53.31",
"V45.4",
"414.01",
"V45.82",
"737.10",
"272.4",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"39.61",
"35.21",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
11966, 12089
|
5434, 7224
|
330, 704
|
9358, 9514
|
4283, 5411
|
12112, 12836
|
3359, 3579
|
7793, 9031
|
9105, 9337
|
7250, 7770
|
9538, 10279
|
3594, 4264
|
2502, 2663
|
236, 292
|
732, 2406
|
2694, 3022
|
2428, 2482
|
3038, 3343
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,632
| 170,704
|
27713
|
Discharge summary
|
report
|
Admission Date: [**2129-5-13**] Discharge Date: [**2129-5-31**]
Date of Birth: [**2082-4-20**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p Motor vehicle crash
Major Surgical or Invasive Procedure:
External fixation bilateral lower extremities
IVC filter placement
ORIF right tibia
Closure of fasciotomy
History of Present Illness:
47 yo male s/p motor vehicle crash vs. pole, unrestrained
driver; with bilateral tibial plateau fractures, right
talonavicular dislocation (splinted),and C5 fracture.
Transportedto [**Hospital1 18**] for further care.
Past Medical History:
EtOH abuse, GERD, depression, anxiety, L knee surgery
Social History:
EtOH abuse
Family History:
Married
Physical Exam:
Upon exam:
O: T:97.8 BP:142 / 90 HR:98 R16 O2Sats 96%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3.0mm to 2.0mm EOMs:full
Neck: Supple. +Palpable,posterior cervical point tenderness.
Reproducable pain.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. Left calf with compartment
firmness. Pulses palpable. Right calf soft. LE exam somewhat
limited due to the splinting on the rt ankle and tibia and also
to pain. No upper extremity radicular pain or paresthesias.
Neuro:
Mental status: Awake and alert, cooperative with exam, slowed
affect. Speech slowed and thick.
Orientation: Oriented to person, "hospital", and date.
Motor:
D B T WE WF IP Q H AT [**Last Name (un) 938**] G
R 5 5 5 5 5 4 splint in place
L 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch, propioception.
Reflexes: B T Br Pa Ac
Right 2 2 2 2 NT
Left 2 2 2 NT 2
Propioception intact
Toes downgoing left.
Pertinent Results:
[**2129-5-13**] 09:01PM TYPE-ART PO2-308* PCO2-42 PH-7.34* TOTAL
CO2-24 BASE XS--2
[**2129-5-13**] 08:58PM GLUCOSE-133* UREA N-12 CREAT-0.9 SODIUM-138
POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-26 ANION GAP-14
[**2129-5-13**] 08:58PM CALCIUM-7.7* PHOSPHATE-3.4 MAGNESIUM-1.4*
[**2129-5-13**] 08:58PM WBC-6.1 RBC-3.45* HGB-10.8* HCT-31.6* MCV-92
MCH-31.4 MCHC-34.3 RDW-13.6
[**2129-5-13**] 08:58PM PLT COUNT-234
[**2129-5-13**] 08:58PM PT-13.5* PTT-22.6 INR(PT)-1.2*
[**2129-5-13**] 09:35AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
CT Head [**2129-5-13**]
IMPRESSION:
1. No acute intracranial process.
2. No definite fracture is seen.
3. Mucosal thickening in the maxillary sinuses, more on the
right, and
minimal mucosal thickening in the ethmoid air cells.
4. Large subgaleal hematoma in the subcutaneous tissue at the
left frontal
region.
CT C-spine [**2129-5-13**]
IMPRESSION: Unusual oblique-axial C5 vertebral body fracture,
with partial
comminution (eg. (400a:18), traversing this vertebra within a
partially-fused C5-C6 spinal segment. Significant bridging
osteophytes at multiple levels, and concern for possible
disruption of the osteophytes at level C4-C5, as part of the
fracture mechanism.
COMMENT: These findings, involving "two column" injury at the C5
level, are concerning for unstable fracture, and MRI of the C-
spine has been recommended to evaluate for associated
ligamentous, disc or spinal cord injury.
Findings were posted on the ED dashboard and discussed with
Trauma Surgery
team members, Dr. [**Last Name (STitle) **] and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11287**].
NOTE ADDED IN ATTENDING REVIEW: There is definite extension of
the
oblique fracture line into the left lateral aspect of the C6
superior
endplate, and involvement of its left pedicle, extending into
the left neural foramen (400a:23, 401b:58); the articular facet
appears spared, and facetal alignment is maintained. There is,
therefore, at least unilateral "three- column" involvement with
Chance fracture-type mechanism, and the fracture may be regarded
as intrinsically unstable.
CT Chest/Abdomen/Pelvis [**2129-5-13**]
IMPRESSION:
1. No CT evidence of acute injury in the thorax, abdomen, or
pelvis.
2. Retrotracheal hematoma, extending from the neck, to the level
of carina, likely from the known fracture at vertebral body of
C5, explaining more details at the CT C-spine from the same day,
[**2129-5-13**].
Gallbladder Scan [**2129-5-24**]:
IMPRESSION: Large amount of sludge without evidence of biliary
obstruction.
CTA Chest [**2129-5-25**]
IMPRESSION:
1. Slightly techically limited study. Within that constraint
there is no
apparent pulmonary embolus.
2. Retained secretions seen in the right main stem bronchus as
well as areas of consolidation the right lower lobe, suggestive
of possible asprition.
3. Infrarenal IVC filter as above.
Brief Hospital Course:
He was admitted to the Trauma Service. Neurosurgery Spine
consulted for the C5 fracture; this was managed nonoperatively
with a cervical collar. He will follow up in 1 month with Dr.
[**First Name (STitle) **] for this.
During his initial ICU stay he required transfusions with PRBC's
and fresh frozen plasma. His most recent Hct was 27 on [**5-24**]. He
also developed a pneumothorax from a central line placement
requiring a dart thoracic tube to be placed. This was eventually
removed.
He was followed by Neurology for seizure history and was started
on anti-convulsant therapy. He will continue on Keppra and will
follow up with neurology as an outpatient; he will also require
an EEG prior to his outpatient appointment.
His Orthopedic injuries were managed operatively, initially he
underwent application multiplanar external fixators bilaterally,
closed treatment bilateral proximal tibia fractures with
manipulation, insertion compartment monitoring device, four
compartment fasciotomy and evacuation deep hematoma left thigh
and right knee. Postoperatively he was taken to the Trauma ICU
where he remained sedated and vented. He was taken back to the
operating room several days later for closure of the
fasciotomies. On [**5-20**] an IVC filter was placed by trauma
surgery. The final Orthopedic procedure was done on [**5-23**] where
he underwent ORIF left bicondylar tibial plateau fracture.
He was followed by the Pain service; sciatic catheters were
placed for pain control. he was also started on IV Methadone.
The catheters were eventually removed and he is now on an oral
regimen; but has minimum requirements of the pain medication.
He remained in the Trauma ICU for over a week and was eventually
weaned from sedation and the ventilator and was extubated
successfully. A bedside swallow was done for which he failed,
discussions regarding Dobbhoff and possibly g-tube took place.
He would later be transferred to the regular nursing unit where
he was noted to be delirious and with elevated LFT's; a repeat
head CT scan was done and did not show any intracranial
processes; he underwent a gallbladder scan which did not reveal
any obstructive process. Over the next 1-2 days his mental
status cleared significantly and he was able to swallow soft
solids and thin liquids with supervision. He was much more alert
and oriented and current with news events but only
intermittently became agitated requiring standing does of
Zyprexa with marked improvement in his mental status.
A 10 day course of Keflex was started per recommendation of
Orthopedics on [**5-30**] for a wound cellulitis which developed at
his pin sites where the external fixator is located.
He was evaluated by Physical and Occupational therapy and is
being recommended for acute care rehab. Social work was closely
involved with patient and family offering emotional support.
Medications on Admission:
Denies
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5,000 Units
Injection TID (3 times a day).
2. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as
needed for constipation.
3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. LeVETiracetam 1,000 mg 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).
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Polyethylene Glycol 3350 100 % Powder Sig: Seventeen (17)
Gram PO DAILY (Daily) as needed for constipation.
9. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
10. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every 4-6 hours
as needed for pain.
13. Keflex 500 mg Capsule Sig: One (1) Capsule PO every six (6)
hours for 10 days: 10 days total, starting on [**5-30**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
s/p Motor vehicle crash
C5 body fracture
Retrotracheal hematoma
Bilateral tibial plateau fractures
Right talonavicular dislocation
Left subgaleal hematoma
Delirium
Wound cellulits at pin sites
Secondary diagnosis:
Seizures
Discharge Condition:
Hemodynamically stable, tolerating a regular diet, pain
adequately controlled
Discharge Instructions:
You must continue to wear the cervical collar at all times for
at least the next 6-8 weeks.
Followup Instructions:
Follow up in 2 weeks with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP for Orthopedics.
Call [**Telephone/Fax (1) 1228**] for an appointment.
Follow up in 2 weeks with Neurology for your seizures. Call
[**Telephone/Fax (1) 44**] for an appointment. An EEG outpatient will need to
be done prior to this appointment so please inform the office so
that they can arrange for this.
Follow up in [**1-4**] weeks with Dr. [**Last Name (STitle) **], Trauma Surgery. Call
[**Telephone/Fax (1) 6429**] for an appointment.
Follow up in 6 weeks with Dr. [**First Name (STitle) **], Neurosurgery for your spine
fracture. Call [**Telephone/Fax (1) 6429**] for an appointment. Inform the
office that a repeat CT scan of your spine for this appointment.
Completed by:[**2129-5-31**]
|
[
"E879.8",
"E815.0",
"805.05",
"958.92",
"920",
"564.00",
"293.0",
"530.81",
"837.0",
"345.90",
"512.1",
"276.2",
"300.4",
"844.1",
"507.0",
"285.1",
"E878.8",
"823.00",
"998.59",
"836.0",
"682.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.47",
"38.7",
"86.59",
"84.72",
"38.93",
"81.46",
"79.36",
"81.91",
"83.09",
"79.87",
"96.72",
"79.06",
"78.17",
"78.67",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
8945, 9015
|
4867, 7737
|
338, 445
|
9283, 9362
|
1920, 4844
|
9502, 10299
|
815, 824
|
7794, 8922
|
9036, 9230
|
7763, 7771
|
9386, 9479
|
839, 1366
|
275, 300
|
473, 692
|
9251, 9262
|
1381, 1901
|
714, 770
|
786, 799
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,475
| 172,559
|
59606
|
Discharge summary
|
addendum
|
Name: [**Known lastname 18284**],[**Known firstname 394**] Unit No: [**Numeric Identifier 18285**]
Admission Date: [**2115-2-4**] Discharge Date: [**2115-2-26**]
Date of Birth: [**2035-12-23**] Sex: M
Service: SURGERY
Allergies:
Levaquin
Attending:[**First Name3 (LF) 4**]
Addendum:
The following d/c summary represents the final summary as
arranged by the attending of record this admission, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
.
Additional Discharge summmary information was input on [**2115-2-26**]
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 1239**] [**Last Name (NamePattern1) 18302**], NP East General Surgery service for Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **].
Chief Complaint:
Hypoxia, Tachycardia, Fever
Major Surgical or Invasive Procedure:
Colonoscopic dilation of stricture [**2115-2-7**]
Exploratory laparotomy on [**2115-2-21**]
History of Present Illness:
79-year-old metastatic prostate ca on Lupron and Casodex, with
retroperitoneal mass encasing duodenum, hx of diverticulitis
status post LAR with ileostomy takedown on [**2114-9-10**] for
diverticulitis presenting with fever, tachycardia, hypoxia after
endoscopic dilation. Hx of partial small bowel obstruction.
Inability to tolerate PO over two weeks, drinking only minimal
amounts of ensure with bilious non bloody feculent emesis
nightly. To oncologist Dr. [**Last Name (STitle) 6733**], elevated creatinine and
appeared volume depleted, admitted for hydration and evaluation
of possible small bowel obstruction.
.
[**2-4**] admission to 11R. Creatinine at 1.5 from 1.1. Pt made NPO,
held reglan, continue PPI IV. Contraction alkalosis with
hypochloremia treated with fluid repletion intravenously
.
Past Medical History:
-prostate cancer
status post radiation therapy, started on Lupron therapy
about one year ago with unfortunate continued rise in his PSA
which was most recently measured at 140. He is now on
hormonal therapy with both Lupron injections and Casodex. Large
RP mass encasing the right ureter, involving the right psoas,
pelvic side wall, inguinal region, extending to the mesenteric
root.
-diverticulosis with LAR [**5-18**] for colovesical fistula, ileostomy
takedown [**10-18**]. sigmoid colectomy, takedown of
a colovesical fistula with a diverting loop ileostomy which
was then taken down on [**2114-9-10**].
- Hx of meningitis
- osteoarthritis
- lower back pain
- GERD
Social History:
He lives with his wife. [**Name (NI) **] has two
daughters. [**Name (NI) **] used to own a few bars and he used to drink
between 0-5 drinks per day. Has not drank recently. He smoked
3-4 packs per day for 20 years but quit in [**2077**]. No IV or
inhaled drug use.
Family History:
Notable for no history of prostate cancer.
Brother expired from pancreatic cancer
Father expired from lung cancer
Physical Exam:
PHYSICAL EXAMINATION: On arrival to the medical [**Hospital1 **], he is
lying in bed. He appears mildly volume depleted with dry
mucous membranes but in no acute distress. His vital signs
are stable and he is afebrile. His heart exam is regular rate
and rhythm with normal S1 and S2, no murmurs, rubs or gallops
are appreciated. His lung fields are clear to auscultation.
On abdominal exam, there are 3 well healed surgical scars.
The abdomen is nondistended, nontender, bowel sounds are
absent. He reports that he is passing flatus, however, and
his abdomen is diffusely nontender, no hepatosplenomegaly is
appreciated. There is no edema noted in his extremities and
no rashes. He is fully alert and oriented. His wife reports
that he is weak on standing but that his gait and station are
intact. However, these were not examined at this time given
his volume depletion. His skin is dry, again no rashes were
appreciated. He is appropriate, interactive and pleasant. No
lymphadenopathy is appreciated. No genitourinary catheter is
present.
.
Exam on discharge to rehab:
Pertinent Results:
Admission labs:
LABORATORY DATA: From today in the clinic, his Chem-7 is as
follows: Sodium 139, potassium 3.3, chloride 90, bicarbonate
38, BUN 52, creatinine 1.5. This is up from the last measured
at 1.1. His magnesium is 2.1, phosphorus 3.9, estimated GFR
is 45. ALT and AST are within normal limits, as are alkaline
phosphatase and LDH. His PSA is again 140.2 on today's
measurement. He has a white blood cell count of 11.7 with
neutrophil predominance at 81.6% and 13% lymphocytes with no
atypical cells appreciated. His hemoglobin is 11.3,
hematocrit 36%. Platelets are 410. No radiographic images
have been obtained as of yet today.
Ct abdomen/pelvis w contrast [**2-5**]
Partial small-bowel obstruction, with transition point at the
site of
previous ileostomy takedown in the right lower quadrant.
Slight increased size of infiltrative retroperitoneal mass,
which encases the right ureter, and extends to involve the right
psoas muscle, right pelvic side wall and inguinal region, and
now extends to surround mesenteric vasculature. Unchanged right
hydronephrosis, secondary to obstruction by above described
mass.
.
Chest Portable AP [**2-7**]
New left perihilar and basilar consolidation consistent with
aspiration and/or evolving aspiration pneumonia.
Distended loops of bowel in upper abdomen. Peridiaphragmatic
lucency
likely represents distention of the stomach.
.
KUB [**2-7**]
Pending offical read, no clear evidence of perforation, air
fluid levels, distended loops of bowel.
.
[**2-7**] colonoscopy: Of note sedation with fentanyl and midazolam.
A 3-4mm stenosis of extrinsic appearance was noted at the ileum
at 30cm. The scope could not traverse the lesion. A 10mm balloon
was introduced for dilation and the diameter was progressively
increased to 12 mm successfully. Liquid stool began emptying
from above the stenosis after the dilation.
.
[**2115-2-4**] 01:05PM BLOOD WBC-11.7* RBC-4.12*# Hgb-11.3*#
Hct-36.0*# MCV-87 MCH-27.5 MCHC-31.5 RDW-12.6 Plt Ct-410#
[**2115-2-22**] 04:28AM BLOOD WBC-6.2 RBC-3.49* Hgb-10.0* Hct-32.4*
MCV-93 MCH-28.7 MCHC-30.9* RDW-15.2 Plt Ct-254
[**2115-2-4**] 01:05PM BLOOD Neuts-81.6* Lymphs-13.0* Monos-4.6
Eos-0.5 Baso-0.3
[**2115-2-22**] 04:28AM BLOOD Plt Ct-254
[**2115-2-22**] 04:28AM BLOOD PT-12.9 PTT-37.2* INR(PT)-1.1
[**2115-2-4**] 01:05PM BLOOD UreaN-52* Creat-1.5* Na-139 K-3.3 Cl-90*
HCO3-38* AnGap-14
[**2115-2-5**] 06:50AM BLOOD Glucose-75 UreaN-42* Creat-1.3* Na-137
K-2.8* Cl-94* HCO3-34* AnGap-12
[**2115-2-6**] 10:24AM BLOOD Glucose-97 UreaN-28* Creat-1.0 Na-140
K-2.8* Cl-99 HCO3-32 AnGap-12
[**2115-2-4**] 01:05PM BLOOD ALT-33 AST-39 LD(LDH)-199 AlkPhos-57
[**2115-2-21**] 07:56PM BLOOD ALT-113* AST-341* AlkPhos-176*
TotBili-2.2*
[**2115-2-22**] 04:28AM BLOOD ALT-107* AST-226* AlkPhos-244* Amylase-80
TotBili-1.5
[**2115-2-22**] 04:28AM BLOOD Lipase-22
[**2115-2-4**] 01:05PM BLOOD Phos-3.9 Mg-2.1
[**2115-2-5**] 06:50AM BLOOD Albumin-2.8* Calcium-7.6* Phos-2.6*
Mg-1.9 Iron-34*
[**2115-2-5**] 06:50AM BLOOD calTIBC-183* TRF-141*
[**2115-2-4**] 01:05PM BLOOD PSA-140.2*
Brief Hospital Course:
1. Vomiting. Bilious and feculent without any report of blood or
coffee grounds for approximately 2 weeks with associated weight
loss and dehydration, concerning for
partial small bowel obstruction and/or ileus. After CT abdomen
(showed transition point in ileum near site of former
anastamosis, AND, a large retroperitoneal mass encasing the 2nd
genu of the Duodenum), and consultation of GI and surgery, and
in discussion with Dr. [**Last Name (STitle) 6733**] of Oncology, decision was made to
attempt colonoscopic dilation of an ileal stricture. This was
done (see colonoscopy report above). After this the pt. vomited
feculent material and then aspirated to the LLL with resultant
high fever (105) and hypoxemia necessetating ICU observation
overnight. He was given antibiotics and rapidly improved, and
was transfered back to the medical [**Hospital1 **] the following day.
Again, multiple and lengthy discussions followed with surgery,
GI, Onc, and myself and pt. and wife. Ultimately, the decisions
were made as follows: GI felt that colonoscopy and stenting may
palliate his sbo, however, this would require likely surgery for
retrieval of stent and/or for further palliation of obstruction,
and would only be a temporizing measure. Surgery proposed
exploratory laparotomy, however, pt. will need to recover fully
from pneumonia before safely undergoing general anesthesia and
intubation. Ultimately, pt. decided he did not want to pursue
colonoscopy and stenting. PICC was placed for TPN, and f/u for
further discussion of options arranged with Dr. [**Last Name (STitle) 6733**] of Onc.
and Dr. [**Last Name (STitle) **] of Surgery.
.
CODE STATUS: Code status was discussed with he and his wife
today at the bedside. His wife is also his health care proxy
and they have stated their wishes for him to be do not
resuscitate, do not intubate.
.
Dr. [**Last Name (STitle) 18303**] discussed surgical options with patient and wife.
It was decided to explore abdomen for possible relief of
obstructive-like symptoms. The operative course was
uncomplicated, but large abdominal mass was noted
intra-abdominally resulting in cessation of further
intervention. Abdomen was closed with staples. He was routinely
monitored in the PACU, and transferred to 12 [**Hospital Ward Name 257**] under care
of General Surgery service for post-op care.
.
POST-Op course: He remains NPO with TPN for nutrition.
Electrolytes remain stable. No insulin added to TPN mixture.
Serum glucose well managed. No Regular insulin sliding scale
required during admission. Palliative care and Heme/Onco
continued to follow his hospital admission. His post-op recovery
has been uncomplicated. He denies nausea & vomiting. Tolerating
ice chips/swabs to mouth for comfort. His abdomen is soft,
appropriately TTP, ND. He has midline is OTA with staples,
healing. Staples will be removed at follow-up appointment with
Dr. [**Last Name (STitle) **] on [**2115-3-11**]. He was evaluated per Physical
Therapy, ambulated with walker, steady, but week. Screened for
[**Hospital 6777**] rehab for management of TPN, and increase in strength
prior to return home. He reported bilateral knee pain a few days
post-op. IV Dilaudid was started with relief, however, patient
became sleepy resulting in decreased activity. Palliative care
consulted, and changes made to pain regimen to manage post-op
pain, and arthritic pain. Reports surgical pain <[**4-20**]. His Foley
was removed on POD3. He has been urinating adequate amounts, but
has been dribbling urine. He has been wearing an undergarment.
No BM since surgery. Bowel sounds present, but hypoactive. He
will follow-up with Dr. [**Last Name (STitle) 6733**] (Heme/Onco) on [**2115-3-12**] to start
chemotherapy at that time. Once his is ready for discharge home,
VNA services with eventual bridge to hospice should be arranged.
Both patient and wife are aware of prognosis, and have discussed
outcomes with Dr. [**Last Name (STitle) 6733**].
Medications on Admission:
1. Casodex 50 mg daily.
2. Lactulose b.i.d. p.r.n.
3. Reglan 10 mg three times a day.
4. Lupron injections given by Dr. [**Last Name (STitle) 6733**].
Discharge Medications:
1. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
2. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1)
ML Intravenous DAILY (Daily) as needed.
3. Zofran 2 mg/mL Solution Sig: [**12-12**] Intravenous every 6-8 hours
as needed for nausea for 2 weeks.
4. Morphine Concentrate 5 mg/0.25 mL Solution Sig: [**12-12**] PO Q2 ()
as needed for pain.
5. Acetaminophen 650 mg Suppository Sig: One (1) Rectal Q4H
(every 4 hours) as needed for Pain, fever, HA.
6. Capsaicin 0.075 % Cream Sig: One (1) Appl Topical TID (3
times a day) as needed for arthritis pain.
7. Morphine 1 mg/mL Syringe Sig: [**12-12**] Injection Q2 () as needed
for pain.
8. TPN
Continue TPN order [**Name8 (MD) **] MD prescription.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 2314**]
Discharge Diagnosis:
Primary:
Small bowel obstruction
Metastatic prostate cancer
Anasarca
Malnutrition
Dehydration
Acute Renal Failure
Aspiration pneumonia
.
Secondary:
prostate CA s/p XRT and chemo - rising PSA (140), lg RP mass,
OA, LBP, diverticulosis w/ colovesical fistula s/p LAR [**5-18**], s/p
ileostomy takedown [**10-18**], open CCY
Discharge Condition:
Stable
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 vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
-Your staples will be removed at your follow-up appointment with
the surgeon, and steri strips will be applied.
