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7,908
| 182,396
|
14180
|
Discharge summary
|
report
|
Admission Date: [**2167-10-25**] Discharge Date: [**2167-10-31**]
Date of Birth: [**2121-7-14**] Sex: M
Service:
HISTORY OF THE PRESENT ILLNESS: This is a 46-year-old man
with a history of genotype 3A hepatitis C, alcohol abuse, and
cirrhosis, chronic renal insufficiency, hypertension, with
multiple hospitalizations secondary to complications of
cirrhosis who presents with lethargy and with one episode of
hematemesis. The patient reports not feeling well for the
past two to three days. He describes feeling fatigued and
sleepy. Yesterday, the patient developed intermittent
nausea, headache, and abdominal pain.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], M.D. [**MD Number(2) 22654**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2167-11-1**] 03:43
T: [**2167-11-3**] 12:09
JOB#: [**Job Number 42194**]
|
[
"070.54",
"585",
"287.5",
"572.2",
"571.2",
"038.49",
"584.9",
"785.52",
"578.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.33",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,495
| 160,504
|
27887
|
Discharge summary
|
report
|
Admission Date: [**2121-6-3**] Discharge Date: [**2121-6-20**]
Date of Birth: [**2063-3-5**] Sex: M
Service: MEDICINE
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
shock, acute respiratory failure, acute renal failure, STEMI,
rhabdomyolysis, seizure.
Major Surgical or Invasive Procedure:
[**2121-6-6**] - temporary hemodialysis line placement. Discontinued on
[**2121-6-18**].
[**2121-6-18**] - tunneled hemodialysis line placement.
[**2121-6-20**] - Fiberoptic Endoscopic Evaluation of Swallowing.
History of Present Illness:
58M h/o meningioma w/ recent radiation therapy found
unresponsive on bathroom floor by home health aide ~ 20:30, and
had last been seen 8 hours prior. At the time, only groaning to
deep noxious stimuli, BP 70s, transported via ambulance to OSH,
where he was intubated upon arrival for decreased level of
consciousness and vomiting/aspiration.
.
CT head at OSH showed known tumor, otherwise no bleed. Abd
pelvis CT showed RLL infiltrate. At OSH given 5L and dopamine
for hypotension, Nadir SBP 62. Urine tea colored. Noted to be
subtherapeutic on dilantin and given a one gram load.
.
Transferred to [**Hospital1 18**] ED, where he continued to receive 7L NS,
and was started on levophed for additional pressor support.
Given 100mcg fentanyl prior to transfer to MICU.
Past Medical History:
Seizure disorder: First seizure [**2120-3-3**], second seizure
[**2120-12-23**]
Meningioma (details unknown) - Baseline unequal pupils per ED
note.
s/p Craniotomy
GERD
MRSA
Social History:
Lives with wife, [**Name (NI) **] [**Name (NI) **] [**Known lastname 5395**], in [**Name (NI) **]. Daughter works
in [**Location (un) 2725**].
Family History:
No relavent at this time.
Physical Exam:
On admission to ICU:
Physical Exam:
VS: T: 98.6; HR: 71; BP: 100/69; Vent: AC 600/14/.50/5
Gen: Intubated, sedated.
HEENT: MMM.
Neck: right subclavian line c/d/i.
CV: RRR S1S2. Difficult to auscultate
Lungs: CTA bilaterally anteriorly
GU: engorged scrotum
Abd: +BS. soft, NT, nd
Ext: +2 b/l LE edema pitting. DP 1+. Right fem: dialysis line.
C/D/I
Neuro: intubated, sedated
Pertinent Results:
[**2121-6-20**] 06:23AM BLOOD WBC-10.5 RBC-3.20* Hgb-9.8* Hct-28.1*
MCV-88 MCH-30.6 MCHC-34.9 RDW-13.9 Plt Ct-370
[**2121-6-3**] 03:26AM BLOOD WBC-15.3* RBC-5.89 Hgb-19.3* Hct-52.8*
MCV-90 MCH-32.7* MCHC-36.4* RDW-13.8 Plt Ct-232
[**2121-6-20**] 06:23AM BLOOD Glucose-101 UreaN-72* Creat-8.1* Na-142
K-4.7 Cl-103 HCO3-27 AnGap-17
[**2121-6-3**] 03:26AM BLOOD Glucose-186* UreaN-21* Creat-1.6* Na-136
K-8.9* Cl-105 HCO3-17* AnGap-23*
[**2121-6-3**] 03:26AM BLOOD ALT-323* AST-1303* LD(LDH)-2980*
CK(CPK)-[**Numeric Identifier 67949**]* AlkPhos-75 Amylase-132* TotBili-0.5
[**2121-6-8**] 04:43AM BLOOD ALT-130* AST-173* CK(CPK)-3297*
AlkPhos-81 Amylase-381* TotBili-0.2
[**2121-6-3**] 10:21PM BLOOD CK-MB-194* MB Indx-0.3 cTropnT-5.17*
[**2121-6-4**] 04:48AM BLOOD CK-MB-127* MB Indx-0.3 cTropnT-5.09*
[**2121-6-4**] 04:42PM BLOOD CK-MB-71* MB Indx-0.3 cTropnT-4.40*
[**2121-6-3**] 05:20AM BLOOD Type-ART pO2-60* pCO2-34* pH-7.29*
calTCO2-17* Base XS--8
[**2121-6-13**] 05:33AM BLOOD Type-ART Temp-37.8 PEEP-5 FiO2-40 pO2-91
pCO2-43 pH-7.43 calTCO2-29 Base XS-3
CT HEAD W/O CONTRAST [**2121-6-3**]:
1. Extra-axial hemorrhage adjacent to the right cerebellum in
the patient's post-surgical site. Additional focus of
hyperdensity is seen in the right temporal lobe.
2. Hypodensity within the brain parenchyma at the surgical site
may represent edema or encephalomalacic changes.
ECG Study Date of [**2121-6-3**] 2:24:46
Sinus rhythm. Technical baseline artifact. Non-specific ST
segment
abnormalities. No previous tracing available for comparison.
ECHO Study Date of [**2121-6-3**]:
Left ventricular wall thicknesses and cavity size are normal.
Overall left ventricular systolic function is severely depressed
with global hypokinesis and akinesis of the infero-lateral,
inferior and infero-septal segments. No masses or thrombi are
seen in the left ventricle. There is mild global right
ventricular free wall hypokinesis. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. There is no valvular aortic stenosis. The
increased transaortic gradient is likely related to high cardiac
output. The mitral valve leaflets are structurally normal.
Trivial mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
EEG Study Date of [**2121-6-4**]
Abnormal portable EEG due to the focal slowing with some
sharp features in the right frontal region and due to the slow
background and bursts of generalized slowing. The right frontal
slowing
suggests a focal subcortical dysfunction there. Nevertheless,
the
higher voltages and sharper features could be due to the skull
defect
from earlier surgery, and there were no clearly epileptiform
features.
The other abnormalities signify a widespread encephalopathy.
Medications, metabolic disturbances, and infection are among the
most
common causes.
CT HEAD W/O CONTRAST [**2121-6-18**] 4:27 PM
No new acute intracranial hemorrhage. Minimal increase in
ventricular size compared to the prior examination.
Brief Hospital Course:
.
Upon admission to the MICU late on the night of [**2121-6-3**], pt was
hypotensive (BPs=80s/60s) and unresponsive requiring ventilatory
support. Initially, pt was treated with aggressive fluid
resuscitation (ultimately +31L), and pressor support (levophed +
vasopressin), which were weaned off completely by [**2121-6-5**]. The
etiology of shock was felt likely secondary to seizure (given
history of recent radiation therapy for meningioma at [**Hospital1 112**]),
resulting in prolonged hypotension, which subsequently resulted
in ARF (creatinine=1.6->5.2 ), STEMI (troponin peak=7.97),
rhabdomyolysis (ck=96,400), and hypoxia (ABG=7.29/34/60)
requiring ventilatory support.
.
Initial fluid support included bicarb in order to alkalinize the
urine, however pt's urine output was minimal (<10cc/hr),
resulting in progressive volume overload. TTE showed poor
LVEF=20% with global hypokenesis, akinesis of the
infero-lateral/septal walls. EKG showed ST elevation in II, II,
V1, and V2. Pt was treated with aspirin, b-blockade was
deferred due to hypotension requiring 2 pressors. Pt was
followed by cardiology who recommended catherization prior to
discharge.
.
Sepsis workup upon admission revealed consolidation in the RLL
on CXR, GPC/GNR on sputum culture, concerning for aspiration
pneumonia, and rising wbc count. Pt was empirically begun on
vanco/ceftaz/flagyl, and flagyl was d/c'd once cultures
returned. Given persistent hypotension, pt was also evaluated
for adrenal insufficiency which revealed cortisol 18.6->20.0
after [**Last Name (un) 104**] stim test. The pt was therefore begun on a 5d course
of fludrocortisone/hydrocortisone.
.
By [**6-5**], pt had been weaned off all pressors and maintaining
stable SBPS in 90s. Troponin and CK/AST/ALT were trending
downward. Creatinine was continuing to rise, and UOP did not
improve with lasix 200mg IV + 250mg diamox. A temporary
hemodialysis catheter was therefore placed, with plan for
dialysis on [**2121-6-6**]. At this time, pt also began to wake up.
Ventilator support was gradually weaned from AC to PS 5/5 with
stable O2 sats, and plan was for extubation [**6-6**] or [**6-7**] after
removal of some fluid with hemodialysis.
.
Remainder of [**Hospital 153**] hospital course as below:
.
1) Resp failure
Respiratory failure improved on abx (see below) and after
trial of PS, pt extubated [**2121-6-15**] on rounds and tolerated on 1 L
face mask and then 4L NC.
.
2) Pneumonia
Initially had RLL infiltrate. [**6-3**] sputum had GNR speciated as
Ecoli and MSSA, both sensitive to Levofloxacin. Pt treated with
10-day course and and then f/u CXR showed only mod bilat pleural
effusions. Started [**2121-6-14**] on Vanc and Zosyn for VAP after [**6-13**]
sputum grm stain showed 4+ GN diplococci and due to inc
secretions. vanc d/c'ed when sensi came back resistant to
acinetobacter. ID was consulted and felt that the acinetobacter
did not need to be treated in the absence of symptoms, fever or
WBC.
.
3) LUE paralysis
Non-contrast head CT ([**6-9**]) was negative for new process. Post
extubation on [**6-15**], patient able to converse with 80-90%
appropriateness. LUE does not move purposefully and has on
occasion withdrawn from pain (proximal>distal). RUE makes
purposeful movements with good strength (distal>proximal). BLE
have minimal strength R>L distal>proximal. Occaisonally
conversant on discharge, but continually making statements that
are seemingly not relevant. He appears to mentate more
appropriately and successfully when his wife is present.
.
4) ARF
ATN likely secondary to rhabdo, muscle breakdown. Continued to
be oliguric and HD performed almost daily. Pt's fluid status
remained overall positive but generalized edema significantly
improved on transfer.
.
5) STEMI
Kept on asa, held BB [**1-9**] hypotension. Felt that the patient
may likely need cardiac catheterization following acute events
here.
.
6) Seizure
It remained unclear if pt had a seizure. No clear epileptiform
foci seen on EEG; however, quite possible. Was on 100 mg tid of
dilantin, and levels remained between .[**4-11**], and were considered
therapeutic because pt was in renal failure. Therefore, pt had
Keppra slowly titrated up with plans to DC dilantin when Keppra
reached full dose. Pt had no seizures during ICU stay.
.
Medications on Admission:
Medications on transfer:
1. Albuterol [**5-17**] IH q4-6 prn
2. Insulin gtt
3. Artificial tears 1-2 drop ou prn
4. Ipratropium bromide MDI 2-10 puffs q4-6 prn
5. Midazolam .5-5 mg IV drip
6. ASA 325 mg po qday
7. Fentanyl citrate 25-100 mcg/hr IV titrate
8. ASA 325 mg po qday
9. Bisacodyl 10 mg po/pr prn
10. Pantoprazole 40 mg IV q24
11. Colace 100 mg [**Hospital1 **]
12. Ceftazidime 2 gm IV g12
13. Vancomycin 1 g q12
14. Phenytoin 100 mg tid
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
5. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
9. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-9**]
Drops Ophthalmic QHS (once a day (at bedtime)).
10. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic TID
(3 times a day).
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
12. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
ASDIR (AS DIRECTED).
13. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
14. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
15. Pantoprazole 40 mg IV Q24H
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
1.Meningioma - post resection and x-ray therapy.
2.Rhabdomyolysis - secondary to being found down.
3.Acute Renal Failure now dependent on hemodialysis - likely
secondary to Rhabdomyolysis.
4.Myocardial Infarction.
5.Respiratory failure and PNA likely secondary to aspiration.
6.Paralysis - likely secondary to anoxic/ishcemic event when
found down.
Discharge Condition:
Vital signs stable. The patient has been steadily improving
from a neurological perspective. He can move his RUE and right
hand. He cannot move his LUE as well and has only recently
begun moving his left hand and digits. He moves his LLE at the
hip and knee and his RLE at the hip only.
Discharge Instructions:
1.Please continue with the medications as described on discharge
from the hospital.
2. Please continue to attend Hemodialysis Monday, Wednesday, and
Friday.
3. Please see your primary care physician who will now handle
your care and coordinating your oncology follow up.
4. While at the [**Hospital1 18**], there was evidence that you had a heart
attack. You should follow up with a cardiologist at your
earliest convenience for treatment of this condition. You will
likely require catheterization.
Followup Instructions:
Will need oncology follow up for Meningioma.
Will need cardiology follow up for Myocardial infarction.
Will need physical and occupational therapy.
Will need wound care for decubitis ulcers.
Completed by:[**2121-6-20**]
|
[
"276.6",
"584.5",
"V43.65",
"507.0",
"530.81",
"225.2",
"518.81",
"344.40",
"780.39",
"285.9",
"458.9",
"041.4",
"728.88",
"785.50",
"342.90",
"410.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.72",
"38.93",
"38.95",
"99.04",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
11426, 11500
|
5300, 9613
|
371, 586
|
11893, 12187
|
2199, 5277
|
12736, 12958
|
1762, 1789
|
10115, 11403
|
11521, 11872
|
9639, 9639
|
12211, 12713
|
1840, 2180
|
244, 333
|
614, 1388
|
9664, 10092
|
1410, 1584
|
1600, 1746
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,615
| 100,586
|
42378
|
Discharge summary
|
report
|
Admission Date: [**2103-12-12**] Discharge Date: [**2103-12-22**]
Date of Birth: [**2049-8-10**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
DOE/Submassive PE
Major Surgical or Invasive Procedure:
Intensive Care Unit stay
History of Present Illness:
This is a 54 yo M with no significant past medical history who
presented to an OSH with 3 days of progressive dyspnea on
exertion. The patient noticed intermittent R calf swelling for
2-3 months prior to presentation. The patient thought that this
was due to trauma from exercise and did not undergo further
workup. Over the past three days, the patient noted increasing
dyspnea on exertion. One day prior to admission, he noted that
he was breathing harder at rest and he presented to OSH for
further workup. At the OSH, the patient had a LE US that showed
a RLE clot and a CTA that showed a sub-massive PE (unable to
view reports yet). He was started on a heparin gtt and
transfered to the [**Hospital1 18**] ED for further workup. For the last 2
weeks, the patient has noted chills, subjective fevers,
myalgias, drneching night sweats, and fatigue. He has taken
intermittent ibuprofen without much relief. He denies cough,
rashes, sore throat, rhinorrhea, abd pain, N/V, diarrhea. The
patient denies sick contacts.
In the ED, initial VS were: 100 112 165/110 22 99% 3L. He was
kept on heparin gtt. He had a bedside, portable US that showed ?
septal bowing and R heart strain. His EKG did not have evidence
of R strain, however. Vitals on transfer were 100, 102, 18,
106/63, 100% 3L.
.
On arrival to the MICU, the patient does not have increased work
of breathing. He is not hypoxic on 3 L. He is comfortable.
Past Medical History:
None
Social History:
Social History:
- Tobacco: None
- Alcohol: Socially
- Illicits: None
Family History:
Family History: No cancers, blood clots, hematological
disorders noted
Physical Exam:
Admission exam
Vitals: T: 101.5 BP: 116/71 P: 96 R: 18 O2: 96% 3L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear without exudates,
EOMI, PERRL
Neck: obese, supple, JVP not elevated to level of mandible, no
discrete LAD but exquisitely tender below left mandible to
palpation
CV: Sinus tachycardia, RV heave, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft obese, non-tender, non-distended, bowel sounds
present, no organomegaly
GU: no foley
Ext: RLE larger than left, no Homigs sign or palpable cords
although slight increased erythema and warmth, TTP of posterior
R calf
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Discharge exam
Vitals: Tm: 97.7 BP: 124/80 P: 79 R: 18 O2: 97 RA
General: Alert, oriented, NAD, speaking in full sentences
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi, no accessory muscle use
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops, no right heart heave.
Abdomen: obese, soft, non-tender, non-distended,
Ext: no right lower extremity edema, no left lower extremity
edema, 2+ DP/PT pulses.
Pertinent Results:
Admission labs
[**2103-12-12**] 09:30PM BLOOD WBC-11.2* RBC-4.76 Hgb-14.0 Hct-40.8
MCV-86 MCH-29.4 MCHC-34.3 RDW-12.0 Plt Ct-229
[**2103-12-12**] 09:30PM BLOOD Neuts-68.7 Lymphs-20.6 Monos-7.4 Eos-2.8
Baso-0.6
[**2103-12-13**] 03:44AM BLOOD PT-12.7* PTT-78.1* INR(PT)-1.2*
[**2103-12-12**] 09:30PM BLOOD Glucose-100 UreaN-15 Creat-1.1 Na-139
K-4.7 Cl-102 HCO3-28 AnGap-14
[**2103-12-12**] 09:30PM BLOOD cTropnT-<0.01
[**2103-12-12**] 09:59PM BLOOD Lactate-1.3
Discharge labs:
[**2103-12-21**] 06:16AM BLOOD WBC-9.6 RBC-4.74 Hgb-13.9* Hct-41.4
MCV-87 MCH-29.4 MCHC-33.6 RDW-12.1 Plt Ct-410
[**2103-12-22**] 06:40AM BLOOD PT-24.5* PTT-68.9* INR(PT)-2.3*
[**2103-12-13**] 06:23AM BLOOD Glucose-121* UreaN-14 Creat-1.1 Na-141
K-4.4 Cl-106 HCO3-25 AnGap-14
Studies
CXR [**2103-12-12**]
Assessment of the lungs is more thoroughly performed on the
outside
hospital CT, though there is no focal consolidation, effusion,
or pneumothorax seen. Cardiomediastinal silhouette appears
normal. Bony structures are intact. No free air below the right
hemidiaphragm.
IMPRESSION: No pneumonia.
TTE [**2103-12-13**]
Overall left ventricular systolic function is normal (LVEF>55%).
The right ventricular cavity is moderately dilated with
borderline normal free wall function. There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. No aortic regurgitation is seen. No
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is an anterior space
which most likely represents a prominent fat pad. IMPRESSION:
Moderately dilated right ventricle with borderline normal
function and evidence of pressure/volume overload. Unable to
determine pulmonary artery pressure on this exam. Normal left
ventricular size and function.
Brief Hospital Course:
54 yo M with no prior medical history who presents with RLE
swelling and SOB, found to have deep venous thrombosis and
submassive pulmonary embolism. Patient was placed on heparin
drip and transitioned to coumadin.
.
# Pulmonary Embolism/DVT: Patient presented with several months
of shortness of breath and worsening dyspnea on exertion. He
also noted a 6 month history of swelling and pain in his right
leg. He reported several 14 hour car trips to the midwest in
the months leading up to his leg swelling. He was sent to an
OSH by his PCP where [**Name Initial (PRE) **] saddle pulmonary embolism was seen on
CTA. The patient was transferred to [**Hospital1 18**] and placed on a
heparin drip. He was unable to bridge to coumadin with lovenox
given his weight (>150 kg) outside of guidelines. He had a slow
to respond INR and was discharged on 10 mg coumadin daily with
INR of 2.3 at discharge after being therapeutic for >48 hours.
He was discharged to follow up with his PCP regarding future INR
checks and coumadin dosing over then 6 months.
.
Transitional issues
# Should have age appropriate cancer screening (colonoscopy) if
not already planned
# Would recommend sleep study to assess for OSA
# Would recommend fasting lipids if not reccently checked
# Will need frequent INR checks until stable INR is achieved.
Medications on Admission:
None
Discharge Medications:
1. Outpatient Lab Work
INR with PT and PTT
fax results to [**Telephone/Fax (1) 29683**]
Care of: [**Last Name (LF) **],[**First Name3 (LF) **] B.
[**Hospital3 **] INTERNAL MEDICINE ASSOCIATES
2. Coumadin 2.5 mg Tablet Sig: Four (4) Tablet PO once a day:
daily at 4 pm.
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
-Pulmonary Embolism
-Deep vein thrombosis
SECONDARY:
-obesity
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital. You were admitted for evaluation of your leg swelling
and shortness of breath. You were found to have both a large
blood clot in your right leg as well as a large blood clot in
your lungs. You were started on blood thinners and transitioned
to an oral medicine called coumadin. On this drug you will
bleed much more easily and will need be careful when shaving and
using sharp objects. Your primary care doctor will help manage
your blood levels. You will need to have regular blood checks
done at [**Hospital3 4107**] and these results will be faxed to his
office.
The following changes were made to your medications:
START
-coumadin 10 mg daily at 4 pm (4 2.5 mg tablets)
Followup Instructions:
Location: [**Hospital3 **] INTERNAL MEDICINE ASSOCIATES
Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 4475**]
Appt: [**12-24**] at 1:45pm
|
[
"415.13",
"729.1",
"784.0",
"782.3",
"429.9",
"453.42",
"790.4",
"288.60",
"416.8",
"780.60",
"278.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6855, 6861
|
5140, 6471
|
323, 350
|
6977, 6977
|
3324, 3785
|
7902, 8145
|
1944, 2001
|
6526, 6832
|
6882, 6956
|
6497, 6503
|
7128, 7879
|
3801, 5117
|
2016, 3305
|
266, 285
|
378, 1793
|
6992, 7104
|
1815, 1821
|
1853, 1911
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,917
| 112,269
|
36565
|
Discharge summary
|
report
|
Admission Date: [**2181-3-26**] Discharge Date: [**2181-4-3**]
Date of Birth: [**2120-5-7**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
Right Parietal Brain Mass
Major Surgical or Invasive Procedure:
[**3-26**]:Right sided craniotomy for mass resection
History of Present Illness:
Patient is an 60F known to the neurosurgery service, who
presents for elective surgery for resection of right sided
parietal brain mass on [**3-26**].
Past Medical History:
None; however the patient states she has not been to a physician
in more than 10 yrs. She does state that she has been smoking
for "longer than she can remember" and has had a "benign" mass
resected from her left breast "many years" ago.
Social History:
Married
Family History:
non-contributory; denies familial history of brain
masses/cancer.