-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.
Followup Instructions:
1. Please follow-up appointment with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 18304**] on [**2115-3-11**] at 1:15pm for removal of your staples.
2. You have follow-up appointment with Dr. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15020**], MD
Phone:[**Telephone/Fax (1) 1578**] Date/Time:[**2115-3-12**] 11:00, and chemotherapy at
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 12459**], RN Phone:[**Telephone/Fax (1) 1578**] Date/Time:[**2115-3-12**]
12:00
3. Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) 220**] [**Doctor Last Name 18305**] APG (SB)
Phone:[**Telephone/Fax (1) 18306**] Date/Time:[**2115-5-14**] 10:10
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16**] MD [**MD Number(1) 17**]
Completed by:[**2115-2-26**]
|
[
"560.89",
"276.3",
"507.0",
"585.9",
"427.32",
"V66.7",
"285.22",
"185",
"276.51",
"783.0",
"261",
"197.6",
"427.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.77",
"54.11",
"38.93",
"46.85",
"99.04",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
12055, 12135
|
7107, 11077
|
890, 984
|
12501, 12510
|
4034, 4034
|
14149, 14973
|
2810, 2926
|
11279, 12032
|
12156, 12480
|
11103, 11256
|
12534, 13676
|
13691, 14126
|
2941, 2941
|
2964, 4015
|
823, 852
|
1012, 1817
|
4051, 7084
|
1839, 2511
|
2527, 2794
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,755
| 142,134
|
13472
|
Discharge summary
|
report
|
Admission Date: [**2126-5-11**] Discharge Date: [**2126-5-24**]
Date of Birth: [**2074-11-14**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
sudden onset severe headache
Major Surgical or Invasive Procedure:
angiogram
History of Present Illness:
Pt is a 51 yo RH woman with HTN and Type I DM who presents after
sudden onset HA. She was in her USOH yesterday talking to a
friend when she had sudden onset of posterior HA bilaterally,
with spread down her neck as far as her upper scapulae. She had
associated diaphoresis and later developed N/V. She also
reports
~10 minutes of very muffled hearing, which resolved. She
denies other neurologic symptoms including dysarthria,
dysphagia,
weakness, numbness, tingling(other than baseline neuropathy),
visual changes, diplopia, ataxia, or vertigo. She did have some
lightheadedness with standing. She continued to have the HA and
came to the ED.
ROS: Patient denies any fever, chills, dysarthria, dysphagia,
weakness, numbness, tingling, dizziness, visual changes,
diplopia, chest pain, shortness of breath.
Past Medical History:
mild HTN
Type I DM since [**2090**] (uses insulin pump)
s/p Splenectomy [**2108**] secondary ITP
Trauma with T12 crush fracture managed conservatively; L pelvic,
R ulna, L tibia, R fibula.
s/p Cholecystectomy
ALL:PCN
Social History:
Married, no children; retired. No EtOH, tobacco, or drugs
Family History:
Father and mother both have HTN and hyperlipidemia
Father with prostate ca. Mother and sister have migraines, but
not patient.
Physical Exam:
T-97.1 BP-154-155/67-80 HR-94 RR-16-18 O2Sat 99% RA
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck;tender with movement and nuchal rigidity present
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender , no masses; insulin pump in situ
ext: no edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Speech is fluent
with normal comprehension. No dysarthria. No right left
confusion. No evidence of apraxia or neglect.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Visual fields are full to confrontation. Fundi NAD.
Extraocular movements intact bilaterally, no nystagmus.
Sensation
intact V1-V3. Facial movement symmetric. Hearing intact to
finger rub bilaterally. Palate elevation symmetrical.
Sternocleidomastoid and trapezius normal bilaterally. Tongue
midline, movements intact
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
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, vibration and proprioception
throughout. No extinction to DSS.
Reflexes:
+2 and symmetric throughout.
Toes downgoing bilaterally
Coordination: finger-nose-finger normal, heel to shin normal,
RAMs normal.
Gait: Deferred
Romberg: Deferred
Pertinent Results:
Admission labs:
CSF
Protein 372 Glucose 127
TUBE #4
CSF WBC 56 RBC [**Numeric Identifier 20939**]
Poly Pnd Lymph Pnd Mono Pnd EOs
TUBE #1
CSF WBC 70 RBC [**Numeric Identifier 40813**] Poly Pnd Lymph Pnd
Mono
Pnd EOs
137 101 16 243 AGap=16
4.7 25 1.0
99
8.9 14.5 430
42.5
N:55.8 L:34.2 M:7.2 E:2.4 Bas:0.4
PT: 11.0 PTT: 18.3 INR: 0.9
Brief Hospital Course:
Pt was admitted to neurosurgery service and had close neurologic
monitoring. She was followed by [**Last Name (un) **] service for her diabetes
(has insulin pump). She was found to have a UTI and treated with
antibiotics. She underwent LP, CTA (Normal CTA of the head with
no evidence of aneurysm or stenosis), and cerebral angiogram
(negative for aneurysm) all in workup for her subarachnoid
hemmorrhage. She had fevers and infectious disease consult was
obtained. Catheter tip culture showed coag. negative staph.
Blood cultures from [**5-19**] showed coag. negative staph also. She
still has pending cultures from [**5-23**] at time of discharge. The
patient will be sent home on linezolid. The patient's fever has
resolved.
She did have much nausea and vomiting and received medication
for that. At the time of discharge her nausea is much better and
she has no headache.
On [**5-23**] the patient had elevated blood pressure with SBP into
the 160s. She was given lisinopril and metoprolol and will
follow-up with her PCP for continued BP management.
Medications on Admission:
Insulin via pump
Lisinopril 5mg qhs incr to 10mg today
Clarynex 5mg qd
Low dose OCP for menopausal symptoms
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for fever, pain.
3. Lisinopril 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*60 Tablet(s)* Refills:*0*
4. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
5. Lorazepam 0.5 mg Tablet Sig: [**1-1**] tablet Tablet PO Q4-6H
(every 4 to 6 hours) as needed for nausea for 2 weeks.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Subarachnoid hemorrhage
Discharge Condition:
Neurologically stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR HEAD INJURY
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
?????? 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:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
IF YOU EXPERIENCE SIMILAR SYMPTOMS, YOU SHOULD GO TO A LOCAL
HOSPITAL AND HAVE A CT SCAN PERFORMED.
Followup Instructions:
You should follow up with your primary care doctor when you
return to [**State 2690**] to manage your blood pressure.
Completed by:[**2126-5-24**]
|
[
"790.7",
"401.9",
"430",
"599.0",
"V45.79",
"250.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.61",
"38.93",
"88.49",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
5440, 5446
|
3612, 4670
|
306, 317
|
5514, 5538
|
3187, 3187
|
6775, 6924
|
1495, 1623
|
4828, 5417
|
5467, 5493
|
4696, 4805
|
5562, 6752
|
1638, 1960
|
238, 268
|
345, 1161
|
2228, 3168
|
3203, 3589
|
1999, 2212
|
1984, 1984
|
1183, 1402
|
1418, 1479
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,073
| 113,302
|
53578
|
Discharge summary
|
report
|
Admission Date: [**2159-7-27**] Discharge Date: [**2159-8-17**]
Date of Birth: [**2119-9-15**] Sex: F
Service: SURGERY
Allergies:
Vasotec / Metformin / Lactose
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
39 yo female who was sent home on [**2159-7-25**] with TPN/picc now
presenting with temp up to 103.
Major Surgical or Invasive Procedure:
PICC placement
History of Present Illness:
The patient is a 39F well-known to the Bariatric Surgery
service, who is s/p laparoscopic Roux-en-Y gastric bypass c/b
intra-abdominal hemorrhage requiring exploratory laparotomy with
omentectomy; also c/b a fall, which possibly contributed to a
left brachial plexus injury. She was readmitted on [**5-20**] for
failure to thrive and wound infection, and then subsequently on
[**6-1**] for wound care and pain control; she was discharged on [**6-6**]
with wound VAC. On [**6-11**] she began to have nausea and vomiting
and
was subsequently admitted on [**6-14**]. She had an EGD on [**6-15**], which
revealed a benign 8mm stricture at the G-J anastomosis, which
was
dilated to 13.5mm. Her VAC dressings were changed to wet-to-dry;
she was discharged on [**6-20**]. The following say she was readmitted
for nausea/vomiting/dizzinness. On [**6-22**], she had an EGD which
again showed an 8mm benign stricture, which was dilated to
13.5mm. She progressed well and tolerated a stage 3 diet at the
time of her last discharge on [**7-12**]. She was instructed to drink
only Isopure until follow up. Discharged on [**7-26**], readmitted on
[**7-27**] with presumed line infection.
Despite having obstructive sleep apnea, and recommendations for
CPAP she refused.
Past Medical History:
Nonalcoholic steatohepatitis, Insulin dependent DM: Questionable
Type I or Type II, Diabetitic nephropathy, HTN, Sleep Apnea,
GERD, Psoriasis, Morbid obesity, h/o VRE urinary tract
infection, brachial plexus injury s/p fall [**5-10**]
Social History:
Patient lives at home with her parents, husband, and two
children (age 4 and 1). Patient is a house wife, and her
husband is a waitor at a chinese restaurant. Patient denies
tobacco, alcohol or drug use.
Family History:
Family history of diabetes: father, paternal grandmother and
grandfather. Maternal grandmother with [**Name2 (NI) 499**] cancer.
Physical Exam:
103.8 146 104/82 20 97% RA
Mild distress, feel hot
AAOx3
Tachy reg
CTAB
soft NT/ND, small central wound opening - no signs of cellulitis
around wound
no edema, extrem warm, no calf pain
mild erythema at PICC site
Pertinent Results:
[**2159-7-27**] 10:41PM TYPE-ART PO2-86 PCO2-36 PH-7.41 TOTAL CO2-24
BASE XS-0
[**2159-7-27**] 08:43PM LACTATE-1.9
[**2159-7-27**] 08:33PM GLUCOSE-272* UREA N-8 CREAT-0.5 SODIUM-142
POTASSIUM-3.8 CHLORIDE-112* TOTAL CO2-22 ANION GAP-12
[**2159-7-27**] 08:33PM CALCIUM-8.1* PHOSPHATE-2.8 MAGNESIUM-1.5*
[**2159-7-27**] 08:33PM WBC-12.8* RBC-3.68* HGB-10.7* HCT-32.3*
MCV-88 MCH-29.1 MCHC-33.1 RDW-14.5
[**2159-7-27**] 08:33PM NEUTS-88.5* LYMPHS-7.9* MONOS-3.0 EOS-0.5
BASOS-0
[**2159-7-27**] 08:33PM PLT COUNT-237
[**2159-7-27**] 05:22PM COMMENTS-GREEN TOP
[**2159-7-27**] 05:22PM LACTATE-1.3
[**2159-7-27**] 05:20PM CALCIUM-7.2* PHOSPHATE-2.6* MAGNESIUM-1.3*
[**2159-7-27**] 05:20PM CORTISOL-25.3*
[**2159-7-27**] 05:20PM CRP-28.2*
[**2159-7-27**] 02:35PM TYPE-[**Last Name (un) **] PO2-46* PCO2-36 PH-7.44 TOTAL CO2-25
BASE XS-0
[**2159-7-27**] 02:35PM GLUCOSE-267* LACTATE-1.9 NA+-136 K+-3.8
CL--99* TCO2-24
[**2159-7-27**] 02:35PM freeCa-1.09*
[**2159-7-27**] 02:30PM GLUCOSE-281* UREA N-15 CREAT-0.6 SODIUM-134
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-26 ANION GAP-12
[**2159-7-27**] 02:30PM ALT(SGPT)-26 AST(SGOT)-34 CK(CPK)-36 ALK
PHOS-69 TOT BILI-0.5
[**2159-7-27**] 02:30PM LIPASE-35
[**2159-7-27**] 02:30PM CK-MB-NotDone cTropnT-<0.01
[**2159-7-27**] 02:30PM ALBUMIN-3.9 CALCIUM-9.1 PHOSPHATE-1.6*#
MAGNESIUM-1.6
[**2159-7-27**] 02:30PM WBC-14.2*# RBC-4.26 HGB-12.2 HCT-36.4 MCV-86
MCH-28.7 MCHC-33.6 RDW-15.4
[**2159-7-27**] 02:30PM NEUTS-89.5* LYMPHS-5.4* MONOS-3.9 EOS-0.9
BASOS-0.2
[**2159-7-27**] 02:30PM PLT COUNT-278
[**2159-7-27**] 02:30PM PT-14.5* PTT-33.0 INR(PT)-1.3*
[**2159-7-27**] 02:30PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.025
[**2159-7-27**] 02:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-100 KETONE-TR BILIRUBIN-SM UROBILNGN-4* PH-5.0 LEUK-TR
[**2159-7-27**] 02:30PM URINE RBC-0-2 WBC-[**4-5**] BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2159-7-27**] 02:30PM URINE MUCOUS-MOD
Brief Hospital Course:
The patient is a 39F well-known to the Bariatric Surgery
service, who is s/p laparoscopic Roux-en-Y gastric bypass c/b
intra-abdominal hemorrhage requiring exploratory laparotomy with
omentectomy; also c/b a fall, which possibly contributed to a
left brachial plexus injury. She was readmitted on [**5-20**] for
failure to thrive and wound infection, and then subsequently on
[**6-1**] for wound care and pain control; she was discharged on [**6-6**]
with wound VAC. On [**6-11**] she began to have nausea and vomiting
and
was subsequently admitted on [**6-14**]. She had an EGD on [**6-15**], which
revealed a benign 8mm stricture at the G-J anastomosis, which
was
dilated to 13.5mm. Her VAC dressings were changed to wet-to-dry;
she was discharged on [**6-20**]. The following say she was readmitted
for nausea/vomiting/dizzinness. On [**6-22**], she had an EGD which
again showed an 8mm benign stricture, which was dilated to
13.5mm. She progressed well and tolerated a stage 3 diet at the
time of her last discharge on [**7-12**]. She was instructed to drink
only Isopure until follow up. Discharged on [**7-26**], readmitted on
[**7-27**] with presumed line infection.
Despite having obstructive sleep apnea, and recommendations for
CPAP she refused.
[**8-1**] Went for EMG, while she was gone the PICC nurse came by,
thus, TPN tonight will go through the central line and the PICC
will be placed tomorrow.
[**8-1**] [**Month/Day (4) 878**] consult: Please switch to long acting medication
such as MS Contin or Oxycontin. Give standing and not PRN meds.
We realize she came in intoxicated on narcotics, but this may be
in part due to increased absorption of the Fentanyl patch with
fever.
If OK from cardiac perspective, consider amitriptyline (25 mg
qHS, to go up to 50 qHS if tolerated. This may worsen her sleep
apnea, but so do all the sedating drugs.).
[**8-2**] D/c central line, PICC in SVC, no pneumothorax, had family
meeting where the patient and family agreed to go to a rehad
facility as long as it is clean and as long as the mother is
allowed to view it beforehand.
[**8-3**] Spoke to discharge planning, all the rehab offices are
closed for the weekend.
VASC C/S RECS [**8-4**]: d/c PICC, start lovenox (1mg/kg) [**Hospital1 **], bridge
to coumadin x3mo, re-U/S in 1 wk and again in 3 mo
[**8-6**] Has been having fevers into the 102 range for the past day
[**2159-8-8**]:
- We await the results of the B12, EBV, and CMV serologies
- Please minimize medications
- Please initiate neutropenic precautions including a
neutropenic diet if ANC < 500
- Do not start G-CSF or GM-CSF
- Please check CBC with differential daily
- Please check ANC daily
- Please check folic acid and B12 levels
- We strongly suggest finding an alternative to pip/tazo
CT neck: no sign of retropharyngeal or any other abscess
CT chest/abd/pelvis: minimal to no change from past CTs;
post-surgical changes in anatomy, no source of fevers or
infection found
[**8-9**] add cipro flagyl, has been without fever for 24 hours
TTE showed: Compared with the report of the prior study (images
unavailable for review) of [**2152-4-10**], the findings are similar.
No vegetations identified but the images are suboptimal.
Positive EBV.
RESPIRATORY CULTURE (Final [**2159-8-9**]):
sputum culture MODERATE GROWTH OROPHARYNGEAL FLORA.
YEAST. MODERATE GROWTH.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
urine negative
ID recs: - d/c vanc, cont fluconazole and zosyn, start
daptomycin, d/c all unnecessary meds, check monospot, CMV
IgG/IgM, check [**Last Name (LF) **], [**First Name3 (LF) **] diff, LDH, haptoglobin, and
fibrinogen, get neck/Abd CT
Abx (zosyn ([**8-7**]), fluconazole ([**8-7**]), dapto([**8-8**])) d/c'd [**2159-8-10**]
[**8-15**] No fevers for 2 days now, spoke to radiology about WBC
scan, they will rescan her tomorrow about questionable uptake in
the area of the symphysis pubis.
[**8-16**] US results: No evidence of right upper extremity deep
venous thrombosis. The previous thrombus has resolved.
[**8-17**] Pt is feeling well and has been afebrile for the last 72
hours
Medications on Admission:
Multivitamins
desonide
cozaar
fentanyl patch
regular insulin
lorazepam
Actos
oxycodone
simvastatin
ursodiol
Vit B12
omeprazole
Discharge Medications:
1. Oxycodone 5 mg/5 mL Solution [**Month/Year (2) **]: [**2-2**] PO every 4-6 hours as
needed for pain.
Disp:*500 mL* Refills:*0*
2. Multivitamins Oral
3. Thiamine HCl 100 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY
(Daily).
1. Lovenox 80 mg/0.8 mL Syringe [**Month/Day (2) **]: One (1) syrine Subcutaneous
twice a day: Please continue for 2 more weeks.
Disp:*28 syringes* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Fever of unknown origin and dehydration
Discharge Condition:
stable
Discharge Instructions:
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items [**11-15**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Followup Instructions:
[**Month (only) **] nutritionist [**2159-8-29**] at 2 pm [**Hospital Ward Name 23**] 3
Dr. [**Last Name (STitle) **] [**2159-8-29**] at 2:30 pm on [**Hospital Ward Name 23**] 3
Completed by:[**2159-8-17**]
|
[
"V13.02",
"723.4",
"E878.1",
"288.50",
"403.90",
"999.31",
"530.81",
"790.7",
"V45.86",
"V58.61",
"453.8",
"278.01",
"693.0",
"571.8",
"585.9",
"250.40",
"276.51",
"250.60",
"996.74",
"357.2",
"327.23",
"V45.79"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9266, 9317
|
4568, 8664
|
388, 404
|
9400, 9409
|
2568, 4545
|
10657, 10865
|
2187, 2319
|
8841, 9243
|
9338, 9379
|
8690, 8818
|
9433, 10634
|
2334, 2549
|
249, 350
|
432, 1689
|
1711, 1947
|
1963, 2171
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,061
| 178,594
|
55033
|
Discharge summary
|
report
|
Admission Date: [**2128-3-22**] Discharge Date: [**2128-3-27**]
Date of Birth: [**2064-9-7**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Coronary Artery Bypass x 1 (LIMA-LAD) [**2128-3-23**]
History of Present Illness:
63F with a history of CAD presented to [**Hospital6 3105**]
with chest pain and ruled in for NSTEMI. She had a myocardial
infarction with subsequent stent placement in [**2121-8-16**].
Cardiac cath revealed multi-vessel coronary artery disease and
she is referred for surgical evaluation.
Past Medical History:
Coronary Artery Disease
Myocardial Infarction s/p stent [**2120**]
Dyslipidemia
Social History:
Lives with: husband
Contact: Phone #
Occupation: physical therapist at [**Hospital1 1501**]
Cigarettes: Smoked no [x] yes [] last cigarette _____ Hx:
Other Tobacco use:
ETOH: < 1 drink/week [x] [**12-23**] drinks/week [] >8 drinks/week []
Illicit drug use, denies
Family History:
Premature coronary artery disease
Physical Exam:
Pulse: 52 Resp:18 O2 sat: 99%
B/P Right: 105/60 Left:
Height: 64" Weight:150lbs
Five Meter Walk Test #1_______ #2 _________ #3_________
General:
Skin: Dry [x] intact [x] left cheek 1cm scab with mild
surrounding erythema
HEENT: PERRLA [x] EOMI []
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[]
Extremities: Warm [], well-perfused [] 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:cath site
Carotid Bruit Right:none Left:None
Pertinent Results:
[**2128-3-23**] Intra-op Echo:
Conclusions
PRE-BYPASS: No spontaneous echo contrast is seen in the body of
the left atrium or left atrial appendage. A patent foramen ovale
is present. A left-to-right shunt across the interatrial septum
is seen at rest. A small secundum atrial septal defect is
present. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of
the results at time of surgery.
POST-BYPASS: The patient is A paced. The patient is on no
inotropes. Biventricular function is unchanged. Mitral
regurgitation is unchanged. Tricuspid regurgitation is
unchanged. The aorta is intact post-decannulation.
.
Brief Hospital Course:
The patient was brought to the Operating Room on [**2128-3-23**] where
the patient underwent CABG x 1 (LIMA-LAD) with Dr. [**Last Name (STitle) **].
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. Plavix was
resumed for her Diagonal stent. The patient was transferred to
the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued and patient had
complaint of right sided chest discomfort. A right pneumothorax
was noted on CXR and a right pigtail catheter was placed with
evacuation of air. CXr showed rigthlung re-inflation. Pigtail
was removed without complication. The patient was evaluated by
the physical therapy service for assistance with strength and
mobility. By the time of discharge on POD #4 the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged to home in
good condition with appropriate follow up instructions.
Medications on Admission:
Plavix 75mg daily
Aspirin 81mg daily
Crestor 40mg daily
Niacin 1000mg daily
Folic acid 1mg daily
fish oil 1000mg daily
Multivitamin
Calcium
Discharge Medications:
1. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
2. niacin 500 mg Capsule, Extended Release Sig: Two (2) Capsule,
Extended Release PO DAILY (Daily).
3. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain, fever.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
12. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
13. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours) for 7 days.
Disp:*28 Tablet Extended Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Coronary Artery Disease
Myocardial Infarction s/p stent [**2120**]
Dyslipidemia
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema: generalized edema.
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
WOUND CARE NURSE cardiac surgery Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2128-4-1**] 10:45 at [**Hospital **] medical office building [**Doctor First Name **]. [**Hospital Unit Name **]
SURGEON [**Name6 (MD) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2128-4-28**] 1:15 at [**Hospital **] medical office building [**Doctor First Name **]. [**Hospital Unit Name **]
Cardiologist Dr.[**Last Name (STitle) 4922**]- his office will call you with in
appointment to be seen in [**12-19**] weeks.
Please call to schedule the following:
Primary [**First Name (STitle) **] [**Telephone/Fax (1) 77368**] in [**2-19**] 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:[**2128-3-27**]
|
[
"E878.2",
"410.71",
"412",
"512.1",
"414.01",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
6012, 6095
|
3204, 4542
|
321, 377
|
6219, 6401
|
1944, 3181
|
7189, 8088
|
1121, 1157
|
4733, 5989
|
6116, 6198
|
4568, 4710
|
6425, 7166
|
1172, 1925
|
270, 283
|
405, 697
|
719, 801
|
817, 1105
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,467
| 190,628
|
47780
|
Discharge summary
|
report
|
Admission Date: [**2157-3-11**] Discharge Date: [**2157-3-16**]
Date of Birth: [**2079-8-7**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Paregoric / Opium
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
hypoxia, altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 77 yo male with hx of chronic diarrhea, repeated
hospital admissions for SOB and confusion, who is transferred
form nursing home for being hypoxic and "groggy". Unable to
obtain further outside history, patient him self does not
remember the events and why he is being admitted. He c/o of
ongoing diarrhea, otherwise ROS is negative.