Physical Exam:
On d/c she remains afebrile. She is awake, alert and oriented
x3. PRRLA . Rt pupil is 4mm to 3mm and the left remains
slightly smaller at 3.5 to 3.0mm. EOM's are full. There is no
nystagmus. Tongue is midline with even facial symmetry. She
continues to have a left pronator drift. Motor strength 4/5 in
the left bicep and tricep only, otherwise she is full in the
upper extremities. In the lower extremities she is decreased in
the left lower extremity as follows: IP-4+, Quad 5, Ham 4,
Gastra 4, AT 4, [**Last Name (un) 938**] 4. Otherwise she is full in the right lower
extremity. She has been ambulating in her room and on the
nursing unit with staff and Physical therapy. Gait is slow
without listing. She is tolerating all p.o. food and fluid well
with no nausea or vomiting. She is passing flattus, urine and
stool without issues. Her clinical exam has remained stable.
Pertinent Results:
Anatomical Pathology report
DIAGNOSIS:
I. Brain, right parietal lesion (A-B):
glioblastoma, (WHO IV), see note.
Note: Necrosis, mitosis, and vascular proliferation are present.
II. Brain, right parietal lesion-research (C-E):
Glioblastoma, (WHO IV), see note.
Note: MIB-1 immunohistochemistry reveals a focal proliferation
index of 80% in a dense small cell focus and 15-20% overall
(block D).
III. Dural, right parietal (F-G):
Leptomeninges focally involved by [**Last Name (un) **].
IV. Brain, white matter (H):
White matter is diffusely infiltrated by [**Last Name (un) **] with mild
hypercellularity and prominent microvascular proliferation.
V. Brain, right parietal lesion (I-K):
Diffusely infiltrating [**Last Name (un) **] with areas of solid [**Last Name (un) **] cell
nodules.
Radiology Report MR HEAD W/CNTRST&[**Last Name (un) **] VOLUMETRIC Study Date of
[**2181-3-26**] 6:08 AM
[**2181-3-26**] 6:08 AM
MR HEAD W/CNTRST&[**Year/Month/Day **] VOLUMET; CT 3D RENDERING W/POST PROCESS
Clip # [**Clip Number (Radiology) 82765**] Reason: pre-surgical mapping for craniotomy
Contrast: MAGNEVIST Amt: 12
Provisional Findings Impression: RXCg MON [**2181-3-26**] 6:41 PM
PFI: Large 4.1 x 3.1 cm heterogeneously enhancing mass in the
right
parietotemporal region causing mass effect on the ipsilateral
lateral
ventricle and effacement of the Ambien cistern.
Final Report
HISTORY: 60-year-old female patient with a right brain mass.
TECHNIQUE: Post-gadolinium contrast images were obtained in the
axial,
coronal, and sagittal planes as per presurgical planning
protocol. MR [**First Name (Titles) **] [**Last Name (Titles) 82766**]y was also obtained of the enhancing portion of the
[**Last Name (Titles) **].
FINDINGS:
There has been slight interval increase in size of the right
parietotemporal heterogeneously enhancing mass. The volume of
enhancing [**Last Name (Titles) **] measures 18.85 cm3. This mass is closely opposed
and appears to involve the overlying dura as indicated by
adjacent dural thickening and enhancement. There is surrounding
perilesional T1 hypointensity reflecting edema versus [**Last Name (Titles) **]
infiltration. There is a mass effect involving the ipsilateral
lateral ventricle as well as midline shift of approximately 4.9
mm, not significantly changed when compared to the prior exam.
There is effacement of the ipsilateral ambient cistern with no
evidence for frank herniation. No other abnormal enhancing
lesions are identified.
IMPRESSION:
Large right parietotemporal heterogeneously enhancing mass.
Differential
diagnostic considerations include primary CNS malignancy (such
as GBM) or
solitary metastases.
CT brain Wet Read: JXKc TUE [**2181-3-27**] 11:54 PM
Post-op changes from right parietal resection with increase in
vasogenic
edema, and leftward shift of midline and subfalcine herniation
of 10 mm
(previously, 4mm). New right subdural hypodense collection,
measuring 4 mm.
Final Report
HISTORY: 60-year-old female with recent right craniotomy for a
mass, with
small bleeding this morning, now increased lethargy and left
hemiparesis.
Evaluate for increase in hemorrhage.
COMPARISON: [**2181-3-26**].
TECHNIQUE: Contiguous axial images of the head were obtained
without IV
contrast.
FINDINS: Changes from a right parietal craniotomy and resection
of the mass are again noted, with a small amount of hemorrhage
and pneumocephalus seen within the resection bed. There
continues to be residual vasogenic edema, which may be slightly
increased, particularly near the vertex, compared to prior
study. There is, however, a marked increase in associated mass
effect and leftward subfalcine herniation, with herniation of
approximately 10 mm (previously 4 mm); there is also evidence of
early left uncal herniation. There is also mass effect on the
ipsilateral lateral ventricle, with an increase in caliber of
the contralateral lateral ventricle, with the frontal [**Doctor Last Name 534**]
measuring approximately 8 mm (previously approximately 6.5 mm).
There is also new dilatation of the left temporal [**Doctor Last Name 534**]. Since
the interval study,there is also a new right subdural
collection, which is relatively hypodense, could reflect a small
subdural hygroma. No new foci of intracranial hemorrhage are
identified.
Visualized paranasal sinuses and mastoid air cells are normally
aerated.
Previously noted dilated superior ophthalmic veins are improved.
Post-surgical
changes are also noted within the soft tissues and scalp
overlying the
craniotomy site, with soft tissue swelling and air.
IMPRESSION:
1. Status post resection of right parietal mass, with increase
in vasogenic
edema and mass effect, with an increase in leftward subfalcine
and early uncal
herniation.
2. Increased caliber of the left lateral ventricle, likely
"trapped" at the
level of the foramen of [**Last Name (un) 2044**], with obliteration of the frontal
[**Doctor Last Name 534**] of the
right lateral ventricle.
3. Small new right subdural collection, measuring 4 mm in
maximal dimension,
could reflect a small subdural hygroma.
MR HEAD W/O CONTRAST Study Date of [**2181-3-29**] 12:26 PM
Final Report
COMPARISON: CT [**2181-3-27**]; MR [**2181-3-27**]; [**2181-3-20**].
TECHNIQUE: Diffusion technique images were obtained.
FINDINGS: There is no diffusion abnormality. Again seen is a
surgical
resection site in the right parietal lobe. Signal change due to
T2
prolongation in this area and representing edema appears little
changed from
the prior MR studies.
IMPRESSION:
1. No diffusion-weighted abnormalities to suggest infarction.
2. Similar appearance to edema in the right parietal
postsurgical area.
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2181-3-31**]
12:00 N
Provisional Findings Impression: GWp SAT [**2181-3-31**] 2:17 PM
PFI:
1. New 3.3 x 1.0 cm focus of hyperdensity within the right
parietal resection area consistent with new bleed.
2. Similar leftward subfalcine shift.
3. Persistent right subdural hypodense collection, essentially
unchanged from prior.
Final Report
Right craniotomy, evaluate for reduction of edema.
COMPARISON: [**2181-3-27**]; [**2181-3-26**].
TECHNIQUE: Non-contrast head CT.
There is a new 3.3 x 1.0 cm focus of hyperdensity within the
right parietal
resection site, compatible with new bleed. Vasogenic edema
persists and the
amount of leftward subfalcine herniation is similar to prior at
10 mm. There
is evidence of uncal herniation. Again seen is mass effect on
the right
lateral ventricle with the frontal [**Doctor Last Name 534**] on the left, again
mildly dilated.
There is a stable appearance to the right subdural collection,
which is
relatively hypodense. Visualized paranasal sinuses and mastoid
air cells are
normal. Post-surgical changes are seen in the soft tissues of
the scalp
overlying the craniotomy site with soft tissue swelling and air.
IMPRESSION:
1. Status post resection of right parietal mass with a new
hyperdense focus
compatible with new bleed. Stable appearance of leftward
subfalcine and uncal
herniation.
2. Stable appearance of left lateral ventricle likely trapped at
the level of
foramen of [**Last Name (un) 2044**] with distortion of the frontal [**Doctor Last Name 534**] of the
right lateral
ventricle.
3. Persistent right subdural collection, unchanged in size, may
reflect some
small subdural hygroma.
Brief Hospital Course:
Patient was electively admitted on [**3-26**] for surgical resection
of right sided parietal brain mass. Post-operatively she was
transferred to the ICU for monitoring overnight. On POD#1 pt
was transfered to the floor with left neglect (old) with left
drift/ CT stable. On the early evening, pt with lethargy, Ct
stable, dilantin changed to Keppra. Later that evening of that
same day - pt with increased lethargy. Second stat CT of the
day showed increased edema with MLS. She was treated
aggressively with mannitol, lasix and decadron and transfered to
step down status. MRI completed wihtout signs of stroke. She
was seen by Dr. [**Last Name (STitle) 724**] / neuro-onc to formulate a plan as her
pathology was finalized as GBM stage IV. The following day she
was more awake and passed speech and swallow. Her exam continued
to improve. On [**2181-3-31**] a routine CT was done to follow
resolution and or improvement of edema. Of note there was a new
area of bleeding into the postop bed. A decision was made to
follow her clinically as she coninues to do well. Her mannitol
was d/c'd after discussion with the attending. On [**2181-4-2**] CT
imaging was completed and she was cleared for d/c to home with
services by Physical therapy. She has also been seen by Dr. [**Last Name (STitle) 724**]
while inpatient and will see him again on [**2181-4-30**] for
further management.
Medications on Admission:
Dilantin
Decadron
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
Disp:*30 Tablet(s)* Refills:*1*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Dexamethasone 4 mg Tablet Sig: 1.5 Tablets PO Q8H (every 8
hours).
Disp:*135 Tablet(s)* Refills:*1*
4. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
5. Outpatient Physical Therapy
For evaluation and continued treatment as needed
6. Protonix 20 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*
7. Fioricet 50-325-40 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours as needed for headache.
Disp:*85 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Right parietal mass
Discharge Condition:
Neurologically stable
Discharge Instructions:
General Instructions/Information
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures have been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? 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.
?????? You have been prescribed Keppra for seizure control.
?????? You are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
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: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**5-25**] days (from your date of
surgery) for removal of your staples/sutures and a wound check.
This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2181-4-30**]@
3:00pm with Dr. [**Last Name (STitle) 724**]. The Brain [**Hospital 341**] Clinic is located on the
[**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building. Their phone
number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????You will not need an MRI of the brain as this was done during
your hospitalization.
Completed by:[**2181-4-3**]
|
[
"191.3",
"342.90",
"348.5",
"784.0",
"780.79",
"729.89",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
11577, 11635
|
9267, 10662
|
343, 398
|
11699, 11723
|
1862, 9244
|
13538, 14483
|
881, 948
|
10730, 11554
|
11656, 11678
|
10688, 10707
|
11747, 13515
|
963, 1843
|
278, 305
|
426, 578
|
600, 839
|
855, 865
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,275
| 125,765
|
43672
|
Discharge summary
|
report
|
Admission Date: [**2135-11-19**] Discharge Date: [**2135-11-20**]
Date of Birth: [**2078-11-11**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Iodine; Iodine Containing / Carbamazepine
Attending:[**First Name3 (LF) 14037**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
hemodialysis
History of Present Illness:
56 yo M with ESRD on HD, CHF (EF 30%) presenting progressive
SOB, "feeling like (I'm) suffocating". Two weeks ago, the
patient sustained a mechanical fall ([**2135-10-31**], head CT negative,
CXR neg), to his left chest wall and left jaw. The pt has been
reporting increasing SOB since this fall from his baseline SOB,
and intermittent left sided chest pain (in location of bruise).
Per son's report the pt has SOB at baseline, not requiring home
oxygen, and was recently placed on 2L NC home O2 for dyspnea.
Per son's report the pt cannot lay flat, and has to sleep
propped up in a sitting or standing position. He does not move
around much at baseline, and sits in a chair all day,
occasionally walking around. Per son, the pt has not missed his
HD (MWF). Patient underwent usual HD yesterday (MWF) which he
tolerated well by report. He has continued to take his meds.
Son also reports increasing lethargy and disorientation, as pt
has difficulty sleeping b/c of sensation of SOB. In [**Last Name (LF) **], [**First Name3 (LF) **]
son's report, no palpitations, abd pain, N/V/D/C. Poor po
intake. Occasionally refuses treatment, and per son,
"difficulty to deal with." Of note, he has an allergy to IV
contrast- causing a rash.
.
In the ED, the pt was satting 94% on 4L NC. Noted to be in "mod
respiratory distress," using accessory muscles, placed on NRB,
satting 99%. Went for CTA, which was negative for PE and
dissection, demonstrating , with the plan being to dialyze
immediately after CTA given contrast allergy and volume
overload. However, apparently pt initially refused HD. Pt was
then transferred to [**Hospital Unit Name 153**] for further care. In [**Name (NI) 153**], pt
requested HD. Renal consult was called, and stated the Renal
attending felt the pt could be dialyzed in AM. Also, pt was
with elevated troponins, but flat CKs, and CKMB X 2. With
lateral ST depressions in V3-V6, and STE in leads V1-V3.
Past Medical History:
seizures since childhood, which began as generalized
tonic-clonic. He was treated with phenobarbitol and Mysoline.
Later, was changed to Depakote and Dilantin. Depakote was
discontinued roughly 4 years ago due to elevated ammonia levels.
Since, then his seizures have increased in frequency and
severity. As a result, muliple medications inculding Lamictal,
Trileptal, Tegretol and Keppra have been tried and he has most
recently been on combination of Keppra and Lamictal. His
seizures have been occuring about once every 1-2 months. Usual
episodes are
characterized by confusion and disorientation with rare,
generalized tonic clonic episodes. As per OMR notes, he has a
history of non-convulsive status which presented as confusion in
the past and responded to ativan.
-ESRD on HD, due to idiopathic glomerulonephritis, s/p two
failed renal transplants
-hypertension
-hypothyroidism
-peripheral [**Name (NI) 1106**] disease
-hypoparathyroidism
-hepatitis C
-CHF-diastolic dysfunction (EF>30% in [**4-/2135**])
-SVT/AVNRT s/p ablation
-multiple fistulas
-H/O MRSA line infection
Social History:
Smoked since he was young, per son, since he was 17-18 y/o.
Used to smoke heavier, now weaned to [**2-13**] ppd, No alcohol or
IVDA. Has been on disability since [**2115**].
Family History:
mother with breast CA
father alive, with CAD, CHF
sons-healthy
Physical Exam:
t 98.0, bp 163/99, p 89, r17 100% ra
Ill appearing male in NAD
PERRL
OP clr. MMM
9cm JVP
Regular s1,s2. no m/r/g
b/l basilar crackles, extending to [**2-13**] lung ht.
+bs. soft. nt. nd
no le edema/cyanosis/clubbing
Pertinent Results:
ECG: 90bpm, L axis, nl intervals, non-specific IVCD, twi I/L,
std V5-V6, j pt elev in V1/V2, unchanged from previously.
.
cxr:
1. Worsening congestive heart failure.
2. Linear atelectasis within right lung base.
3. Cardiomegaly.
4. Dialysis access catheter in stable position within the mid
SVC.
.
ct chest/abd:
1. No pulmonary embolism or aortic dissection.
2. Bilateral pleural effusions, cardiomegaly, and pulmonary
edema. The previously visualized pulmonary nodules are not
visualized today, but could be obscured by the other lung
findings.
3. Cholelithiasis, and prominent common bile duct. No other
evidence of cholecystitis.
4. Trace free fluid in the pelvis, without other significant
abnormality.
[**2135-11-19**] 10:25AM TYPE-ART TEMP-36.3 PO2-76* PCO2-50* PH-7.41
TOTAL CO2-33* BASE XS-5 INTUBATED-NOT INTUBA
[**2135-11-19**] 10:10AM GLUCOSE-85 UREA N-23* CREAT-5.8*# SODIUM-139
POTASSIUM-5.6* CHLORIDE-98 TOTAL CO2-26 ANION GAP-21*
[**2135-11-19**] 10:10AM CK(CPK)-76
[**2135-11-19**] 10:10AM CK-MB-NotDone cTropnT-0.12*
[**2135-11-19**] 10:10AM WBC-5.8 RBC-4.34* HGB-12.5* HCT-36.2* MCV-84
MCH-28.8 MCHC-34.5 RDW-18.8*
[**2135-11-19**] 10:10AM NEUTS-61 BANDS-1 LYMPHS-15* MONOS-17* EOS-0
BASOS-1 ATYPS-5* METAS-0 MYELOS-0
[**2135-11-19**] 10:10AM PLT SMR-NORMAL PLT COUNT-244
[**2135-11-19**] 10:10AM PT-12.6 PTT-28.4 INR(PT)-1.1
Head CT: Comparison was made with the previous study of [**2135-10-31**].
Again, mild brain atrophy and mild changes of small vessel
disease are seen in the periventricular white matter. No
evidence of hemorrhage, mass effect, or midline shift seen.
Exuberant [**Date Range 1106**] calcifications are noted.
IMPRESSION: Stable appearance of the brain compared to the
previous CT examination of [**2135-10-31**]. No evidence of acute
intracranial abnormalities.
Brief Hospital Course:
57 yo m w/ ESRD on HD, who p/w CHF and ongoing CP, w/ non-focal
exam, ruled out for PE/dissection, w/ evidence of vol o/l,
admitted to [**Hospital Unit Name 153**] for dialysis.
.
1) pulm edema- initially assessed as vol o/l vs worsening chf.
o2 sat near baseline of prior week, but unclear why patient
inceasingly hypoxemic over the prior month (previously not on
oxygen). ? possible decompensation in cardiac fxn given that
patient has not missed dialysis sessions and was not grossly
volume overloaded on exam. ecg w/o significant changes.
patient was admitted to [**Hospital Ward Name **] icu, ruled out for mi. continued
on bb/acei. Had planned to check tte but patient left AMA
immediately after he was transferred to the floor on HD2.|
.
2) contrast allergy- history not c/w anaphylaxis. initial plan
in ED had been to premedicate w/ steroids and diphenydramine
followed by dialysis. on admission to [**Hospital Unit Name **], renal refused to
dialyse sighting lack of clear indication and that patient had
add'l room as far as hypoxia to tolerate the osmotic load.
patient had no adverse reaction to the conrast dye
administration.
.
3) cp- likely msk given recent fall. ruled out for
dissection/pe. romi'd as above.-pain well controlled w/
percocet.
.
4) sz d/o- averaging 1 tonic/clonic per month
-stabilized on keppra/lamictal/oxazepam
.
5) htn- bp mildly elev on admission but did not receive antihtn
on day of admission.
-cont acei/bb
.
6) esrd- no absolute indication for dialysis.
-planned for dialysis on transfer to floor but patient left AMA.
Medications on Admission:
. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Lamotrigine 150 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
3. Lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO QPM (once a
day (in the evening)).
4. Levetiracetam 250 mg Tablet Sig: 1.5 Tablets PO BID (2 times
a day).
5. Oxazepam 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
6. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO DAILY (Daily).
11. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
12. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
.
Discharge Condition:
.
Discharge Instructions:
Patient left AMA
Followup Instructions:
.
|
[
"E878.0",
"403.91",
"070.70",
"518.0",
"996.81",
"428.0",
"428.30",
"780.39",
"E849.8",
"585.6",
"574.20"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8517, 8523
|
5812, 7383
|
340, 354
|
8568, 8571
|
3955, 5327
|
8636, 8640
|
3640, 3704
|
8544, 8547
|
7409, 8494
|
8595, 8613
|
3719, 3936
|
281, 302
|
382, 2324
|
5336, 5789
|
2346, 3431
|
3447, 3624
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,611
| 168,370
|
52234
|
Discharge summary
|
report
|
Admission Date: [**2109-4-17**] Discharge Date: [**2109-4-25**]
Date of Birth: [**2041-10-28**] Sex: F
Service: MEDICINE
Allergies:
Bactrim Ds / Zithromax
Attending:[**Known firstname 898**]
Chief Complaint:
Mental Status Changes
Major Surgical or Invasive Procedure:
Cantreal Venous Line Placement
History of Present Illness:
66 yo F with history of chronic back pain on chronic narcotics
who is brought in by EMS for narcotic/benzodiazepine overdose.
Patient reported that she fell at home at 3AM. She reports
taking two pills (0.5mg) of Klonipin and two pills (60mg)of MS
contin last night. However, she is not a reliable historian. EMS
found the patient on the couch asleep with pinpoint pupils. EMS
also found 20 pills of MS contin missing from bottle which was
filled 2 days ago. Patient denies suicidal ideation. Had
response to Narcan given by EMS.
.
At baseline she ambulates with a walker at home. She states that
she went to the kitchen at 3am early this morning and "slipped
and fell." She fell on her bottom and hit her back and the back
of her head. She denied loss of consciousness.
.
Upon transport to floor, patient found to have O2sat in 72 on
2L. Patient O2sat improved to high 90s when alert and talking.
However, patient continued to fall asleep with decreasing
respiratory rate and O2 sat. Good response to Narcan 0.4 x 2,
transferred to MICU for stabilization. MICU course notable for
development of aspiration pneumonia, hypotension requiring
dopamine gtt, acute renal failure, and rhabdomyelisis.
Past Medical History:
-anxiety
-depression
-chronic pain in back
-s/p hip surgery
-s/p TAH BSO
-chronic rhinitis
-nasoseptal vestibulitis s/p maxillary surgery w/bone grafting
-osteoporosis,
-s/p appemdectomy
-s/p CCY, anemia
-eosinophilia
-hx ETOH abuse
-hx SDH s/p fall in past
-diverticulutis
-GERD
Social History:
The patient smokes 1ppd, etoh abuse in past, on chronic
narcotics for pain.
Family History:
Non-contributory
Physical Exam:
Vitals: 98.6 81/55 96 18 93% RA (99% 2L)
Gen: chronically ill appearing, NAD. Falls asleep in
mid-sentence. Easily arousable. Oriented to self, month, and
hospital (thought it was [**2009**])
HEENT: anicteric, pupils reactive, OP: clear
CV: reg arate,S1, S2, no MRG
PULM: Mostly clear with R>L bibasilar rales
Abd: soft, diff. abd tenderness, no rebound, vol guarding, and
NABS, ND.
EXT: no CCE
Neuro: CN II-XII intact, no pronator drift or asterixis, gait
unsteady with walker, strength 4/5 in LEB and [**5-16**] in UEB. Speech
fluent, mood depressed with [**Last Name (un) 11181**] affect at times. Coherent
speech. No suicidal/homicidal ideation.
Pertinent Results:
[**2109-4-17**]
WBC-11.7*# HGB-11.1* HCT-34.5* MCV-88 PLT COUNT-193
PLT SMR-NORMAL
NEUTS-82* BANDS-1 LYMPHS-8* MONOS-9 EOS-0 BASOS-0 ATYPS-0
METAS-0 MYELOS-0
SODIUM-142 POTASSIUM-4.6 CHLORIDE-99 TOTAL CO2-18* UREA N-61*
CREAT-3.9*#
GLUCOSE-84
CALCIUM-8.9 PHOSPHATE-10.0*# MAGNESIUM-2.9*
[**2109-4-17**] 03:45PM URINE
bnzodzpn-POS barbitrt-POS opiates-POS cocaine-NEG amphetmn-NEG
mthdone-NEG
ASA-4 ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG
tricyclic-NEG
[**2109-4-17**] 03:45PM URINE HOURS-RANDOM UREA N-211 CREAT-192
SODIUM-56 POTASSIUM-62 CHLORIDE-24
Head CT: No acute intracranial abnormalities. No intracranial
hemorrhage is identified. Bilateral frontal encephalomalacia.
Renal US: No hydro or other abnml.
Brief Hospital Course:
A/P 66YO f with anxiety/depression, chronic LBP on narcotics who
presents with suspected narcotic overdose c/b hypotension and
rhabdo leading to renal failure.
1) Respiratory - likely aspiration pneumonia and developed
pulmonary edema in the ICU requiring lasix diuresis.
- Cont Lev Flagyl for 14d for aspiration coverage
- added vanco [**4-19**] for possible MRSA, which was stopped [**4-22**]
after neg cultures
-Pt titrated off suppl O2 and was breathing comfortably at time
of discharge
2) Narcotic overdose- Pt is unreliable historian. Denies SI by
ED report during admission.
- Psych consult obtained. Felt that pt has impulsive tendencies,
no evidence of homicidal/suicidal tendencies. [**Month (only) 116**] have
confusional/early dementia component that is limiting her
ability to care for herself appropriately. Advised to DC
sedating medications.
-Social Work followed patient in house as well
-No evidence of withdrawal
3) Hypotension- [**2-13**] meds, [**2-13**] hypovolemia
- Normotensive during remainder of course.
4) Renal failure- creat peak: 3.9, pre-renal by labs on
admission, ARF from hypotension/hypovolemia but also likely from
rhabdo. Normal renal ultrasound [**4-17**]. Creatinine improved to
baseline.
5) Hematocrit drop- likely represents hemodilution; will follow,
close to baseline.
- guaiac trace positive then negative upon DC.
- Hct stable
6) ORTHO: h/o T-L compression deformitties in spine on chronic
pain meds.
-S/p fall- No obvious signs of injury. CT head negative.
-PT consult (pt can walk with walker)
-Getting Tylenol #3 for pain with good effect
7) Abd Pain: Pt has h/o ampullary mass on ERCP, biopsy negative,
h/o CCY/Appy, no evidence of obstruction on exam or KUB. C-diff
neg x 1, pt tolerating POs. LFTs/[**Doctor First Name **]/Lip wnl. Since persistent
CT Abd obtained: no evidence of acute pathology, RLL
consolidation vs mass likle effect, likley in setting of PNA
with bialteral pleural effusions. [**Month (only) 116**] need dedicated Chest CT as
an outpt once PNA is treated to evaluate perenchyma.
-PPI, Maalox, daily LFTs were normal.
8) Proph: PPI, pneumoboots
9) CODE: FULL (per PCP)
10) COMM/Dispo: Mother [**First Name4 (NamePattern1) **] [**Name (NI) **]) [**Telephone/Fax (1) 108043**], to Rehab
Medications on Admission:
MS Contin 60mg po BID
Clonazepam 0.5mg po Qhs
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days.
4. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO twice a day.
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO TID (3 times a day) as needed for gas/bloating.
8. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day): Until ambulatory.
9. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for back pain.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day as needed for
constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] - [**Location (un) **]
Discharge Diagnosis:
1. Narcotic and Benzodiazepine Overdose
2. Aspiration Penumonia
3. Chronic Back Pain secondary to compression freactures
4. Acute renal failure
5. Abdominal Pain
6. Depression/anxiety
7. Early Dementia (needs work-up)
Discharge Condition:
Stable
Discharge Instructions:
Please see your PCP [**Name Initial (PRE) 176**] 2 weeks of discharge.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 9119**] [**Name12 (NameIs) 9120**] MEDICINE (PRIVATE) Where: ADULT
MEDICINE UNIT [**Hospital3 **] HEALTHCARE - 1000 [**Location (un) **] - [**Location (un) 2352**],
[**Numeric Identifier 9121**] Phone:[**Pager number **] Date/Time:[**2109-5-16**] 12:00
Provider: [**Name Initial (NameIs) **] Where: [**Name Initial (NameIs) 9119**]-GI PRIVATE PRACTICE (NHB)
Date/Time:[**2109-5-17**] 12:00
|
[
"724.2",
"728.88",
"294.8",
"E853.2",
"969.4",
"733.00",
"518.81",
"530.81",
"584.9",
"285.9",
"276.5",
"428.0",
"507.0",
"300.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.17",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6942, 7007
|
3440, 5708
|
304, 337
|
7268, 7276
|
2687, 3255
|
7395, 7840
|
1976, 1994
|
5805, 6919
|
7028, 7247
|
5734, 5782
|
7300, 7372
|
2009, 2668
|
243, 266
|
365, 1562
|
3264, 3417
|
1584, 1866
|
1882, 1960
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,283
| 152,623
|
6295
|
Discharge summary
|
report
|
Admission Date: [**2191-7-7**] Discharge Date: [**2191-7-15**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Morphine / Ritalin
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Nausea, vomiting, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
88 y/o female with h/o HTN, mitral regurgitation, depression,
and h/o breast ca who presented with 4 days of nausea/vomiting
and dark loose stools. She denied CP, SOB, or palpitations. She
denies cough. She states that she recently had a fever (?102).
She received a course of azithromycin at NH. She was ordered to
start ceftriaxone today.
.
In ED, initial BP in 70s, given IVF, PRBC, and started on
dopamine gtt. EKG found to have STE in V2, V3, aVf, V3-6 with
STD in V1-2. Guaiac positive black stools. Unable to pass NGT.
GI did not feel EGD at this time was appropriate secondary to
the patient's cardiac issues.
.
She was transferred to the CCU for further management of her
STEMI.
Past Medical History:
Mitral regurgiation
Depression
Anxiety
Delusional psychosis
HTN
Glaucoma
s/p R knee replacement
s/p R hip fracture - prosthesis removed [**1-13**] to infection
Urinary incontinence
Chronic abd discomfort - hiatual hernia
Cancer L breast (s/p lumpectomy [**1-/2184**])
Injury to L SC artery ([**2-11**])
Social History:
Lives at [**Hospital 100**] Rehab. Denies tobacco, EtOH, or IVDU. Used to be
nurse. Worked in North [**Country 480**] during WW2.
Family History:
No hx of CAD
Physical Exam:
Gen: NAD, pleasant
HEENT: dry MMM, marked anisocoria, lt pupil 5 mm and rt pupil 2
mm.
Neck: 1+ bilateral carotid bruits
CVS: irregular, 2/6 systolic murmur along upper sternal border
Lungs: diffuse wheezing
Abd: soft, mild tender to palpation at mid lower abdomen, NT,
+BS
Ext: trace pedal edema
Pertinent Results:
[**2191-7-7**] WBC-9.8 Hct-29.8 Plt Ct-164 Glucose-142 UreaN-76
Creat-1.4 Na-145 K-4.0 Cl-106 HCO3-28
CK(CPK)-279-->171-->144-->97-->43-->64
cTropnT-1.54-->1.32-->1.31
.
[**2191-7-15**] WBC-8.5 RBC-3.84* Hgb-11.6* Hct-35.4* MCV-92 MCH-30.2
MCHC-32.8 RDW-14.4 Plt Ct-173 Glucose-169* UreaN-16 Creat-0.9
Na-144 K-4.1 Cl-106 HCO3-35* AnGap-7* Mg-2.0
.
EKG: [**2191-7-8**]: Atrial fibrillation with a rapid ventricular
response. Compared to the previous tracing of [**2188-2-9**] atrial
fibrillation with a rapid ventricular response has appeared. STE
in V2, V3, aVf, V3-6 with STD in V1-2.
.
Imaging:
CXR ([**2191-7-7**])
No definite evidence of consolidation. However, examination of
the left lower lung fields is limited secondary to overlying
hiatal hernia.
.
CXR ([**2191-7-12**]):
The right PICC line tip is in the inferior portion of superior
vena cava. The whole left hemithorax is opacified with a
leftward mediastinal shift due to complete or near-complete
atelectasis of the left lung. The previously demonstrated hiatal
hernia is again noted.
.
CXR ([**2191-7-13**]):
Left lung has reexpanded, though the base is chronically
elevated by a large diaphragmatic hernia containing stomach and
intestine. Persistent atelectasis of the right lower lobe and
small bilateral pleural effusion has increased. Cardiac
silhouette is largely obscured. Mediastinal venous engorgement
suggests volume overload or at least elevated right heart
pressure. There is no free subdiaphragmatic gas. Tip of the
right subclavian catheter projects over the superior cavoatrial
junction. No pneumothorax.
.
CXR ([**2191-7-14**])
New collapse of left upper lung. This may be due to mucus
plugging , atelactasis or endobronchial lesion. Bronchoscopy
would be helpful to evaluate cause of intermittent obstruction
of left mainstem bronchus.
.
CXR ([**2191-7-15**])
Re-expansion of left upper lobe. Worsening of mild-to-moderate
right lower lobe atelectasis and effusion. Stable, chronic
elevation, left hemidiaphragm and small, left pleural effusion.
.
Echocardiogram ([**2191-7-7**]): The left atrium is dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is small. LV systolic function appears depressed
secondary to extensive apical akinesis. However, the basal and
midventricular segments are markedly hyperdynamic, resulting in
a moderate resting left ventricular outflow tract obstruction.
The gradient increased with the Valsalva manuever. A
mid-cavitary gradient is also identified. Right ventricular
chamber size is normal. There is focal hypokinesis of the apical
free wall of the right ventricle. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present; the
increased flow velocity across the aortic valve is due to
preacceleration in the left ventricular outflow tract. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. There is systolic
anterior motion of the mitral valve leaflets. Trivial mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
Echocardiogram ([**2191-7-12**]):
Conclusions:
Focused study. Left ventricular wall thicknesses and cavity size
are normal. There is mild regional left ventricular systolic
dysfunction with hypokinesis of the distal [**12-14**] of the left
ventricle, and akinesis of the true apex. No left ventricular
thrombus is seen. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are mildly
thickened. The mitral valve leaflets are structurally normal.
There is no mitral valve prolapse. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction.
Moderate
pulmonary hypertension. Compared with the prior study (images
reviewed) of [**2191-7-7**], there has been some improvement in the
contractility of the distal [**12-14**] of the left ventricle,however
the rest of the walls are no longer hyperkinetic. Pulmonary
arterial pressure is similar.
.
Culture data:
1. UCx [**2191-7-7**]
URINE CULTURE (Final [**2191-7-10**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION. OF TWO COLONIAL
MORPHOLOGIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
2. BCx [**2191-7-7**] (total of 4 bottles)
No growth.
.
3. SCx [**2191-7-8**]
Contaminated, culture cancelled
Brief Hospital Course:
88 y/o female with h/o HTN and no prior h/o CAD presents with
vomiting/loose stools and found to have STEMI and guaiac
positive stools. The following issues were addressed during this
hospitalization.
.
1. Cardiac
- Ischemia
The patient presented with a STEMI with STE in inferior and
septal leads. She was found to have positive cardiac enzymes.
Due to GI bleed and patient's functional status, conservative
management of her STEMI ensued with aspirin 81 mg daily and
clopidogrel 75 mg PO daily.
.
- Pump
The patient was found to have an EF of 50% by echocardiography.
The patient's initial echo on dopamine gtt revealed extensive
apical akinesis; the basal and midventricular segments were
markedly hyperdynamic, resulting in a moderate resting left
ventricular outflow tract obstruction. Dopamine gtt was
discontinued within the first few hours in the CCU with
subsequent decrease in HR and increased in BP due to improved
diastolic filling. Patient had CHF secondary to diastolic
dysfunction and was successfully diuresed with IV Lasix. Repeat
echo revealed some improvement in the contractility of the
distal [**12-14**] of the left ventricle and the rest of the walls were
no longer hyperkinetic.
.
- Rhythm
The patient went into AFib and Aflutter with RVR intermittently
(as high as HR 150-160s), with associated hypotension. The
patient was loaded and maintained on amiodarone. Her episodes
of RVR responded to IV diltiazem, so she was started on an oral
regimen of diltiazem. She intermittently required IV diltiagem
gtt. On discharge, the patient continued to alternate between
NSR in 50s to AF with RVR to 100-120 range and remained
hemodynamically stable. She needs to continue amiodarone load
400 mg daily for 2 days followed by a maintenance dose of 200 mg
daily.
.
2. GIB
There was an initial concern for UGIB given patient's h/o of
melena. Hematocrit remained stable in mid-30s. No blood
transfusions required. GI was consulted early in presentation
and did not proceed with EGD due to patient's cardiac issues.
.
3. Aspiration PNA
The patient was empirically treated with levofloxacin and
metronidazole for aspiration pneumonia. Metronidazole was later
discontinued and the patient 7 days of levofloxacin and has 3
more days remaining upon discharge to complete a 10 day course.
.
4. Mucous plugging
The patient was noted to have intermittent mucous plugging
contributing to SOB and wheezing. She had CXRs on [**2191-7-13**] and
[**2191-7-15**] which showed collapse of the entire left lobe [**1-13**] mucous
plugging and atelectasis. Pt responded to chest PT, suctioning,
and exsufflation. Aggressive chest PT will be recommended upon
discharge.
.
5. Wheezing
The patient was noted to have intermittent wheezing which is
multifactorial secondary to aspiration pneumonia, mucous
plugging, CHF (successfully diuresed), and possible underlying
COPD in setting of smoking history. Pt was given standing
atrovent nebs and flovent. She required frequent prn albuterol
treatments. Pt was given solumedrol for 1 day.
.
6. Hypernatremia
The etiology of the patient's hypernatremia was thought to be
secondary to poor PO intake and a free water deficit. She was
given free water via IVF and her sodium level corrected. This
will need to be monitored upon discharge.
.
7. UTI
The patient was found to have a UTI and was treated with 3 days
of levofloxacin.
.
8. Depression
The patient was continued on outpatient regimen of Remeron.
.
9. Insomnia
The patient was given trazodone 25mg qhs prn for to aid in
sleep.
.
CODE: DNR/DNI
.
Access upon discharge: Porta-cath
Medications on Admission:
Bisacodyl
Combivent nebs
Lisinopril 2.5 mg daily
Aluminum hydroxide
Docusate 200 mg [**Hospital1 **]
Protonix 40 mg qhs
Reglan 5 mg qid
MVI
Magnesium citrate 240 mg qd
Mirtazapine 15mg qhs
Depakote ED 250 mg [**Hospital1 **]
Alubuterol INH
Tigan 200 mg [**Hospital1 **] prn
Calcium carbonate
Ceftriaxone 1gm q24 (start [**7-6**] - [**7-13**])
Azithromycin
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q2H PRN ().
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q2H (every 2 hours) as needed.
5. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain,
SOB.
11. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
12. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
13. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
14. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
15. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
16. Levofloxacin in D5W 250 mg/50 mL Piggyback Sig: One (1)
Intravenous Q24H (every 24 hours) for 3 days.
17. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily) for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
18. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
Please start after 400mg dose x 2 days.
19. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
20. Depakote ER 250 mg Tablet Sustained Release 24HR Sig: One
(1) Tablet Sustained Release 24HR PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary diagnoses:
STEMI
CHF
AF/Aflutter with RVR
Mucous plugging
Aspiration PNA
UTI
GIB
LVOT obstruction
.
Secondary diagnoses:
Depression
Hx breast cancer
Discharge Condition:
Normal O2 sats on 5L supplemental O2 (stable)
The patient was discharged hemodynamically stable, afebrile with
appropriate follow up.
Discharge Instructions:
1. Please take all medications as prescribed.
.
2. Please return to the ED or call your PCP if you develop chest
pain, difficulty breathing, palpitations/rapid heart rate,
fevers, or any other concerning symptoms.
.
3. Please keep all follow up appointments.
Followup Instructions:
Follow up with the doctor [**First Name (Titles) **] [**Last Name (Titles) 100**] Rehab.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2191-7-19**]
|
[
"365.9",
"578.0",
"401.9",
"V10.3",
"276.0",
"934.8",
"780.52",
"507.0",
"427.31",
"428.0",
"427.32",
"414.01",
"578.1",
"599.0",
"V43.65",
"410.41",
"518.82",
"786.07",
"300.00",
"311",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
12996, 13062
|
7078, 10625
|
275, 281
|
13263, 13399
|
1836, 7055
|
13706, 13955
|
1489, 1503
|
11060, 12973
|
13083, 13191
|
10679, 11037
|
13423, 13683
|
1518, 1817
|
13212, 13242
|
209, 237
|
10641, 10653
|
309, 999
|
1021, 1326
|
1342, 1473
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,122
| 187,374
|
6496+55761
|
Discharge summary
|
report+addendum
|
Admission Date: [**2141-3-20**] Discharge Date: [**2141-5-9**]
Service: CARDIOTHORACIC
Allergies:
Ciprofloxacin / Ambien / Trazodone
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
AORTIC STENOSIS
Major Surgical or Invasive Procedure:
[**2141-3-20**] - Aortic valve replacement(19-mm Biocor tissue valve)
History of Present Illness:
This 89 year old woman with severe diastolic
dysfunction,critical calcific aortic stenosis and severe
pulmonary hypertension and has had numerous hospitalizations for
acutely decompensated heart failure over the last few years. Her
most recent admission was [**Date range (3) 24942**].
She has shortness of breath that occurs when she exerts herself
and when she is emotionally stressed. She can walk 10 feet
before needing to rest due to shortness of breath. She
occasionally has chest pain in the setting emotional distress.
She reports having some dizziness when she changes position
quickly or after ambulation. She was undergoing consideration
for Corevalve protocol vs surgical AVR. Under this study, she
was randomized to surgical intervention and was admitted for
same day surgery.
Past Medical History:
hypertension
coronary artery disease
multiple percutaneous coronary interventions/stents
h/o paroxysmal atrial fibrillation(no Coumadin secondary to
gastrointestinal bleeds
Diastolic dysfunction (LVEF >55%)
aortic stenosisH:
chonic kidney disease
Gout
Diverticulosis
obstructive sleep apnea(CPAP)
Spinal stenosis
Obesity
s/p L ORIF of femur fx
s/p cholecystectomy
Social History:
- Tobacco: Denies
- EtOH: Denies
- Illicit Drugs: Denies
Lives at [**Hospital3 **] facility. Close support supports in
place, 3 children deeply involved in her care. Widowed >30
years. Becomes dyspneic with walking 5 feet or talking for
extended periods of time.
Family History:
Family History: Father, mother and 5 siblings all had or have
heart disease.
Physical Exam:
Admission
VSS
Height: 60" Weight: 156lbs
General: Well-developed elderly female in no acute distress
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Mostly clear bilaterally, sl decreased at base
Heart: RRR [X] Irregular [] Murmur [X] grade [**2-28**] sys
Abdomen: Soft [X] non-distended [X] non-tender [X] +BS [X]
Extremities: Warm [X], well-perfused [X] Edema trace
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right/Left: trans murmur
Discharge
Gen NAD
Neuro A&O x3, MAE-nonfocal exam
Pulm diminished bases bilat-scattered rhonchi
CV RRR, sternum stable incision CDI
Abdm soft, NT/ND/NABS, obese
Ext warm, well perfused. no edema
Pertinent Results:
ECHO [**2141-3-20**]
PRE BYPASS The left atrium is dilated. Mild spontaneous echo
contrast is seen in the body of the left atrium. Moderate to
severe spontaneous echo contrast is present in the left atrial
appendage. The left atrial appendage emptying velocity is
depressed (<0.2m/s). A left atrial appendage thrombus cannot be
completely excluded. The right atrium is dilated. No thrombus is
seen in the right atrial appendage A patent foramen ovale is
present. A left-to-right shunt across the interatrial septum is
seen at rest. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). [Intrinsic
left ventricular systolic function is likely more depressed
given the severity of valvular regurgitation.] The right
ventricle displays normal free wall contractility. [Intrinsic
right ventricular systolic function is likely more depressed
given the severity of tricuspid regurgitation.] There are simple
atheroma in the ascending aorta. There are complex (>4mm)
atheroma in the descending thoracic aorta. The aortic valve
leaflets are severely thickened/deformed. There is critical
aortic valve stenosis (valve area <0.8cm2). Trace aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. 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. 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 AV paced. There is normal
biventricular systolic function. There is a bioprosthesis
located in the aortic position. It appears well seated. The
leaflets are not well seen. The maximum pressure through the
aortic valve was 28 mmHg with a mean pressure of 14 mmHg at a
cardiac output of about 3.5 liters/minute. The effective orifice
area is in the range of 0.8 to 1 cm2. The rest of the cardiac
valves appear unchanged from pre-bypass. The thoracic aorta is
intact after decannulation. Left to right shunt flow persists
through the patent foramen ovale.
Admission [**Last Name (STitle) **]:
[**2141-3-20**] 09:40AM CK-MB-6
[**2141-3-20**] 09:40AM CK(CPK)-298*
[**2141-3-20**] 10:07AM HGB-9.8* calcHCT-29
[**2141-3-20**] 10:07AM GLUCOSE-109* LACTATE-0.9 NA+-141 K+-3.9
CL--109*
[**2141-3-20**] 01:06PM FIBRINOGE-254
[**2141-3-20**] 01:06PM PT-14.4* PTT-28.5 INR(PT)-1.3*
[**2141-3-20**] 01:06PM WBC-6.7 RBC-3.12* HGB-8.9* HCT-28.5* MCV-91
MCH-28.5 MCHC-31.2 RDW-14.3
[**2141-3-20**] 01:06PM PLT COUNT-134*
[**2141-3-20**] 02:36PM UREA N-66* CREAT-1.1 SODIUM-139 POTASSIUM-4.9
CHLORIDE-112* TOTAL CO2-20* ANION GAP-12
Discharge [**Month/Day/Year **]:
[**2141-4-20**] 04:37AM BLOOD WBC-7.9 RBC-3.39* Hgb-9.5* Hct-32.8*
MCV-97 MCH-27.9 MCHC-28.9* RDW-15.9* Plt Ct-190
[**2141-4-17**] 02:16AM BLOOD PT-10.0 PTT-30.3 INR(PT)-0.9
[**2141-4-20**] 04:37AM BLOOD Glucose-85 UreaN-48* Creat-1.0 Na-140
K-3.5 Cl-100 HCO3-30 AnGap-14
Brief Hospital Course:
Ms. [**Known lastname 24834**] was admitted to the [**Hospital1 18**] on [**2141-3-20**] for surgical
management of her aortic valve disease. She was taken to the
Operating Room where she underwent aortic valve replacement
using a 19-mm Biocor tissue valve. Please see operative note for
details. Cardiopulmonary Bypass time= 53 minutes. Cross clamp
time=40 minutes. Postoperatively she was taken to the intensive
care unit for monitoring. She awoke neurologically intact, was
weaned from the ventilator and extubated on the day of surgery.
Her chest tubes and epicardial pacing wires were removed per
cardiac surgery protocol. Amiodarone was resumed for paroxysmal
atrial fibrillation, and was stopped when LFTs became elevated.
Coumadin was not started due to a history of GI bleed. She
transfered to the floor on POD2 where she was diuresed towards
her preoperative weight. On POD 3 she developed severe
shortness of breath and was transferred back to the ICU where
for additional pulmonary support. BiPAP was used and a right
thoracentesis was performed. She gradually improved and on POD
10 she returned to the step down floor. She was evaluated by
Physical Therapy for mobility and screened for rehabilitation
placement. A CXR on [**4-1**] showed a large right sided pleural
effusion. She had another thoracentesis which yielded 350cc
serosanguinous fluid. She developed a contraction alkalosis.
Lasix was stopped and she began Diamox. She continued to be
diuresed and developed acute on chronic renal failure. Increased
somnolence along with a reaccumulation of her bilat effusions
resulted in yet another transfer back to the CVICU where she was
reintubated. A PA catheter was placed, a chest tube was placed
to drain the effusion and she was seen by the renal service to
assist with ongoing diuresis. She was noted to have a UTI and
appropriate antibiotics were initiated. The patient was also
seen by the heart failure service. Her renal function gradually
improved and she continued to diurese. Her chest tube continued
to drain serous fluid and thoracic surgery was consulted for
possible pleuradesis.