.
In the emergency department, initial vitals: T 97.4 HR 93 BP
86/62 RR 19 O292% on 2 L. CTA torso was obtained, and negative
for acute pathology. He triggered for hypotension and hypoxia.
He was given empiric Vanc/Cefepime/Levo amd 2 L NS. and admitted
to medicine for further workup.
.
On the floor, his psychoactive medications were held but the
patient improved rapidly to his baseline and stated the his
confusion arose over the last 24hrs. AVSS throughout. Work up
for a cause was otherwise negative except for equivocal U/A. All
medications were restarted except for vicodin and klonopin. He
was started on tincture of opium for diarrhea.
.
On morning of transfer to ICU, he was found to be acutely
somnolent and unarousable. ABG 7.10/101/41. A code was called
and the patient was intubated. Access proved difficult. He
arrived to the MICU awake off sedation. Propofol transiently
lowered his BP. After obtaining consent from his son, a RIJ was
placed.
.
In the MICU, pt's many psychoactive meds were held. ABG improved
w/ ventillator, extubated w/o complications. Given a trial of
Narcan 0.4mg IV x1 w/ improvement of sleepiness
.
Currently, does not have any complaints. Continues to have
diarreha. Does not know why he came here in the first place.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
1. partial SBO s/p ERCP and CBD stent [**5-28**]
2. MRSA PNA
3. h/o L hip osteo
4. Diverticulitis
5. Chronic Diarrhea: His diarrhea started in [**5-/2144**] when he had
diverticulitis, a partial colectomy with diverted colostomy and
Hartmann's pouch. He had a stoma takedown in [**6-/2144**]
complicated by ischemia and necrosis of the descending colon,
and a cecal perforation, and then had repeat surgery with a
right colonic resection, ileal transverse colon anastomosis. He
subsequently had an enterocutaneous fistula. It was taken down
with a small bowel resection, ileostomy on [**2144-9-7**], and he
was finally reversed on [**2155-1-26**] with a midileum and
transverse anastomosis. He had several areas of small bowel
resected
6. OA
7. L THR [**2143**]
8. CAD s/p MI in 01 associated with surgical procedure
9. h/o ETOH and Opioid abuse
10. Multiple bowel surgeries including: Sigmoid Resection in 96,
c/b fistula
11. First Degree AVB
12. s/p open CCY and intra-op cholangiogram with removal of
Antibiotic spacer and girdle stone of Left Hip [**7-29**]
13. ERCP and stent removal [**10-28**]
14. Citrobacter Bacteremia
15. Cholangitis
16. Prostatitis
17. COPD
18. IBS
19. Pernicious Anemia
20. Chronic Pain Syndrome
21. Depression
22. Nephrolithiasis
23. Right hemidiaphragmatic dysfunction
24. BCC L shin excised [**5-2**]
25. C diff colitis
26. repeated UTI
27. FTT
28. Hypomagnesia
29. Anemia
30. chronic neuropathic pain
Social History:
Living at Roscommon on the Parkway. Son appointed temporary
guardian at previous hospitalization.
Family History:
parents both died of CAD - father at 74, mother at 71
Physical Exam:
On admission:
VITAL SIGNS: T 97.2 BP 112/73 HR 84 RR 14 O2 100%2L
GENERAL: well appearing in NAD, AOx3, jokes and appropriate
affect
HEENT: No conjunctival pallor. No scleral icterus. PERRLA/EOMI.
MMM. OP clear. Neck Supple, No LAD, No thyromegaly. poor
dentition
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP flat
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain
Pertinent Results:
UA: RBC-0-2 WBC-[**5-4**]* Bacteri-FEW Yeast-NONE Epi-0, Blood-MOD
Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG
Urobiln-NEG pH-5.0 Leuks-SM
blood cx: NGTD
urine cx: GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha streptococcus or
Lactobacillus sp.
CXR: Low volume lungs with atelectasis at the right lung base
and increased interstitial markings. The possibility of an
infiltrate at the right lung base cannot be entirely excluded.
Clinical correlation is recommended as well as a repeat PA and
right lateral chest radiograph for further assessment.
CTA torso: 1. No pulmonary embolism or acute aortic pathology.
2. Chronic right lower lobe hypoventilatory changes with
bronchial impaction. 3. Small calculi layering in the bladder.
4. Skin thickening over the right posterior iliac spine.
Recommend correlation with direct visual inspection for early
development of decubitus ulcer.
.
Labs
[**2157-3-11**] 02:00PM BLOOD WBC-6.4 RBC-4.55* Hgb-12.3* Hct-39.3*
MCV-86 MCH-27.0 MCHC-31.2 RDW-17.8* Plt Ct-157
[**2157-3-12**] 08:20AM BLOOD WBC-7.3 RBC-4.31* Hgb-11.4* Hct-36.4*
MCV-85 MCH-26.6* MCHC-31.5 RDW-17.3* Plt Ct-175
[**2157-3-13**] 01:10PM BLOOD WBC-7.3 RBC-4.49* Hgb-11.9* Hct-37.3*
MCV-83 MCH-26.5* MCHC-31.8 RDW-17.3* Plt Ct-175
[**2157-3-14**] 05:30AM BLOOD WBC-7.5 RBC-4.36* Hgb-12.0* Hct-38.0*
MCV-87 MCH-27.5 MCHC-31.6 RDW-17.8* Plt Ct-180
[**2157-3-14**] 10:11AM BLOOD WBC-6.8 RBC-4.59* Hgb-12.9* Hct-40.6
MCV-88 MCH-28.2 MCHC-31.9 RDW-17.8* Plt Ct-187
[**2157-3-15**] 04:28AM BLOOD WBC-5.2 RBC-3.82* Hgb-10.3* Hct-32.2*
MCV-84 MCH-26.9* MCHC-32.0 RDW-17.3* Plt Ct-157
[**2157-3-11**] 02:00PM BLOOD Glucose-89 UreaN-25* Creat-1.1 Na-140
K-4.1 Cl-108 HCO3-23 AnGap-13
[**2157-3-12**] 08:20AM BLOOD Glucose-108* UreaN-23* Creat-1.0 Na-142
K-4.2 Cl-108 HCO3-25 AnGap-13
[**2157-3-13**] 01:10PM BLOOD Glucose-89 UreaN-16 Creat-0.8 Na-139
K-5.1 Cl-103 HCO3-27 AnGap-14
[**2157-3-14**] 05:30AM BLOOD Glucose-106* UreaN-20 Creat-1.2 Na-136
K-4.6 Cl-101 HCO3-28 AnGap-12
[**2157-3-14**] 10:11AM BLOOD Glucose-108* UreaN-22* Creat-1.5* Na-137
K-6.2* Cl-102 HCO3-21* AnGap-20
[**2157-3-14**] 01:59PM BLOOD Glucose-88 UreaN-24* Creat-1.3* Na-140
K-5.4* Cl-105 HCO3-24 AnGap-16
[**2157-3-15**] 04:28AM BLOOD Glucose-80 UreaN-21* Creat-1.1 Na-141
K-4.7 Cl-107 HCO3-25 AnGap-14
[**2157-3-14**] 10:11AM BLOOD CK(CPK)-47
[**2157-3-15**] 04:28AM BLOOD CK(CPK)-467*
[**2157-3-11**] 02:00PM BLOOD proBNP-687
[**2157-3-14**] 10:11AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2157-3-15**] 04:28AM BLOOD CK-MB-12* MB Indx-2.6 cTropnT-0.03*
[**2157-3-11**] 02:00PM BLOOD Calcium-9.9 Phos-2.7 Mg-1.9
[**2157-3-12**] 08:20AM BLOOD Calcium-9.6 Phos-2.6* Mg-1.7
[**2157-3-14**] 10:11AM BLOOD Calcium-9.5 Phos-5.9*# Mg-2.2
[**2157-3-14**] 01:59PM BLOOD Mg-1.9
[**2157-3-15**] 04:28AM BLOOD Calcium-8.9 Phos-3.3# Mg-1.9
[**2157-3-14**] 08:59AM BLOOD Type-ART pO2-41* pCO2-101* pH-7.10*
calTCO2-33* Base XS--2
[**2157-3-14**] 09:14AM BLOOD Type-ART pO2-206* pCO2-110* pH-7.06*
calTCO2-33* Base XS--2
[**2157-3-14**] 10:59AM BLOOD Type-ART pO2-206* pCO2-57* pH-7.28*
calTCO2-28 Base XS-0
[**2157-3-14**] 12:20PM BLOOD Type-ART pO2-151* pCO2-49* pH-7.31*
calTCO2-26 Base XS--2
[**2157-3-14**] 06:05PM BLOOD Type-ART pO2-69* pCO2-54* pH-7.40
calTCO2-35* Base XS-6 Intubat-NOT INTUBA
Brief Hospital Course:
Mr. [**Known lastname **] is a 77 yo man with chronic diarrhea, on and
multiple sedating medications, presenting with MS change,
hypotension, and hypoxia.
.
# MS change / Hypercapnic respiratory failure: On admission, the
patient was confused, but he improved quickly after rehydartion
back to baseline. Per patient he had no other symptoms before
the day of admission but notes becoming progressively more
confused prior to coming to the hospital. His presentation is
more likely medication effect in the setting of dehydration. As
above, we did not feel that his positive urine culture
represented a true pathogen given lack of leukocytosis and
organism obtained. All meds with sedating side effects were
held and initially his mental status improved. However, he was
then started on opium tincture for diarrhea and was restarted on
several of his medications. Unfortunately, he then became more
somnolent again and developed hypercarbic respiratory failure
with an ABG 7.10/101/41, and required intubation and transfer to
the ICU. He was successfully extubated several hours later.
Several hours after extubation, he became somewhat somnolent
again and responded to narcan 0.4mg on the evening on [**2157-3-14**].
Since then he was awake, alert, oriented x [**11-26**] and converstant
although tangential. The day prior to discharge his mental
status was back at baseline AOx3, conversing well with good
memory. We recommend that he stop sedating and anticholenergic
medications: specifically, amytriptilline, lomotil, hyocyamine,
klonopin, vicoden, zolpidem and that gabapentin be changed from
TID to [**Hospital1 **]. Given that his pain regimen is being significantly
reduced, we recommend that he be seen in the pain clinic for
recommendations of how to improve his pain control.
.
# Positive Urine Culture: Patient has no urinary symptoms, and
his urine culture is growing a typically non-pathogenic bacteria
(alpha hemolytic strep). Furthermore, he is afebrile and without
leukocyosis. We elected to treat this urinalysis and urine
culture result as contamination and the patient was not treated
with antibiotics.
.
# Hypoxia: The patient has been stable on room air since the
morning of admission; unclear precipitant but resolved quickly
without intervention. CT with atelectasis but no consolidation
consistent with PNA. Aspiration pneumonitis possible given
altered mental status but no features suggestive of pneumonia.
Consider swallowing evaluation at living facility if coughing
noticed after eating. Respiratory cx did show moderate S.aureus
and pt does have a history of recent MRSA pneumonia and did have
recent instrumentation from intubation, but given the lack of
current symptoms, no leukocytosis or fevers, pt wasn not treated
with antiboitics.
.
# Hypotension: The patient's low blood pressure resolved with 2L
IVF given in the ED. He has remained afebrile, without
leukocysosis or other signs of infection, so sepsis thought
unlikely. Given patient's response to fluids was likely due to
dehydration in setting of his chronic diarrhea. Over the last
24h prior to discharge pt was normotensive and asymptomatic
.
# Chronic diarrhea: Has been extensively worked up in the past.
We added tincture of opium to his usual antidiarrheal regimen as
he explained this had worked for him in the past. However, as
noted above, he became unresponsive with the medication and he
should not receive it in the future. On review of his
medications, it appears as thought he is on many medications
that can cause diarrhea and is then also on medications to stop
diarrhea. In [**2155**], his gastroenterologist had also noted this
problem and made the following recommendations which we
reinstitued:
The following medications were stopped:
- Lomotil (Diphenoxylate-Atropine)
- Milk of Magnesia
- Dulcolax
- Fleet's enemas
The following medications were changed :
- start Metamucil daily as needed for constipation
- Dicyclomine (increased to 20mg TID)
- Omeprazole (increased to 20mg [**Hospital1 **])
- Magnesium oxide (decreased to 400mg [**Hospital1 **], should only be taken
if really necessary for low magnesium, and then should be to be
taken with meals and with calcium)
.
# CAD s/p MI: We continued ASA 81 mg daily. He is not on a beta
blocker, ACE or statin. Beta blocker not given in the past due
to bradycardia at baseline. No statin given in past due to
chronic malnutrition. ACEi held in past due to low BP. The
patient can follow up with his usual providers regarding
initiation of these medications.
.
# Chronic Neuropathic Pain: Continue gabapentin at a reduced
dose.
.
# Anemia: He has a history of anemia of chronic disease and B12
def (pernicious
anemia). Continue B12 injections Q monthly.
.
# FEN: We continued thiamine, folate, calcium and vitamin D,
multivitamin and magnesium.
.
# PPX: Lovenox (on as outpatient), PPI, fall precautions,
aspiration precautions.
.
CODE STATUS: FULL CODE
Medications on Admission:
1. Acetaminophen 325 mg PO Q6H as needed.
2. Amitriptyline 50 mg PO HS
3. Cholestyramine-Sucrose 4 gram PO TID
4. Dicyclomine 10 mg PO TID
5. Diphenoxylate-Atropine 2.5-0.025 mg 2tabs PO QID
6. Ergocalciferol (Vitamin D2) 50,000 unit Q WEEK
7. Folic Acid 1 mg PO DAILY (Daily).
8. Gabapentin 300 mg three times a day.
9. Hyoscyamine Sulfate 0.125 mg Sublingual HS
10. Loperamide 1 mg/5 mL (4) mg PO TIDAC 3 times a day before
meals
11. Loperamide 1 mg/5 mL Liquid Sig: Four (4) mg PO HS
12. Omeprazole 20 mg PO DAILY (Daily).
13. Multivitamin
14. Zinc Oxide-Cod Liver Oil 40 % Ointment
15. Aspirin 81 mg Tablet,
16. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule
Two (2) Cap PO TID W/MEALS
17. Zolpidem 5 mg PO HS (at bedtime) prn
18. Calcium Carbonate 500 mg PO QID
18. Magnesium Oxide 400 mg PO TID
20. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) Injection
Q MONTHLY ().
21. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily).
22. Naprosyn 375 [**Hospital1 **] prn
23. Klonipine 0.5 [**Hospital1 **]
24. Celexa 40 mg daily
25. Valproic acid 500mg qhs
26. Hydrocodone-APAP 5-500 Q6H
27. vit b1 50 mg daily
28. milk of magnesia 30 ml prn
29. dulcolax prn
30. fleet enemas prn
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours): Max: 4grams daily.
2. Cholestyramine-Sucrose 4 gram Packet Sig: One (1) Packet PO
three times a day.
3. Bentyl 20 mg Tablet Sig: One (1) Tablet PO three times a day.
4. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a week.
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
7. Loperamide 1 mg/5 mL Liquid Sig: One (1) mg PO QIDACHS (4
times a day (before meals and at bedtime)).
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: AS DIRECTED
Topical as needed.
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed
Release(E.C.) PO TID w/ meals.
13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
14. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO twice a
day: To be taken with Calcium Carbonate.
15. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) mL
Injection once a month.
16. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Syringe
Subcutaneous Q24H (every 24 hours).
17. Naprosyn 375 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for pain.
18. Celexa 40 mg Tablet Sig: One (1) Tablet PO once a day.
19. Valproic Acid 500 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO at bedtime.
20. Vitamin B-1 50 mg Tablet Sig: One (1) Tablet PO once a day.
21. Metamucil 1.7 g Wafer Sig: One (1) Wafer PO once a day as
needed for constipation.
Discharge Disposition:
Extended Care
Facility:
Roscommon
Discharge Diagnosis:
Primary Diagnosis:
Hypotension, resolved
Dehydration, resolved
Altered Mental Status, resolved
Chronic Diarrhea, stable
Secondary:
Chronic pain syndrome
history of COPD
history of coronary artery disease
Discharge Condition:
Patient alert, oriented x1-2, able to interact but poor
historian.
Discharge Instructions:
You came to the hospital with increased confusion. We found
your blood pressure was low. We treated you with IV fluids and
you improved.
Please stop taking clonazepam 0.5 mg twice per day as this can
make you more confused. Please only take 5 mg ambien before bed
for sleep as increased doses of this medication can make you
more confused.
We started tincture of opium as needed for your diarrhea. Please
monitor your symptoms on this new medication and adjust its use
accordingly.
Please contact your primary care physician or return to the
emergency room should you develop any of the following symptoms:
fever > 101, chills, increased confusion, nausea or vomiting
with inability to keep down liquids or medications, low blood
pressure, difficulty breathing, or any other concerns.
Followup Instructions:
Please call your PCP [**Last Name (NamePattern4) **] [**Telephone/Fax (1) **] and set up a follow up
appointment in the next 2 weeks.
.
Please call the [**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**] Center to make an appointment in teh
next 2-4 weeks. ([**Telephone/Fax (1) 100864**]
Completed by:[**2157-3-16**]
|
[
"292.81",
"496",
"518.81",
"787.91",
"338.29",
"564.1",
"412",
"V43.64",
"276.51",
"799.02",
"356.9",
"E935.2",
"281.0",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
15931, 15967
|
7869, 12791
|
321, 328
|
16216, 16285
|
4519, 7846
|
17123, 17465
|
3942, 3997
|
14057, 15908
|
15988, 15988
|
12817, 14034
|
16309, 17100
|
4012, 4012
|
1979, 2349
|
251, 283
|
356, 1960
|
16007, 16195
|
4026, 4500
|
2371, 3811
|
3827, 3926
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,872
| 161,650
|
28166
|
Discharge summary
|
report
|
Admission Date: [**2142-2-1**] Discharge Date: [**2142-2-10**]
Service: MEDICINE
Allergies:
Penicillins / Heparin Agents / Bee Pollens
Attending:[**First Name3 (LF) 3129**]
Chief Complaint:
Tachycardia, Diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a [**Age over 90 **] yo female with a past medical history notable for
dialysis-dependent ESRD, HIT, CAD, PVD who is currently POD 12
s/p left AKA for apparent vascular insufficieny who was
discharged home on [**2142-1-27**], but was readmitted on [**2142-1-31**]
with persistent diarrhea, sinus tachycardia, and hypotension.
.
According to [**Name (NI) 1094**] son she had been experiencing tachycardia and
diarrhea for a number of days prior to her last admission
([**Date range (1) 68456**] during which she had left AKA) and continued to have
these symptoms at home following discharge.
.
She was re-admitted on [**1-31**] with continued diarrhea,
tachycardia, and hypotension that was not immediately fluid
responsive. Denied fevers/chills/ns at home, no HA, chest pain,
abdominal pain, or new skin rashes.
Past Medical History:
1. PVD s/p right fem-DP bypass with in situ saphenous vein on
[**2141-9-26**], Left AKA [**2142-1-25**]
2. CAD, s/p MI last fall (NSTEMI related to HIT?)
3. ESRD, dialysis dependent since [**7-/2141**], h/o anemia, renal
osteodystrophy
4. GERD, on protonix
5. Hypothyroidism, on levothyroxine
Social History:
Lives at home, son is primary caretaker and is very involved in
day-to-day care
Family History:
9 brothers/sisters, no h/o renal disease. Denies
etoh/tobacco/drugs.
Physical Exam:
T: 98.2 HR:108(108-127) BP:120/65 (97-124/50-67) RR: 14 97% 2L
NC
Gen: NAD, resting in chair. Sleeping but arousable
HEENT: NCAT, OP clear, sclera non-icteric
Neck: Supple, no JVD appreciated, no LAD, no carotid murmurs
CV: Rapid rate, no murmurs appreciated
Pulm: Minimal rales appreciated throughout, no egophony
Abdominal: soft, non-tender, non-distended, no masses
appreciated
Extremities: Warm, 1+ pitting edema in the RLE, LLE surgical
wound is healing well with no erythema or drainage (staples in
place). Pulses in the RLE (DP/PT) were not palpable.
Neurologic examination: Pt arousable and following commands.
Oriented somewhat to time (thought it was [**2141**]), but couldn't
name this hospital, or identify who the examiner was. Motor and
sensation grossly intact.
Pertinent Results:
[**2142-2-8**] Albumin-2.0*
[**2142-2-1**] ALBUMIN-1.8*
[**2142-2-2**] WBC-19.4* Hgb-9.1* Hct-30.7*
[**2142-2-3**] WBC-12.7* Hgb-7.6* Hct-25.8*
[**2142-2-5**] WBC-9.1 Hgb-11.2*# Hct-37.3
[**2142-2-6**] WBC-11.9* Hgb-11.2* Hct-37.7
[**2142-2-7**] WBC-9.7 Hgb-10.0* Hct-33.2
[**2142-2-8**] WBC-10.4 Hgb-10.7* Hct-35.3
[**2142-2-1**] WBC-17.6* HGB-8.7* HCT-29.0*
[**2142-1-31**] WBC-22.8* HGB-9.8* HCT-32.6*
[**2142-1-31**] NEUTS-86* BANDS-0 LYMPHS-8* MONOS-4
[**2142-2-2**] STOOL OVA + PARASITES-FINAL; CLOSTRIDIUM DIFFICILE
TOXIN - neg
[**2142-2-2**] STOOL OVA + PARASITES-FINAL; CLOSTRIDIUM DIFFICILE
TOXIN - neg
[**2142-2-2**] BLOOD CULTURE Blood Culture, Routine- neg
[**2142-2-1**] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER
CULTURE-FINAL; OVA + PARASITES-FINAL; FECAL CULTURE - R/O E.COLI
0157:H7-FINAL; CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL INPATIENT
- neg
[**2142-2-1**] SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS-neg
[**2142-2-1**] MRSA SCREEN MRSA SCREEN-neg
[**2142-2-1**] URINE URINE CULTURE-neg
[**2142-1-31**] BLOOD CULTURE Blood Culture, Routine- neg
[**2142-1-31**] BLOOD CULTURE Blood Culture, Routine-neg
Radiology:
[**2142-2-7**] Cardiology ECHO - no change from previous
[**2142-2-1**] Radiology CTA CHEST/ABD/PELVIS - no pulmonary embolus
Brief Hospital Course:
Pt was admitted on [**1-31**] with diarrhea, sinus tachycardia, and
hypotension that was not immediately fluid responsive. She
required pressure support with neosynephrine and was admitted to
the ICU. She quickly weaned from pressors and was transferred to
the floor. Her persistent issues were diarrhea, sinus
tachycardia and malnutrition.
#) Tachycardia: Throughout the hospitalization Pt was
tachycardic (HR 100-120s). Pulmonary embolus was ruled out with
a CTA on [**2-1**]. Sepsis related tachycardia was ruled out with
persistently negative blood cultures and the absence of fever.
Acutely decreased cardiac function was ruled out by TTE on [**2-7**],
which was unchanged from previous. The diagnosis of sinus
tachycardia secondary to intravascular volume depletion was made
in light of the above negative studies and an albumin of 1.8 on
admission. Pt was discharged on metoprolol 50mg PO TID with
encouragment for increased PO nutritional intake.
.