On POD# 28 she was again transferred to the step down floor.
The remainder of her hospital course was essentially uneventful.
On POD#31 she was discharged to [**Hospital1 100**] Rehabilitaion. All follow
up appointments were advised.
Medications on Admission:
CARVEDILOL - 12.5 mg Tablet - 1 Tablet(s) by mouth twice a day
CHOLESTYRAMINE (WITH SUGAR) - 4 gram Packet - 1 by mouth once a
day
COMPRESSION STOCKING - as directed wear daily please measure pt
for size. Knee high. diagnosis: edema
FEBUXOSTAT [ULORIC] - 40 mg Tablet - one Tablet(s) by mouth once
a day
IPRATROPIUM BROMIDE - 21 mcg Spray, Non-Aerosol - 1 spray
nasally
twice a day
LOSARTAN - 25 mg Tablet - one Tablet(s) by mouth daily
METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 25 mg
Tablet Extended Release 24 hr - 1 Tablet(s) by mouth DAILY
NITROGLYCERIN - 0.3 mg Tablet, Sublingual - 1
Tablet(s)sublingually as needed [**Month (only) 116**] repeat 2 times in 10
minutes.
SIMVASTATIN [ZOCOR] - 80 mg Tablet - 1 Tablet(s) by mouth once a
day
TORSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth DAILY (Daily)
Medications - OTC
ACETAMINOPHEN [TYLENOL EXTRA STRENGTH] - 500 mg Tablet - 1 (One)
Tablet(s) by mouth four times a day as needed
ASPIRIN - 325 mg Tablet - 1 (One) Tablet(s) by mouth once a day
CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) -
1,000 unit Tablet, Chewable - 1 (One) Tablet(s) by mouth once a
day
LORATADINE [CLARITIN] - (OTC) - 10 mg Tablet - 1 Tablet(s) by
mouth
SODIUM CHLORIDE [DEEP SEA NASAL] - (Prescribed by Other
Provider) - Dosage uncertain
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-26**] Sprays Nasal
QID (4 times a day) as needed for dryness.
8. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ACHS: per SS.
9. nifedipine 10 mg Capsule Sig: Three (3) Capsule PO Q8H (every
8 hours).
10. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours).
11. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
12. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
16. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for fever.
18. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
19. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for dyspnea.
20. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for dyspnea.
21. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
22. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
23. torsemide 20 mg/2 mL (10 mg/mL) Solution Sig: One (1)
Intravenous [**Hospital1 **] (2 times a day).
24. sodium chloride 0.9 % Aerosol, Spray Sig: [**12-26**] Sprays Nasal
QID (4 times a day) as needed for dry nose.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
s/p aortic valve replacement
obesity
diastolic heart failure(class IV )
Critical aortic stenosis
Severe pulmonary hypertension
tricuspid regurgitation
Hypertension
Hypercholesterolemia
Coronary artery disease -s/p PCI,[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2 midLAD
Instent restenosis treated with PTCA and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2 to Mid LAD
[**6-29**]
Paroxysmal atrial fibrillation
Chronic kidney disease (baseline crea 1.7)
Gout
Diverticulosis
Obstructive sleep apnea(CPAP)
Spinal stenosis
Obesity
s/p LEFT ORIF of femur fracture
h/o gastrointestinal bleed
s/p cholecystectomy
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with assistance-very deconditioned
Incisional pain managed with Tramadol
Incisions:
Sternal - healing well, no erythema or drainage
Edema 1+ bilat
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for one month or while taking narcotics. Driving
will be discussed at follow up appointment with surgeon.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
*Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **]([**Telephone/Fax (1) 170**]) on [**2141-5-3**] at 2:30pm
Cardiologist:Dr.[**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] on [**2141-4-24**] at 1pm on [**Hospital Ward Name 23**] 7
Please call to schedule appointments with:
Primary Care: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]([**Telephone/Fax (1) 2010**]) in [**3-30**] 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:[**2141-4-20**] Name: [**Known lastname 4229**],[**Known firstname 1194**] Unit No: [**Numeric Identifier 4230**]
Admission Date: [**2141-3-20**] Discharge Date: [**2141-5-9**]
Date of Birth: [**2052-1-7**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ciprofloxacin / Ambien / Trazodone
Attending:[**First Name3 (LF) 741**]
Addendum:
[**2141-4-20**] Ms.[**Known lastname 4251**] discharge was recinded due to worsening
shortness of breath. She became progressively dyspneic with
increased work of breathing. CXR and arterial blood gas was
drawn. Due to respiratory failure and respiratory acidosis she
was transferred back to CVICU and reintubated. Dr.[**Last Name (STitle) **]
discussed with the patient and her family the possibility of her
failing a repeat extubation and requiring a tracheostomy. Over
the next several days she was weaned in preparation for an
extubation trial. On [**4-27**] she was extubated and remained so for
the rest of this admission.
Chief Complaint:
respiratory failure
Major Surgical or Invasive Procedure:
[**2141-3-20**] - Aortic valve replacement(19-mm Biocor tissue valve.)
History of Present Illness:
please refer to discharge summary [**2141-4-20**]
Past Medical History:
hypertension
coronary artery disease
multiple percutaneous coronary interventions/stents
h/o paroxysmal atrial fibrillation(no Coumadin secondary to
gastrointestinal bleeds
Diastolic dysfunction (LVEF >55%)
aortic stenosisH:
chonic kidney disease
Gout
Diverticulosis
obstructive sleep apnea(CPAP)
Spinal stenosis
Obesity
s/p L ORIF of femur fx
s/p cholecystectomy
Social History:
- Tobacco: Denies
- EtOH: Denies
- Illicit Drugs: Denies
Lives at [**Hospital3 2065**] facility. Close support supports in
place, 3 children deeply involved in her care. Widowed >30
years. Becomes dyspneic with walking 5 feet or talking for
extended periods of time.
Family History:
Family History: Father, mother and 5 siblings all had or have
heart disease.
Physical Exam:
VSS
Height: 60" Weight: 156lbs
General: Well-developed elderly female in no acute distress
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Mostly clear bilaterally, sl decreased at base
Heart: RRR [X] Irregular [] Murmur [X] grade [**2-28**] sys
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema trace
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) **]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right/Left: trans murmur
Pertinent Results:
Admission labs:
[**2141-3-20**] 09:40AM CK-MB-6
[**2141-3-20**] 09:40AM CK(CPK)-298*
[**2141-3-20**] 10:07AM HGB-9.8* calcHCT-29
[**2141-3-20**] 01:06PM FIBRINOGE-254
[**2141-3-20**] 01:06PM PT-14.4* PTT-28.5 INR(PT)-1.3*
[**2141-3-20**] 01:06PM WBC-6.7 RBC-3.12* HGB-8.9* HCT-28.5* MCV-91
MCH-28.5 MCHC-31.2 RDW-14.3
[**2141-3-20**] 02:36PM UREA N-66* CREAT-1.1 SODIUM-139 POTASSIUM-4.9
CHLORIDE-112* TOTAL CO2-20* ANION GAP-12
Radiology Report CHEST (PORTABLE AP) Study Date of [**2141-5-7**] 7:34
AM
Final Report: Cardiac silhouette is enlarged and accompanied by
pulmonary
vascular congestion. Persistent moderate right and small left
pleural
effusions with adjacent basilar lung opacities, which probably
reflect
atelectasis, although coexisting pneumonia is possible in the
appropriate
clinical setting.
[**Hospital1 8**] ECHOCARDIOGRAPHY REPORT
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.4 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.1 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 70% >= 55%
Left Ventricle - Lateral Peak E': 0.17 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.05 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 14 < 15
Aortic Valve - Peak Velocity: *3.3 m/sec <= 2.0 m/sec
Aortic Valve - LVOT diam: 1.7 cm
Mitral Valve - E Wave: 1.5 m/sec
Mitral Valve - E Wave deceleration time: 237 ms 140-250 ms
TR Gradient (+ RA = PASP): *50 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Moderate LA enlargement.
LEFT VENTRICLE: Moderate symmetric LVH. Overall normal LVEF
(>55%). No resting LVOT gradient.
RIGHT VENTRICLE: RV hypertrophy. Normal RV chamber size. Normal
RV systolic function.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR
well seated, normal leaflet/disc motion and transvalvular
gradients.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Severe
mitral annular calcification. Mild thickening of mitral valve
chordae. Calcified tips of papillary muscles. No MS. Mild (1+)
MR. [Due to acoustic shadowing, the severity of MR may be
significantly UNDERestimated.]
TRICUSPID VALVE: Normal tricuspid valve leaflets. Normal
tricuspid valve supporting structures. No TS. Moderate [2+] TR.
Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR. Normal main PA. No Doppler evidence for
PDA
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Conclusions
The left atrium is moderately dilated. There is moderate
symmetric left ventricular hypertrophy. Overall left ventricular
systolic function is normal (LVEF 70%). The right ventricular
free wall is hypertrophied. Right ventricular chamber size is
normal. with normal free wall contractility. A bioprosthetic
aortic valve prosthesis is present. The aortic valve prosthesis
appears well seated, with normal leaflet/disc motion and
transvalvular gradients. The mitral valve leaflets are mildly
thickened. There is severe mitral annular calcification. Mild
(1+) mitral regurgitation is seen. [Due to acoustic shadowing,
the severity of mitral regurgitation may be significantly
UNDERestimated.] Moderate [2+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2141-3-27**], the tricuspid regurgitation (which was frankly
severe in the prior study) is markedly reduced.
CHEST ULTRASOUND REPORT:Date: [**2141-4-21**]
CHEST ULTRASOUND FINDINGS:
Right Hemithorax: (x) Done ( ) Not Examined
Pleural Effusion:
Volume: ( ) none ( ) Minimal (x) Small ( ) Moderate ( ) Large
Ecogenicity: ( ) Anechoic (x) Hypoechoic ( ) Isoechoic ( )
Hyperechoic
Loculations: (x) none ( ) Thin ( ) Thick
Diaphragmatic Motion:
(x) Normal ( ) Diminished ( ) Absent
Lung:
Lung sliding: (x) Present ( ) Absent
Consolidation: ( ) Present (x) Absent
Atelectasis: (x) Present ( ) Absent
Pleura:
(x) Normal ( ) Thick ( ) Nodular
Left Hemithorax: (x) Not Examined
COMPLICATIONS: (x) None
SPECIMENS: (x) None
POST PROCEDURE DIAGNOSIS: small right-sided exudative effusion,
suspect post-cardiac injury effusion vs. pseudoexudate.
PLAN: - No current benefit expected from drainage of small
effusion.
- Continued efforts at diuresis.
- Might consider treatment for post-cardiac injury syndrome.
- Page with further questions or concerns #[**Numeric Identifier 4252**]
Discharge labs:
[**2141-5-9**] 03:18AM BLOOD WBC-6.3 RBC-3.06* Hgb-8.2* Hct-27.4*
MCV-89 MCH-26.8* MCHC-30.0* RDW-15.4 Plt Ct-256
[**2141-5-8**] 02:10AM BLOOD WBC-7.1 RBC-3.16* Hgb-8.5* Hct-28.7*
MCV-91 MCH-26.8* MCHC-29.5* RDW-15.6* Plt Ct-229
[**2141-5-9**] 03:18AM BLOOD PT-10.6 PTT-35.1 INR(PT)-1.0
[**2141-5-8**] 02:10AM BLOOD PT-10.7 PTT-29.6 INR(PT)-1.0
[**2141-5-9**] 03:18AM BLOOD Glucose-118* UreaN-89* Creat-1.3* Na-138
K-4.5 Cl-89* HCO3-40* AnGap-14
[**2141-5-8**] 02:10AM BLOOD Glucose-174* UreaN-81* Creat-1.3* Na-136
K-3.8 Cl-90* HCO3-35* AnGap-15
[**2141-5-7**] 02:19AM BLOOD Glucose-246* UreaN-72* Creat-1.4* Na-143
K-3.8 Cl-95* HCO3-38* AnGap-14
Brief Hospital Course:
Mrs [**Known lastname **] is an 89yr old female s/p tissue AVR [**2141-3-20**] for
symptomatic critical AS. Randomized to surgical arm of corevale
trial. Prior to admission, could ambulate only 10 ft before
stopping for dyspnea,occasional associated lightheadedness &
chest pain. She's had multiple admissions over last few years
for decompensated CHF,
last in 12/[**2139**]. Intra-op bypass time 53min, cross-clamp time
40min. She arrived from the OR in stable condition on Neo and
fully vented, her post-op EF was approx 55%. She weaned
successfully off her pressors and extubated without difficulty.
Her
chest tubes & epicardial pacing wires were removed shortly
thereafter per standard protocol. Tfr'd to floor on POD2. On
POD3, readmitted to ICU for dyspnea attributed to right pleural
effusion & volume overload, treated with diuresis, intermittent
BiPAP, & right thoracentesis draining 550cc ([**3-28**]). Pleural
effusion recurred by [**4-1**], repeat right thoracentesis drained
350cc serosanguinous fluid, aggressive diuresis continued with
acetazolamide added for contraction alkalosis. Bipap at night
OSA. Persistent intermittent dyspnea prompted CT chest [**4-8**]
demonstrated RLL collapse in setting of moderate right pleural
effusion, prompting chest tube placement and reintubation. She
was relined and PA line placed and TTE obtained which showed
stable hemodynamics except for continued pulmonary htn. She was
started on sildenafil but did not toletate it and was switched
to nifedipine. Pulmonary was consulted and they felt that her
failure was due to deconditioning, heart failure and fluid
overload. Therefore she continued to be diuresed but this was
initially limited due to acute on chronic renal failure. She
was eventually extubated several days later [**4-17**] and was
transferred to the floor. On [**4-20**] she again developed
respiratory distress and was noted to have a significant
respiratory acidoses and was urgently reintubted. Chest CT
showed RLL collapse and recurrent effusion but was not
signifcant to tap. She underwent bronchoscopy for minimal
secretions. She remained intubated for several more days with
the decision made to proceed with trach. After family meeting
the decision was made to attempt one more extubation prior to
trach. Therefore she was medically optimized to improve
ventilation and to attempt to limit co2 production. Diamox was
dc'd and she was started on Ritalin to help stimulate her
respiratory drive. Eventually she was extubated on [**4-24**]. Despite
being at her pre-op weight she was continued on low dose
demadex for diuresis. She extubated without difficulty with
continued pulmonary toileting and support she has remained
extubated with mild respiatory acidosis. Follow-up US of right
lung did not show signifcant effusion. She completed her course
of cefipime and repeat urine culture was negative. She has
remained afebrile. Flexiseal in place for loose stool but she
was C-diff negative. Tolerating a full diet. She also became
confused while on Ritalin which was stopped. Low dose seroquel
was trialed to help her sleep at night, but stopped as it had
little effect. Througout her post-op course she has not been
sleeping well at night and this we felt was contributing to her
overall fatigue and deconditioning.
Despite her complicated postop course she was screened for rehab
and on POD#50 she was deemed safe for discharge to [**Hospital **] Rehab
for continued pulmonary management.
Medications on Admission:
CARVEDILOL - 12.5 by mouth twice a day
CHOLESTYRAMINE - 4 gram Packet - 1 by mouth once a day
FEBUXOSTAT [ULORIC] - 40 mg once a day
IPRATROPIUM BROMIDE twice a day
LOSARTAN - 25 mg daily
METOPROLOL SUCCINATE - 25 mg DAILY
NITROGLYCERIN - 0.3 mg sublingually [**Month (only) 412**] repeat 2 times in 10
minutes.
SIMVASTATIN -80 mg once a day
TORSEMIDE -20 mg DAILY
ACETAMINOPHEN -500 mg four times a day as needed
ASPIRIN -325 mg once a day
CHOLECALCIFEROL (VITAMIN D3) -1,000 unit once a day
LORATADINE [CLARITIN] -10 mg
SODIUM CHLORIDE [DEEP SEA NASAL] - Dosage uncertain
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-26**] Sprays Nasal
QID (4 times a day) as needed for dryness.
7. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for dyspnea.
13. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for dyspnea.
14. sodium chloride 0.9 % Aerosol, Spray Sig: [**12-26**] Sprays Nasal
QID (4 times a day) as needed for dry nose.
15. metolazone 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
16. torsemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
17. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
18. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
19. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day.
20. nifedipine 10 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
21. insulin glargine 100 unit/mL Solution Sig: Fourteen (14)
units Subcutaneous QHS.
22. insulin regular human 100 unit/mL Solution Sig: sliding
scale Injection QAC&HS.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - MACU
Discharge Diagnosis:
s/p aortic valve replacement
obesity
diastolic heart failure(class IV )
Critical aortic stenosis
Severe pulmonary hypertension
tricuspid regurgitation
Hypertension
Hypercholesterolemia
Coronary artery disease -s/p PCI,[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2 midLAD
Instent restenosis treated with PTCA and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2 to Mid LAD [**6-29**]
Paroxysmal atrial fibrillation- no Coumadin due to
gastrointestinal bleed
Chronic kidney disease (baseline crea 1.7)
Gout
diverticulosis
Obstructive sleep apnea(CPAP)
Spinal stenosis
Obesity
s/p LEFT ORIF of femur fracture
h/o gastrointestinal bleed
Discharge Condition:
Alert and oriented x3, nonfocal
Bed->chair w/assistance-very deconditioned
Incisional pain managed with Tylenol
Incisions: Sternal-healing well, no erythema or drainage
Edema trace-bilat
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for one month or while taking narcotics. Driving
will be discussed at follow up appointment with surgeon.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 1477**]
*Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 1477**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **]([**Telephone/Fax (1) 1477**]) on [**6-14**] @1:15P
Cardiologist: Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]/[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4253**], [**MD Number(3) 4254**]:[**Telephone/Fax (1) 337**] Date/Time:[**2141-5-31**] 11:00
Please call to schedule appointments with:
Primary Care: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4255**]([**Telephone/Fax (1) 1576**]) in [**3-30**] 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) 747**] MD [**MD Number(2) 748**]
Completed by:[**2141-5-9**]
|
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icd9cm
|
[
[
[]
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] |
[
"96.72",
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[]
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,124
| 171,344
|
50563
|
Discharge summary
|
report
|
Admission Date: [**2120-5-28**] Discharge Date: [**2120-6-2**]
Date of Birth: [**2063-9-7**] Sex: F
Service: ORTHOPEDIC
DISCHARGE DIAGNOSIS: T10, T11 osteomyelitis.
PROCEDURES PERFORMED:
1. T10 vertebrectomy.
2. T11 partial vertebrectomy.
3. Anterior spinal fusion with instrumentation T9-T11.
4. Reinsertion of PICC line.
HISTORY OF PRESENT ILLNESS: The patient is a pleasant 56
year old woman with long-standing diabetes mellitus and
multiple medical problems, who developed a [**Name (NI) 105261**] discitis
with subsequent osteomyelitis of the vertebral bodies of
T10-T11. She was initially managed nonoperatively with
prolonged intravenous antibiotics with progression of
infection and bony destruction. Due to progression of the
disease despite antibiotic treatment, she now presents
electively for planned surgical debridement and anterior
spinal fusion with instrumentation.
For further details of history and physical examination,
please see the chart.
HOSPITAL COURSE: The patient was admitted to the hospital on
[**2120-5-28**], after undergoing the aforementioned procedures.
The patient tolerated the procedure well with no apparent
intraoperative or postoperative complications. Surgery was
performed through a left T8 thoracotomy approach and a chest
tube was subsequently placed intraoperatively. The patient
was subsequently admitted to the Intensive Care Unit
following her operative procedure for postoperative
ventilator management. Postoperative course was essentially
unremarkable. The patient was subsequently extubated
uneventfully. Chest tube was removed on postoperative day
number two. The patient does have a history of brittle
diabetes mellitus and did have significant lability of her
blood sugar. This was eventually brought under control with
the assistance of the [**Last Name (un) **] Diabetes Center. The patient
was additionally seen by infectious disease regarding her
antibiotic treatment. She was placed back on her Vancomycin
with monitoring of peak and trough. Intraoperative cultures
revealed the presence of a Methicillin sensitive
Staphylococcus aureus organism which was sensitive to
multiple antibiotics including Vancomycin. The patient was
maintained on Vancomycin due to the presence of hardware.
The patient did have postoperative anemia which was treated
with a transfusion of two units of packed red blood cells.
Hematocrit did remain stable without need for further
transfusion following this. The patient was slow to advance
to a general diet secondary to nausea and emesis. On further
questioning, it was noted that the patient had not had a
bowel movement in twenty-one days. Abdominal series was
obtained which showed the presence of a large amount of stool
but no evidence of obstruction. She was subsequently treated
aggressively with both oral stimulation and enemas and
eventually had multiple bowel movements with resolution of
her nausea and vomiting symptoms and progression of her diet.
The patient did have a TLSO brace fitted preoperatively and
was subsequently placed into the TLSO brace postoperatively
for ambulation. She was seen by physical therapy and was up
and ambulating in the halls prior to her transfer to
rehabilitation. The patient was felt to be a good candidate
for transfer to a rehabilitation facility for continuance of
her postoperative therapies and medical monitoring. She will
have further optimization of her insulin dosing and
management [**First Name8 (NamePattern2) **] [**Last Name (un) **] prior to her transfer to the
rehabilitation facility. She will continue on Vancomycin one
gram intravenously q24hours with peak and trough as well as
renal function to be monitored at the rehabilitation facility
for adjustment of her Vancomycin dosing. The patient's PICC
line was noted to be pulled approximately four to six
centimeters out of the skin prior to her transfer. As such,
a new PICC line was placed on the day of transfer to
rehabilitation. Standard PICC line care should be observed.
The wound was noted to be clean, dry and intact throughout
her hospitalization with no evidence of infection.
Neurologically, she had normal strength and sensation
throughout the lower extremities.
DISCHARGE INSTRUCTIONS: The patient will follow-up with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] in two weeks for wound check and staple removal.
She will follow-up sooner should she experience fevers,
chills, worsening pain, wound drainage, neurologic changes or
other concerns.
DISCHARGE ACTIVITY: The patient may be up as tolerated in
her TLSO brace. She does not need to have the brace on while
in bed.
DISCHARGE DIET: General without restriction.
PICC LINE CARE: The patient should have standard PICC line
care.
OTHER INSTRUCTIONS: The patient needs to have frequent
monitoring of liver function tests, complete blood count with
differential, ESR and CRP, as well as peak and trough for
Vancomycin dosing.
OTHER FOLLOW-UP INSTRUCTIONS: The patient will need to
follow-up with infectious disease clinic in one month.
MEDICATIONS ON DISCHARGE:
1. Moexipril 50 mg p.o. once daily.
2. Diltiazem 60 mg one p.o. twice a day.
3. Pantoprazole 40 mg p.o. once daily.
4. Docusate Sodium 100 mg p.o. twice a day.
5. Bisacodyl 10 mg p.o. once daily.
6. Metoprolol 25 mg p.o. twice a day.
7. Hydromorphone 2 to 4 mg p.o. q4hours p.r.n. pain.
8. Vancomycin 1000 mg intravenously q24hours.
9. Insulin regular human per sliding scale. See attached
documentation.
10. Scheduled insulin doses as per attached documentation,
current recommendations not available at the time of this
dictation.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 3863**]
Dictated By:[**Last Name (NamePattern4) 38908**]
MEDQUIST36
D: [**2120-6-2**] 10:21
T: [**2120-6-2**] 10:58
JOB#: [**Job Number 105262**]
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72,426
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40171
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Discharge summary
|
report
|
Admission Date: [**2193-12-26**] Discharge Date: [**2194-1-23**]
Date of Birth: [**2157-3-21**] Sex: F
Service: SURGERY
Allergies:
Zithromax / Propofol
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
fatigue with sore throat, noted to have acute hepatitis at OSH,
transferred for further workup
Major Surgical or Invasive Procedure:
[**2193-12-30**] Tricep Muscle and Right sural nerve biopsy
[**2194-1-9**] subtotal colectomy end ileostomy
[**2194-1-16**] Tracheostomy
History of Present Illness:
36 y.o female with no pmhx. presenting
from outside hospital with labs indicating acute hepatitis, new
ascites, malaise and myalgias. Her symptoms started before
[**Holiday 1451**] when she developed a sore throat and generalized
malaise, body aches, and fever. Her symptoms lasted for [**3-7**]
days and subsided on their own. The following week however, she
became progressively weaker. She saw her PCP and complained of
athralgias/myalgias and sore throat once again. Her PCP
prescribed Azithromycin, and a few days later she developed a
rash on her hands, arms, lower back and buttocks. Her PCP
stopped the azithromycin due to a fear that the rash was
Azithromycin-induced. Her rash continued to worsen. Labs drawn
at that time showed lymphopenia and thrombocytopenia, and she
was referred to a hematologist on [**2193-12-18**]. His impression was
that her symptoms were consistent with a viral syndrome. She
also had a mild elevation of LFTs at that time. Her fatigue
continued to worsen, and she could not ambulate. She went to
[**Hospital 1727**] [**Hospital3 **], where she improved with IV fluids and
was discharged. She saw her PCP who, after reviewing her labs,
observing her rash, and noting her worsening LFTs, referred her
to a inland hospital. She was then transferred to [**State 48444**] Center the same day.
.
At Eastern [**State 1727**], ultrasound of the abdomen was done on [**12-23**]
and was normal. MRCP on [**2193-12-25**] showed no obstructive
process but was significant for ascites. CMV antibodies, Herpes
Simplex, HIV, SPEP, and UPEP were drawn and are pending at the
time of transfer to [**Hospital1 18**]. Ferritin was elevated to 1489,
platelets decreased to 68. RF was less than 10. [**Doctor First Name **] was 1:40. No
improvement in rash or clinical status. No improvement in LFTs.
Transferred to [**Hospital1 18**] for further workup.
.
On the floor, the following additional history was obtained. The
patient's initial viral syndrome included 3-4 days of non bloody
diarrhea which spontaneously resolved. She denies any abdominal
pain and nausea and vomiting. She says her weight has been
stable, has lost 3 pounds since [**Month (only) **]. She does complain of
dysphagia in the last month. She also describes dull pain in the
substernal region with swallowing. She has been cutting her food
into small pieces as a result but denies any bloating or
dyspepsia. Last week she was noted to have thrush and was
treated with Nystatin for a couple of days. She also describes
the pain/stiffness of her joints/ muscles and weakness as
initially being worse at her lower extremities and moving up her
body to her upper extremties in the past few weeks. She is also
complaining of neck and upper back stiffness and pain. She
notes that she received prednsione for 1-2 days in the past few
weeks which was stopped for unknown reasons. At times her rashes
have been pruritic and her hands and joints are swollen in the
morning. Both her and her husband feel like her rashes are
worsening in that they are becoming "more red" and continuous.
Past Medical History:
None
Social History:
Lives with her husband. Monogamous. Schoolteacher. Her 3
children are healthy. She has never smoked. She denies alcohol,
tobacco, or recreational drug use.
Family History:
Father had DM, mother had [**Name2 (NI) **], aunt with breast cancer in her
40s.
Physical Exam:
On discharge:
98.3 100 127/71 24 100%TM
Gen: NAD, on trach mask, anxious appearing, erythematous rash
CV: RRR
Pulm: rhonchi on L side, R CTA
Abd: soft, appropriately TTP, incision c/d/i, ostomy pink and
healthy, bag with air and brown BMs
Ext: 3+ edema x 4, erythematous rash with scab on dorsum of
hands
Pertinent Results:
Labs:
Admission:
LABS: TSH 1.61
UA showed large blood, protein of 30
Monospot was negative, Acetaminophen 1.2 , ESR-1 CRP less than
0.1 Na-136, potassium 5, chloride 102, bicarb 25, BUN 18,
creatinine 0.6 , albumin 2.9, calcium 8.2, phospohorus 2.9,
magnesium 2 . T. Bili 0.5 ALk phos 327, ALT-492, AST 1453
ammonia 44 amylase 102 lipase 72 INR 1.1WBC 4 Hemoglobin
15.7,platelets 99
.
Discharge:
145 112 61
-------------- 145
4.5 25 0.8
Ca: 8.5 Mg: 1.9 P: 2.2
10.3 >----< 418
23.0
ALT 51 AST 34 LD(LDH) 542 CK(CPK) 287 TotBili 0.7
.
CRP 10.6
IgG 344, IgA 152, IgM 79
.
IMAGING:
MRCP [**2193-12-25**] - small amount of ascites in upper abdomen , no
liver lesions, no biliary pathology, trace pleural effusions
bilaterally.
Abdominal US [**12-24**] - Normal
CXR [**2193-12-27**] - Minimal bilateral pleural effusions, otherwise
normal chest radiograph.
MR [**Last Name (Titles) **] [**2193-12-27**]:
1. Limited study, though there is evidence of diffuse muscle
edema in the
right upper extremity, most evident in the triceps. A more
complete exam can be performed when the patient is clinically
able to tolerate the exam.
2. Significant subcutaneous edema. Questionable edema tracking
along fascial planes. Correlate clinically to exclude
cellulitis.
3. Moderate right pleural effusion.
[**2193-12-28**] CT head:
No acute intracranial hemorrhage or mass effect. A few
hypodense foci in the braina t the vertex- which are of
uncertain
significance- ? related to volume averaging/real. MR can be
considered for
better assessment if not CI.
MRI head [**2193-12-28**]:
Multiple T2 hyperintense foci within the cortex and subcortical
white matter of both cerebral hemispheres, as well as the
left-sided
periventricular white matter. However, such other entities as
posterior reversible encephalopathy syndrome (PRES),
particularly given the distributino of the lesions and diffusion
findings, venous infarction, and a rare neoplastic condition
(intravascular lymphoma) could also be considered.
CT head [**2193-12-28**]:
No major vascular stenoses or occlusive processes.
MRV head [**2193-12-29**]:
No sign of venous sinus thrombosis. Multiple enhancing lesions
within the cerebral hemispheres and left periventricular white
matter.
Differential diagnosis includes encephalitis, multiple infarcts,
and perhaps posterior reversible encephalopathy, with the
appropriate clinical context needed for the latter diagnosis.
CT torso [**2193-12-29**]:
1. Bilateral moderate pleural effusions with overlying
atelectasis.
2. Diffuse and severe anasarca with bilateral effusions,
ascites,
subcutaneous and interfascial fluid.
3. Bowel wall thickening which is most likely secondary to
third-spacing.
Pelvic US [**2193-12-30**]:
1. Essentially nondiagnostic pelvic ultrasound due to inability
to position for the examination. Grossly normal transabdominal
appearance of the uterus and endometrium; neither ovary
visualized.
2. Free fluid in the pelvis consistent with ascites.
CT torso [**2194-1-1**]:
1. No etiology for hematocrit drop identified. Specifically, no
sites of
retroperitoneal or intramuscular hematoma noted.
2. Interval worsening in degree of subcutaneous and
intramuscular anasarca. Increased size to bilateral pleural
effusions.
3. Persistent bilateral nephrograms in the setting of prior
contrast exposure possibly related to ATN.
KUB [**2194-1-8**]:
Large pneumoperitoneum.
CT torso [**2194-1-15**]:
1. No radiologic findings to suggest bowel ischemia.
2. Diffuse opacities involving the right middle lobe and left
lung base,
largely appearing atelectatic; however superimposed infection
may be present,
especially where multiple nodular opacities are seen closely
abutting the left fissure.
3. Diffuse ground-glass opacities involving the left upper lobe,
may be
infectious or inflammatory in nature, or representing focal
edema.
4. Small left pleural effusion with adjacent areas of
compressive
atelectasis, markedly improved from [**2194-1-1**] exam.
5. Moderate amount of free fluid within the pelvis.
Pathology:
[**2193-12-16**]: L hand and thigh skin biopsy
Part 1, Left hand: The dominant finding in this biopsy is of
marked papillary dermal edema with subepidermal vesiculation.
There is some red blood cell extravasation into the bulla, but
there is minimal inflammation. The overlying epidermis is
intact. It shows some hyperkeratosis with occasional
dyskeratotic cells and intraepidermal lymphocytes. Significant
interface inflammation is not appreciated in this sample in the
multiple tissue levels examined. The basement membrane zone is
highlighted by a PAS stain. It shows focal minimal thickening.
No fungal organisms are seen in the overlying stratum corneum.
There is a superficial perivascular lymphocytic infiltrate
containing rare fragmented nuclei in the dermis underlying the
bulla. Necrotizing vasculitis is not seen. Alcian blue and
colloidal iron stains highlight superficial dermal mucin. There
is minimal mucin deposition in the deep reticular dermis. A
tissue Gram stain (bacterial organisms) is negative.
Part 2, Left thigh: The changes in this biopsy are much more
subtle than those in the biopsy from the hand. There is mild
epidermal spongiosis, focal basal vacuolar change, scattered
dyskeratotic keratinocytes and sparse intraepidermal
lymphocytes. Nuclear fragments are seen at the dermoepidermal
junction and within the superficial dermis. The basement
membrane zone is highlighted by a PAS stain. It shows focal
minimal thickening. No fungal organisms are seen in the
overlying stratum corneum. There is a superficial perivascular
lymphocytic infiltrate which is of variable density. There is
focal red blood cell extravasation and vascular endothelial
cells show reactive changes. Necrotizing vasculitis is not seen.
Alcian blue and colloidal iron stains highlight superficial
dermal mucin. There is minimal mucin deposition in the deep
reticular dermis.
Comment: The findings in these two biopsies are unusual, and the
features are dissimilar at the two sites. The histologic
differential diagnosis of the papillary dermal edema found in
the left hand biopsy includes bullous connective tissue disease,
vesiculobullous disease, drug reactions, vasculitis and
infections. Necrotizing vasculitis was not identified, and Gram
and PAS stains are negative for bacterial and fungal organisms.
The findings in the biopsy from the left thigh are not
specifically diagnostic, however, the differential diagnosis
includes connective tissue disease, drug reaction and a viral /
post viral dermatosis.
[**2193-12-30**] flow cytometry:
Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield.
CD45 bright and low side scatter, lymphocyte gated events
constitute less than 2% of total analyzed events.
Due to paucicellular nature of the specimen, a limited panel is
performed to determine B-cell clonality.
B cells are scant in number precluding evaluation of clonality.
CD5 positive T cells comprise approximately 50% of lymphoid
gated events.
INTERPRETATION Non-diagnostic study.
A limited cell marker analysis was attempted, but was
non-diagnostic in this case due to insufficient numbers of B
cells for analysis.
Flow cytometry immunophenotyping may not detect all lymphomas
due to topography, sampling or artifacts of sample preparation.
Review of corresponding cytospin shows monocytes, red blood
cells and predominantly small mature-appearing lymphocytes.
[**2193-12-30**] sural nerve and tricep muscle biopsy:
1. Specimen labeled "Triceps muscle biopsy": -- PRELIMINARY
DIAGNOSIS--
Skeletal muscle with mild perivascular and perimysial
inflammation.
NOTE: Overall, the PRELIMINARY findings are that of mild
chronic inflammatory infiltrates essentially restricted to the
perivascular and perimysial space. Some lymphocytes appear to
be within vessel walls. These findings are nonspecific but
could be seen in the setting of an inflammatory myopathy
(dermatomyositis > polymyositis), vasculitis, rheumatologic
disease (e.g. lupus, mixed connective tissue disorder, etc.) or
less likely post-viral etiology. As patient has been treated
with steroids starting several days prior to the biopsy, the
inflammatory infiltrates seen in the current biopsy may be
significantly diminished and therefore the preliminary findings
may not accurately represent the extent of disease noted at the
time of clinical presentation. There is no evidence of
perifascicular atrophy, inclusion bodies, or myofiber
destruction.
A frozen section panel, including histochemical stains and
immunoperoxidase studies, is pending and results will be
reported in an addendum.
Microscopic Description:
Examination of paraffin-embedded H&E sections (levels examined)
show skeletal muscle in longitudinal and cross sections with
minimal variation in fiber size but no evidence of necrotic,
degenerating or regenerating fibers. Endomysial connective
tissue is not increased. There are mild perivascular and
perimysial LCA-positive inflammatory infiltrates predominantly
composed of CD3-positive T cells with only very rare
CD20-positive B cells. There is no evidence of perifascicular
atrophy, vasculitis, myophagocytosis or myofiber destruction.
2. Specimen labeled "Sural nerve biopsy":
Peripheral nerve with mild perivascular and perineurial
inflammation.
NOTE: The sections show peripheral nerve tissue in longitudinal
and cross sections with preservation of myelin content
(highlighted by trichrome stain). Perineurial blood vessels are
focally thickened and associated with mild perivascular and
perineurial LCA-positive chronic inflammatory infiltrates
essentially composed of CD3-positive T cells with no significant
B cell (CD20) component. [**Country 7018**] Red stain and beta-amyloid
immunostain are negative for amyloid.
ADDENDUM:
A frozen section panel was performed on tissue from the specimen
labeled "triceps muscle biopsy." An H&E section reveals
histologic features similar to those seen on prior paraffin
sections: mild chronic inflammatory infiltrates largely
restricted to perivascular and perimysial regions, minimal
variation in fiber size, and no evidence of degenerating fibers.
Gomori trichrome reveals no rimmed vacuoles, endomysial
fibrosis or ragged red fibers. PAS and PAS/D stains do not
reveal accumulation of glycogen and the Oil Red O stain is
unremarkable. NADH reveals a normal stippled staining pattern.
[**Doctor Last Name **] staining reveals rare fibers with a lack of staining. MHCf
and MHCs immunostains reveal a predominance of Type II fibers.
CD4 and CD8 immunohistochemical stains (on paraffin sections)
reveal that the majority of T-cells in the inflammatory
infiltrates are CD4+CD8-.
Additional stains were performed on the specimen labeled "sural
nerve biopsy." A Bodian stain reveals longitudinal and
cross-sections of nerve with an appropriate complement of
myelinated and unmyelinated axons. CD4 and CD8 immunostains
reveal scattered CD4+ and CD8+ T-cells.
[**2193-12-31**] blood immunophenotyping:
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: CD19, Kappa,
Lambda, CD45.
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield.
CD45-bright, low side scatter lymphoid gated events are 1% of
total analyzed events.
Due to scant proportion of lymphocytes, a limited panel is
performed to determine B-cell clonality.
B cells comprise 32% of lymphoid-gated events and are polyclonal
by surface immunoglobulin light chain staining.
INTERPRETATION
Non-specific lymphoid profile; diagnostic immunophenotypic
features of involvement by B-cell non-Hodgkin lymphoma are not
seen in specimen on a limited panel. Correlation with clinical
findings and morphology is recommended. Flow cytometry
immunophenotyping may not detect all lymphomas due to
topography, sampling or artifacts of sample preparation.
[**2194-1-2**] bone marrow immunophenotyping:
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: CD2, CD3, CD4,
CD5, CD7, CD8, CD10, CD19, CD20, CD16, CD56, FMC-7, HLA-DR,
Kappa, Lambda, CD45, CD23.
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield. B cells comprise 25% of lymphoid
gated events, are polyclonal, and do not express aberrant
antigens.
T cells comprise 63% of lymphoid gated events, express mature
lineage antigens, and have a normal helper-cytotoxic ratio of
1.0 (usual range in blood 0.7-3.0). Natural Killer cells are
quantitatively normal (6%).
INTERPRETATION
Non-specific T cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by non-Hodgkin lymphoma
are not seen in specimen. Correlation with clinical findings and
morphology (see S10-[**Numeric Identifier **]) is recommended. Flow cytometry
immunophenotyping may not detect all lymphomas as due to
topography, sampling or artifacts of sample preparation.
[**2194-1-9**] total colon:
1. Left colon (A-H):
1. Colon with perforation and associated acute serositis,
margins viable.
2. Three unremarkable lymph nodes.
3. Melanosis coli.
2. Total colon (I-AF):
1. Patchy, severely active colitis with few transmural ulcers;
superficial ulceration present at distal colonic margin.
2. Appendix with Enterobius vermicularis infection.
3. Proximal terminal ileal margin unremarkable.
4. Melanosis coli.
5. Twelve unremarkable lymph nodes.
6. Cytomegalovirus stains on blocks Q, R, AB, and AC are
negative with adequate controls.
3. Omentum (AG-AK):
Unremarkable mature adipose tissue.
Brief Hospital Course:
ASSESSMENT AND PLAN: 36 y.o female with no pmhx presenting with
approx. 1 month fatigue, elevated LFTs, athralgias, and myalgias
after sore throat and diarrhea. She decompensated rapidly while
in the hospital and was diagnosed with fulminant dermatomyositis
and macrophage activating syndrome. Her hospital course was
complicated by colonic perforation after a decompressive
colonoscopy and required a subtotal colectomy and end ileostomy.
Given her progressive weakness, acute kidney injury and
subsequent volume overload, she was unable to be weaned off the
vent and was given a tracheostomy. Problem based course is as
follows:
.
#Skin rash/joint pain- Initially the patient was transferred to
the liver service from an OSH for concern of liver failure.
However, her elevated LFTs were thought to be due to a more
systemic process. At presentation, her lower extremities had
weakness to knee flexion and extension and less so with thigh
flexion. Her upper extremities were weaker. Specifically, she
lacked proximal shoulder strength. She had a glove distribution
of her rash bilaterally, as well her upper/lower back and
anterior chest. She also had been experiencing dysphagia for 1
month. The constellation of myositis, rash, thrombocytopenia,
and acute altered mental status was concerning for a vasculitis
or cerebritis. She was transferred to the MICU on [**12-27**] for
mental status change and required intubation. The patient's
pertinent findings included a CK that continued to trend up
([**Numeric Identifier **] on [**1-1**]), thrombocytopenia to plt=93 on [**1-1**] and an
increasing creatinine (1.4 on [**1-1**]). Many services were
consulted, including Derm, Neuro, Rheum and ID. Per rheum recs,
she was started on 1g Methylprednisone x3 days and then switched
to 48mg. An MRI of her head showed enhancing lesions. A muscle
biopsy was done on [**1-1**] showing mild chronic inflammatory
infiltrates. A sural nerve biopsy was done on [**1-1**] showing mild
perivascular and perineurial inflammation. As of [**1-1**] the
working differential included PRES, vasculitis, cerebritis,
connective tissue disorder and dermatomyositis. This
differential was narrowed to dermatomyositis and macrophage
activating syndrome. On [**1-2**], under advisement from
nephrology, rheumatology and pharmacology the patient was
started on sucrose free IVIG and was restarted on pulse
methylprednisolone 1g QD x 2days. Dexamethasone 10mg [**Hospital1 **]
started on [**2194-1-5**]. Post opertatively from the colecotomy, she
recieved stress dose steroids then was tapered down as her rash,
weakness, LFTs and CKs improved.
.
# Mental Status Changes: On [**12-27**] the patient had an acute
mental status change followed by a seizure. She was loaded with
dilantin and later switched to Keppra per neuro recs. She was
started on Vanco/CTX/Acyclovir for meningitis coverage. Later
doxycycline was added for coverage of Lyme and [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] spotted
fever. These medications were all d/c'd as an LP and lyme titer
were negative. She was placed on continuous EEG which showed no
sub-clinical seizure activity. Her propofol was d/c'd on [**12-31**],
and her MS improved on [**1-1**] when she was able to follow
commands such as nodding and moving her toes. Her keppra was
later stopped. She has been extremely anxious; Lorazepam,
Methadone, Quetiapine, and Sertraline were added with good
effect.
.
# Respiratory distress: The patient was intubated on [**12-28**] for
airway control after seizure. She was noted to have frothy
output from the tube, concerning for fluid overload, which
improved after CVVH started. The patient maintained excellent
saturations, however intubation was continued due to need for
high level of sedation for pain control. She failed extubation
twice post operatively from the colectomy and ultimately
required tracheostomy. She has been weaned to trach mask
successfully. She was also found to have a stenotrophomoas PNA
[**2194-1-10**] and is on levofloxacin.
.
#Elevated LFTs- She was found to have elevated LFTs at the OSH,
and her imaging workup, including an ultrasound and MRCP, did
not find any evidence of liver disease. However, ascites was
noted. Her anti-mitochondrial Ab was negative, and she has
ceruloplasmin, HSV, HIV pending at the OSH. Suspicion for
intrinsic liver disease was low, and her elevated LFTs were
thought to be due to muscle breakdown. They trended down during
her admission and have nearly normalized.
.
# Hypertension/Tachycardia: The pt was hypertensive while
intubated. On [**1-1**] the patient was started on Labetolol PO
100mg [**Hospital1 **]. She required occasional doses hydralazine. Following
this, she was switched to lopressor, and she is now on
metoprolol 37.5 mg PO BID. This may be titrated down as needed
Her HTN/tachycardia is likely secondary to pain and anxiety so
she was also started on seroquel, ativan, methadone and zoloft.
.
#Poor UOP/Acute Kidney Injury: Her creatinine on admission was
0.6 and trended upwards to 1.4 on [**1-1**]. It was thought to be
due to rhabdo vs. prerenal vs. rheumatologic process vs.
contrast nephropathy. Urine lytes show 0.01%. 24-hr urine
protein= 195. A trial of albumin 5% on [**12-31**] did not increase
her urine output. She was 17L postive for length of stay as of
[**1-1**] so IVF was held and she was given albumin 25% in order to
help with albumin=1.8. On [**1-1**], Lasix 80mg IV was given. On
[**1-2**] IVF was switched to D5W and 3 amps bicarbonate at 50cc/hr.
The patient's creatinine continued to rise, and she was started
on CVVH on [**2194-1-4**]. She diuresed 6L over 24 hours on [**1-5**]. The
next 24 hours she diuresed a further 9 L. CVVH was discontinued
on [**1-7**]. Her BUN and Cr are now normal.
.
# CK elevation: Her CK was elevated to 20,000 on admission,
slightly improved on high dose pulse steroids of 1gm IV
solumedrol, but afterwards continued to trend up to 30,000 on
[**1-1**] then 80,000 by [**1-2**] afternoon. She had a CT scan showing
evidence of myositis in her tricep. Given her rash, it was
thought she may have dermatomyositis. A muscle biopsy was done
on [**1-1**] that was consistent with possible vasculitis or
dermatomyositis. She was given IVFs, albumin, and furosemide to
maintain good UOP in order to prevent kidney injury from the
elevated CK. On [**1-2**], she was started on IVIG and high-dose
solumedrol with improvement in her CK. Dexamethasone 10mg IV BID
started on [**1-5**], and CK continued to trend down. CK is still
mildly elevated but continues to trend down.
.