#) Diarrhea: Diarrhea subsided on flagyl. C.diff was negative on
this admission as was O&P, stool cultures, and blood cultures.
Vanco/Cipro/flagyl were begun on [**1-31**], but Vanco/Cipro were
d/c'd on [**2-4**], Pt remained on Flagyl throughout hospitalization.
C.diff was thought to be the likely pathogen as pt had received
antibiotics on her previous admission and was symptomatically
improving as well as displaying a decreasing leukocytosis while
on flagyl.
.
#) Dysphagia/Cough: Throughout admission Pt was experiencing a
persistent dry cough (that son says is chronic). Pt maintained
O2 saturations in the mid-90's on 1-2L NC throughout admission.
At one point Pt was observed to aspirate and son mentioned that
she occasionally chokes/spits out food. Speech and swallow saw
Pt on [**2-7**] and, despite a limited exam, noted that she was
manifesting signs of dysphagia and they recommended a soft diet
with future barium swallow study if deemed appropriate. In the
setting of multiple medical problems and [**Name (NI) 1094**] ability to consume
soft/liquid diet without difficulty it was determined to defer
the barium study during this admission, with recommendation of
continued soft diet at home following discharge. Pt was also
noted to have bilateral pleural effusions thought to be
secondary to low albumin. She was continued on ipratropium
nebulizers on discharge.
.
#) ESRD: Stable throughout admission. Pt received dialysis while
in house. Will commence MWF home dialysis on discharge.
.
#) LLE Ulcers/Cellulitis: Pt s/p Left AKA with no surgical site
induration or drainage of purulent fluid. Wound was healing well
and vascular surgery recommended to have staples removed on
[**2142-2-12**] or [**2142-2-13**].
.
#) Malnutrition: Pt was noted to have an albumin of 1.8 on [**2-1**]
and an albumin of 2.0 on [**2-8**]. This is likely secondary to poor
PO intake, but by the time of discharge Pt was tolerating a soft
diet with supplemental ensure.
.
#) Hypothyroid: Pt continued to take levothyroxine, but was
noted to have an elevated TSH 13. This was presumably secondary
to missing a few doses secondary to dysphagia. Levothyroxine was
continued on discharge.
.
#) GERD: Stable, maintained on PPI.
Medications on Admission:
1. Aspirin 81 mg Tablet Daily
2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release PO Q24H
4. Calcitriol 0.5 mcg PO Daily
5. Simvastatin 20 mg PO Daily
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Metoprolol Tartrate 25 mg PO TID
10. Coumadin 1.5mg PO M/W/F
11. Colace 100mg PO BID
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): Please take 1 pill two times per day for a total
of 4 days following discharge.
Disp:*8 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): Take 1 tablet three times/day. Hold if systolic
blood pressure is <90 or if heart rate is <55.
Disp:*90 Tablet(s)* Refills:*0*
10. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO at bedtime:
Please have your INR checked by VNA the day after discharge to
determine if your dose needs to be adjusted.
Disp:*60 Tablet(s)* Refills:*2*
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
Disp:*120 nebulizer* Refills:*0*
12. Outpatient Lab Work
Please check INR daily for next week to determine appropriate
coumadin dose.
13. O2 2L NC
Titrate to maintain O2 sat >90%
Discharge Disposition:
Home With Service
Facility:
vna shouth shore
Discharge Diagnosis:
Primary
- Volume depletion sinus tachycardia
- Malnutrition
- Dysphagia
- Diarrhea, likely infectious colitis
Secondary
- endstage renal disease on hemodialysis
- history of heparin induced thrombocytopenia
- peripheral vascular disease
- coronary artery disease
Discharge Condition:
Stable, in sinus tachycardia, diarrhea resolved.
Discharge Instructions:
You were admitted with the symptoms of persistent tachycardia
and persistent diarrhea following a recent hospitalization for a
left above the knee amputation. Your tachycardia is likely due
to volume depletion in the setting of poor nutritional status
and your diarrhea possibly due to a C. diff infection.
Please continue to increase your nutritional intake as much as
possible and avoid dry, tough foods (particularly meats,
breads/sandwiches, etc.). Please continue to take your
medications as instructed.
If you notice any lightheadedness, loss of consciousness,
confusion, chest pain, shortness of breath, abdominal pain, or
relapse of diarrhea please contact your PCP or return to the
hospital for evaluation.
Followup Instructions:
- Vascular Surgery for staple removal on [**2-12**] or [**2-13**] (call
[**Telephone/Fax (1) 1237**] to make an appointment)
- Nephrology/Dr. [**Last Name (STitle) 118**] (please call [**Telephone/Fax (1) 60**] to discuss
appropriate follow up)
- Primary care provider/[**Last Name (LF) **],[**First Name3 (LF) **] C.
Completed by:[**2142-2-10**]
|
[
"008.45",
"443.9",
"530.81",
"412",
"V49.76",
"263.9",
"276.50",
"403.91",
"585.6",
"511.9",
"427.89",
"293.0",
"244.9",
"787.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
8930, 8977
|
3765, 6949
|
271, 278
|
9284, 9335
|
2440, 3742
|
10101, 10450
|
1555, 1625
|
7440, 8907
|
8998, 9263
|
6975, 7417
|
9359, 10078
|
1640, 2200
|
210, 233
|
306, 1125
|
2224, 2421
|
1147, 1442
|
1458, 1539
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,769
| 132,312
|
46427+46428
|
Discharge summary
|
report+report
|
Admission Date: [**2196-8-12**] Discharge Date: [**2196-8-17**]
Service:
NOTE: Dictation ended after 0.5 minutes.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Name8 (MD) 3219**]
MEDQUIST36
D: [**2196-8-18**] 17:22
T: [**2196-8-26**] 13:48
JOB#: [**Job Number 34771**]
Admission Date: [**2196-8-12**] Discharge Date: [**2196-8-17**]
Service: [**Company 191**]
HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old
female with a complex medical history of coronary artery
disease, chronic obstructive pulmonary disease, hypertension,
congestive heart failure, and paroxysmal atrial fibrillation
who presented to her primary care physician three days prior
to admission to the admission to the floor with a headache,
facial pain, and fevers.
She was treated with azithromycin for sinusitis, but her
symptoms worsened, and she went to the Emergency Department
on [**8-11**] with fevers, headache, nausea, and dry heaves. A
CT and lumbar puncture were negative, and the patient was
sent home with a diagnosis of sinusitis.
She returned to the Emergency Department on [**8-12**] with
shortness of breath and chest tightness. While there, she
became very short of breath; had an arterial blood gas of
[**2165-8-3**]/153. She was placed on BiPAP with improvement and
also improved with nitroglycerin paste, morphine, and Lasix.
Electrocardiogram showed pseudonormalization of T waves. A
chest x-ray showed new left lower lobe consolidation. She
was stabilized in the Medical Intensive Care Unit and
transferred the next day to the floor, saturating well, and
complaining of only mild shortness of breath.
PAST MEDICAL HISTORY: (Past medical history is significant
for)
1. Coronary artery disease; status post 3-vessel coronary
artery bypass graft in [**2193**].
2. Persantine MIBI in [**2196-1-19**] was negative.
3. She has chronic obstructive pulmonary disease with an
FEV1 of 0.76.
4. She has hyperlipidemia.
5. Hypertension.
6. Hypothyroidism.
7. Status post surgery for Grave's disease.
8. Congestive heart failure with diastolic function.
9. Paroxysmal atrial fibrillation after coronary artery
bypass graft.
10. She had a cholecystectomy.
11. Right hip open reduction/internal fixation.
12. Hysterectomy.
13. Diverticulosis.
14. Bilateral carotid endarterectomy.
MEDICATIONS ON ADMISSION: Medications on admission included
Accupril 40 mg p.o. q.d., Levoxyl 100 mcg p.o. q.d.,
Lipitor 10 mg p.o. q.d., aspirin 81 mg p.o. q.d., Tums 500 mg
p.o. q.d., Lopressor 50 mg p.o. b.i.d., amiodarone 200 mg
p.o. q.d., Lasix 40 mg p.o. q.d., Procardia, Flovent,
Combivent, vitamin D 400 mg p.o. q.d., Ambien.
ALLERGIES: Allergy to IODINE and INTRAVENOUS CONTRAST.
PHYSICAL EXAMINATION ON PRESENTATION: Blood pressure
was 160/70, pulse was 60, oxygen saturation of 99% on 2
liters nasal cannula. In general, she was sitting in bed in
moderate discomfort. Head, eyes, ears, nose, and throat
revealed anicteric. Extraocular movements were intact.
Mucous membranes were moist. The oropharynx was clear.
Cardiovascular revealed a regular rate and rhythm. Pulmonary
revealed she had decreased breath sounds at the left base and
mild crackles. No wheezes or rhonchi. The abdomen revealed
normal active bowel sounds, nontender, and nondistended.
Extremities revealed no edema.
PERTINENT LABORATORY DATA ON PRESENTATION: Pertinent
laboratory values revealed a white blood cell count of 14.7,
hematocrit was 26.2. Her creatine kinase was 46. Iron
was 13, total iron-binding capacity was 186, TRF was 143.
Her urinalysis was negative.
RADIOLOGY/IMAGING: Her chest x-ray was notable for left
lower lobe consolidation and collapse, persistent mild
congestive heart failure.
HOSPITAL COURSE: She was placed on prednisone 60 mg and
was also started on Levaquin 500 mg for pneumonia or a
possible sinusitis. She continued to improve. Her
prednisone was tapered.
CONDITION AT DISCHARGE: She was discharged in good
condition.
DISCHARGE STATUS: Discharged to [**Hospital3 **]
Center.
DISCHARGE INSTRUCTIONS: She was to continue her prednisone
taper and complete 10 days of Levaquin.
DISCHARGE DIAGNOSES:
1. Chronic obstructive pulmonary disease exacerbation.
2. Sinusitis.
3. Pneumonia.
MEDICATIONS ON DISCHARGE:
1. Prednisone 40 mg p.o. q.d. (with a taper to continue
for 12 more days).
2. Levaquin 500 mg p.o. (for four more days).
3. Accupril 40 mg p.o. q.d.
4. Levoxyl 100 mcg p.o. q.d.
5. Lipitor 10 mg p.o. q.d.
6. Aspirin 81 mg p.o. q.d.
7. Tums 500 mg p.o. q.d.
8. Lopressor 50 mg p.o. b.i.d.
9. Amiodarone 200 mg p.o. q.d.
10. Lasix 40 mg p.o. q.d.
11. Procardia.
12. Flovent.
13. Combivent.
14. Vitamin D 400 mg p.o. q.d.
15. Senokot and Colace as needed for constipation.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Name8 (MD) 3219**]
MEDQUIST36
D: [**2196-8-18**] 17:38
T: [**2196-8-26**] 13:49
JOB#: [**Job Number **]
|
[
"428.0",
"461.9",
"V45.81",
"491.21",
"427.31",
"272.0",
"244.9",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4243, 4330
|
4357, 5078
|
2427, 3807
|
3827, 4008
|
4146, 4222
|
4023, 4121
|
489, 1710
|
1733, 2400
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,598
| 136,739
|
18278
|
Discharge summary
|
report
|
Admission Date: [**2175-12-22**] Discharge Date: [**2176-1-24**]
Date of Birth: [**2117-10-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine / Zestril
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Admitted from home unresponsive and hypotensive s/p
R-VATS/decort [**11-16**] complicated by MRSA empyema.
Major Surgical or Invasive Procedure:
[**2175-12-23**] Open thoracostomy and drainage of empyema cavity,
creation of thoracic window, left chest tube placement, right
chest tube placement, flexible bronchoscopy.
Trach placed [**2176-1-4**]
History of Present Illness:
Mr. [**Known lastname 1617**] is a 58-year-old
gentleman who had a VATS total decortication
of the right lung for chronic and recurrent pleural
effusions, which led to bilateral fibrothoraces. He
suffered a postoperative empyema in the basilar space where
his lung did not fully expand. This was managed by chest tube
drainage and intrapleural and intravenous antibiotics. He was
recommended to undergo a window thoracoplasty for full
debridement of this
empyema cavity and access for wet-to-dry dressing changes,
however, the patient did not want to have this done several
days prior to this acute admission. He presented tonight to an
outside institution with
sepsis. He is now taken to the operating room urgently for
full drainage of the infected space.
Past Medical History:
Non-Hodgkin's lymphoma
Congential lymphatic atresia
Seminoma s/p radiation and resection
Appendectomy, perforated
Cholecystectomy
SBO ([**2174-12-14**]) s/p resection
right VATS decortication [**2175-11-17**]
right thoracic window and full surgical debridement [**2175-12-23**]
Trach [**2176-1-4**]
Social History:
Supportive wife, otherwise denies [**Name (NI) **]/EtOH/IDU.
Family History:
Father - PVD
Mother - questionable metastatic ovarian cancer
Physical Exam:
General: intubated and sedated. Opens eyes to name.
HEENT: intubated, sedated. remainder of exam unremarkable.
Neck: no masses, supple.
CV: RRR S1, S2, no murmurs, rub, regurg
Resp; decreased breath sounds at right base, otherwise clear.
Right chest tube in place draining clear yellow fluid.
Abd; soft, distended (baseline), NT, +BS.
Extrem: +[**1-1**] pedal edema bilat. Has chronic LE edema.
Neuro: sedated.
Brief Hospital Course:
In brief, patient is a 50-year-old man with a history of large
cell lymphoma, for which he underwent R-CHOP chemotherapy most
recently in [**2175-6-30**]. He has had known bilateral effusions by
his report dating back to [**2158**]. Patient was previously admitted
for a VATS/decortication [**2175-11-17**]. On POD# 13 his chest tube was
noted to be draining pus and his empyema was treated initially
with vanc and zosyn and then later IV and intra-pleural
vancomycin. The pus cultured out MRSA and he was discharged on
[**2175-12-10**] with plans for a 2 wk course of vanco.
[**2175-12-22**] Pt was re-admitted from OSH intubated after developing
hypoxemic respiratory failure. Pt was taken directly to the OR
for open thoracostomy and drainage of empyema cavity, creation
of thoracic window, left chest tube placement, right chest tube
placement, flexible bronchoscopy on [**2175-12-23**] (see operative log
for details).
Events:
Immediately post op: Started on vanco, zosyn, fluc, levo. Right
chest open w/ [**Hospital1 **] dressing changes by thoracic surgery. Remained
sedated requiring pressure control ventilation. Attempts to wean
to PSV unsuccessful-returned to PC and did not tolerate volume
control.
POD#[**3-2**] Tube feeds started. Remains on PC ventilation, / fio2
40% -sats 100%. Lasix gtt started. Wound clean and granulating.
Lasix gtt was started.
[**2176-12-22**] Taken to the operating room for open thoracostomy and
drainage of empyema cavity, creation of thoracic window, left
chest tube placement, right
chest tube placement, and flexible bronchoscopy.
[**2176-12-29**] - Diagnostic therapeutic flexible bronchoscopy was
performed and bronchioalveolar lavage of the lingula was sent.
[**2176-1-1**] -Continued on vanc/zosyn for MRSA + enterococcal empyema
annd pseudomonas empyema.
[**2176-1-4**] Percutaneous tracheostomy.
[**2176-1-14**] Developing consolidation in the right perihilar region
concerning for pneumonia.
[**2176-1-16**] Bronchoscopy with therapeutic aspiration and BAL. Fever,
infiltrate on CXR.
[**2176-1-22**] ventilation with high airway pressures but poor
oxygenation and CO2 retention. Acidotic, given bicarb.
Hemodialyzed [**2176-1-22**], hypotensive and on pressors.
[**2176-1-23**] p.m. code blue - asystolic / PEA, chest compressions +
epi/bicarb
[**2176-1-24**] Multisystem organ failure, ventilator withdrawn per
family request at 12:23am.
Medications on Admission:
claritin 10', lopressor 12.5'', prilosec 40', calcium,
multivitamins, colace, senna, ditropan 5', asa 81', acidophilus,
levothyroxin 25'
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
s/p R VATS / decortication
s/p thoracic window
large cell lymphoma
+MRSA empyema
ATN renal failure
pseudomonas PNA
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
n/a
Completed by:[**2176-1-24**]
|
[
"584.5",
"518.84",
"482.1",
"428.0",
"V09.91",
"510.9",
"427.5",
"202.80",
"038.11",
"995.92",
"511.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.60",
"96.72",
"38.93",
"39.95",
"00.14",
"99.04",
"34.59",
"38.91",
"31.1",
"99.15",
"33.22",
"96.6",
"33.24",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
4934, 4943
|
2314, 4719
|
393, 597
|
5102, 5112
|
5169, 5203
|
1802, 1864
|
4906, 4911
|
4964, 5081
|
4745, 4883
|
5136, 5146
|
1879, 2291
|
247, 355
|
625, 1385
|
1407, 1707
|
1723, 1786
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,639
| 142,378
|
42452
|
Discharge summary
|
report
|
Admission Date: [**2140-12-31**] Discharge Date: [**2141-1-6**]
Date of Birth: [**2077-10-14**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Trauma: MVC:
Injuries:
L. 2-6th rib fx
L. sacral alar fx,
L ant column acetabular fx,
R sub pubic fx
L 5th metacarpal fx
R pilon fx
Major Surgical or Invasive Procedure:
[**2141-1-4**] ORIF Left 5th MC fx (PRS)
[**2141-1-1**] I+D, Ex fix/ORIF of R pilon fx
History of Present Illness:
HISTORY OF PRESENTING ILLNESS
This patient is a 63 year old male who complains of leg
pain.
This patient was the unrestrained driver of a car that was
involved in a head-on collision at a high rate of speed. He
went to an outside hospital where he was diagnosed with
several left-sided rib fractures, a pelvic fracture, and an
open tib-fib fracture on the right.
Apart from pulmonary fibrosis, he is relatively healthy. At
the outside hospital, the patient received 2 g of Ancef as
well as a tetanus shot.
Timing: Sudden Onset
Quality: Sharp
Severity: Severe
Duration: Several hours,
Location: Right ankle
Context/Circumstances: See above
Past Medical History:
Past Medical History: Pulmonary fibrosis
Social History:
Social History: No smoking or drugs
Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION: [**2140-12-31**]
HR: 123 BP: 117/78 Resp: 22 O(2)Sat: 99% Normal
Constitutional: The patient is boarded and collared.
HEENT: Extraocular muscles intact with pupils 3-2 mm; there
is a scalp hematoma
C-spine is nontender
Chest: He has severe left-sided chest wall tenderness
Cardiovascular: Normal first and second heart sounds
Abdominal: Nontender
Extr/Back: The patient has some mild T-spine tenderness
without step-off.
Upper extremities show no long bone findings.
There is a left thigh abrasion.
There is a splint on the right lower extremity. Distal
neurovascular is normal in both legs.
Neuro: Speech fluent and he moves all 4 extremities. Rectal
sphincter tone normal.
Psych: Normal mood
Pertinent Results:
[**2141-1-4**] 05:17AM BLOOD WBC-7.0 RBC-2.98* Hgb-9.2* Hct-26.9*
MCV-90 MCH-30.9 MCHC-34.2 RDW-13.4 Plt Ct-215
[**2141-1-3**] 04:55AM BLOOD WBC-7.9 RBC-2.80* Hgb-8.6* Hct-25.8*
MCV-92 MCH-30.5 MCHC-33.1 RDW-13.6 Plt Ct-166
[**2141-1-4**] 05:17AM BLOOD Plt Ct-215
[**2140-12-31**] 05:30PM BLOOD Fibrino-382
[**2141-1-4**] 05:17AM BLOOD Glucose-93 UreaN-14 Creat-1.0 Na-137
K-3.7 Cl-103 HCO3-28 AnGap-10
[**2141-1-3**] 04:55AM BLOOD Glucose-95 UreaN-12 Creat-1.1 Na-139
K-4.8 Cl-107 HCO3-28 AnGap-9
[**2141-1-4**] 05:17AM BLOOD Calcium-8.7 Phos-4.2# Mg-1.7
[**2140-12-31**] 05:42PM BLOOD Glucose-139* Lactate-3.5* Na-138 K-3.6
Cl-102
[**2140-12-31**] 05:42PM BLOOD freeCa-1.14
[**2140-12-31**]: chest x-ray:
FINDINGS: The lung volumes are low. Borderline width of the
mediastinum
without evidence of pathologic mediastinal contours. No
pneumothorax, no
pleural effusions. Borderline size of the cardiac silhouette.
Minimal
crowding of the parenchymal vessels without safe evidence of
parenchymal
opacities or overt pulmonary edema.
[**2140-12-31**]: hand x-ray:
IMPRESSION: Acute fracture, comminuted involving the
mid-to-distal shaft of the fifth metacarpal.
[**2140-12-31**]: Ct right lower ext:
ReportIMPRESSION:
Preliminary Report1. Comminuted intra-articular fracture of the
distal tibia, with tibiotalar
Preliminary Reportsubluxation and widening of the medial mortise
joint as described.
Preliminary Report2. Comminuted fracture of the distal fibular
diaphysis, with disruption of
Preliminary Reportthe distal tibiofibular joint.
Preliminary ReportAir within the joint, consistent with an open
fracture.
Preliminary ReportUndisplaced fractures involving the medial
cuneiform and base of the second
Preliminary Reportmetatarsal and additional tiny fracture
fragment adjacent to the navicular
Preliminary Reportbone.
Preliminary ReportThere appears to be proximal distraction of
the navicular ossicle with respect
Preliminary Reportto the medial navicular bone (3:173), which
raises suspicion for avulsion of
Preliminary Reportthe posterior tibial tendon.
[**2140-12-31**]: cat scan of abdomen and pelvis:
Multiple pelvic fractures, involving bilateral superior and
inferior pubic rami, extension to the left anterior acetabular
lip, and left sacral alar fracture. Associated small pelvic
hematoma.
2. Multiple left posterior rib fractures, specifically involving
left 3-6th ribs with associated small left hemothorax.
3. Interstitial pulmonary fibrosis.
[**2141-1-1**]: right lower ext. fluro:
FINDINGS: Surgical repair via ORIF of the right ankle is
documented in a
total number of twelve fluoroscopic images. No radiologist was
present at the intervention
[**2141-1-2**]: Bil. lower ext. veins:
IMPRESSION:
1. No DVT in the left lower extremity.
2. Limited examination of the right lower extremity demonstrates
no DVT up to the level of the left distal SFV, beyond which
assessment could not be performed
[**2141-1-3**]: chest x-ray:
IMPRESSION:
1. Bibasal predominant pulmonary fibrosis, better evaluated on
recent torso CT dated [**2140-12-31**].
2. Small presumed bilateral pleural effusions.
Brief Hospital Course:
63 year old gentleman unrestrained driver involved in a MVC. He
was transferred from an OSH. Trauma activation initiated. ACS
evaluation performed and consultation to orthopedics placed in
ED. Imaging obtained and patient admitted to TSICU for further
management given mechanism of injury, extensive orthopedic
injury and need for close pulmonary monitoring.
.
INJURIES:
L. 2-6th rib fx
L. sacral alar fx,
L ant column acetabular fx,
R sub pubic fx
L 5th metacarpal fx
R pilon fx
.
Neuro: Patient mentated well on admission with no signs of TBI.
Dilaudid PCA analgesia was initiated with good effect and
adequate pain control. His pain medication was converted to oral
analgesia once he started liquids.
.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
.
Pulmonary: Patient w multiple L rib fx's. Of note, patient seen
to have significant interstitial lung dz on trauma CT chest.
This likely represents a new diagnosis. Pain control adequate
with respiratory function adequate on admission to TSICU.
Pulmonary toilet including incentive spirometry and early
ambulation were encouraged. The patient was stable from a
pulmonary standpoint
.
GI/GU: On admission, the patient was given IV fluids and
maintained NPO in anticipation of OR with orthopedics.
.
ID: On admission, patient was started on IV cefazolin for open
RLE fracture. MSK: Patient w orthopedic injuries as listed
above. Taken to OR by orthopedics [**1-1**] for I+D, Ex fix/ORIF of
R pilon fx. Operative course was stable.
.
Orthopedic surgery completed ORIF of the right distsal tibia on
[**2141-1-1**]. He recovered well post-operatively, worked with
physical therapy, and will follow up with orthopedic surgery as
an outpatient.
.
Plastic surgery was consulted for his hand fracture as listed
above. He was taken to the operating room on [**1-4**] where he
underwent an open reduction and internal fixation of left fifth
metacarpal. His operative course was stable. He will follow up
with plastic surgery as an outpatient.
.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
.
He was transferred to the surgical floor on [**1-1**]. His
post-operative course has been stable. He has had difficulty
voiding after his [**Known lastname **] cathether was removed and was started on
flomax. He will be discharged with his [**Known lastname **] catheter in place.
His vital signs are stable and he is afebrile. He is tolerating
a regular diet. He did receive a laxative today to help promote
peristalisis. He was evaulated by physical therapy who made
recommended discharge to a rehabiltation facility where he can
further regain his strength and mobility.
Medications on Admission:
none
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for loose stools.
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
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. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
7. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
9. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain: hold for increased sedation, resp. rate <10.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Trauma: MVC
Injuries:
L. 2-6th rib fx
L. sacral alar fx,
L ant column acetabular fx,
R sub pubic fx
L 5th metacarpal fx
R pilon fx
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
LUE:NWB
RLE:NWB
LLE:WBAT
Discharge Instructions:
You were admitted to the hospital after you were involved in a
motor vehicle accident in which you sustained rib fracture,
pelvic fracture, and a right open tib/fib fracture which was
repair. You also sustained a fracture to the left fifth finger.
For this, you were taken to the operating room for repair. Your
vital signs are stable and you are preparing for dishcarge to a
rehabilitation facility where you can further regain your
strenght and mobility.
Followup Instructions:
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: TUESDAY [**2141-1-24**] at 3:00 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Please follow up with Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**] in 2 weeks. You can schedule
this appointment by calling # [**Telephone/Fax (1) 31444**].
You will also need to follow-up with Orhtopedics, Nurse
Practitioner, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The telephone number to
schedule this appointment is [**Telephone/Fax (1) 1228**]. You will need to
have follow-up in 2 weeks.
Completed by:[**2141-1-6**]
|
[
"327.23",
"V45.73",
"V15.84",
"807.05",
"808.0",
"850.5",
"305.1",
"805.6",
"823.92",
"808.2",
"815.03",
"E812.0",
"516.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.72",
"79.66",
"79.36",
"78.17",
"79.33"
] |
icd9pcs
|
[
[
[]
]
] |
9129, 9176
|
5369, 8142
|
439, 528
|
9353, 9353
|
2207, 5346
|
10044, 10842
|
1449, 1453
|
8197, 9106
|
9197, 9332
|
8168, 8174
|
9562, 10021
|
1468, 1468
|
1490, 2188
|
265, 401
|
556, 1314
|
9368, 9538
|
1358, 1379
|
1411, 1433
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,268
| 164,044
|
44308
|
Discharge summary
|
report
|
Admission Date: [**2137-8-8**] Discharge Date: [**2137-8-13**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**Last Name (NamePattern1) 14062**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
This is a 87 year old man with history of EtOH abuse (last drink
6 months ago) with esopaphageal varices, previous dieulafoy
lesion now resolved, CAD, CHF (EF 45%), essential
thrombocytosis, Afib, HTN, type II diabetes mellitus, discharged
[**2137-8-3**] after admission for GI bleed, presenting from [**Hospital 4382**] with guiaic positive stool, delta MS. The patient was
admitted to the [**Hospital Unit Name 153**] in [**6-9**] with CHF exacerbation and upper GI
bleed. He was again admitted [**Date range (1) 95014**] with GI bleed. EGD
at that time showed grade II non-bleeding varices at distal
third of esophagus. He was discharged to home and since that
time has had continued black stools. Today at [**Hospital3 **]
he was noted to be more lethargic and confused, and so was
brought to [**Hospital1 18**] ED.
.
On presentation to ED T 97.0 HR 100 BP 130/70 HR RR 20 99%RA.
Initial Hct 15.5, and patient was transfused two units PRBC. GI
was consulted, and patient was started on octreotide gtt. BP
dropped to 108/60 as patient spiked temp 101.8 rectal.
Urinalysis was positive for UTI. ECG 110bpm Aflutter,
borderline left-axis deviation, nml intervals, no ST-changes,
TWI V4-V6. He denied recent fevers, headaches, dizziness,
visual changes, chest pain, palpitations, SOB, cough, abdominal
pain, nausea, vomiting, dysuria.
Patient admited to MICU for emergent scope and received 6 PRBC
total. Spironolactone, lasix, metoprolol, lisinopril were held
due to reflex tachycardia. ASA and plavix were held secondary to
possible GI bleed. EGD showed gastric telangiectasia which were
treated and showed esophageal varices intact. UTI and possible
pneumonia treated with Cipro. Hct has been stable today and
patient was transferred to the floor.
Past Medical History:
1. CHF - Right sided failure, LVEF 45-50% Intrinsic LV systolic
function depressed given the severity of valvular regurgitation
from ECHO [**2137-6-21**] Previous ECHO w/ EF 30%
2. CAD - large reversable mod severe inferior wall defect by
pMIBI [**4-9**]; refused PCI [**4-9**] admission but was considering outpt
cath
3. Essential thrombocytosis - followed by Dr. [**First Name (STitle) **], on
hydroxyurea
4. Atrial fibrillation - was on coumadin but d/c'd by PCP
([**4-9**]) due to elevated INR and bleed
5. HTN
6. DM2, on insulin
7. H/O Dieulafoy's lesion w/ [**Hospital Unit Name 153**] stay ([**6-9**])
Social History:
Denies tobacco use. Extensive EtOH x 50 yrs, last drink 6 mo
ago. Lives alone. Has girlfriend. [**Name (NI) **] visiting nurse. Cooks for
self (mostly canned food).
Family History:
N/C
Physical Exam:
PE: T 101.8rectal, HR 106, BP 115/59 RR 16 94%RA
Gen: comfortable, NAD, oriented x3, alert
HEENT: PERRL (3-2mm), anicteric, MM moderately dry
Neck: supple, no LAD,
CV: tachy, regular, no rubs or gallops
Resp: CTAB
Abd: +BS, soft, moderately distended, no HSM by percussion,
nontender to palpation, guiaic positive
Ext: 2+ pitting edema, venous stasis changes, decreased DP
pulses, palpable
Neuro: A&Ox3, strength and sensation intact grossly, no
asterixes
Pertinent Results:
[**2137-8-8**] 09:00AM BLOOD WBC-5.4 RBC-1.62*# Hgb-4.7*# Hct-15.5*#
MCV-96 MCH-29.0 MCHC-30.3* RDW-23.3* Plt Ct-906*
[**2137-8-9**] 03:43AM BLOOD WBC-6.9 RBC-2.95*# Hgb-8.9*# Hct-26.3*
MCV-89# MCH-30.1 MCHC-33.8# RDW-20.4* Plt Ct-790*
[**2137-8-10**] 06:18AM BLOOD WBC-8.8 RBC-3.46* Hgb-10.4* Hct-30.7*
MCV-89 MCH-30.1 MCHC-33.9 RDW-19.9* Plt Ct-762*
[**2137-8-8**] 09:00AM BLOOD Neuts-83* Bands-0 Lymphs-14* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-3* Other-1*
[**2137-8-8**] 09:00AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-2+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
Target-OCCASIONAL Schisto-OCCASIONAL Ellipto-OCCASIONAL
[**2137-8-8**] 12:04PM BLOOD PT-16.0* PTT-32.6 INR(PT)-1.7
[**2137-8-8**] 09:00AM BLOOD Glucose-93 UreaN-56* Creat-1.4* Na-140
K-4.5 Cl-103 HCO3-27 AnGap-15
[**2137-8-8**] 09:00AM BLOOD ALT-14 AST-15 LD(LDH)-239 CK(CPK)-25*
AlkPhos-151* Amylase-85 TotBili-1.7*
[**2137-8-8**] 09:00AM BLOOD Lipase-25
[**2137-8-8**] 09:00AM BLOOD cTropnT-0.08*
[**2137-8-8**] 05:02PM BLOOD CK-MB-NotDone cTropnT-0.09*
[**2137-8-8**] 09:00AM BLOOD Albumin-3.1* Calcium-8.8 Phos-3.9 Mg-2.2
[**2137-8-8**] 09:14AM BLOOD Lactate-2.2*
[**2137-8-8**] 09:35AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
[**2137-8-8**] 09:35AM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2137-8-8**] 09:35AM URINE RBC-[**6-14**]* WBC-[**11-24**]* Bacteri-MOD
Yeast-NONE Epi-0-2
[**2137-8-8**] 09:35AM URINE CastHy-0-2
[**2137-8-8**] 9:35 am URINE Site: CATHETER
URINE CULTURE (Final [**2137-8-10**]):
ENTEROBACTER CLOACAE. >100,000 ORGANISMS/ML..
Trimethoprim/sulfa sensitivity confirmed by
[**Doctor Last Name 3077**]-[**Doctor Last Name 3060**].
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.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
PIPERACILLIN---------- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
US ABD LIMIT, SINGLE ORGAN PORT [**2137-8-8**] 1:21 PM
Reason: eval for ascites, liver pathology. If ascites, please
mark
FINDINGS: There is a moderate to large amount of intra-abdominal
ascites present in all four quadrants.
An ink mark was placed over the pocket of ascites in the right
lower quadrant. The anterior abdominal wall measures less than 2
cm in thickness at that level and there is relying pocket of
ascites which measures over 5 cm in depth at that level.
CHEST (PA & LAT) [**2137-8-8**] 9:38 AM
Reason: r/o infiltrate
Comparison was done to the prior portable chest x-ray done
earlier today at 9:10 a.m.
There is mild-to-moderate left pleural effusion with left lower
lobe consolidation. There is mild cardiomegaly. The mediastinal
and hilar contours are normal.
[**2137-8-8**] EKG
Probable atrial flutter with 2:1 AV block
Incomplete right bundle branch block
Probable old inferior infarct
Anterolateral ST-T changes may be due to myocardial ischemia
Since previous tracing of [**2137-8-8**], atrial flutter less apparent
Intervals Axes
Rate PR QRS QT/QTc P QRS T
111 182 102 374/439.71 97 -18 127
-59 DISTINCT PROCEDURAL SERVICE [**2137-8-12**] 3:50 PM
UNILAT UP EXT VEINS US LEFT; -59 DISTINCT PROCEDURAL SERVIC
Reason: ? venous thrombosis/phlebitis
CONCLUSION: Focal area of thrombus adjacent to the catheter tip
within the left cephalic vein. The other left upper limb veins
are patent.
UNILAT LOWER EXT VEINS LEFT [**2137-8-12**] 3:50 PM
Reason: ?DVT
CONCLUSION: No evidence of left lower limb DVT.
Brief Hospital Course:
This is 87yo man with h/o EtOH abuse (last drink 6mos ago) with
esopaphageal varices, previous dieulafoy lesion now resolved,
CAD, CHF (EF 45%), essential thrombocytosis, Afib, HTN, type II
diabetes mellitus, discharged [**2137-8-3**] after admission for GI
bleed, presenting from [**Hospital3 **] with guiaic positive
stool, delta MS.
.
#. GI bleed: Initial Hct 15.5, started on octreotide gtt. BP
dropped to 108/60 as patient spiked temp 101.8 rectal.
Urinalysis was positive for UTI. ECG 110bpm Aflutter, borderline
left-axis deviation, nml intervals, no ST-changes, TWI V4-V6.
Patient admited to MICU for emergent scope and received 6 PRBC
total. Spironolactone, lasix, metoprolol, lisinopril were held
due to reflex tachycardia. ASA and plavix were held secondary
to possible GI bleed. EGD showed gastric telangiectasia which
were treated and showed esophageal varices intact. Was likely
upper GI source given stomach telangiectasia seen on EGD.
Hemodynamically stable now with stable Hct @31. On Protonix [**Hospital1 **]
and advanced diet as tolerated.
.
#. Mental status changes: Improved close to baseline per
adopted son. Likely due to blood loss and UTI. Treated GI bleed
and infection. Patient was evaluated for SBP and no paracentesis
was performed given known source of infection (UTI/PNA).
.
#. UTI: Treated with ciprofloxacin, urine culture
sensitivities enterobacter pan sensitive - cont Cipro x7days.
.
#. Aflutter: h/o pAfib. Tachycardia likely due to volume loss
and anemia. Restarted metoprolol
.
#. CHF: EF 45% on echo [**6-9**]. JVP was elevated to base of ear
on initial exam. Patient was monitor closely for crackles,
decreased O2sat with low threshold to give lasix as needed.
Spironolactone, lasix, metoprolol and lisinopril were initially
held and then resumed as mentioned above.
.
#. Fever: Likely due to GI bleed and UTI. However, patient
with ascites, concerning for SBP. Blood and urine cultures were
pending. CXR showed no evidence of PNA. Started Cipro for UTI
and followed up cultures. Patient was afebrile at discharge.
.
#. ARF: Baseline creat 1.2. Cr was elevated at 1.4 with
increased BUN suggestive of prerenal etiology. Lisinopril was
resumed with good effect. Also, restarted lasix and aldactone
once renal function improved to treat ascites and to decrease
risk of variceal bleed per GI recs.
#. CAD: Nonspecific lateral t-wave inversions on ECG. Troponin
was likely elevated in the setting of demand ischemia, CK's
were flat. ASA and Plavix were held in setting of acute GIB.
Patient was continued atorvastatin for secondary prevention and
restarted on lisinopril 5mg QD.
.
#. L UE swelling/LE posterior calve burning: Patient had L UE
swelling and complained of LE "burning" sensation L>R
posterior>anterior of calves and had Doppler US of L UE and LE
on [**2137-8-12**] which were negative for L LE and showed a small clot
at IV sight which was subsequently removed without
complications.
.
#. Type II diabetes mellitus: QID FS's, RISS
.
#. FEN: repleted lytes PO, limited IVF given worsening ascites
.
#. Access: peripheral iv ( 3 18g)
.
#. Communication: w/ patient, adopted son, girlfriend
.
#. Full Code
Medications on Admission:
Lipitor 40mg daily
Aspirin 325mg daily
Spironolactone 50mg daily
Folate 1mg daily
Lasix 80mg [**Hospital1 **]
Plavix 75mg daily
Hydrea 1500mg TID
Metoprolol 12.5mg [**Hospital1 **]
Protonix 40mg daily
Lisinopril 10mg daily
Novolin 70/30 16units QAM
Discharge Medications:
1. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Hydroxyurea 500 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
4. Ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 3 days.
Disp:*12 Tablet(s)* Refills:*0*
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1. GI bleed from AVM in stomach
2. Thrombocytosis, likely reactive
3. Congestive heart failure
4. Hypertension
5. Diabetes
Discharge Condition:
good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Please finish your course of Ciprofloxacin for your urinary
tract infection.
Do not take your Aspirin or Plavix until you follow up with your
primary care doctor.
Please call you doctor or return to the ER with any signs of
bleeding, increased fatigue, lightheadedness/dizziness, or
fainting.
Followup Instructions:
Follow-up with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] on Thurs [**8-22**] at 2:30pm. Phone:
[**Telephone/Fax (1) 250**]
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 27555**], MD Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2137-8-22**] 3:30
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 5004**] [**Last Name (NamePattern1) **] MD, [**MD Number(3) 14063**]
Completed by:[**2137-10-27**]
|
[
"584.9",
"789.5",
"287.3",
"599.0",
"427.31",
"401.9",
"285.9",
"571.2",
"453.8",
"456.21",
"996.74",
"428.0",
"250.00",
"276.5",
"537.83"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
11894, 11952
|
7662, 10846
|
236, 242
|
12119, 12125
|
3375, 7639
|
12569, 13111
|
2867, 2872
|
11146, 11871
|
11973, 12098
|
10872, 11123
|
12149, 12546
|
2887, 3356
|
188, 198
|
270, 2036
|
2058, 2668
|
2684, 2851
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,128
| 197,437
|
48742
|
Discharge summary
|
report
|
Admission Date: [**2129-5-27**] Discharge Date: [**2129-6-5**]
Date of Birth: [**2065-3-23**] Sex: M
Service: Cardiology
CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 24927**] is a 64-year-old
male who was admitted to the Cardiology Service on [**5-27**]
with an episode of chest pain. His workup revealed that he
had severe reversible perfusion defects in his lateral and
inferolateral walls on perfusion studies. They also found
that he had an ejection fraction of 46%. The patient
complains of symptoms of neck pain radiating to the chest and
back for the last four months. His pain is associated with
significant gas and would last approximately one to five
minutes. It would come on with meals, exertion, rest, and
more recently he has woken him from sleep. His pain would
also resolve with resting, burping, and passing flatus. He
typically has diaphoresis with his pain but rarely becomes
nauseated. He has not had any vomiting. He reports that his
pain has become more frequent occurring anywhere from one to
five times per day. Of note, he also sleeps on two pillows
at night but denies having any paroxysmal nocturnal dyspnea.
PAST MEDICAL HISTORY:
1. Renal cell carcinoma, now status post left nephrectomy.
2. Chronic obstructive pulmonary disease.
3. ? Hyperlipidemia.
He denies having any history of diabetes or hypertension,
prior myocardial infarction or coronary artery disease.
PAST SURGICAL HISTORY: Past surgical history was notable
only for an appendectomy and a hernia repair.
SOCIAL HISTORY: He is married and lives with his wife. [**Name (NI) **]
has smoked half a pack of cigarettes per day for the last 40
years.
MEDICATIONS ON ADMISSION:
1. Enteric-coated aspirin.
2. Ativan 1 mg p.o. b.i.d.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination his pulse was 59, his blood pressure was 146/83,
he was saturating 96% on room air. His neck was without
jugular venous distention. There was no bruits. His lungs
were clear to auscultation. His heart had a regular rate and
rhythm without murmurs, rubs or gallops. The abdomen was
soft and nontender with normal active bowel sounds.
Extremities revealed he had 1+ dorsalis pedis and posterior
tibialis pulses bilaterally.
PERTINENT LABORATORY DATA ON PRESENTATION: On laboratory
studies, his baseline blood urea nitrogen 23 and creatinine
was 1.4. His white blood cell count on admission was 8. His
hematocrit was 40. His INR was 1.3, and his liver function
tests were normal.
HOSPITAL COURSE: The patient was admitted to the Cardiology
Service and had a cardiac catheterization. He was started on
intravenous nitroglycerin which appeared to have been
continued up until the time of operation.
Following his catheterization, his renal function was stable
with no resultant increase in his creatinine. Preoperatively
he was started on Lipitor. Prior to his operation, he had an
episode of chest pain while in the hospital. For this
reason, he was started on intravenous heparin, and his
intravenous nitroglycerin was continued. While he was
waiting for his operation he also had three to four episodes
of polymorphic nonsustained ventricular tachycardia at the
rate of 150 to 180. This was while he was experiencing chest
pain. He was loaded with magnesium, and his nitroglycerin
was titrated.
On [**2129-6-1**], the patient was taken to the operating room
where he had a coronary artery bypass graft times two.
Vessels grafted were left internal mammary artery to diagonal
and saphenous vein graft to obtuse marginal. Total
cardiopulmonary bypass time was 54 minutes. Cross-clamp time
was 29 minutes. The patient's procedure itself was
unremarkable. He was taken intubated to the Cardiothoracic
Intensive Care Unit on a nitroglycerin and propofol drips.
Later that evening, he was extubated, and the following
morning his chest tube was discontinued. He was transferred
to the hospital floor. There, he had a temperature of 101.2
on the evening of the first postoperative day. A sputum
sample was sent that grew both oropharyngeal flora and
gram-negative rods suggesting hemophilus influenza. He was
started on oral Levaquin.
During his postoperative recovery, on day two, he had an
episode of rapid atrial fibrillation to 190 beats per minute.
During this time he was mentating correctly and sustained his
blood pressure. This broke spontaneously after approximately
two minutes with no intervention. He was loaded with both
calcium and magnesium for marginally low levels and given an
extra dose of Lopressor. The next day his Lopressor was
subsequently increased. He had no further episodes of atrial
fibrillation for the remainder of his hospitalization.
By the fourth postoperative day, the patient was eating,
ambulating, and voiding. He was afebrile and felt well
enough to be discharged home. In addition, the Physical
Therapy staff ambulated with him and felt that he was safe to
be discharged.
DISCHARGE STATUS: On [**2129-6-5**] the patient was discharged
to home in the care of his family.
CONDITION AT DISCHARGE: In stable condition.
DISCHARGE FOLLOWUP: He was instructed to follow up with his
primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **], in two weeks and with
Dr. [**Last Name (STitle) 70**] in six weeks.
MEDICATIONS ON DISCHARGE: (The patient was discharged to
home on the following medications)
1. Levaquin 500 mg p.o. q.d. (times seven days).
2. Lopressor 50 mg p.o. b.i.d.
3. Aspirin 325 mg p.o. q.d.
4. Lipitor 10 mg p.o. q.d.
5. Colace 100 mg p.o. b.i.d.
6. Lasix 20 mg p.o. b.i.d. (times seven days).
7. Potassium chloride 20 mEq p.o. b.i.d. (times seven days).
8. Percocet one to two tablets p.o. q.4-6h. p.r.n.
DISCHARGE DIAGNOSES:
1. Coronary artery disease; now status post coronary artery
bypass graft times two.
2. Nonsustained ventricular tachycardia.
3. Nonsustained rapid atrial fibrillation.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 9638**]
MEDQUIST36
D: [**2129-6-5**] 12:34
T: [**2129-6-7**] 19:43
JOB#: [**Job Number 102457**]
|
[
"411.1",
"V45.73",
"427.31",
"E878.2",
"997.1",
"414.01",
"496",
"443.9",
"V10.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"44.32",
"36.15",
"39.61",
"37.23",
"88.72",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
5812, 6286
|
5393, 5791
|
1740, 2547
|
2566, 5113
|
1490, 1571
|
5128, 5150
|
156, 169
|
5172, 5366
|
198, 1202
|
1224, 1465
|
1588, 1714
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,425
| 184,212
|
21459
|
Discharge summary
|
report
|
Admission Date: [**2148-11-7**] Discharge Date: [**2148-11-12**]
Service: SURGERY
Allergies:
Morphine / Keflex / Zithromax / Flagyl
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Abdominal pain and chest pain
Major Surgical or Invasive Procedure:
Laparoscopic converted to open cholecystectomy.
History of Present Illness:
Ms. [**Known lastname 56654**] is an 89 year old female who presented to the ED
with complaints of chest pain and abdominal pain since midnight
the night before. Ms. [**Known lastname 56654**] had been diagnosed with a UTI 2
weeks before and just completed a course of Cipro 3 days
previously. At that time she also had elevated transaminases
(ALT 265, AST 358, Bili normal) which subsequently returned to
[**Location 213**]. For the prior 2 nights she had been having night sweats
and chills. At midnight the night before presentation she awoke
with generalized abdominal pain and substernal chest discomfort.