# [**Last Name (un) 3696**] Syndrome: She was noted to have dilatation of her
large bowel on KUB on [**2194-1-4**]. Tube feeds were held as she did
not have any bowel sounds. Methylnaltrexone and several enema,
lactulose along with full bowel regimen produced 1 liter of
liquid stool. KUB consistent with [**Last Name (un) 3696**] syndrome. Surgery
placed a rectal tube, which was not very effective. GI performed
a colonoscopic decompression c/b perforation. KUB post procedure
revealed free air so she was taken to the OR for ex-lap,
subtotal colectomy and end ileostomy on [**1-9**].
She was given lasix in attempt to diurese for extubation. She
was extubated then desaturated and was reintubated on [**1-10**]. On
[**1-11**], she was transfused 2U RBC for low Hct of 20.3->26.9 and
started on tube feeds. Steroids were continued per rheumatology
recs Started methadone, lasix, and lorazepam. Neuro status
dramatically improved. She was extubated again on [**1-13**] but
desaturated again with demand ischemia and troponin leak. She
was reintubated and bronchoscopy showed copious thick secretions
and mucous plugs in LLL and LUL. On [**1-16**] she had percutaneous
tracheostomy and was weaned off the ventilator to trach collar.
BAL grew stenotrophomonas so she was started on levofloxacin. On
[**1-21**] she had another acute desat overnight down to high 50s and
was bronched twice to remove large mucus plugs. Given her
improving CK and LFTs, her steroids were weaned down
approximately 10% every 3 days. PT and OT have been working with
the patient daily while she is in the ICU.
Summary of systems as they are now:
Neuro: High anxiety. Stabilized on Acetaminophen, Lorazepam,
Methadone, Quetiapine, Sertraline. No further seizures noted,
keppra d/c'd.
CV: Hemodynamically stable but tachycardic, presumably due to
anxiety. Increased lopressor dose on the day of discharge. [**Month (only) 116**]
wean as tolerated.
Pulm: Trached and stable on trach mask. her trach is currently
an 8.0. This may be downsized today and a PSM valve trial
attempting when appropriate. She is receiving levofloxacin
until [**2194-1-31**] for stenotrophomonas PNA. This will be a 14 day
course.
GI: Tube feeds are to goal through NGT. Will need speech and
swallow evaluation. LFTs are nearly normalized. Ostomy is pink
and healthy, producing air and bowel movements.
GU: BUN and creatinine are fine. Making good urine through
foley.
Heme: Hct is stable at 23.0. No recent transfusions needed.
Endocrine: Rheumatology is controlling the steroid taper. As of
today ([**2194-1-23**]), she was changed to Methylprednisolone 18mg IV
BID. The instructions for the taper are: Decrease amount by 10%
every 3 days until a level of 8mg IV BID. She will not go below
this level. She is also on an insulin sliding scale.
ID: The patient is on bactrim prophylaxis due to her high
steroid dose. She is also on levofloxacin for stenotrophomas
and will be on this until [**2194-1-31**].
MSK: PT/OT is working with the patient.
Misc: Change central line to PICC when edema has subsided.
Medications on Admission:
None
Discharge Medications:
Acetaminophen 325-650 mg PO/NG Q6H:PRN fever
Albuterol Inhaler 6 PUFF IH Q4H:PRN sob
Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes
Calcium Carbonate Suspension 500 mg PO/NG [**Hospital1 **]
Docusate Sodium (Liquid) 100 mg PO/NG [**Hospital1 **]
Glucagon 1 mg IM Q15MIN:PRN hypoglycemia
Heparin 5000 UNIT SC TID
Lansoprazole Oral Disintegrating Tab 30 mg PO/NG DAILY
Levofloxacin 750 mg IV Q24H until [**2194-1-31**]
Lorazepam 0.5 mg IV Q8H:PRN anxiety
MethylPREDNISolone Sodium Succ 18 mg IV Q 12H, decrease by 10%
q3 days
Methadone 7.5 mg PO/NG Q6H
Metoprolol Tartrate 37.5 mg PO/NG TID hold for SBP<100 or HR<60
Ondansetron 4 mg IV Q8H:PRN nausea
Quetiapine Fumarate 12.5 mg PO/NG Q 24H
Quetiapine Fumarate 25 mg PO/NG QHS
Sertraline 50 mg PO/NG DAILY
Sulfameth/Trimethoprim SS 1 TAB PO/NG 3X/WEEK (MO,WE,FR)
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Fulminant dermatomyositis, macrophage activating syndrome,
colonic perforation
Discharge Condition:
stable
Mental status: alert. Anxious at times.
Non-ambulatory secondary to profound weakness/deconditioning.
Will need intensive rehabilitation.
Discharge Instructions:
Neuro: High anxiety. Is stabilized on Lorazepam, Methadone,
Quetiapine, Sertraline. No further seizures noted, keppra d/c'd.
CV: Hemodynamically stable but tachycardic, presumably due to
anxiety. Increased lopressor dose on the day of discharge. [**Month (only) 116**]
wean as tolerated.
Pulm: Trached and stable on trach mask. her trach is currently
an 8.0. This may be downsized today and a PSM valve trial
attempt when appropriate. She is receiving levofloxacin until
[**2194-1-31**] for stenotrophomonas PNA.
GI: Tube feeds are to goal through NGT. Will need speech and
swallow evaluation. LFTs are nearly normalized. Ostomy is pink
and healthy, producing air and bowel movements. Titrate output
to 1-1.5L per day using imodium as needed. If ostomy output >1
liter, give 4mg of Imodium, repeat 2mg with each episode of
loose stool. Do not exceed 16mg/24 hours.
GU: BUN and creatinine are fine. Making good urine through
foley.
Heme: Hct is stable at 23.0. No recent transfusions needed.
Endocrine: Rheumatology is controlling the steroid taper. As of
today ([**2194-1-23**]), she was changed to Methylprednisolone 18mg IV
BID. The instructions for the taper are: Decrease amount by 10%
every 3 days. Exact schedule is pasted below. IVIg -
rheumatology will contact the [**Name (NI) **] regarding IVIg treatment in
the next week. She is also on an insulin sliding scale.
ID: The patient is on bactrim prophylaxis due to her high
steroid dose. She is also on levofloxacin for stenotrophomas
and will be on this until [**2194-1-31**].
MSK: PT/OT is working with the patient. No restrictions.
Misc: Change central line to PICC when edema has subsided. [**Month (only) 116**]
not bathe but may have sponge baths and showers.
Steroid taper:
[**2194-1-23**]: 18mg IV BID
[**2194-1-26**]: 16mg IV BID
[**2194-1-29**]: 14mg IV BID
[**2194-2-1**]: 13mg IV BID
[**2194-2-4**]: 12mg IV BID
[**2194-2-7**]: 11mg IV BID
[**2194-2-10**]: 10mg IV BID
[**2194-2-13**]: 9mg IV BID
[**2194-2-16**]: 8mg IV BID
**do NOT taper past 8mg IV BID. Will stay at this level once it
is reached.
Followup Instructions:
Patient should have follow up in the Acute Care Surgery Clinic,
call ([**Telephone/Fax (1) 2537**] to schedule appt. Follow up in 2 weeks.
-Neurology follow up: Please follow up with Dr. [**Last Name (STitle) 1206**] in the
clinic (building [**Hospital Ward Name 23**] 8) on [**2194-2-25**] at 4:30pm. Please
call to confirm your appointment.
-Rheumatology follow up: Please follow up with Dr. [**First Name (STitle) 3443**] on
Febuary 3rd in clinic. Please call to confirm your appointment.
Rheumatology will contact the [**Name (NI) **] regarding IVIg treatment in
the next week.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
|
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icd9cm
|
[
[
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[
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"46.21",
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icd9pcs
|
[
[
[]
]
] |
28457, 28522
|
17871, 27557
|
375, 513
|
28644, 28651
|
4263, 5576
|
30931, 31082
|
3836, 3918
|
27612, 28434
|
28543, 28623
|
27583, 27589
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28815, 30908
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3933, 3933
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31303, 31628
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3948, 4244
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241, 337
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541, 3619
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5585, 17848
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28666, 28791
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3641, 3647
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3663, 3820
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,127
| 147,633
|
52136
|
Discharge summary
|
report
|
Admission Date: [**2137-6-14**] Discharge Date: [**2137-6-24**]
Date of Birth: [**2057-4-23**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides) / Morphine / Penicillins / Codeine
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Angina
Major Surgical or Invasive Procedure:
Cardiac Catheterization [**2137-6-14**]
Coronary Artery Bypass Graft x 3 (LIMA to LAD, SVG to Diag, SVG
to OM) [**2137-6-18**]
History of Present Illness:
80 y/o female with h/o CAD s/p PCI LAD who developed worsening
exertional chest pain and dyspnea over last two months.
Underwent adenosine ETT showing no ischemic EKG changes and
nuclear imaging showing no definite ischemia/infarct.
Transferred to [**Hospital1 18**] for cath. Underwent cath [**2137-6-14**] showing L
main disease. Pt. transfered to [**Hospital Unit Name 196**] service with plan for CT
surgery consult.
Past Medical History:
Coronary Artery Disease s/p NQWMI s/p PTCA LAD (93, 99),
Hypertension, Hypercholesterolemia, Peripheral Vascular Disease,
Kidney Stones, Psoriasis, Hiatal Hernia, s/p AV seq. pacemaker,
s/p L Renal Artery Stenting, s/p Bladder suspension and D&C, s/p
L Breast Lumpectomy, s/p Total Abdominal Hysterectomy & Bilat.
Salpingo-oophorectomy, s/p Bilat. Total Knee Replacement, s/p
Aortobifemoral Bypass, s/p R Carotid Endarterectomy
Social History:
SH: Married, 10 adult children. Retired cashier.
Family History:
FH: Mother died MI [**73**], Brother died rheumatic heart disease 10,
Father died cancer 62
Physical Exam:
VS - 97.6, 145/68 (127-148/60-76), 60, 18, 99% 2L
HEENT - NC/AT, EOMI, PERRL, Conjunctivae pink, OP clear, MMM
Neck: Supple, FROM, -JVD, -Carotid Bruits
LUNGS - CTA at apices/bases
HEART - RRR, S1, S2, no rmg
ABD - Soft, NT, ND, +BS
EXT - wwp, + chronic venous stasis changes, + no edema. 2+ DP,
PT pulses, no hematoma at R groin site, no bruit, -varicosities
NEURO - MAE, A&Ox3, non-focal
Pertinent Results:
Cardiac Cath [**2137-6-14**]: 1. Selective coronary angiography showed a
right dominant system with two vessel disease. The LMCA had a
distal 80 stenosis. The LAD showed mild irregularities without
flow limiting stenoses. The proximal LAD stent was patent. The
Ramus was without flow limiting stenoses. The LCX had a 60%
stenosis prximally. The RCA was a large dominant vessel with no
flow limitations.
Echo [**2137-6-18**]: PREBYPASS: There is mild symmetric left ventricular
hypertrophy. Overall left ventricular systolic function is
normal(LVEF>55%). The ascending aorta is moderately dilated. The
descending thoracic aorta is mildly dilated. There are complex
(>4mm) atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. Tricuspid
regurgitation is present but cannot be quantified. The pulmonic
valve leaflets are thickened. POSTBYPASS: Preserved
biventricular systolic function. The study is otherwise
unchanged from prebypass.
[**2137-6-14**] 10:30AM BLOOD WBC-7.3 RBC-4.08* Hgb-12.7 Hct-36.5
MCV-90 MCH-31.3 MCHC-34.9 RDW-14.7 Plt Ct-185
[**2137-6-23**] 04:45AM BLOOD WBC-11.3* RBC-3.23* Hgb-10.0* Hct-29.5*
MCV-91 MCH-31.0 MCHC-34.0 RDW-15.1 Plt Ct-237
[**2137-6-14**] 07:35AM BLOOD INR(PT)-1.1
[**2137-6-24**] 04:10AM BLOOD PT-17.0* PTT-65.4* INR(PT)-1.6*
[**2137-6-14**] 10:30AM BLOOD Glucose-142* UreaN-32* Creat-1.4* Na-142
K-3.8 Cl-104 HCO3-29 AnGap-13
[**2137-6-23**] 04:45AM BLOOD Glucose-108* UreaN-26* Creat-1.4* Na-140
K-3.8 Cl-102 HCO3-30 AnGap-12
[**2137-6-23**] 04:45AM BLOOD Mg-2.2
[**2137-6-14**] 03:48PM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-8.0 Leuks-NEG
[**2137-6-14**] 03:48PM URINE RBC->50 WBC-0-2 Bacteri-RARE Yeast-NONE
Epi-0
Brief Hospital Course:
As mentioned in the HPI, Ms. [**Known lastname **] was transferred from OSH for
cardiac cath. Cath revealed severe left main disease. She was
started on a Heparin drip and awaited cardiac surgery. She
remained stable for several days, had usual pre-op work-up and
was brought to the operating room on [**2137-6-18**]. She underwent a
coronary artery bypass graft x 3. Please see operative report
for surgical details. She tolerated the procedure well and was
transferred to the CSRU for invasive monitoring in stable
condition. Later on op day she was weaned from sedation, awoke
neurologically intact and was extubated. Chest tubes were
removed on post-op day one. Beta blockers and diuretics were
started and she was gently diuresed during post-op course
towards her pre-op weight. On post-op day two she was transfused
2 units of PRBCs secondary to anemia with HCT of 23.6. Also
early on post-op day two she had an episode of Atrial
Fibrillation which converted with Lopressor and Amiodarone
Bolus. Over the rest of the hospital course she had several more
episodes of atrial fibrillation. She remained on Amiodarone and
Anti-coagulation was started. She was transferred to the cardiac
surgery step down floor on post-op day three. Epicardial pacing
wires were removed. Beta blockers were titrated for maximum BP
and HR control. Physical therapy followed patient during entire
post-op course for strength and mobility. She remained stable
over the remainder of post-op course. Anti-coagulation was
discontinued after 24 hrs of being in sinus rhythm per Dr.
[**Last Name (STitle) **] as risks of anticoagulation greater than risk of CVA. At
time of discharge her labs, vital signs, and physical exam were
stable. She was discharged home on post-op day six with the
appropriate follow-up appointments and VNA services.
Medications on Admission:
Lipitor 20mg daily every night
Atenolol 50 mg twice a day every morning and night
Diovan HCT 160mg-25mg daily every morning
Potassium 10meq daily every morning
Aspirin 81mg daily every morning
Multivitamin 1 tablet daily every morning
Imdur 60mg daily every morning
Hydrochlorothiazide 25 mg daily every morning
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*1*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] for 7 days. Than 200mg [**Hospital1 **] for 7 days.
Finally, 200mg qd until stopped by Cardiologist. .
Disp:*60 Tablet(s)* Refills:*1*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 2
weeks.
Disp:*56 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3
PMH: NQWMI s/p PTCA LAD (93, 99), Hypertension,
Hypercholesterolemia, Peripheral Vascular Disease, Kidney
Stones, Psoriasis, Hiatal Hernia, s/p AV seq. pacemaker, s/p L
Renal Artery Stenting, s/p Bladder suspension and D&C, s/p L
Breast Lumpectomy, s/p Total Abdominal Hysterectomy & Bilat.
Salpingo-oophorectomy, s/p Bilat. Total Knee Replacement, s/p
Aortobifemoral Bypass, s/p R Carotid Endarterectomy
Discharge Condition:
Good
Discharge Instructions:
You may take shower. Wash incisions with water and gentle soap.
Gently pat dry. Do no take bath.
Do not apply lotions, creams, ointments or powders to incisions.
Do no drive for 1 month.
Do no lift greater than 10 pounds for 2 months.
If you develop a fever or notice redness or drainage from
incisions, please contact office immediately.
Please call to schedule follow-up appointments.
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks.
Dr. [**Last Name (STitle) 5686**] in [**2-15**] weeks.
Dr. [**Last Name (STitle) 12982**] in [**1-14**] weeks.
[**Hospital 409**] Clinic on [**Hospital Ward Name 121**] 2 in 2 weeks.
Completed by:[**2137-7-19**]
|
[
"412",
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"997.1",
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"V45.01",
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"V43.65",
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"443.9",
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] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
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icd9pcs
|
[
[
[]
]
] |
7219, 7277
|
3857, 5678
|
329, 457
|
7787, 7793
|
1961, 3834
|
8228, 8483
|
1442, 1536
|
6040, 7196
|
7298, 7766
|
5704, 6017
|
7817, 8205
|
1551, 1942
|
283, 291
|
485, 907
|
929, 1358
|
1374, 1426
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,738
| 147,642
|
43951
|
Discharge summary
|
report
|
Admission Date: [**2164-3-6**] Discharge Date: [**2164-3-14**]
Date of Birth: [**2110-10-2**] Sex: F
Service: Medicine
CHIEF COMPLAINT: Shortness of breath
HISTORY OF PRESENT ILLNESS: The patient is a 53 year old
female with a past medical history significant for
hypertension, Type 2 diabetes times approximately 30 years,
complicated by retinopathy, neuropathy and nephropathy who
states that she has had worsening shortness of breath,
increasing lower extremity edema, increasing abdominal girth
for the past several weeks. The patient has also had very
little urine output over the past several days. She has not
responded to large doses of diuretics. She has recently got
up to 200 mg p.o. a day of Lasix and 2.5 mg p.o. q. day of
Zaroxolyn without any effects. The patient was seen at
[**Hospital6 733**] Clinic the day prior to admission,
primarily for her lower extremity edema and cellulitis. (She
had been treated with Amoxicillin in [**2163-12-19**], however,
she developed a rash while on those medications. The
cellulitis resolved somewhat, however, it seemed to return.)
The night prior to admission the patient's breathing got
progressively worse. She called her nurse practitioner
([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8271**]) and she was instructed to go to the
Emergency Room for further evaluation.
PAST MEDICAL HISTORY: Diabetes Type 2 complicated by
nephropathy, retinopathy and neuropathy. Hypertension.
Gastroesophageal reflux disease. Status post toe amputations
for osteomyelitis on her left first and second toes. History
of congestive heart failure. Chronic renal insufficiency.
History of right and left lower extremity cellulitis, status
post treatment with antibiotics. History of chronic anemia
on Epogen.
ALLERGIES: Penicillin, the patient gets a rash.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 q. day
2. Lipitor 40 q. day
3. Epogen 3000 units three times a week
4. Iron Sulfate 325 mg p.o. q. day
5. Glyburide 5 mg q. day/prn
6. Hydralazine 25 mg t.i.d.
7. Isordil 30 mg t.i.d.
8. Lasix 200 mg q. day
9. Zaroxolyn 2.5 mg q. day
10. Zantac 150 mg b.i.d.
11. Verapamil SR 240 mg q. day
SOCIAL HISTORY: The patient lives with her husband, has no
children. No tobacco, no alcohol and no drugs. Husband
currently with prostate cancer and in the hospital.
FAMILY HISTORY: Father died at age 70, complications of
diabetes. Mother died at age 75 secondary to an myocardial
infarction.
PHYSICAL EXAMINATION: Physical examination on admission
reveals temperature 97.7, pulse 78, blood pressure 148/71.
Oxygen saturation is 90-94% on room air. In general the
patient is a slightly overweight pleasant female in no acute
distress. Head, eyes, ears, nose and throat, pupils are
equal, round, and reactive to light. Oropharynx clear.
Moist mucous membranes. Neck is supple. No lymphadenopathy.
Lungs, there are crackles heard approximately two-thirds the
way up the bilateral lung fields. Heart is regular rate and
rhythm, normal S1 and S2, II/VI systolic murmur at the left
upper sternal border and right upper sternal border. Abdomen
is soft, nontender, nondistended. Positive bowel sounds.
Extremities, there is 1+ pitting edema in the lower
extremities bilaterally with pretibial erythema bilaterally.
Neurological examination, alert and oriented times three.
Speech fluent. Cranial nerves II through XII intact. Motor
and sensory are grossly intact with some peripheral
neuropathy.
LABORATORY DATA: On admission white blood cell count 11 with
a differential of 87% polys, 7% lymphocytes, hematocrit 26,
platelets 295. Chemistries within normal limits. BUN 117,
creatinine 9.7, glucose 118, INR 1.1, PTT 27. Calcium,
magnesium and phosphate 6.4, 12.5, 2.3. Baseline creatinine
levels ranging between [**1-23**].
HOSPITAL COURSE: The patient was admitted to the Medicine
Service for further evaluation and treatment of her acute and
chronic renal failure. The patient's urine electrolytes were
checked. Renal ultrasound was obtained. Renal ultrasound on
[**2164-3-7**] shows no mass, no hydronephrosis, bilateral
nephrolithiasis. Renal consult was obtained immediately
after admission and followed the patient throughout her
hospitalization. On [**2164-3-7**], the patient was
transferred to the Medical Intensive Care Unit for
hypotension and bradycardia. The patient's blood pressure
was stabilized and the patient transferred back to the
medical floor. After several days in the Intensive Care Unit
she was transferred to the regular medicine floor [**2164-3-10**]. During her intensive care stay, the patient was
started on hemodialysis three times a week. While on the
medical floor the patient was noted to have episodes of rapid
atrial fibrillation, however, she remained hemodynamically
stable. Beta blockers were used cautiously given her history
of a junctional rhythm and resultant hypotension in response
to beta blockers prior to her Intensive Care Unit stay. The
patient was ultimately discharged on [**2164-3-14**].
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSIS: Acute renal failure on chronic renal
insufficiency.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q.d.
2. Lipitor 40 mg p.o. q.d.
3. Ranitidine 150 mg p.o. b.i.d.
4. Iron Sulfate 325 mg p.o. q.d.
5. Lopressor 12.5 mg p.o. b.i.d.
6. Isordil 30 mg p.o. t.i.d.
7. Hydralazine 25 mg p.o. t.i.d.
8. TUMS two tablets p.o. t.i.d. with meals
9. Imodium 2 mg p.o. after each loose bowel movement prn
10. Epogen three times a week
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5629**], M.D. [**MD Number(1) 94379**]
Dictated By:[**Name8 (MD) 20162**]
MEDQUIST36
D: [**2164-11-15**] 12:34
T: [**2164-11-16**] 14:52
JOB#: [**Job Number 94380**]
|
[
"584.9",
"458.9",
"414.01",
"585",
"250.60",
"250.40",
"518.81",
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icd9cm
|
[
[
[]
]
] |
[
"38.91",
"39.95",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5088, 5126
|
2379, 2492
|
5224, 5849
|
5148, 5201
|
1877, 2192
|
3853, 5066
|
2515, 3835
|
158, 179
|
208, 1375
|
1398, 1851
|
2209, 2362
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,941
| 125,893
|
45350
|
Discharge summary
|
report
|
Admission Date: [**2172-2-14**] Discharge Date: [**2172-2-18**]
Service: MEDICINE
Allergies:
Sertraline
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Sudden shortness of breath x 1 day
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is a [**Age over 90 **] year old woman with a history of diastolic CHF,
chronic stable coronary heart disease, atrial fibrillation on
coumadin with recent cardioversion [**12-26**], HTN, HLP who presents
from nursing home with acute onset shortness of breath x 1 day.
She was reported to have a viral syndrome and wheezing over the
past few days and on [**2172-2-11**] her PCP there started on prednisone
50mg PO daily with taper, and osteltamivir 50mg PO BID given a
recent influenza outbreak at her nursing home. On the morning of
[**2172-2-13**] she was noted to have tachycardia to 130s on routine
vitals check and complaining of acute shortness of breath. EMS
was called who brought her to the emergency department.
.