She took tylenol with no resolution. She had also been having
decreased appetite for several days. She complained of mild
nausea but no vomiting.
Of note, history was obtained via son and granddaughter who
speak English well.
The patient is Farsi speaking and refused a translator.
Past Medical History:
PMH: CAD, AFib, osteoarthritis
PSH: R. shouder surgery, b/l knee replacements, infected
epidermal inclusion cyst drained from her back [**2-8**] ([**Doctor Last Name 2819**])
Social History:
Never smoked; does not drink. Lives at home with son.
[**Name (NI) **]: morphine, kelflex (rash)
Family History:
NC
Physical Exam:
PE: 99.6 88 128/53 12 100% RA
A&O X 3, NAD
PERRL, EOMI, anicteric
RRR
CTAB
Abdomen soft, mildly distended, normal bowel sounds, old lower
midline incision well healed, easily reducible incisional
hernia.
Moderate tenderness in RUQ to deep palpation. No rebound or
guarding. Negative [**Doctor Last Name 515**].
LE warm, trace b/l edema
Pertinent Results:
[**2148-11-7**] 09:00PM PT-15.4* PTT-33.4 INR(PT)-1.4*
[**2148-11-7**] 12:50PM CK-MB-2 cTropnT-0.01
[**2148-11-7**] 06:50AM GLUCOSE-88 UREA N-12 CREAT-0.8 SODIUM-139
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-26 ANION GAP-11
[**2148-11-7**] 06:50AM ALT(SGPT)-21 AST(SGOT)-27 CK(CPK)-37 ALK
PHOS-65 AMYLASE-70 TOT BILI-0.8 DIR BILI-0.3 INDIR BIL-0.5
[**2148-11-7**] 06:50AM LIPASE-23
[**2148-11-7**] 06:50AM CALCIUM-8.3* PHOSPHATE-3.3 MAGNESIUM-1.9
[**2148-11-7**] 06:50AM WBC-12.4* RBC-3.52* HGB-9.2* HCT-28.9* MCV-82
MCH-26.1* MCHC-31.8 RDW-16.1*
Brief Hospital Course:
The patient was admitted for abdominal and back pain on [**2148-11-7**].
She was ruled out for a cardiac event with echo, EKG and
cardiac enzymes. After HIDA scan was positive, the patient
underwent a laproscopic, coverted to open, cholecystectomy. Her
diet was advanced and on post-operative day three she was
tolerating a regular diet, her pain was controlled on oral pain
medication, and she was having bowel function. She was then
discharged to home.
Medications on Admission:
atenolol 25', lipitor 10', digoxin 125', ASA 81', diclofenac
75', fosamax weekly
Discharge Medications:
1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
2. Acetaminophen 650 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8
hours).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
7. Diclofenac Sodium 75 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO once a day.
8. Fosamax Oral
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Laparoscopic converted to open cholecystectomy.
Discharge Condition:
Good. Tolerating regular diet. Pain controlled on oral pain
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.
* 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 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.
Followup Instructions:
Call Dr.[**Name (NI) 15146**] office for follow-up in [**2-2**] weeks after
discharge.
|
[
"E849.7",
"458.29",
"V64.41",
"E930.9",
"414.01",
"515",
"285.9",
"574.10",
"427.31",
"693.0",
"574.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.22"
] |
icd9pcs
|
[
[
[]
]
] |
3737, 3795
|
2541, 3001
|
276, 326
|
3887, 3963
|
1961, 2518
|
5494, 5584
|
1580, 1584
|
3133, 3714
|
3816, 3866
|
3027, 3110
|
3987, 5133
|
5148, 5471
|
1599, 1942
|
207, 238
|
354, 1250
|
1272, 1449
|
1465, 1564
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,038
| 171,871
|
43852
|
Discharge summary
|
report
|
Admission Date: [**2104-3-17**] Discharge Date: [**2104-3-28**]
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 317**]
Chief Complaint:
diarrhea
Major Surgical or Invasive Procedure:
placement of BiV pacer
History of Present Illness:
Mr. [**Known lastname 41684**] is a 87 yo male with PMH significant for CAD s/p CABG,
CHF, AF, s/p temporary pacemaker, and DM2. He presented to [**Hospital1 18**]
on [**2104-3-17**] with hypotension and diarrhea. She had empirically
been started on Vancomycin at [**Hospital1 **] and had been bolused with
IVFs and then sent to [**Hospital1 18**] ED. In the ED she was febrile to
101.8 and cxray suggested pulmonary edema. She was diuresed with
acute drop in his blood pressure which then normalized on its
own. He was transferred to the MICU for closer monitoring.
In the MICU he was empirically started on Vancomycin and Zosyn.
He continued to have diarrhea and stool culture was positive for
c.diff. He was started on Flagyl.
Patient has no complaints at this time. He continues to have
loose BMs, 3 today. He denies any SOB, chest pain, abdominal
pain, or any other concerning symptoms.
.
Medications on transfer:
Insulin SC
Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB,
Levothyroxine 25 micrograms PO daily
Amiodarone 200mg PO daily
Flagyl 500mg PO TID
Atorvastatin 10mg PO daily
Carvedilol 3.125mg PO BID
Pantoprazole 40mg PO Q24H
Cyanocobalamin 100mcg PO daily
Finasteride 5 mg PO DAILY
Fluticasone-Salmeterol (250/50) 1 INH IH [**Hospital1 **]
Spironolactone 12.5 mg PO DAILY
.
Allergies: ASA
.
Family History: NC
.
Social History: Currently residing at [**Hospital3 7**] &
Rehabilitation Center. Previously lived by himself, though his
son lived in a separate unit in the same house. Retired, but
previously worked delivering milk. Widower. Denies tobacco past
or present, previous moderate EtOH use, no IVDU.
.
.
Laboratory results: see below
.
Relevant Imaging:
1)Cxray ([**2104-3-19**]): Compared with [**2104-3-17**], what appeared to have
been interstitial pulmonary edema has now cleared considerably.
.
2)ECHO ([**2104-3-18**]): The left atrium is markedly dilated. The right
atrium is markedly dilated. Overall left ventricular systolic
function is moderately depressed. The right ventricular cavity
is moderately dilated. There is mild global right ventricular
free wall hypokinesis. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. Moderate
to severe [3+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension.
.
Past Medical History:
1. CAD s/p CABG in [**2089**]
2. CHF, last ECHO w/EF 30%
3. Atrial fibrillation
4. s/p ICD in [**7-27**]; upgrade to BiV/ICD in [**7-28**]; generator change
in [**2-28**]; device and lead extraction on [**2104-2-4**] for MRSA
bacteremia and temporary pacemaker on [**2104-2-4**]
5. History of idiopathic intrinsic lung disease
- on 3L O2 at home
6. Type 2 DM, diet controlled
7. BPH
8. Hx of GI bleed
9. Hypothyroidism
10. Right ear melanoma s/p exicision
Social History:
Used to deliver milk for job. Lives by himself but son is in
same house, widower, retired. Denies tobacco past or present,
previous moderate EtOH use, no IVDU.
Family History:
Father>>Tb
Physical Exam:
per admitting resident:
Gen: Pleasant male, lying in bed, NAD
HEENT: MMM
Heart: nl s1/s2, no s3/s4, +systolic murmur
Lungs: CTAB, scattered wheezes and crackles posteriorly
Abdomen: soft, non-tender, +distended but no guarding or
rebounding
Extremities: [**11-27**]+ pitting edema, 2+ DP/PT pulses bilaterally
Pertinent Results:
[**2104-3-17**] 09:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2104-3-17**] 09:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2104-3-17**] 09:30PM URINE RBC-[**10-14**]* WBC->50 BACTERIA-FEW
YEAST-NONE EPI-0
[**2104-3-17**] 08:15PM GLUCOSE-101 UREA N-60* CREAT-2.7*# SODIUM-134
POTASSIUM-5.1 CHLORIDE-89* TOTAL CO2-29 ANION GAP-21*
Brief Hospital Course:
1)C. diff: Patient presented with diarrhea, stool positive for
C.diff toxin. Started on flagyl for 14 days. Stool toxin now
negative, no diarrhea.
.
2)Hypotension: Baseline in 90s-100s. Monitor I/Os closely.
Mentating well.
.
3)Arrhythmia: Patient has history of MRSA bactermia secondary to
pacemaker lead infection. He was treated with course of
Vancomycin and surveillance blood cultures remain negative.
After removal of the old device and placement of temporary wire,
a new BivICD was placed on [**2104-3-27**]. Patient is on amiodarone and
digoxin, as well as warfarin. Target HR is less than 80 to allow
for pacing.
On 7-day-IV vancomycin. On heparin drip and warfarin, INR on
discharge 1.8.
.
4)CHF: Patient has history of systolic dysfunction. Recent ECHO
with EF~35%. Cxray on admission consistent with pulmonary edema
but improved with Lasix he received in the ED. Given his
sub-optimal blood pressures he was diuresed cautiously.
.
5)Renal failure: Baseline Cr~1.4. Elevated to 2.7 on admission;
slowly improving now.
.
6)Sterile pyuria/BPH: U/A with >50 WBCs but negative nitrite and
leuks. Asymptomatic. Antifungal cream for penile thrush. Outpat
appointment with Dr. [**Last Name (STitle) **] (urology). Send to rehab with foley.
Medications on Admission:
Insulin SC
Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB,
Levothyroxine 25 micrograms PO daily
Amiodarone 200mg PO daily
Flagyl 500mg PO TID
Atorvastatin 10mg PO daily
Carvedilol 3.125mg PO BID
Pantoprazole 40mg PO Q24H
Cyanocobalamin 100mcg PO daily
Finasteride 5 mg PO DAILY
Fluticasone-Salmeterol (250/50) 1 INH IH [**Hospital1 **]
Spironolactone 12.5 mg PO DAILY
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB, wheezing.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB, wheezing.
11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 5 days.
12. Carvedilol 6.25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
13. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
14. Insulin Lispro (Human) 100 unit/mL Solution Sig: per sliding
scale Subcutaneous ASDIR (AS DIRECTED).
15. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO MWF
(Monday-Wednesday-Friday).
16. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
17. Vancomycin 1000 mg IV Q 24H new ICD. Duration: 7 Days
ok to switch to PO equivalent on D/C or per ID recommendations.
18. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
19. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: per protocol Intravenous ASDIR (AS DIRECTED).
20. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
c.diff colitis
CAD s/p CABG in [**2089**]
CHF
Atrial fibrillation
s/p ICD in [**7-27**]; upgrade to BiV/ICD in [**7-28**]; generator change in
[**2-28**]; device and lead extraction on [**2104-2-4**] for MRSA
bacteremia and temporary pacemaker on [**2104-2-4**]
History of idiopathic intrinsic lung disease
- on 3L O2 at home
Type 2 DM, diet controlled
BPH
Hx of GI bleed
Hypothyroidism
Right ear melanoma s/p exicision
Discharge Condition:
fair.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500 cc
.
You were admitted with C.difficile colitis. For that, you are
treated with an antibiotic (flagyl)for 15 days. Please take all
your medication as prescribed.
Please go to your follow-up appointments.
Please call your doctor if you have increased diarrhea, fever
>101.0, chills or any other concerning medical problems.
Followup Instructions:
Please have your PCP arrange [**Name Initial (PRE) **] followup with GI since you had
blood in your stool. Please call for an appointment with PCP:
[**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 608**].
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2104-6-11**]
10:00
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name 9406**] Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2104-4-8**]
11:30
Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2104-4-2**] 1:00
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2104-4-4**]
10:00
Completed by:[**2104-3-28**]
|
[
"428.20",
"250.00",
"414.01",
"593.9",
"008.45",
"584.9",
"458.9",
"244.9",
"427.31",
"496",
"600.01",
"285.9",
"428.0",
"414.8",
"V45.81",
"791.9",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.33",
"00.51"
] |
icd9pcs
|
[
[
[]
]
] |
7663, 7729
|
4130, 5376
|
223, 248
|
8195, 8203
|
3672, 4107
|
8698, 9494
|
3314, 3326
|
5840, 7640
|
7750, 8174
|
5402, 5817
|
8227, 8675
|
3341, 3653
|
175, 185
|
2001, 2641
|
276, 1173
|
1198, 1631
|
2663, 3120
|
3136, 3298
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,333
| 111,188
|
27380
|
Discharge summary
|
report
|
Admission Date: [**2190-5-10**] Discharge Date: [**2190-5-16**]
Date of Birth: [**2130-11-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
CABG x 3 [**2190-5-11**] (LIMA to LAD, SVG to OM, SVG to PDA)
History of Present Illness:
59 yo Caucasian male with back and shoulder chest pain with +
ETT. Referred for cath which showed 80% LM, 60% LAD, 60% OM1 ,
99% RCA. Transferred in from [**Hospital3 1443**] for CABG with Dr.
[**Last Name (STitle) **].
Past Medical History:
HTN
obesity
tonsillectomy
Social History:
pathologist
lives alone
no tobacco use
no ETOH use
Family History:
non-contributory
Physical Exam:
HR 53 RR 17 170/74 left
5'[**93**]" 121.6 kg
NAD
skin/HEENT unremarkable
neck supple with full ROM, no carotid bruits
CTAB
RRR, no murmurs
abd soft, NT, ND
trace peripheral edema with no varicosities
neurologically grossly intact
2+ bilat. fem/DP/PT/radial pulses
Pertinent Results:
[**2190-5-14**] 08:15AM BLOOD WBC-9.4 RBC-3.23* Hgb-9.8* Hct-27.4*
MCV-85 MCH-30.4 MCHC-35.9* RDW-14.0 Plt Ct-173
[**2190-5-16**] 05:00AM BLOOD Hct-27.4*
[**2190-5-10**] 04:10PM BLOOD Neuts-78.5* Lymphs-15.7* Monos-4.1
Eos-1.4 Baso-0.3
[**2190-5-14**] 08:15AM BLOOD Plt Ct-173
[**2190-5-10**] 04:10PM BLOOD PT-13.1 PTT-30.7 INR(PT)-1.1
[**2190-5-15**] 05:25AM BLOOD Glucose-134* UreaN-19 Creat-1.1 Na-135
K-3.7 Cl-99 HCO3-27 AnGap-13
[**2190-5-16**] 05:00AM BLOOD K-4.0
[**2190-5-10**] 04:10PM BLOOD ALT-23 AST-23 AlkPhos-50 TotBili-0.6
[**2190-5-14**] 08:15AM BLOOD Mg-2.1
[**2190-5-10**] 04:10PM BLOOD %HbA1c-6.5* [Hgb]-DONE [A1c]-DONE
[**2190-5-10**] 04:10PM BLOOD Triglyc-120 HDL-35 CHOL/HD-4.6
LDLcalc-102
Brief Hospital Course:
Admitted on [**5-10**] to cardiology service and underwent CABG x3
with Dr. [**Last Name (STitle) **] on [**5-11**]. Transferred to the CSRU in stable
condition on neo and propofol drips. Extubated and off all drips
on POD #1. Swan removed. Chest tubes removed and transferred to
the floor on POD #2 to begin increasing his activity level.
[**Last Name (un) **] consult obtained for newly diagnosed DM and oral agents
started. Gentle diuresis and beta blockade continued. Pacing
wires removed on POD #3. Short burst of AFib on POD #4 that
spontaneously converted to SR. Cleared for discharge to home
with VNA on POD #5.
Medications on Admission:
plavix 300 mg (LD [**5-10**])
lovenox 120 mg SC
ASA 325 mg daily
atenolol 100 mg daily
lipitor 80 mg daily
lisinopril 10 mg daily
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 4
days.
Disp:*16 Capsule, Sustained Release(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*25 Tablet(s)* Refills:*0*
8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
tba
Discharge Diagnosis:
Coronary artery disease
CABG x3 [**5-11**]
HTN
NIDDM
obesity
Discharge Condition:
Good
Discharge Instructions:
Please take all medications as prescribed. Seek medical
attention if fever, chills, nausea, vomiting, shortness of
breath, or increased pain occurs.
Take all medications as prescribed.
No driving or heavy lifting (> 10 lbs) for 6 weeks.
Followup Instructions:
Please call Dr.[**Name (NI) 5572**] office at [**Telephone/Fax (1) 170**] within the next
few weeks to schedule a follow-up appointment.
Please call Dr. [**Last Name (STitle) **] within the first few days after
discharge to schedule a follow-up appointment.
Please call Dr. [**Last Name (STitle) 67060**] within the first few days following
discharge to schedule a follow-up appointment.
Please follow-up with the [**Hospital **] [**Hospital 982**] clinic within the
first day after discharge.
Completed by:[**2190-5-18**]
|
[
"427.31",
"414.01",
"794.39",
"272.4",
"278.00",
"250.00",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"39.61",
"36.15",
"88.72",
"36.12",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
3886, 3920
|
1835, 2456
|
333, 398
|
4024, 4031
|
1100, 1812
|
4319, 4847
|
780, 798
|
2638, 3863
|
3941, 4003
|
2482, 2615
|
4055, 4296
|
813, 1081
|
283, 295
|
426, 647
|
669, 696
|
712, 764
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,980
| 135,834
|
52016
|
Discharge summary
|
report
|
Admission Date: [**2176-8-2**] Discharge Date: [**2176-8-14**]
Date of Birth: [**2101-11-20**] Sex: F
Service: NEUROLOGY
Allergies:
Aspirin / Beta-Adrenergic Blocking Agents / Lovastatin
Attending:[**First Name3 (LF) 5341**]
Chief Complaint:
black stools
Major Surgical or Invasive Procedure:
EGD
HD MTX
History of Present Illness:
Ms. [**Known lastname 107686**] is a 74 yo female with CNS lymphoma, newly
diagnosed colon CA, CAD, HTN, DM, dementia, Afib, and h/o polio,
who presents with "large amount" of maroon stools this AM and
episode of relative hypotension at her nursing home ([**Hospital1 599**] of
[**Location (un) 55**]). Vitals at NH: T 93.2, BP 90/60, HR 74, RR 20. Pt
had recent admission to [**Hospital1 18**] s/p fall, and had black/maroon
stools during that admission with stable hct. Pt was due for
chemotherapy today, but did not undergo treatment due to ANC<500
yesterday (WBC count 0.7). Pt is poor historian, but reports
someone else noticed black stools and large maroon stool this
AM. Denies N/V, BRBPR. Has had L sided abd pain x several weeks.
Denies fevers, chills, but does c/o dysuria x 3 weeks. Pt denies
CP/SOB.
.
In the ED, vitals were: T 96.2, BP 126/53, HR 72, RR 18, O2 sat
77% on RA, up to 84% on 2L NRB. She had a change in mental
status (was confused as to place, thought she was in [**State 38104**]). She
was found to have guaiac positive melanotic stool. She was also
found to have a lactate of 4.4, dirty UA, pulmonary emboli, and
hct of 25. She was given 2L NS, vanc 1g IV, cefepime 2g IV,
mucomyst, bicarb, and 2 U PRBC's.
Past Medical History:
- CNS Lymphoma: diagnosed in [**8-24**], presented with
disorientation, LP and brain bx done at that time, high grade
B-cell lymphoma (CD 20 and CD79a positive). The pattern of
infiltration was most suggestive of primary CNS lymphoma. She is
currently being treated with MTX (last dose [**2176-7-19**]),
complicated by ARF
- Colon Cancer: adeoncarcinoma found on colonoscopy [**2176-7-4**]
-progressive CRI- thought likely from methotrexate, ATN, DM
- s/p DDD [**Month/Day/Year 4448**] placement secondary to tachy-brady syndrome,
currently followed by Dr. [**Last Name (STitle) **]
- s/p portacath placement and pheresis cath placement
- HTN
- hypercholesterolemia
- Afib
- Diabetes with retinopathy, on insulin
- h/o retinal hemorrhage
- Glaucoma
- CAD s/p CABG
- h/o dyspnea: A NIF in [**2171-3-21**] was 33% of predicted and the
DL VA was 85% of predicted.
- s/p appendectomy.
- Polio as a child c/b post polio syndrome in adulthood
- GERD
- legal blindness in right eye
Social History:
Patient came from [**Hospital1 599**] of [**Location (un) 55**]. She is a retired
French literature professor. She has 20 pack/years tobacco, quit
in [**2141**]. No EtOH. Her best friend serves as her health care
proxy.
Family History:
Mother died of breast cancer at 66. Maternal grandmother died of
colon cancer. Father died of ?PE. Paternal grandfather died of
coronary artery disease at 62. No fam history of diabetes or
thyroid disease.
Physical Exam:
Vitals: T 98.2 BP 139/47 HR 87 RR 27 O2 100% 2L NC
Gen: NAD
HEENT: OP clear. R pupil fixed and dilated, L pupil smaller than
R and non-reactive
Cardio: RRR, nl S1S2, no m/r/g
Resp: crackles [**1-22**] way up on R, basilar crackles on L
Abd: soft, mildly distended, +BS, + L sided tenderness, no
rebound/guarding.
Ext: no c/c/e. No calf tenderness.
Neuro: Awake, alert, oriented to person and place (but thinks
it's [**2186-2-20**]). 4/5 strength of RLE, otherwise 5/5 strength
throughout. R pupil fixed and dilated, L pupil small and NR,
other CN intact. Normal sensation. + word finding difficulties.
Pertinent Results:
[**8-13**] TTE: Compared with the findings of the prior report (images
unavailable for review) of [**2175-9-27**], diastolic
dysfunction of the left ventricle is now evident; otherwise no
major change.
.
[**8-12**] EGD: Erythema and friability and ulcerations in the lower
third of the esophagus (from 37cm to 27cm) compatible with
esophagitis (biopsy, biopsy, brushing) Mild streaky erythema in
the antrum compatible with gastritis. Normal mucosa in the
duodenal bulb and second part of the duodenum Otherwise normal
EGD to second part of the duodenum
.
[**8-6**] Head CT: Slightly more probable central necrosis of large
corpus callosal mass, but relatively unchanged extent of
surrounding edema.
.
[**8-2**] CTA IMPRESSION: Motion artifact, most pronounced in right
lower thorax. This precludes evalaution for PEs in this region.
A repeat scan would be recommended, or, alternatively lower
extremity ultrasound exam to evalaute for DVT. By report, the
patient has not been anticoagulated due to GI bleed. Mild
dependent atelectasis at the right lung base.
.
AEROBIC BOTTLE (Final [**2176-8-8**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2176-8-6**]): VIRIDANS STREPTOCOCCI.
ISOLATED FROM ONE SET ONLY. CLINDAMYCIN. <= 0.12 MCG/ML.
VIRIDANS STREPTOCOCCI
|
CLINDAMYCIN----------- S
ERYTHROMYCIN---------- 2 R
PENICILLIN------------<=0.06 S
VANCOMYCIN------------ <=1 S
.
[**2176-8-2**] 09:12PM GLUCOSE-80 UREA N-49* CREAT-1.4* SODIUM-137
POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-18* ANION GAP-15
[**2176-8-2**] 09:12PM ALT(SGPT)-24 AST(SGOT)-26 LD(LDH)-699* ALK
PHOS-67 AMYLASE-71 TOT BILI-1.5
[**2176-8-2**] 09:12PM LIPASE-38
[**2176-8-2**] 09:12PM ALBUMIN-3.1* CALCIUM-7.6* PHOSPHATE-3.9
MAGNESIUM-1.9 URIC ACID-5.4
[**2176-8-2**] 09:12PM WBC-7.1 RBC-3.62*# HGB-11.1*# HCT-30.4*
MCV-84 MCH-30.6 MCHC-36.5* RDW-19.5*
[**2176-8-2**] 09:12PM NEUTS-48* BANDS-9* LYMPHS-22 MONOS-13* EOS-0
BASOS-0 ATYPS-6* METAS-1* MYELOS-1* NUC RBCS-4*
[**2176-8-2**] 09:12PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+ SCHISTOCY-1+
[**2176-8-2**] 09:12PM PLT SMR-LOW PLT COUNT-70*
[**2176-8-2**] 09:12PM PT-12.2 PTT-29.4 INR(PT)-1.0
[**2176-8-2**] 04:07PM LACTATE-2.2*
[**2176-8-2**] 11:50AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.017
[**2176-8-2**] 11:50AM URINE BLOOD-MOD NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2176-8-2**] 11:50AM URINE RBC-0-2 WBC->50 BACTERIA-MANY YEAST-NONE
EPI-0
[**2176-8-2**] 10:05AM LACTATE-4.1*
[**2176-8-2**] 10:00AM GLUCOSE-202* UREA N-67* CREAT-1.7* SODIUM-137
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-17* ANION GAP-18
[**2176-8-2**] 10:00AM CALCIUM-7.9* PHOSPHATE-4.6* MAGNESIUM-2.3
[**2176-8-2**] 10:00AM WBC-5.9# RBC-2.88* HGB-8.8* HCT-25.1* MCV-87
MCH-30.6 MCHC-35.0 RDW-23.2*
[**2176-8-2**] 10:00AM NEUTS-35* BANDS-23* LYMPHS-16* MONOS-15*
EOS-1 BASOS-0 ATYPS-0 METAS-4* MYELOS-2* PROMYELO-4* NUC RBCS-6*
[**2176-8-2**] 10:00AM HYPOCHROM-NORMAL ANISOCYT-3+ POIKILOCY-2+
MACROCYT-2+ MICROCYT-1+ POLYCHROM-2+ OVALOCYT-OCCASIONAL
SCHISTOCY-OCCASIONAL BURR-OCCASIONAL STIPPLED-OCCASIONAL
BITE-OCCASIONAL
[**2176-8-2**] 10:00AM PLT SMR-LOW PLT COUNT-123*
[**2176-8-2**] 10:00AM PT-11.4 PTT-29.7 INR(PT)-1.0
Brief Hospital Course:
Ms. [**Known lastname 107686**] is a 74 year old female with CNS lymphoma, newly
diagnosed colon CA, CAD, HTN, DM, dementia, Afib, and h/o polio,
who presents with melanotic stools, strep viridans bacteremia
and serratia UTI.
.
Melanotic stools: Ms. [**Known lastname 107686**] presented with black/melanotic
stools most consistent with an upper GI source, however an EGD
done on admission showed ulcers/erosions but no active source of
bleeding. Ms. [**Known lastname 107686**] has known colon cancer, so there may be
a component of lower GI bleeding as well. She was given 2U RBC
on admission with an appropriate hct bump. On admission she was
started on a PPI twice per day, carafate slurry and placed on a
clear liquid diet. Hematocrits were followed twice daily.
During the hospitalization she required 3 units of blood. She
received 2 units on [**8-12**] with a good bump in her hct.(25.5 to
36) After the patient cleared her MTX therapy, she underwent a
repeat EGD for reevaluation of continued melanotic stool as well
as for biopsy. The repeat EGD did not reveal any active
bleeding, only known esophagitis and gastritis. Biopsy revealed
HSV and she was started on Acyclovir 400mg 5x/day for 14days.
She will need to be followed with regular hematocrits to monitor
GI bleed.
.
CNS lymphoma: Ms. [**Known lastname 107686**] is s/p several cycles of high-dose
MTX and was due for MTX treatment on the day of admission,
however treatment was initially held due to acute GI bleeding
and recent neutropenia. During the hospitalization she was
discovered to have a strep viridans bacteremia (1/4 bottles) in
addition to her urinary tract infection. She was treated with
Ceftriaxone as above for this. ID was consulted and felt that
she was cleared to begin MTX therapy once the remaining 3blood
culture bottles remained negative for three days, making the
source of the bacteremia less likely to be endocarditis. She
began HD MTX therapy with no signs or symptoms of toxicity. She
cleared the MTX dose in 96hrs followed by 24hours of leukovorin.
She had good urine output, no nausea, vomiting and took good PO
throughout. She will follow up with Dr. [**Last Name (STitle) 4253**] on [**2176-8-21**] for
an additional cycle of chemotherapy.
.
Strep viridans bacteremia: Ms. [**Known lastname 107686**] [**Last Name (Titles) 28316**] a fever on the
day of admission and blood cultures grew Strep viridans in one
bottle of 4. A TTE was done which showed no changes from a
previous TTE, no vegetations on her valves. ID felt that a TEE
was not necessary to do as she had a likely GI source. ID felt
that as she has a GI cancer, the strep viridans was likely due
to that and not likely to be due to endocarditis. She was
treated with ceftriaxone in the hospital and will continue on
discharge to complete a course of 14 days (To be completed on
[**8-18**]).
.
UTI: The patient presented with dysuria and a positive UA on
admission. It was reported that she had relative hypotension at
rehab. Given recent neutropenia and presence of 2 central
lines, she was treated broadly with cefepime and vancomycin due
to concern for sepsis. She was given 2L of normal saline and 2U
PRBCs in the ED. During the hospitalization her white count
improved and blood cultures revealed serratia sensitive to
ceftriaxone. She was switched from cefepime and vancomycin to
ceftriaxone. The ceftriaxone also helped to treat the strep
viridans bacteremia as above. She remained afebrile throughout
the admission.
Colon CA: Ms. [**Known lastname 107686**] has recently diagnosed colon cancer. She
is currently not undergoing active treatment for this cancer,
despite the fact that it is likely contributing to current GI
bleeding, as she has been consistently guaiac positive and has
had melanotic stools in the past. Once she is clear from a
neurooncologic perspective, she should be evaluated by surgery
for possible resection of colon CA.
.
Pulmonary emboli: On admission the patient presented with
shortness of breath and hypoxia. CT scan done in the ED was
non-conclusive due to motion artifact. On review once on the
floor, her story was not consistent with PE. Bilateral lower
extremity ultrasound was negative for DVT. Hypoxia and
shortness of breath resolved on their own. She is satting well
on room air on discharge.
.
Chronic renal failure: Ms. [**Known lastname 107686**] has a baseline creatinine of
1.4-1.9 and presented to the hospital with a Cr of 1.7. Her
chronic renal failure is likely due to recent MTX therapy,
progressive HTN, and pre-renal state on admission. Her
medications were renally dosed and with rehydration, her
creatinine trended down to 1.2.
.
CAD: Ms. [**Known lastname 107686**] has a history of CABG. EKG shows V-pacing.
She did not have chest pain during the hospitalization. TTE
compared with the findings of the prior report (images
unavailable for review) of [**2175-9-27**], revealed diastolic
dysfunction of the left ventricle which is now evident;
otherwise no major change. She remained hemodynamically stable
during the hospitalization.
.
HTN: Ms. [**Known lastname 107686**] is on metoprolol and amlodipine at NH. Her
anti-hypertensives were held on admission. However, once she
was stabilized her amlodipine was restarted with good response
in blood pressure. Her beta blocker was held throughout the
hospitalization secondary to the GI bleed.
.
Diabetes Mellitus: Ms. [**Known lastname 107686**] is on 70/30 and RISS at NH.
She was maintained on a sliding scale on this hospitalization.
.
Psych: The patient has a history of depression, paxil was
maintained throughout hte hospitalization.
.
Glaucoma: The patient was kept on her home eye drops for
glaucoma.
Medications on Admission:
Paroxetine HCl 20 mg qd
Dorzolamide 2 % Drops 1 drop opthalmic [**Hospital1 **]
Latanoprost 0.005 % Drops 1 Drop Ophthalmic qhs
Folic Acid 1 mg qd
Amlodipine 10 mg qd
Metoprolol Tartrate 25 mg [**Hospital1 **]
Acetaminophen 325-650mg q4-6h PRN pain
Simethicone 80 mg qid PRN
Epoetin Alfa 4,000 units QMOWEFR
Ferrous Sulfate 325mg qd
B Complex-Vitamin C-Folic Acid 1 mg qd
Clotrimazole 10 mg Troche qid (to be d/c'd [**2176-8-10**])
Olanzapine 5 mg qhs
Dexamethasone 8 mg tid
insulin (70/30 20 units qAM and 15 units qpm, also RISS)
Neupogen 300 mcg [**Hospital1 **] until ANC>1500
Heparin 5000 U SC tid
Discharge Medications:
1. Ceftriaxone-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One
(1) g Intravenous Q24H (every 24 hours) for 4 days.
2. Paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) injection
Injection QMOWEFR (Monday -Wednesday-Friday).
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
QID (4 times a day).
10. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Dexamethasone 4 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
12. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
13. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
16. Calcium Carbonate 500 mg Tablet, Chewable Sig: 1.5 Tablet,
Chewables PO TID (3 times a day).
17. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl
Topical PRN (as needed).
18. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical PRN
(as needed).
19. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
20. Lidocaine HCl 2 % Gel Sig: One (1) Appl Urethral PRN (as
needed).
21. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO four times a day.
22. Outpatient Lab Work
Surveillance blood culture 1 week after completing antibiotics.
23. Regular insulin sliding scale
Please see attached.
24. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO 5X/D (5
times a day) for 14 days.
25. Lidocaine-Diphenhyd-[**Doctor Last Name **]-Mag-[**Doctor Last Name **] 200-25-400-40 mg/30 mL
Mouthwash Sig: Thirty (30) mL Mucous membrane every 4-6 hours
as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Primary: CNS Lymphoma
Esophagitis
Colon cancer
UTI
S. viridans bacteremia
Secondary: HTN, CAD
Discharge Condition:
Stable. Patient continues to have melanotic stool however her
hematocrit remains stable. Afebrile.
Discharge Instructions:
1. You will need to complete a 14 day course of antibiotics for
an infection of your blood (you have 4 days remaining - finish
on [**8-18**]). One week after you are finished with the antibiotics,
you will need a follow up blood culture.
2. Please take all medications as prescribed.
3. Please follow up with all outpatient appointments.
4. If you begin to feel lightheadead or weak, notice dark
stools, bright red blood in the toilet, or experience any other
concerning symptoms please [**Name6 (MD) 138**] your MD.
Followup Instructions:
Please follow up with these appointments:
1. [**Name6 (MD) **] CALL Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2176-8-20**] 11:15
2. [**Month/Day/Year **] CALL Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2176-9-24**] 11:15
3. [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Date/Time:[**2176-10-9**] 10:45
Please return to [**Hospital3 **] for treatment with Dr. [**Last Name (STitle) 4253**] on
[**2176-8-21**] for HD MTX.
|
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icd9cm
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[
[
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[
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icd9pcs
|
[
[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,369
| 135,030
|
40077
|
Discharge summary
|
report
|
Admission Date: [**2192-3-1**] Discharge Date: [**2192-3-5**]
Date of Birth: [**2107-7-26**] Sex: M
Service: MEDICINE
Allergies:
Keflex
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Bright Red Blood Per Rectum
Major Surgical or Invasive Procedure:
Upper Endoscopy
History of Present Illness:
84 yo M with CAD s/p CABG and history of recent GI bleed due to
varicies from liver disease of unknown etiology. He was admitted
to [**Hospital1 18**] from [**2192-2-8**] to [**2192-2-12**] after GI bleed and first
discovered of grade II esophageal varicies. Presents this time
following large melanic stool at home. Patient originally
presented to [**Hospital3 **] where HCT was 24, and he given 1
unit PRBC prior to transfer to [**Hospital1 18**] ED.
.
Upon arrival to the ED vitals were: T 98.8, HR 66, BP 165/92, RR
18, O2Sat 99% RA. HCT at presentation was 26.3. Dark red stool
upon rectal exam in ED. GI saw patient in ED and recommended
transfer to MICU and stated that hepatology would likely perform
endoscopy there. Vitals prior to transfer to the MICU were: HR
73, BP 160/71, O2Sat 99% 2L NC.
.
Upon arrival to MICU, patient reports that he was feeling fine
at home, but he felt sudden urge to defecate and was incontinent
of a single large bloody stool. He became concerned and went to
[**Hospital3 4107**]. He had several smaller stools prior to that
with minimal blood, and attributed these to his hemorrhoids.
Denied lightheadedness, pre-syncope, nausea, vomiting, or
abdominal pain.
.
REVIEW OF SYSTEMS:
(+)ve: melena, diarrhea, rectal bleeding
(-)ve: fever, chills, night sweats, chest pain, palpitations,
rhinorrhea, hemoptysis, dyspnea, orthopnea, paroxysmal nocturnal
dyspnea, nausea, vomiting, constipation, abdominal pain,
dysuria, urinary frequency, urinary urgency, focal numbness,
focal weakness, myalgias, arthralgias
Past Medical History:
1) Upper GI bleed with endoscopy [**2192-2-9**] showing grade II
esophageal varicies
2) Osteomyelitis at the age of 8 resulting in shortening of his
left leg
3) Hearing impairment
4) Bilateral hip replacement
5) Coronary artery bypass grafting 28 years ago
6) Pacemaker insertion three years ago (unknown indication)
7) Recent nose skin biopsy
8) Anti-K antibody, patient should receive K-antigen negative
products for all red cell transfusions
Social History:
Patient is a former professional accordian player, now retired
and lives with his second wife. [**Name (NI) **] performs own ADLs and takes
care of wife, who has spinal stenosis.
TOBACCO: Remote
ETOH: Denies
ILLLICTS: Denies
Family History:
Father: heart disease
One son died of suddent cardiac death.
Second son died in [**Country 3992**].
No family history of colon cancer or ulcers.
Physical Exam:
At admission:
VS: T 98.2, HR 70, BP 154/80, RR 18, O2Sat 100% 2L NC
GEN: NAD
HEENT: PERRL, EOMI, oral mucosa moist
NECK: Supple, no [**Doctor First Name **]
PULM: CTAB
CARD: Sternotomy scar, RR, nl S1, nl S2, II/VI murmur RUSB
ABD: BS+, soft, NT, ND, no palpable splenomegaly
EXT: Left lower leg deformity, left leg shorter than right,
trace bipedal edema
SKIN: no rashes
NEURO: Oriented x 3, no focal motor deficits, difficulty hearing
.
On discharge:
brown, formed stool
Pertinent Results:
ENDOSCOPY REPORT [**2192-3-1**]:
Impression:
-Varices at the lower third of the esophagus at 2 o'clock
position
-Varices at the lower third of the esophagus
-Congestion, petechiae and mosaic appearance in the antrum,
stomach body and fundus compatible with portal hypertensive
gastropathy
-Polyp in the stomach body
-Otherwise normal EGD to third part of the duodenum
- 3 bands were successfully placed in the lower third of the
esophagus, 1 band was could not be placed.
.
Hct stable 26.3 -> 25.6
.
INR 1.3 Cr 0.9
MELD = 9
.
On discharge:
[**2192-3-5**] 06:40AM BLOOD WBC-2.0* RBC-2.69* Hgb-9.0* Hct-25.6*
MCV-95 MCH-33.5* MCHC-35.4* RDW-17.9* Plt Ct-69*
[**2192-3-5**] 06:40AM BLOOD PT-15.4* PTT-45.9* INR(PT)-1.3*
[**2192-3-5**] 06:40AM BLOOD Glucose-94 UreaN-15 Creat-0.9 Na-138
K-3.6 Cl-106 HCO3-24 AnGap-12
[**2192-3-5**] 06:40AM BLOOD ALT-15 AST-33 AlkPhos-114 TotBili-1.4
Brief Hospital Course:
84 yoM with CAD s/p CABG and history of recent GI bleed due to
varices from liver disease of unknown etiology, p/w bloody stool
to OSH transferred for further management of care
.
#. GI bleed:
Given history of melena and known esophageal varices, was likely
upper GI source of bleeding. Hepatology performed endoscopy
shortly after patient arrived to MICU and found one cord of
grade III varicies as well as 3 cords of grade II varicies.
There was successful banding of 3 of the 4 varices. Patient also
noted to have portal hypertensive gastropathy and a stomach
polyp. There was no evidence of bleeding at time of endoscopy.
Patient was started on octreotide drip and stabilized overnight
in the MICU. He was then called out to the floor. Hematocrit
remained stable at 25.6. The patient's stools turned to brown in
color prior to discharge. He was discharged on sucralfate x 14
days, pantoprazole, cipro prophylaxis x 3 days, and nadolol 40
mg qday. He was scheduled for repeat endoscopy.
.
#. Renal and liver mass:
Abdominal U/S at last admission reported 7 cm left kidney
complex cyst and right hepatic hypodensity. Patient was due for
outpatient MRI abdomen on monday, [**3-5**]. MRI was not performed
due to the patient having an implanted pacemaker. CT Abdomen w/
contrast was scheduled in 2 weeks time prior to outpatient
follow-up appointment with hepatology.
.
#. CAD s/p CABG: No recent chest pain. Patient does not have
history of problems since his CABG in [**2162**]. Continued
rosuvastatin 5 mg daily. Aspirin was held but should be
restarted at the discretion of the [**Name6 (MD) 228**] primary MD.
.
#. Hypertension: Patient presented to MICU with BP elevated. Was
not on an anti-hypertensive regimen at home. He was started on
nadolol 40 mg qday upon discharge and was tolerating this
medication well.
.
#. Pancytopenia:
Unknown reason for pancytopenia, though stable from last
admission. Potential for patient to have MDS. Patient may
require hematology follow-up if abnormalities persist.
.
Transitional Issues:
- repeat endoscopy
- continuing nadolol therapy as tolerated
- CT scan for HCC screening
Medications on Admission:
*from recent discharge [**2192-2-12**], confirmed with [**Company **]
pharmacy*
1) sucralfate 1 gram PO QID
2) lansoprazole 20 mg PO Q24H
4) tamsulosin 0.4 mg PO HS
5) rosuvastatin 5 mg PO DAILY
6) multivitamin PO DAILY
7) furosemide 20 mg DAILY
Discharge Medications:
1. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day) for 10 days: Last day is [**3-15**]. .
Disp:*40 Tablet(s)* Refills:*0*
2. ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 3 days.
Disp:*12 Tablet(s)* Refills:*0*
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
5. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. multivitamin Tablet Sig: One (1) Tablet PO once a day.
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
GI Bleeding
.
Secondary:
Cryptogenic cirrhosis c/b portal hypertension and grade III
varices
CAd s/p CABG
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted for a gastrointestinal bleed.
You had a repeat endoscopy, which showed dilated veins in your
esophagus (esophageal varices) but no signs of bleeding. Your
hematocrit was stable throughout your admission and you did not
require a blood transfusion. We started a medication called
nadolol to help prevent the varices from bleeding.
.
We made the following changes to your medications:
We STARTED Ciprofloxacin (antibiotic) to be taken for 3 more
days; last day is [**2192-3-7**]
We CONTINUED Sucralfate to be taken until [**2192-3-15**]
We STARTED Nadolol 40 mg per day to be continued indefinitely to
help prevent bleeding
.
Your follow-up information is listed below. You will need a
repeat endoscopy (information below) as well as a CT scan of
your abdomen.
Followup Instructions:
Department: RADIOLOGY
When: MONDAY [**2192-3-19**] at 10:00 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: DIGESTIVE DISEASE CENTER
When: MONDAY [**2192-3-26**] at 2:30 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**]
Campus: EAST Best Parking: Main Garage
Department: ENDO SUITES
When: MONDAY [**2192-3-26**] at 2:30 PM
[**2192-4-4**] 08:20a
[**Last Name (LF) **],[**First Name3 (LF) **] (LIVER CENTER)
LM [**Hospital Ward Name **] BLDG ([**Doctor First Name **]), [**Location (un) **]
LIVER CENTER (SB)
|
[
"572.3",
"537.89",
"V43.64",
"600.00",
"211.1",
"456.20",
"414.00",
"284.1",
"571.5",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.33"
] |
icd9pcs
|
[
[
[]
]
] |
7452, 7458
|
4170, 6182
|
292, 310
|
7617, 7617
|
3266, 3792
|
8630, 9516
|
2610, 2757
|
6590, 7429
|
7479, 7596
|
6319, 6567
|
7768, 8201
|
2772, 3211
|
3806, 4147
|
6203, 6293
|
8230, 8607
|
1558, 1883
|
225, 254
|
338, 1539
|
7632, 7744
|
1905, 2351
|
2367, 2594
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,518
| 129,150
|
20319+20320
|
Discharge summary
|
report+report
|
Admission Date: [**2152-4-7**] Discharge Date: [**2152-4-12**]
Date of Birth: [**2122-1-24**] Sex: M
Service: [**Last Name (un) **]
ADMISSION DIAGNOSIS: Elevated creatinine.
HISTORY OF PRESENT ILLNESS: The patient is a 29 year old
male status post renal transplant x3, first one in [**2136**], for
end stage renal disease from vesicoureteral reflux, then had
another transplant in [**2136**], due to acute rejection and third
[**2152-2-29**], due to chronic graft nephropathy. The patient had
surgery recently on [**2152-3-28**], of a living donor kidney
transplant. The patient discharged to home on [**2152-3-31**].
Postoperatively, the patient had constipation, decreased
appetite, but doing well otherwise. The patient came in
yesterday for follow-up, routine laboratories drawn and the
results demonstrated a creatinine from 1.0 on [**2152-4-3**],
to 4.9 on [**2152-4-6**].
The patient was asked to come in today on [**2152-4-7**], for
kidney biopsy because of elevated creatinine. Ultrasound
demonstrated mild hydronephrosis. No calculus seen. Renal
artery and vein patent. Indices 0.65.
The patient admitted for increased creatinine.
PAST MEDICAL HISTORY: History of vesicoureteral reflux with
end stage renal disease, status post renal transplant in
[**2136**], x2.
Hypercholesterolemia.
Hypertension.
Right knee chondromalacia.
Status post living donor kidney transplant [**2152-3-28**],
due to end stage renal disease.
ALLERGIES: HMG-CoA reductase inhibitor.
MEDICATIONS ON ADMISSION:
1. Prograf 4 mg b.i.d.
2. Prednisone 5 mg daily.
3. Bactrim single strength 1 daily.
4. Cefazolin b.i.d.
5. Colace 100 mg b.i.d.
6. Nystatin 5 mg q.i.d.
7. Valcyte 900 mg daily.
8. Famotidine 20 mg b.i.d.
9. Neutra-phos 2 mg b.i.d.
SOCIAL HISTORY: Married. Alcohol rarely. No tobacco. No
recreational drugs.
FAMILY HISTORY: Mother has hypertension. Maternal
grandmother early myocardial infarction.
REVIEW OF SYSTEMS: No fever, no chills, no nausea, vomiting,
positive constipation, no change in urination, no edema, no
lethargy.
PHYSICAL EXAMINATION: The patient is awake and alert, laying
supine in bed, afebrile. Vital signs are stable. Weight 58.6.
HEENT - The pupils are equal, round and reactive to light and
accommodation. Extraocular movements are full. Mouth - tongue
midline, no exudates. Neck supple, no palpable nodes, no
thyromegaly, no carotid bruits bilaterally. Cardiovascular
regular rate and rhythm, normal S1 and S2, without murmurs.
Lungs clear to auscultation on both sides bilaterally.
Abdomen positive bowel sounds, soft, slightly tender right
lower quadrant, stable incision which is clean, dry and
intact. No flank pain bilaterally. Biopsy site clean, dry and
intact. Extremities - No cyanosis, clubbing or edema,
2+ pulses, dorsalis pedis and posterior tibialis bilaterally.