Per EMS, her FS 450s, had received duoneb, was speaking in short
sentences at triage, and working to breathe. She had been on 2L
O2 round the clock.
.
In the ED, initial vs were: 98.4 143/92 130 24 97%RA. Her max
heart rate came up to 140 in a fib. She remained 100% on 2L
throughout her course. Patient was given dilt 15mg IV ONCE,
followed by dilt 30mg PO ONCE which brought her rate down to
120s. Pressures remained stable. CXR revealed CHF, therefore,
she was given Lasix 40mg IV ONCE with 900cc urine made. She was
also given vancomycin 1gm IV ONCE, and zosyn 4.5gm IV ONCE for
possible HAP.
.
On the floor, the patient reports what's bothering her most now
is a sore throat. She also complains of a cough with clear/white
sputum, headache, poor PO intake, nausea, vomitting, loose
stools, fatigue, and weakness and fevers (up to 99 per pt). She
denies any fevers, chills, chest pain, shortness of breath,
abdominal pain, rashes. Does report she is thirsty.
.
Review of systems:
(+) Per HPI, occasional chronic palpitations.
(-) Denies chills, night sweats, recent weight loss or gain.
Denies sinus tenderness, rhinorrhea or congestion. Denies
shortness of breath, or wheezing. Denies chest pain, chest
pressure. Denies constipation, abdominal pain, black/bloody
stools. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
--Hypertension
--Atrial flutter s/p DC cardioversion
--Breast cancer: invasive ductal carcinoma of the left breast,
ER/PR+, HER2/neu negative, status post resection in [**2165-3-18**],
treated with Arimidex; followed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2036**] in
hematology/oncology clinic
--Chronic diastolic CHF
--Stable angina
--Hypothyroidism
--Chronic renal insufficiency
--Gout
--Cataracts
Social History:
Denies tobacco, alcohol, drug use. Originally from [**Country 3399**],
immigrated in [**2118**] to [**Country 6171**] after Seuz crisis, then to United
States in [**2124**]. Previously married, husband passed away at age
50 from brain cancer. Has 1 son who lives in [**Name (NI) 108**], 2
granddaughters, 3 great-grandchildren. Lives in [**Location 583**] in
B'nai Brith assited living. Has a homemaker for 10.5 hours/week.
Has a VNA who helps with medications.
Family History:
per OMR: father died at 57 of typhoid. Mother died at 62 of a
stroke. One sister died of uterine cancer, another died of lung
cancer. Two brothers had strokes, one brother died of a strep
infection. No family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
Admission Physical Exam
General: Alert, oriented x 3 elderly woman with audible wheeze
in no acute distress
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear,
PERRLA
Neck: supple, JVP elevated to jaw, no LAD
Lungs: Diffuse end-expiratory wheezes L>R, bibasilar rales with
reduced breath sounds at bases. No egophony or dullness.
CV: Tachycardic and irregular 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 with yellow/clear urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Discharge Physical Exam:
General: A&Ox3
HEENT: MMM
Neck: supple
Lungs: Mild end expiratory wheezing.
CV: Irregular, S1, S2 90s.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, nontender knee joints b/l.
Pertinent Results:
Admission Labs
[**2172-2-14**] 12:04AM BLOOD WBC-8.7 RBC-3.53* Hgb-10.6* Hct-31.5*
MCV-89 MCH-29.9 MCHC-33.5 RDW-15.9* Plt Ct-234
[**2172-2-14**] 12:04AM BLOOD Neuts-54.1 Lymphs-39.6 Monos-5.9 Eos-0
Baso-0.4
[**2172-2-14**] 12:04AM BLOOD PT-30.2* PTT-22.3 INR(PT)-3.0*
[**2172-2-14**] 12:04AM BLOOD Glucose-389* UreaN-82* Creat-2.2* Na-130*
K-5.0 Cl-93* HCO3-18* AnGap-24*
[**2172-2-14**] 12:04AM BLOOD ALT-25 AST-41* AlkPhos-73 Amylase-206*
TotBili-0.3
[**2172-2-14**] 12:04AM BLOOD Lipase-273*
[**2172-2-14**] 12:04AM BLOOD cTropnT-<0.01 proBNP-[**Numeric Identifier 37509**]*
[**2172-2-14**] 06:01AM BLOOD TSH-1.1
[**2172-2-14**] 06:01AM BLOOD Albumin-3.9 Calcium-9.0 Phos-4.5 Mg-2.2
[**2172-2-14**] 12:04AM BLOOD ASA-NEG
[**2172-2-14**] 12:07AM BLOOD Lactate-4.3*
[**2172-2-14**] 01:50AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2172-2-14**] 01:50AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009
[**2172-2-14**] 06:26AM URINE Hours-RANDOM UreaN-454 Creat-52 Na-24
K-32 Cl-17
.
CT Abdomen/Pelvis ([**2172-2-14**]):
1. No acute CT findings to explain elevated lactate. Limited
evaluation for mesenteric ischemia given lack of IV contrast,
however, no pneumatosis.
2. No signs of complications of pancreatitis.
3. Diverticulosis without evidence of diverticulitis.
4. Thickening of the medial fundal wall of the stomach,
incompletely assessed on this non-contrast examination. This
area may be further evaluated by endoscopy or upper GI study.
.
CXR ([**2172-2-14**]): Heart remains mildly enlarged, but pulmonary
vascular congestion has resolved. No areas of consolidation to
suggest acute pneumonia.
Knee XR [**2172-2-18**]: Diffuse osteopenia, with severe osteoarthritis
of the medial femorotibial joint with joint narrowing,
subchondral sclerosis, marginal osteophyte formation, with
compensatory widening laterally.
Brief Hospital Course:
HOSPITAL COURSE
Ms. [**Known lastname **] is a [**Age over 90 **] year old woman with a history of diastolic CHF,
chronic stable coronary heart disease, atrial fibrillation on
coumadin with recent cardioversion [**12-26**], hypertension, who
presented from nursing home with acute onset shortness of breath
x 1 day and an acute viral syndrome concerning for influenza.
.
ACTIVE ISSUES
1. DYSPNEA: Patient's shortness of breath is of unclear etiology
but likely due to combination of CHF exacerbation plus
influenza. Influenza DFA returned positive. [**Month (only) 116**] also be
exacerbated by conversion into atrial fibrillation with RVR
(triggered by viral infection/ fever/dehydration). No cough or
focal consolidation on CXR concerning for pneumonia. She was
continued on tamiflu for 5 days. She was diuresed with IV lasix
which improved her shortness of breath. Patient did not complain
of SOB for the remainder of her hospital stay.
.
2. ATRIAL FIBRILLATION with RVR: Status post cardioversion on
[**2171-12-27**]. TTE showed normal LVEF but left atrium enlargement.
She was noted to be in atrial fibrillation with rapid
ventricular response in 140s on admission to the ED with no
effect on blood pressure. She was started on amiodarone drip in
the MICU as as lopressor and diltiazem had little effect on her
rate control. Her heart rate improved to high 90s once
amiodarone drip was started. TSH was noted to be within normal
limits. Her cardiac enzymes were negative x 2 with unchanged
EKG.
-patient will continue on Amiodarone as outlined. Repeat
cardioversion can be attempted in about a month, once amiodarone
has been loaded.
-patient will continue on Metoprolol increased dose for better
rate control.
.
3. ELEVTED LACTATE: Level of 4.3 concerning for abdominal
process such as mesenteric ischemia, however has come down to
1.6 overnight. CT abdomen at admission showed no acute process
(although limited by lack of IV contrast). Likely secondary to
CHF.
.
4. ELEVATED LIPASE: Perplexing marker in patient without
epigastric pain, very minimal epigastric TTP, and normal CT
findings of pancreas. Possible mild, asymptomatic pancreatitis.
Ddx is the following: both renal disease and furosemide and
also bowel ischemia can cause elevations in lipase. This is
likely subclinical, since patient denies any abdominal symptoms
and there are no physical exam findings consistent with these
etiologies.
.
5. ELEVATED INR: Probably secondary to antibiotics given in ED.
Coumadin was held on admission. Coumadin restarted on HD 3 when
INR at goal [**2-20**] at 2.5mg per day. This will be monitored at
rehab with goal INR [**2-20**].
.
6. HYPONATREMIA: Most likely secondary to acute CHF and volume
overload state. Resolved on discharge.
.
7. CHRONIC KIDNEY INSUFFICIENCY: Baseline Cr 1.9-2.2, consistent
with values this admission.
.
8. HYPERGLYCEMIA: No known history of diabetes, but may have
undiagnosed case in the setting of multiple elevated glucose
levels vs starting of prednisone by primary care three days ago.
Treated with sliding scale insulin.
.
9. HYPOTHYROID: She was continued on home dose of levothyroxine.
TSH was normal on admission.
.
10. Knee Pain: Patient complained of Right knee pain, that was
relieved with a hot pack. There was no swelling or warmth at the
site, with full range of motion, with mild tenderness on the
medial aspect. A X-ray of the knee suggestive of osteoartritis.
.
11. Leukocytosis: patient initially presented with elevated
white blood cell count, which normalised during her stay. It
became elevated again prior to D/C but patient was afebrile and
asymptomatic. There was no apparent gut pathology on the CT of
[**2172-2-14**]. This should be followed up on as outpatient.
.
TRANSITIONAL ISSUES
# Medical Management: Started amiodarone
# Elevated WBCs, and Lipase: Patient could have had subclinical
bowel ischemia. Her CT scan here as of [**2172-2-14**] showed no acute
CT findings to explain elevated lactate (resolved on discharge).
This likely needs follow up as outpatient.
# Code Status: DNR/I
Medications on Admission:
1) Allopurinol 100mg PO every other day
2) Lasix 100mg PO BID
3) Isosorbide mononitrate 30mg SR PO Daily
4) Lisinopril 5mg PO Daily
5) Metoprolol Succinate 50mg PO Daily
6) Nitroglycerin 0.4mg SL Q5min x3 doses PRN chest pain
7) Aspirin 325mg PO daily
8) Colace 100mg PO BID
9) Multivitamin 1 tab PO Daily
10) Lidocaine 5% patch daily to R shoulder
11) Coumadin 4mg PO daily for goal INR [**2-20**]
12) Prednisone 50mg PO daily (started on [**2172-2-11**] with plans to
taper by 10mg every 3 days)
13) Tamiflu 50mg PO BID (started [**2172-2-11**])
14) Levothyroxine 50cg daily
Discharge Medications:
1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
2. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
3. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual once a day: may repeat twice, if you need to use this
medication more than once, please contact your physician.
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
6. multivitamin Tablet Sig: One (1) Tablet PO once a day.
7. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
8. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. warfarin 2 mg Tablet Sig: 1-2 Tablets PO Once Daily at 4 PM:
Please have your INR checked (should be between [**2-20**]) and follow
up regarding how much of this medication to take. .
10. metoprolol succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
11. amiodarone 200 mg Tablet Sig: 1-2 Tablets PO once a day:
start 400mg [**Hospital1 **] for 1 week (until [**2172-2-23**]) , then 400mg daily for
one week and then 200 mg daily.
.
12. furosemide 40 mg Tablet Sig: 2.5 tablets Tablets PO twice a
day.
13. isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
PRIMARY:
1. Atrial Fibrillation with Rapid Ventricular Response
2. Acute Decompensation of Diastolic Heart Failure\n3. Influenza
SECONDARY:
1. Osteoarthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for evaluation and management of the flu and
shortness of breath. You were found to have atrial
fibrillation, an irregular fast heart beat that required
admission to the intensive care unit. You were started on a new
medication to help control this fast heart rate, amiodarone, and
increased dose of metoprolol. You were not cardioverted, a
procedure that gives a small shock to your heart in order to
restore the normal rhythm, since it was decided that you will do
better with medications.
.
You were noted to have an exacerbation of your heart failure.
You given medications to help remove some of the fluid that had
collected in your lungs and legs.
.
You were also treated for Influenza A and completed a 5 day
course of therapy.
.
Medication changes:
- START amiodarone 400 mg twice a day until [**2172-2-23**], then 400mg
daily for 1 week and then 200 mg daily.
- START Metoprolol Succinate SR 100mg once a day
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2172-4-29**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: [**Hospital3 249**]
When: WEDNESDAY [**2172-5-6**] at 1:45 PM
With: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2172-2-18**]
|
[
"427.32",
"790.92",
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"274.9",
"V49.86",
"577.0",
"715.90",
"427.31",
"487.1",
"585.9",
"276.1",
"428.33",
"414.01",
"428.0",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12725, 12815
|
6622, 10688
|
253, 259
|
13017, 13017
|
4693, 6599
|
14254, 14965
|
3359, 3673
|
11315, 12702
|
12836, 12996
|
10714, 11292
|
13200, 13958
|
3688, 4333
|
2020, 2415
|
13978, 14231
|
179, 215
|
287, 2001
|
13032, 13176
|
2437, 2864
|
2880, 3343
|
4358, 4674
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,223
| 135,039
|
33840
|
Discharge summary
|
report
|
Admission Date: [**2174-5-4**] Discharge Date: [**2174-5-19**]
Date of Birth: [**2103-4-23**] Sex: F
Service: MEDICINE
Allergies:
Actonel / Augmentin
Attending:[**First Name3 (LF) 1666**]
Chief Complaint:
lung abscess
Major Surgical or Invasive Procedure:
broncheoalveolar lavage
History of Present Illness:
71F with COPD, etoh hepatitis who presents as a transfer from
[**Hospital1 1562**] with lung abscess. She presented to [**Hospital1 1562**] on [**4-25**]
with 3 days of weakness, chills and purulent cough. She was
noted to be hyptensive in the ED and required vasopressin
initially. CTA showed no PE though showed a cavitary lung lesion
for which the patient was treated empiricially with ceftriaxone
and azithro at first though this was changed to
levo/clinda/zosyn. Over the course of the hospital stay,
infectious work-up was pursued. Thoracentesis was done which
drained 700ml fluid from the R side. RUQ US was pursued
revealing CBD stone with biliary ductal dilatation. On [**5-3**] the
decision was made to transfer the pt to [**Hospital1 18**] for further
evaluation of the cavitary lung lesion. She was intubated, by
report, for transfer and she was satting high 90s all day on 3L.
Past Medical History:
COPD
etoh hepatitis
GIB
breast CA
Social History:
smoking and per family has ETOH history and still drinks hard
liquor daily
Family History:
non-contributory
Physical Exam:
VS: Temp: 97.1 BP: 103/50 HR: 91 RR: 18 O2sat:100%
AC 360 12 0.4 5
GEN: intubated, sedated, cachectic
HEENT: 2mm, equal
RESP: decreased BS, rhonchi RML
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt,
EXT: cachectic, no c/c/e
Pertinent Results:
[**2174-5-4**] 02:09AM BLOOD WBC-23.9* RBC-3.36* Hgb-11.1* Hct-32.6*
MCV-97 MCH-33.1* MCHC-34.2 RDW-16.2* Plt Ct-257
[**2174-5-4**] 02:09AM BLOOD Neuts-90.8* Lymphs-6.4* Monos-2.0 Eos-0.6
Baso-0.1
[**2174-5-4**] 02:09AM BLOOD Glucose-89 UreaN-19 Creat-0.6 Na-138
K-3.2* Cl-103 HCO3-29 AnGap-9
[**2174-5-4**] 02:09AM BLOOD ALT-38 AST-52* LD(LDH)-249 AlkPhos-147*
Amylase-233* TotBili-0.6
[**2174-5-4**] 02:09AM BLOOD Albumin-2.0* Calcium-7.3* Phos-3.1 Mg-1.8
[**2174-5-5**] 03:22AM BLOOD Triglyc-119
[**2174-5-4**] 02:55AM BLOOD Type-ART pO2-167* pCO2-45 pH-7.42
calTCO2-30 Base XS-4
[**2174-5-4**] 01:21PM BLOOD Type-[**Last Name (un) **] Temp-37.7 Rates-[**11-16**] Tidal
V-350 PEEP-5 FiO2-40 pO2-192* pCO2-47* pH-7.38 calTCO2-29 Base
XS-2 Intubat-INTUBATED Vent-CONTROLLED
[**2174-5-4**] 02:55AM BLOOD Lactate-1.4
.
MICRO
[**2174-5-4**] 02:23PM BAL WBC-0 RBC-0 Polys-72* Lymphs-2* Monos-0
Macro-26*
.
[**2174-5-5**] SPUTUM ACID FAST SMEAR-neg; ACID FAST CULTURE-....
[**2174-5-4**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-neg; RESPIRATORY
CULTURE-...; POTASSIUM HYDROXIDE PREPARATION-neg; FUNGAL
CULTURE-...; ACID FAST SMEAR-neg; ACID FAST CULTURE-...
[**2174-5-4**] SPUTUM ....
.
[**2174-5-10**] 05:48AM BLOOD WBC-12.5* RBC-3.21* Hgb-10.6* Hct-31.2*
MCV-97 MCH-32.9* MCHC-33.8 RDW-16.0* Plt Ct-363
[**2174-5-11**] 12:09PM BLOOD WBC-16.0* RBC-3.34* Hgb-11.1* Hct-32.2*
MCV-96 MCH-33.1* MCHC-34.3 RDW-16.4* Plt Ct-375
[**2174-5-12**] 06:26AM BLOOD WBC-31.8*# RBC-3.79* Hgb-12.1 Hct-36.4
MCV-96 MCH-31.9 MCHC-33.2 RDW-16.9* Plt Ct-408
[**2174-5-13**] 04:56AM BLOOD WBC-15.5*# RBC-3.06* Hgb-10.0* Hct-30.0*
MCV-98 MCH-32.5* MCHC-33.2 RDW-16.6* Plt Ct-314
[**2174-5-10**] 05:48AM BLOOD ALT-126* AST-114* LD(LDH)-160
AlkPhos-173* Amylase-76 TotBili-0.3
[**2174-5-12**] 06:26AM BLOOD ALT-140* AST-96* LD(LDH)-175 AlkPhos-191*
Amylase-105* TotBili-0.4
[**2174-5-13**] 04:56AM BLOOD ALT-81* AST-42* LD(LDH)-141 AlkPhos-139*
Amylase-72 TotBili-0.5
CT CHEST W/O CONTRAST [**2174-5-4**] 9:36 AM
IMPRESSION:
1. Large cavitary lesion within the right lower lobe. Comparison
with outside hospital studies would be helpful in evaluation of
evolution of this process. Given highly elevated white blood
count, an infectious process is highly favored and
necrotic/abscess transformation of focal pneumonia is likely. A
second differential diagnosis includes TB. A similar appearance
has been described post- radiation of an intraparenchymal tumor
focus, however, I believe, is much less likely.
2. Total body volume overload with large left pleural effusion
and moderate right effusion, ascites, and anasarca.
3. Right mastectomy and fiducial markers in the left breast
(oncologic history currently unknown). Soft tissue prominence in
the left posterolateral upper abdomen wall does not appear to
correlate on physical exam and may represent inferiorly oriented
breast tissue/skinfold.
4. Moderate-to-severe emphysema.
ABDOMEN U.S. (COMPLETE STUDY) [**2174-5-4**] 10:06 AM
IMPRESSION:
1. Bilateral pleural effusions and small ascites identified.
2. Thickened gallbladder wall with a small gallstone identified.
3. No evidence of choledocholithiasis.
CHEST (PORTABLE AP) [**2174-5-4**] 2:48 AM
IMPRESSION: AP chest reviewed in the absence of prior chest
radiographs:
There is a large ring shadow in the right mid lung, from 4 to as
much as 7 cm in diameter, with perimeter consolidation
suggesting a lung abscess or cavitary pneumonia, less likely
malignancy. Small left and even smaller right pleural effusions
are dependent. Consolidation at the base of the left lung could
be atelectasis or pneumonia. Heart size is normal. No
pneumothorax.
ET tube tip is no more than 25 mm from the carina. Left PIC
catheter ends in the upper right atrium.
.
RUQ u/s [**5-12**]:
IMPRESSION: Unchanged appearance of the gallbladder with a small
gallstone but no signs of cholecystitis. No biliary dilatation.
Trace of ascites and right pleural effusion as seen before.
.
CXR [**5-12**]:
FINDINGS: Endotracheal tube has been removed. There is
substantial increase to now large bilateral effusions. There is
new mild pulmonary edema. Cavitary lesion within the superior
segment of the right lower lobe is no longer appreciated;
however, opacity within the right upper lobe has increased in
size. No pneumothorax is detected.
IMPRESSION:
1. New mild pulmonary edema and significant increase in pleural
effusions.
2. Increase in right upper lobe opacity since previous study, in
which developing pneumonia is in the differential.
Repeat CT scan [**5-16**]:
1. Mixed response with decreased size of right lower lobe
cavitary lesion
but appearance of new nodular focus within the left lower lobe
and new patchy
lingular/middle lobe consolidations. Given the mixed response to
treatment, a
multiorganism process should be considered.
2. Bilateral moderate-to-large pleural effusions with associated
relaxation
atelectasis.
3. New small pericardial effusion.
4. Diffuse pancreatic ductal dilatation only partially evaluated
on this
study. Further evaluation with MRCP should be considered if
clinically
appropriate to evaluate this finding.
5. Severe emphysema.
6. Secretions layering within bilateral mainstem bronchi
suggesting
aspiration or inability to properly clear secretions.
Discharge labs:
[**2174-5-19**] 06:00AM BLOOD WBC-7.7 RBC-3.08* Hgb-9.8* Hct-29.8*
MCV-97 MCH-31.8 MCHC-32.9 RDW-16.0* Plt Ct-406
[**2174-5-19**] 06:00AM BLOOD Neuts-77.4* Lymphs-18.0 Monos-2.9 Eos-1.3
Baso-0.3
[**2174-5-19**] 06:00AM BLOOD Plt Ct-406
[**2174-5-19**] 06:00AM BLOOD Glucose-75 UreaN-7 Creat-0.4 Na-134 K-4.0
Cl-100 HCO3-26 AnGap-12
[**2174-5-19**] 06:00AM BLOOD ALT-38 AST-30 LD(LDH)-141 TotBili-0.3
Brief Hospital Course:
71 year old female with COPD, ETOH hepatitis who presented as a
transfer from [**Hospital1 1562**] with a lung abscess. Hospital course by
problem:
.
1. Mechanical ventilation: The patient was intubated at the OSH
reportedly for transfer, and was easily extubated after
obtaining a chest CT in the MICU. She was transitioned to 4L NC
before being called out the floor the day after admission. She
was weened to room air.
.
2. Cavitary lung lesion:
Likely aspiration given history of alcoholism and failed swallow
study. No real risk factors for hospital acquired pathogens. Had
been afebrile since arrival from OSH. At the OSH the patient
had 700cc pleural effusion tapped at OSH reportedly transudative
in nature without evidence of infection, cytology negative.
While intubated in the ICU, the patient underwent bronchoscopy,
without sampling of abcess. Sputum cultures positive for yeast,
likely contaminant, otherwise unremarkable, AFB negative x 3.
She was seen by thorasic surgery, and it was felt that no
surgical intervention needed for now, with a planned f/u CT scan
on [**5-18**]. After being called out from ICU, the patient's
vanc/zosyn was switched to levo/clinda. She remained afebrile
with a resolving WBC count. As discussed below, the patient
elected to eat despite failed swallow study and risk of
aspiration. The following day she had rise of WBC to 30, new
hypoxia requiring NRB, and new fever. She was switched to
vanc/zosyn and cipro for pseudamonas double coverage. Her
oxygenation improved also with 20mg IV lasix given mild
pulmonary edema on CXR. She was reweened off O2 and
vanc/zosyn/cipro will be continued for one month from [**2174-5-4**].