Cranial nerves II through XII are intact.
HOSPITAL COURSE: The patient was admitted, IV fluids. On
[**2152-4-8**], the patient had a nuclear medicine scan
demonstrating no visualized excretion from the transplanted
kidney to the urinary bladder. The possibility indicates
postsurgical ATN versus an imperforate ureter. Tracer uptake
of the urinary bladder presumably from residual activity of
old renal transplant within the left lower quadrant. The
patient also received a dose of ___________________ 325 mg/kg
IV and also IVIG 1 gram/kg. On hospital day #1, BUN 44 and
creatinine 5.8 and the next day decreased to 29 and
creatinine 3.0 on [**2152-4-9**]. The patient continued to be
hydrated. On [**2152-4-9**], the patient had a nephrostogram
and nephrostomy tube placement demonstrating mild
hydronephrosis of the transplanted kidney with suggestion of
probable narrowing at the anastomosis of the ureter and the
bladder. The patient had an uncomplicated nephrostomy tube
placement. On [**2152-4-12**], the patient went for another
study in which nephrostomy tube was converted to
nephroureteric stent and it was successfully exchanged with
an internal-external 8French 12 centimeter nephroureteric
stent. On [**2152-4-12**], pertinent laboratories showed
sodium 132, potassium 4.4, chloride 106, bicarbonate 19, BUN
4 and creatinine 1.0 with a glucose of 94. The patient's
tacrolimus level since being in the hospital on [**2152-4-6**], was 13.6, [**2152-4-9**], 8.2, [**2152-4-10**], 14.2,
[**2152-4-11**], 14.1, and [**2152-4-12**], 13.5. The patient
does well overnight and afebrile, urinating well. The patient
will be able to go home.
MEDICATIONS ON DISCHARGE:
1. Tylenol 325/650 p.o. every 4-6 hours p.r.n.
2. Aluminum magnesium hydroxy simethicone 15 to 30 mg p.o.
q.i.d. p.r.n.
3. Calcium Carbonate 500 mg q.i.d. as needed.
4. Levofloxacin 500 mg every 24 hours.
5. MMF 1000 b.i.d.
6. Nystatin oral suspension 5 mg q.i.d.
7. Prednisone 5 mg daily.
8. Famotidine 20 mg b.i.d.
9. Ferrous Sulfate 325 mg daily.
10. Epogen 4000 units Monday, Wednesday and Friday.
11. Bactrim single strength one tablet daily.
12. Tacrolimus 3 mg b.i.d.
13. Valganciclovir HCl 450 daily.
The patient is to have laboratories drawn every Monday and
Thursday for a CBC, Chem7, AST, total bilirubin, calcium,
phosphorus, albumin and a Prograf trough. Results should be
faxed immediately to transplant office at [**Telephone/Fax (1) 54522**].
FOLLOW UP: Appointments with Dr. [**Last Name (STitle) **] in the [**Hospital Unit Name 20119**] [**2152-4-17**], at 11:10 a.m. Please call [**Telephone/Fax (1) 54523**] as difficulty with an appointment. Also, follow-up with
Dr. _______________on [**2152-4-25**], at 3:40 p.m. in the
[**Hospital Unit Name **] in the transplant office. Also
________________on [**2152-5-1**], at 11:00 a.m.
MAJOR SURGICAL INVASIVE PROCEDURES: Kidney biopsy [**2152-4-7**].
Nephrostomy tube placement and nephrostogram with placement
of a nephroureteric stent on [**2152-4-12**].
[**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 4841**]
Dictated By:[**Last Name (NamePattern1) 4835**]
MEDQUIST36
D: [**2152-4-12**] 20:22:49
T: [**2152-4-12**] 22:05:41
Job#: [**Job Number 54524**]
Admission Date: [**2152-4-7**] Discharge Date: [**2152-4-13**]
Date of Birth: [**2122-1-24**] Sex: M
Service: SURGERY
Allergies:
Hmg-Coa Reductase Inhibitors
Attending:[**First Name3 (LF) 3127**]
Chief Complaint:
elevated creatinine
Major Surgical or Invasive Procedure:
kidney biopsy [**2152-4-7**]
renal scan
nephrostomy tube
History of Present Illness:
Admitted s/p transplant kidney biopsy under ultrasound after
creatinine was noted to be elevated to 5.6. Baseline was _______
since living unrelated kidney transplant from father in law
3.29/05. He did complain of some abdominal discomfort with
urinary urgency.
Past Medical History:
1. s/p renal transplant ([**2136**]) secondary to ESRD from
Vesicoureteral reflux
2. Chronic renal allograft rejection ([**2144-7-31**])
3. Hypercholesterolemia
4. Hypertension
5. Right knee chondromyalasia
Pertinent Results:
[**2152-4-7**] 01:45PM GLUCOSE-123* UREA N-40* CREAT-5.6* SODIUM-138
POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-21* ANION GAP-14
[**2152-4-7**] 01:45PM ALBUMIN-3.3* CALCIUM-6.8* PHOSPHATE-2.1*
MAGNESIUM-1.9
[**2152-4-7**] 01:45PM WBC-8.6 RBC-3.36* HGB-8.3* HCT-25.4* MCV-76*
MCH-24.6* MCHC-32.5 RDW-15.6*
[**2152-4-7**] 01:45PM PLT COUNT-381
[**2152-4-7**] 01:45PM PT-13.2 PTT-22.5 INR(PT)-1.1
[**2152-4-7**] 04:20PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2152-4-7**] 04:20PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2152-4-7**] 04:20PM URINE RBC-[**3-4**]* WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2152-4-6**] 03:45PM UREA N-39* CREAT-4.9*# SODIUM-136
POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-23 ANION GAP-16
[**2152-4-6**] 03:45PM ALT(SGPT)-57* AST(SGOT)-36 TOT BILI-0.4
[**2152-4-6**] 03:45PM FK506-13.6
[**2152-4-6**] 03:45PM URINE HOURS-RANDOM CREAT-38 TOT PROT-38
PROT/CREA-1.0*
[**2152-4-6**] 03:45PM WBC-6.9 RBC-3.40* HGB-8.7* HCT-26.1* MCV-77*
MCH-25.7* MCHC-33.4 RDW-15.7*
[**2152-4-6**] 03:45PM PLT COUNT-359
[**2152-4-6**] 03:45PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.005
[**2152-4-6**] 03:45PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2152-4-6**] 03:45PM URINE RBC-9* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2152-4-6**] 03:45PM URINE MUCOUS-RARE
Brief Hospital Course:
Admitted to transplant unit s/p transplant kidney biopsy in
ultrasound. Biopsy performed due to elevated creatinine of 5.3.
His creatinine had dropped to as low as 1.0 post transplant. The
ultrasound findings revealed comparison with prior study dated
[**2152-3-29**], the small amount of perinephric fluid surrounding
the transplant kidney was unchanged, however, there was new mild
hydronephrosis. The renal artery and renal vein were widely
patent, and resistive indices within the intrarenal arterial
branches were approximately 0.65. The urinary bladder appearance
was unremarkable, although there was slight prominence of the
ureteric insertion site.
IMPRESSION:
1) New mild hydronephrosis. Stable resistive indices within the
renal artery branches.
The concern for acute cellular rejection vs. antibody mediated
rejection vs. structural problems were raised and evaluated by
doing a renal scan. This scan revealed early and dense tracer
uptake within the new transplant
kidney in the right upper quadrant, without evidence of leak.
There was good
cortical uptake and filling of the calyces, but there was no
evidence of tracer
excretion. Limited tracer uptake was also seen within the old
transplant kidney
in the patient's left lower quadrant. On delayed imaging, there
was tracer
excretion from the kidney in the left lower quadrant to the
urinary bladder.
IMPRESSION: No visualized excretion from new transplant kidney
to the urinary
bladder. This possibly indicates postsurgical ATN versus an
imperforate ureter.
Tracer uptake of the urinary bladder presumably from residual
activity of old
renal transplant within left lower quadrant.
Given the concern for an antibody mediated rejection for which
this patient was at high risk given a third kidney transplant,
IV Rituximab was given as well as IVIG. The patient was
transfered to the ICU for monitoring of his vital signs during
the rituximab infusion. A foley catheter was placed to decomress
the bladder as well as record urinary output.
Medications on Admission:
prednisone 5mg po qd, bactrim ss 1 po qd, cellcept 1 gram [**Hospital1 **],
colace 100mg [**Hospital1 **], kayexalate prn, nystatin 5ml po qid, valcyte
900mg qd, famotidine 20mg [**Hospital1 **], prograf, neutraphos
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. Epoetin Alfa 4,000 unit/mL Solution Sig: 4000U Injection
QMOWEFR (Monday -Wednesday-Friday).
12. Valganciclovir HCl 450 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
13. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
Disp:*5 Tablet(s)* Refills:*0*
14. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO BID (2
times a day).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
elevated creatinine s/p living unrelated kidney translant
[**2152-3-28**]
Discharge Condition:
stable
Discharge Instructions:
call transplant office if fevers, chills, nausea, vomiting, lack
of urine output via nephrostomy tube or inability to urinate,
abdominal pain.
Lab draw every Monday & Thursday for cbc, chem 7, ast, t.bili,
calcium, phosphorus, albumin and trough prograf level. Results
to be fax'd asap to transplant office at [**Telephone/Fax (1) 697**]
Followup Instructions:
Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2152-4-17**] 11:10
Provider: [**Name10 (NameIs) 2106**],[**Name11 (NameIs) 2105**] TRANSPLANT MEDICINE (NHB) Where: LM
[**Hospital Unit Name 5628**] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2152-4-25**]
3:40
Provider: [**Name10 (NameIs) 454**],TEN DAY CARE [**Hospital Ward Name **] 8 Where: DAY CARE [**Hospital Ward Name **] 8
Date/Time:[**2152-5-1**] 11:00
Completed by:[**2152-4-13**]
|
[
"401.9",
"996.81",
"591",
"584.9",
"272.0",
"E878.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"87.75",
"55.23",
"55.03",
"59.8"
] |
icd9pcs
|
[
[
[]
]
] |
12007, 12065
|
8501, 10511
|
6410, 6469
|
12183, 12191
|
7009, 8478
|
12577, 13145
|
1860, 1936
|
10777, 11984
|
12086, 12162
|
4515, 5299
|
10537, 10754
|
2902, 4489
|
12215, 12554
|
5311, 6334
|
2092, 2884
|
175, 197
|
1956, 2069
|
6351, 6372
|
6497, 6760
|
6782, 6990
|
1782, 1843
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,873
| 187,469
|
34748
|
Discharge summary
|
report
|
Admission Date: [**2151-11-1**] Discharge Date: [**2151-11-9**]
Date of Birth: [**2086-2-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Percocet
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Esophageal Cancer
Major Surgical or Invasive Procedure:
[**2151-11-1**]: [**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **] esophagectomy (laparoscopy,
thoracoscopic mobilization of esophagus, and intrathoracic
esophagogastric anastomosis).
History of Present Illness:
The patient is a 65-year-old male with a T3, N0 esophageal
adenocarcinoma of the
gastroesophageal junction. He received induction chemoradiation
therapy and is being admitted for esophagectomy.
Social History:
Married live with wife.
[**Name (NI) 1139**]: [**12-9**] pack-40 years, quit [**2151-5-9**], ETOH: occasional
drink
Family History:
non-contributory
Physical Exam:
VS: T: 97.2 HR: 84 SR BP: 122/72 Sats: 95% RA
General: 65 year-old male no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple, no lymphadenopathy
Card: RRR, normal S1, S2 no murmur/gallop or rub
Resp: breath diminished but clear
GI: bowel sounds positive, abdomen soft non-tender/non-distended
Extr: warm no edema
Skin: Right flank induration/erythema. no warmth.
Incision: right abdominal/chest site clean dry intact
Neuro: non-focal
Pertinent Results:
[**2151-11-9**] WBC-6.8 RBC-3.68* Hgb-11.5* Hct-32.4* Plt Ct-398
[**2151-11-7**] WBC-6.5 RBC-3.89* Hgb-12.1* Hct-34.1* Plt Ct-286#
[**2151-11-1**] WBC-9.1 RBC-3.98* Hgb-12.3* Hct-35.8* Plt Ct-180
[**2151-11-8**] Glucose-123* UreaN-16 Creat-0.6 Na-137 K-4.4 Cl-100
HCO3-31
[**2151-11-6**] Glucose-107* UreaN-16 Creat-0.6 Na-139 K-3.6 Cl-100
[**2151-11-1**] Glucose-154* UreaN-19 Creat-0.7 Na-138 K-4.6 Cl-105
HCO3-25
MRSA SCREEN (Final [**2151-11-4**]): No MRSA isolated.
[**2151-11-8**]: Esophagus study: IMPRESSION: Status post esophagectomy
with no evidence for leak or obstruction.
[**2151-11-6**]: CXR: There is a small right pleural effusion with
right lower lobe atelectasis. Small left pleural effusion and
left lower lobe atelectasis.
Brief Hospital Course:
Mr. [**Known lastname 1137**] was admitted on [**2151-11-1**] and taken to the operating
room for [**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **] esophagectomy (laparoscopy, thoracoscopic
mobilization of esophagus, and intrathoracic esophagogastric
anastomosis). He tolerated the procedure, was transferred to
the SICU. While in the SICU he responded to a fluid
resuscitation for hypotension. He was extubated without
difficulty. The acute pain service managed his with pain with
an Bupivicaine Epidural.
POD1 he transferred to the floor. The chest-tube and
nasogastric tube were placed to low wall suction. A Dilaudid
PCA was started for better pain control.
Tube feeds were started at 20cc/hr.
POD2 the NG tube accidently came out. The tube feeds were
increased to 40cc which he tolerated. He ambulated in the room.
POD3 the [**Doctor Last Name **] drain was removed and a follow-up chest x-ray
revealed no pneumothorax
POD4-5 his tube feeds were increased to goal and cycled
POD6 He was seen physical therapy who deemed him safe for home.
The epidural was removed and he voided without difficulty. His
pain was well controlled with Dilaudid PCA.
POD7 He had an esophagus study which revealed no anastamotic
leak. He was started on a full liquid diet which he tolerated.
His right flank region was noted to have mild edema, slight
erythema/tender, no warmth. He was started on Clindamycin x 7
days. He was converted to PO Dilaudid with good pain control.
POD8 He had an abdominal/pelvic CT for the right flank and it
showed tissue edema, no hematoma or infection. His wife was
taught tube feed teaching and flushing. He continued to ambulate
in the halls and was discharged to home with VNA. He will
follow-up with Dr. [**First Name (STitle) **] as an outpatient.
Medications on Admission:
Tenoretic 50-25mg daily, allopurinol 300mg daily, lipitor 20mg
daily, nexium 20mg daily, ativan 0.5 q4-6prn
Discharge Medications:
1. Tube Feeds
Isosource Full strength; Goal rate: 100 ml/hr
Cycle start: 1500 Cycle end: 0900
2. Prevacid SoluTab 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
3. Hydromorphone 2 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
4. Tenoretic 50 50-25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a
day.
5. Allopurinol 300 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day:
hold until seen by Dr. [**First Name (STitle) **].
6. Docusate Sodium 50 mg/5 mL Liquid [**First Name (STitle) **]: Five (5) PO BID (2
times a day) as needed for constipation.
7. Clindamycin Palmitate 75 mg/5 mL Recon Soln [**First Name (STitle) **]: Twenty (20)
ML PO every six (6) hours for 5 days.
Disp:*400 ML* Refills:*0*
8. Lipitor 20 mg Tablet [**First Name (STitle) **]: One (1) Tablet PO once a day.
9. [**Doctor First Name **] 60 mg Tablet [**Doctor First Name **]: One (1) Tablet PO once a day.
10. Meclizine 25 mg Tablet [**Doctor First Name **]: One (1) Tablet PO once a day as
needed for dizziness.
11. Ambien 10 mg Tablet [**Doctor First Name **]: One (1) Tablet PO at bedtime as
needed for insomnia.
12. Sodium Fluoride 1.1 % Cream [**Doctor First Name **]: One (1) Dental twice a
day: apply as directed.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Esophageal Cancer
GERD
Hypertension/Hyperlipidemia
L5-S1 disc herniation s/p surgery.
Discharge Condition:
stable
Discharge Instructions:
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if experience:
-Fevers > 101 or chills
-Increased cough, or chest pain
-Nausea, vomiting, diarrhea, abdominal pain
-Incision develops drainage.
-J-tube: call with any questions or concerns. Should tube fall
out call immediately to have it replaced.
-Flush J-tube with 50cc water every 6 hours or more to maintain
patency.
-No medications through J-tube unless it is liquid.
-Daily weights: keep log bring to your appointment.
-Head of bed elevated 30 degrees at all times (wedge under
mattress)
-Yogurt while taking clindamycin. Please call if develops
diarrhea
Followup Instructions:
Follow-up with Dr. [**First Name4 (NamePattern1) **] [**2154-11-22**]:00am on the [**Hospital Ward Name 516**]
[**Hospital Ward Name 23**] Clinical Center [**Location (un) **].
Report to the [**Location (un) 861**] Radiology Department for a Chest X-Ray
45 minutes before your appointment.
Completed by:[**2151-11-10**]
|
[
"530.81",
"458.29",
"401.9",
"272.4",
"151.0",
"782.8",
"519.3",
"E879.2",
"338.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.52",
"96.6",
"43.5",
"42.41",
"46.39",
"40.3"
] |
icd9pcs
|
[
[
[]
]
] |
5596, 5645
|
2172, 3976
|
306, 505
|
5775, 5784
|
1398, 2149
|
6462, 6784
|
879, 897
|
4134, 5573
|
5666, 5754
|
4002, 4111
|
5808, 6439
|
912, 1379
|
249, 268
|
533, 729
|
745, 863
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,028
| 164,696
|
50804
|
Discharge summary
|
report
|
Admission Date: [**2108-1-28**] Discharge Date: [**2108-1-31**]
Date of Birth: [**2062-11-12**] Sex: F
Service: CRITICAL CARE
DISCHARGE DIAGNOSIS:
1. Diarrhea.
2. Hypotension.
HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old
lady who is known to have down's syndrome, ...............
cirrhosis, portal hypertension, and seizure disorder. She
was admitted on [**2108-1-26**], at [**Hospital **] [**Hospital 1459**]
Hospital with diarrhea, volume depletion, increasing sodium,
and lethargy. She required Dopamine to treat the
hypotension, and a diagnosis of possible GI bleed was
considered.
There was no history of hematemesis. No history of bright
red blood per rectum. She gave a history of passing black
stools, but the patient has been on iron to treat chronic
anemia. Some days prior to the admission, the patient had
been on antibiotics, Zithromax, for upper respiratory tract
infection. Her diarrhea was reduced at the time of admission
to our hospital, and the stool tested positive for hemoccult,
but there was no evidence of active bleed at this time.
PAST MEDICAL HISTORY: Down's syndrome. Cirrhosis of the
liver since childhood with unclear etiology. History of
Port-A-Cava shunt in childhood. History of esophageal
varices. Status post ................ therapy in [**2100**].
Hemorrhoidal varices status post ligation. Insulin-dependent
diabetes mellitus. Seizure disorder. Dementia.
Alzheimer's.
CURRENT MEDICATIONS: Tegretol 200 mg p.o. t.i.d., Protonix
40 mg IV twice a day, Dopamine infusion, Insulin, Flagyl 500
mg p.o. 3 times a day.
LABORATORY DATA: Hematocrit remained stable at 33.5, white
blood cell count 8.2, platelet count 215; INR 1.1, PT 12.6,
PTT 27.2; sodium 141, potassium 3.8, chloride 107, bicarb 23,
creatinine 0.7, glucose 111; Tegretol level was in
therapeutic range at 8.2.
Chest x-ray showed patchy opacities in the right mid and
lower lobe and also the left lower zone in the retrocardiac
area. This also showed atelectasis and possible
consolidation, and clinical correlation was recommended.
The first set of stools was negative for C-diff toxin assay.
HOSPITAL COURSE: GI consult was obtained during her stay.
Their recommendations were to continue intravenous fluids, to
correct the hyponatremia, sent stools for C-diff times three
and culture, Flagyl 500 mg 3 times a day, and to continue
Protonix 40 mg once a day. They also indicated that there
was urgent indication for upper GI endoscopy at this point.
During her stay, she remained afebrile. Her heart rate has
been 85-93, and at the time of this dictation, the patient
has been off Inotropes for more than 24 hours, and her blood
pressure has been very stable. Systolic blood pressure has
been between 100 and 120 with a diastolic in the 50s. She
was not tachycardiac. Heart rate is between 70 and 80 beats
per minute. Her oxygen saturation were 97-100% on room air.
Respiratory rate was from 14-18/min.
PHYSICAL EXAMINATION: General: She was awake and alert.
She was moving all extremities. Chest: Air entry
bilaterally and equal. There was no wheeze. Cardiovascular:
S1 and S2 heard. Abdomen: Soft. There was a site of an old
surgical scar seen in the left subcostal area. Extremities:
Warm and well perfused. She had no peripheral edema. Skin:
Intact. She developed a skin rash during her stay which was
thought to be from the Flagyl. This cleared with one dose of
Benadryl, and she has had no other signs and symptoms to
suggest any other drug allergy.
DISCHARGE PLAN: The patient is to continue on all her usual
medications including Tegretol which has been reduced down to
200 mg three times a day. She is to continue Flagyl 500 mg
p.o. 3 times a day for seven days, and all of her usual
medications which include Lasix 80 mg, Aldactone 60 mg b.i.d.
Dr. [**Last Name (STitle) 5448**] was [**Name (NI) 653**], and the patient and her caregiver
will follow-up with Dr. [**Last Name (STitle) 5448**] regarding sending another
stool sample to assess for C-diff, and if these stool samples
are negative for C-diff, then the patient can stop taking the
Flagyl. Once sample has already tested negative in the [**Hospital6 1760**] at this time. The rest of
the culture results are still pending.
Respiratory wise, there was radiological evidence of
atelectasis; clinically there was no evidence of respiratory
distress or fever, or white blood cell count to suggest any
active pulmonary infection. Dr. [**Last Name (STitle) 5448**] is aware of the
radiological changes and will be keeping a close eye on the
temperature, and if there is any evidence of respiratory
involvement, the patient might need antibiotics to treat the
possible consolidation.
Regarding the treatment of seizure disorder, the patient is
presently on Tegretol 200 mg 3 times a day, and the Tegretol
levels are therapeutic at this time. If she has seizures
despite, the patient's caregiver decided that she would
follow-up with her usual neurologist in ................, and
we did offer a neurology appointment with our neurological
services here at [**Hospital6 256**]. The
patient's caregiver will discuss this with the patient's
family and decide whether a change in neurology service is
deemed appropriate at a later date.
SUGGESTIONS: The patient caregiver has been advised to give
a bland diet and give plenty of oral fluids to the patient,
and until the symptoms resolve, avoid dairy products as these
may aggravate the diarrhea.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Name8 (MD) 35814**]
MEDQUIST36
D: [**2108-1-31**] 11:27
T: [**2108-1-31**] 12:06
JOB#: [**Job Number 105654**]
|
[
"758.0",
"780.39",
"456.21",
"572.3",
"571.5",
"789.5",
"276.1",
"787.91",
"250.01"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
168, 200
|
2168, 2969
|
2992, 3537
|
1481, 2150
|
229, 1102
|
3554, 5733
|
1125, 1459
|
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