She had a repeat CT scan on [**5-16**], which showed improvement in
size of abcess in RLL, but did show new nodular focues and
patchy changes consistent with aspiration. The patient remained
on room air, afebrile, and with a normal WBC count. When blood
cultures showed VRE, the patient was switched from vanc to
linezolid. She should complete antibiotics on [**5-30**]. She will
require follow up with pulmonolgy and repeat CT scan after that
time.
.
# VRE Bacteremia: Patient grew out blood cultures on 2
consecutive days with VRE. She was started on linezolid on
[**5-15**]. since that time she has remained afebrile and had a
normal WBC. Her PICC was removed, and tip was culture negative.
Her PICC has been replaced.
.
#. Hypotension: The patient was put on a very low dose of
levophed during transfer, though she had no signs of active
sepsis, was afebrile, and had no leukocytosis. Her levophed was
weaned off over the first night and she remained hemodynamically
stable.
.
# Choledocholithiaisis noted on OSH abdominal US: The patient's
abdominal exam was benign and she had a repeat abdominal US in
the MICU which showed no evidence of choledocholithiasis. Her
LFTs were trended which showed continued to rise, although the
patient denied abdominal pain. A repeat RUQ u/s in the setting
of her jump in WBC to 30 and rise in LFTs was unremarkable. Her
LFTs on time of discharge are normal and she is without
abdominal pain. Chest CT showed diffuse pancreatic
calcification and ductal dilitation, and she will require GI
follow up after stabilization of current medical issues.
.
# COPD: She was started on solumedrol 125 qAM at the OSH for
possible COPD flare given her hypoxia and significant smoking
history. This was tapered quickly upon transfer. She was
continued on ipratropium nebs, and discharged on spiriva.
Albuter was avoided given MAT.
.
# MAT: Patient with tachycardia to 150s, EKG showing multifocal
atrial tachycardia in setting of low Mg and K+. Her BP was
stable and she was asymptomatic. Her electrolytes were repleted
and she was started on diltiazem for rate control to good
deffect. Her blood pressure became too low when doses were
increased in attempts for improved control.
.
# Alcoholism:
There is no evidence of alcohol withdrawl, and Valium PRN CIWA
was discontinued. Patient admits to having a drinking problem,
and social work was consulted.
.
# Dysphagia: Patient failed video swallow study here and
[**Hospital1 **]. Explained to patient options of feeding tube vs.
eating w/ risk of continued aspiration. Explained that risk of
aspiration would be reduced given her the risk of aspiration
given her swallowing dysfunction. Patient elected to eat,
despite high potential to further aspirate/repsiratory distress.
Patient demonstrated understanding of risks. After discussion w/
patient, patient now DNR/DNI, and will take in PO diet.
Explained to paitent high likelihood of aspiration. Palliative
care consulted to further assess patient's goals of care, which
should be a continued conversation with patient.
.
# PPx: Hep SQ, ppi
# contacts: HCP is son [**Name (NI) **] lives on cape cell: [**Telephone/Fax (1) 78218**].
Son's wife [**Telephone/Fax (1) 78219**]. Daughter [**First Name8 (NamePattern2) 1060**] [**Last Name (NamePattern1) **] in [**State 108**].
.
# DNR/DNI
Medications on Admission:
from OSH notes:
nystatin
lovenox
vasopressin
atrovent/levalbuterol
levaquin
zosyn
clinda
lactobacillus
thiamine
nicotene
Solumedrol 125 qAM
TPN
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours).
3. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation once a day.
4. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig:
One (1) Intravenous Q8H (every 8 hours) for 11 days: to stop on
[**5-30**].
5. Morphine 2 mg/mL Syringe Sig: [**12-1**] Injection Q4H (every 4
hours) as needed for resp distress.
6. Linezolid 600 mg/300 mL Parenteral Solution Sig: One (1)
Intravenous Q12H (every 12 hours) for 11 days: [**5-30**].
7. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Male First Name (un) 4542**] Nursing Center - [**Hospital1 1562**]
Discharge Diagnosis:
Primary Diagnosis
Pulmonary Abcess with Aspiration Pneumonia
Swallowing dysfunction
VRE bacteremia
Multifocal atrial tachycardia
Alcoholism
Discharge Condition:
Stable
Discharge Instructions:
You are being discharged from the hospital after admission for a
lung abcess. The cause of this abcess is likely due to
aspiration in the setting of your alcoholism and swallowing
dysfunction. You had a swallow study which showed gross
aspiration of all consistency. After a lengthy discussion of
risks, you have elected to continue to eat despite risk of
contintued aspiration w/ recurrent pneumonia or possibly
respiratory distress. You have been started on antibiotics to
treat your current lung infection, and will need to complete a
one month course. You have also gotten an infection of your
blood, and will need to be on antibiotics to treat that
infection. You are being discharged to a rehab facility for
further care.
Followup Instructions:
You should follow up with your PCP, [**Name10 (NameIs) 78220**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
[**Telephone/Fax (1) 78221**], upon discharge from rehab.
You will require a pulmonary follow up in [**Hospital1 1562**] following
discharge from rehab. You should discuss with your PCP who he
would recommend and set up a follow CT scan.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]
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28,883
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|
47275
|
Discharge summary
|
report
|
Admission Date: [**2122-10-19**] Discharge Date: [**2122-10-25**]
Date of Birth: [**2043-3-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4309**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with stent placement
History of Present Illness:
79 F with multiple sclerosis, complicated by neurogenic bladder,
CAD s/p MI, PVD, long-term care resident of [**Hospital1 599**] of [**Location (un) 16824**]. Recent hospitalization at [**Hospital1 336**] 1 week ago for
musculocutaneous flap for stage 4 right ischial pressure ulcer.
.
Was in USOH until this past Saturday when felt chest congestion.
Received nebs with improvement in symptoms. Then, again had an
episode of chest congestion while receiving IV Zosyn on day of
admit. VS T 97.8, BP 120/72, HR 65, RR 20, O2 sat 93% on 3L O2.
.
She otherwise denied any chest discomfort, palpitations, nausea,
emesis, diaphoresis, lightheadedness. She had chest pressure at
the time of her MI in [**2116**]. She did have similar symptoms in [**Month (only) **]
of this year, and was admitted, but was ruled out by cardiac
biomarkers, and has not had similar symptoms since.
.
Referred by [**Hospital1 18**] ED where noted to be tachycardic to 130s with
up to 3mm ST depressions v2-v4. Received ASA 325, SL NTG,
metoprolol 5 mg IV with improvement in rate to 80s, BP down to
90s systolic. CTA peformed which did not show PE, but was
consistent with failure. Started on BiPAP, as was felt not to
tolerate lasix due to hypotension.
.
Past Medical History:
CAD
- s/p inferior MI in [**2117-10-29**]
- Cath: 30% dLMCA, 70% pLCx, 90% pRCA, 50% dRCA; BMS -> RCA
* Multiple Sclerosis
- wheelchair bound
- neurogenic bladder with suprapubic catheter - changed qmonth
* Sacral decub ulcer
- complicated by osteomyelitis in [**2121-4-28**]
* Diastolic dysfunction
* Peripheral vascular disease
* Left tib/fib fx s/p external fixation ([**6-1**])
* Osteoporosis
* s/p multiple falls
* Depression
Social History:
Previous 2ppd tobacco x several years, quit 15 years ago.
History of EtOH abuse, but no ETOH for ~50 years. No IVDU.
Currently lives at [**Hospital1 599**] of [**Location (un) 55**] x 2 years, after
losing ability to walk. Previously lived in subsidized housing
for disabled and elderly.
Family History:
Non contributory
Physical Exam:
VS - T 97.5, BP 98/46 (SBP 95-123), HR 74 (60-70), RR 15-22, O2
sat 95% 2L O2 LOS + 600 cc; Access: R picc; 2 PIV
general - well-appearing, elderly female, in NAD, speaking in
full sentences, initially sleeping
HEENT - EOMI, OP clr, MMM, JVP ~10 cm
CV - RRR, nl s1 s2, no m/r/g - distant hs
chest - bilat crackles at bases
abd - soft, NT/ND, no g/r; + suprapubic catheter
ext - R PICC; no edema appreciate; pink, warm, 2+ DP, PT b/l
Pertinent Results:
LABS
WBC RBC Hgb Hct MCV MCH Plt
Ct
[**2122-10-25**] 04:40AM 9.7 3.37* 10.3* 31.0* 92 30.6
537*
Glucose UreaN Creat Na K Cl HCO3
[**2122-10-25**] 04:40AM 89 9 0.5 141 3.7 105 29
ALT AST LD(LDH) AlkPhos TotBili
[**2122-10-24**] 05:15AM 13 15 183 86 0.5
Calcium Phos Mg
[**2122-10-25**] 04:40AM 8.2* 3.2 2.2
.
Chest X-ray [**10-24**]
Since the prior study there has been improved aeration of the
right paracentral regions suggesting improved CHF. Residual
features persist. There is some left basilar atelectasis. No new
focal consolidations and no increased distention of the
pulmonary vasculature. Heart size is within normal limits.
.
Cardiology Report C.CATH Study Date of [**2122-10-22**]
1. Coronary angiography in this right dominant system
demonstrated an LMCA with 40% distal stenosis. The LAD was
calcified with 40% midvessel lesion; the diagonal had a 40%
lesion. The LCX had a mid 50% lesion and supplied collaterals to
the right. The RCA had a 90% ostial lesion and there was diffuse
60-70% restenosis through the entire course of the RCA.
2. Limited resting hemodynamics revealed normal systemic
arterial pressures.
3. Distal aortography was performed to ensure that
initial-access guidewire passage did not cause trauma. There was
no sign of perforation or dye extravasation. The common femoral
artery had 50% stenosis.
4. Successful PTCA and stenting of the ostial rca with a 3.0x18
cypher and a 3.0x8 cypher. Successful PTCA and stenting of the
mid-distal RCA with overlapping 3.0x33 and 2.5x28mm Cypher
stents. Final angiography revealed 0% residual stenosis in the
stented areas, no angiographically apparent dissection and TIMI
3 flow.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Successful PCI of RCA.
.
Portable TTE (Complete) Done [**2122-10-20**]
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild to
moderate regional left ventricular systolic dysfunction with
severe inferior wall hypokinesis and mild inferolateral wall
hypokinesis. Transmitral Doppler and tissue velocity imaging are
consistent with Grade I (mild) LV diastolic dysfunction. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. Mild to moderate
([**12-30**]+) mitral regurgitation is seen. The left ventricular inflow
pattern suggests impaired relaxation. The estimated pulmonary
artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion. Compared with the
report of the prior study (images unavailable for review) of
[**2118-2-7**], the wall motion abnormality is new and consistent
with single vessel CAD. The mitral regurgitation is also new.
.
CTA CHEST W&W/O C&RECON Study Date of [**2122-10-19**] 1:06 AM
1. No evidence of pulmonary embolism or aortic dissection.
2. Small-to-moderate bilateral simple layering pleural
effusions with
peribronchovascular opacities and septal thickening, most
suggestive of alveolar and interstitial pulmonary edema.
Appropriate treatment and repeat
radiographs is recommended to assess for resolution and exclude
infectious
etiology.
3. Dense calcifications within the left and right coronary
circulation,
intrathoracic aorta, and aortic root. Mild LVH and left atrial
enlargement.
4. Stable small hypoattenuating right thyroid lesion is likely
a benign
nodule and could be further evaluated with a dedicated
ultrasound on a
nonemergent basis if clinically indicated.
5. Centrilobular emphysema.
Brief Hospital Course:
Assessment and Plan:
Patient is 79 F with multiple sclerosis, admitted with pulmonary
edema and hypotension, found to have NSTEMI.
.
# NSTEMI and likely resultant CHF/hypotension:
NSTEMI with enzyme bump with failure both clinically and by
radiographic studies. Last assessment of EF by nuclear imaging
in [**2120-7-29**] was nl, though a TTE in [**2117**] did suggest diastolic
dysfunction. Echo on [**2122-10-20**] showed new diastolic dysfunction
with inferior and lateral hypokinesis, and mitral regurgitation.
Gave aspirin, statin, Plavix and 48 hours of heparin drip.
Initially did not tolerate small doses of Beta blockers due to
hypotension, but did tolerate small dose of Ace-I. Was taken to
cath [**10-22**] where a diffusely diseased RCA was intervened on
w/multiple drug-eluting stents. Her CHF was felt to be
exacerbated by acute diastolic dysfunction in the setting of an
NSTEMI. Was transferred to the floor for continued diuresis,
which she tolerated well, remaining hemodynamically stable x 48
hours. Also tolerated low dose Metoprolol of 12.5 mg daily
(previously on 25 mg poi [**Hospital1 **] on admit). Upon discharge she was
stable and tolerating low dose BB, ACE-I, ASA, statin and
Plavix. Should have LFTs checked by primary physician [**Last Name (NamePattern4) **] [**4-3**]
weeks to monitor for elevation given increased statin.
.
#Sacral Decubitus: No fevers at this time, mild leukocytosis on
admit that resolved.
Being followed @ [**Hospital1 336**] by Dr. [**Last Name (STitle) **] for skin flap. Dr.
[**Last Name (STitle) **] was contact[**Name (NI) **] on admission and stated that the drain
and staples should remain in place until she sees him in follow
up. She was to continue on Zosyn as well. Upon discharge she's
afebrile and without evidence of flap infection, and the wound
is healing well. Should continue daily dressing changes in an
attempt to keep fecal material out of the drain. Recommended
she schedule an appointment with Dr. [**Last Name (STitle) **] upon discharge.
Should also have sand bed at her facility, which has already
been set-up.
.
# Anemia - Patient with relative anemia since [**Name (NI) 216**] (Hct 35),
it was 28 upon admission, drifted to 23 - she received 2 units
of PRBCs on [**10-22**] with an appropriate bump to 29.5. Since then
her Hct has been stable and was likely low in the setting of
cardiac catheterization. Also found to have low Fe, but also
low TIBC. B12 and folate within normal ranges. On discharge
Hct was 31 and trending upward. Should have continued work-up
by her Primary Care, but most likely associated with chronic
disease and transiently lowered with her various procedures and
lab draws.
.
# Constipation - On [**10-24**] patient stated she hadn't had BM in 14
days. Her abdomen was distended at that time, but nonpainful.
She was given a Fleet's enema and had her Senna changed to
scheduled rather than PRN. Within 24 hours her constipation
resolved, though she never had loose stools. Discharged with
PRN bowel regimen.
.
PPx - heparin sq, PPI
.
Code status - DNR/DNI, confirmed with patient.
.
Contact - [**Name (NI) 1154**] [**Name (NI) 100084**] (friend) at [**Telephone/Fax (1) 100085**] or [**First Name8 (NamePattern2) **]
[**Name (NI) **] [**Name (NI) **] (sister) at [**Telephone/Fax (1) 100086**]
.
Discharged back to [**Hospital1 599**] for extended treatment and care.
Medications on Admission:
Prilosec 20 mg PO Q24H
Vitamin C 500 [**Hospital1 **]
Colace 200 QPM
Tylenol 1g QAM
Oxycodone [**5-7**] Q4h prn
Zosyn 4.5 IV q8h
Remeron 30 QHS
MVI QD
ASA 81 QAM
Baclofen 15 QID
Lipitor 10 QPM
Actonel 35 Qwed
Protonix 40 QAM
Seroquel 37.5 QHS
Metoprolol 25 [**Hospital1 **]
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Quetiapine 25 mg Tablet Sig: 1.5 Tablets PO QHS (once a day
(at bedtime)).
4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. Baclofen 10 mg Tablet Sig: 1.5 Tablets PO QID (4 times a
day).
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
9. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
[**Month (only) 116**] repeat q5 minutes x 3.
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
12. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily): Hold for BP < 100 and/or HR < 65. Previously
prescribed 25mg po BID, so may need readjustment by facility
physician [**Name Initial (PRE) **].
14. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
15. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
Sig: 4.5 gm Intravenous Q8H (every 8 hours): Per plastic
surgery, should follw-up with them for definition of course.
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
unit Injection TID (3 times a day).
17. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Primary: NSTEMI (heart attack)
Secondary:
* CAD
- s/p inferior MI in [**2117-10-29**]
- Cath: 30% dLMCA, 70% pLCx, 90% pRCA, 50% dRCA; BMS -> RCA
* Multiple Sclerosis
- wheelchair bound
- neurogenic bladder with suprapubic catheter - changed qmonth
* Sacral decub ulcer
- complicated by osteomyelitis in [**2121-4-28**]
* Diastolic dysfunction
* Peripheral vascular disease
* Left tib/fib fx s/p external fixation ([**6-1**])
* Osteoporosis
* s/p multiple falls
* Depression
Discharge Condition:
Hemodynamically stable, afebrile and free of chest pain.
Discharge Instructions:
You were admitted to the hospital with chest pain. You were
evaluated with cardiac catheterization and found to have
narrowing of some of your cardiac vessels. Several stents were
placed in your vessels to try and open them, this was
successful.
.
Please keep all your outpatient appointments.
.
While inpatient the following medications have been changed:
Your metoprolol was decreased because your blood pressure was
too low, thus it changed from 25mg twice daily to 12.5mg daily.
Lasix 20mg po daily was added. Nitroglycerin SL was added for
symptomatic chest pain relief.
.
Please seek medical care or return to the emergency department
immediately if you have chest pain, new shortness of breath,
feel very lightheaded, have fever or chills, or for any other
symptoms for which you are conerned.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD
Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2122-11-9**] 8:30
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD
Phone:[**Telephone/Fax (1) 4022**]
Date/Time:[**2123-1-4**] 2:00
.
You additionally should follow-up with your Plastic Surgeon, Dr.
[**Last Name (STitle) **], for your sacral decubitus flap as planned prior to
admission.
.
Please schedule an appointment with your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 622**]
[**Last Name (NamePattern1) **], [**Telephone/Fax (1) 719**], in the next 1-2 weeks to discuss further
management.
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|
2111, 2402
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,474
| 183,533
|
13828+13829
|
Discharge summary
|
report+report
|
Admission Date: [**2167-3-27**] Discharge Date: [**2167-4-3**]
Service: Cardiac surgery.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 41531**] is an unfortunate
78 year old gentleman who was admitted to [**Hospital1 41532**] transferred from an outside
hospital, after he sustained an episode of chest pain.
Once in the outside hospital, an electrocardiogram revealed
electrocardiogram changes and he ruled in for a new non Q
wave myocardial infarction by troponin enzymes. He received
heparin infusion, Plavix and Aggrestatin. He was transferred
to [**Hospital1 69**] for further
management.
Once at [**Hospital1 69**], he [**Hospital1 1834**] a
cardiac catheterization that showed a critical LM, 90% left
anterior descending, 80% first diagonal, moderate diseased
circumflex, 90% right coronary artery with a LBEDT of 37 and
an ejection fraction of 20%. Cardiac surgical service was
consulted for a potential coronary artery bypass graft.
PAST MEDICAL HISTORY: The patient's past medical history is
significant for aortic stenosis with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of .6 cms.
History of colon cancer; status post colectomy; history of
non insulin dependent diabetes mellitus and
hypercholesterolemia.
MEDICATIONS: Medications at the time of admission to the
hospital included the following: Glucophage, Lipitor,
Atenolol, Aspirin.
ALLERGIES: No known drug allergies.
HOSPITAL COURSE: The patient remained on the CCU service and
he was optimized, as he was found to be a suitable candidate
upon surgical evaluation. On [**2167-3-31**], Mr. [**Known lastname 41531**] was
taken to the operating room and he [**Known lastname 1834**] a coronary
artery bypass graft times three, including left internal
mammary artery to the left anterior descending, saphenous
vein graft to the posterior descending artery and saphenous
vein graft to the diagonal. He also had an AVR repair with a
#19 mm [**Last Name (un) 3843**]-[**Doctor Last Name **] pericardial valve. He tolerated
the procedure well. He was transferred in stable condition
to the Intensive Care Unit.
Once in the unit, he continued to put more than 200 cc of
bloody drainage through his mediastinal and pleural tubes.
This ongoing bleeding went on for a couple of hours, without
decreasing in volume or amount and the decision was made to
take him back to the operating room for re-exploration. There
was no specific bleeding site identified.
After good hemostasis was confirmed, the patient was
transferred back again to the CSRU for further monitoring.
Overnight, he remained on pressors, requiring epinephrine,
Levophed, Milrinone, Propofol to keep good hemodynamic
parameters. He was transfused multiple times during the
course of the hospitalization.
By postoperative day two, he remained pressor dependent with
a hematocrit of 43.3 and he was noticed to have a K of 6.0.
His urine output fell and despite receiving simultaneous
doses of Lasix, he had no good renal response.
Over the course of that day, Mr. [**Known lastname 41531**] [**Last Name (Titles) 1834**] several
runs of ventricular tachycardia, requiring multiple
cardioversions. Lidocaine drip was started but, inspite of
all of this, the ventricular tachycardiac runs persisted.
The patient was started on hemodialysis for 50 minutes and
the decision was made to take him back to the catheterization
laboratory to further study him. Upon the catheterization,
he was found to have a 90% saphenous vein graft to R1
occlusion. This occlusion was ballooned open.
After this study, the patient returned to the CSRU for
further management and was started on Amudrip and pressors
including epinephrine, Levophed, a Lidocaine drip, Milrinone,
Neo-Synephrine and a bicarbonate drip to control his ongoing
acidosis.
Overnight, he continued to have runs of ventricular
tachycardia, requiring cardioversion, without improvement of
his overall status. Early in the morning of his postoperative
day #3, in an effort to control his renal ischemic acute
tubular necrosis, TVVHD was started.
Despite of all of the above, the patient continued to
deteriorate and his ongoing acidosis worsened. Finally,
around 4:10 p.m., the patient had an asystolic arrest and
ACLS resuscitation protocol was started.
Despite of chemical, electrical and mechanical stimulation,
the patient didn't respond. He was noticed to have non
spontaneous breathing. No pulse was palpable. There were no
audible heart sounds. No gag reflex. No pupillary or
coronary reflexes were evident.
The patient was pronounced dead by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
4:16 p.m. on [**2167-4-3**]. The family was notified and a post
mortem examination was rejected. The case was reported
routinely to the medical examiner and he waived the case.
The most likely cause of death was cardiac arrest, secondary
to cardiogenic shock.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern4) 26544**]
MEDQUIST36
D: [**2167-4-3**] 17:17
T: [**2167-4-9**] 04:42
JOB#: [**Job Number 41533**]
Admission Date: [**2167-3-27**] Discharge Date: [**2167-4-3**]
Service: Cardiac surgery.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 41531**] is an unfortunate
78 year old gentleman who was admitted to [**Hospital1 41532**] transferred from an outside
hospital, after he sustained an episode of chest pain.
Once in the outside hospital, an electrocardiogram revealed
electrocardiogram changes and he ruled in for a new non Q
wave myocardial infarction by troponin enzymes. He received
heparin infusion, Plavix and Aggrestatin. He was transferred
to [**Hospital1 69**] for further
management.
Once at [**Hospital1 69**], he [**Hospital1 1834**] a
cardiac catheterization that showed a critical LM, 90% left
anterior descending, 80% first diagonal, moderate diseased
circumflex, 90% right coronary artery with a LBEDT of 37 and
an ejection fraction of 20%. Cardiac surgical service was
consulted for a potential coronary artery bypass graft.
PAST MEDICAL HISTORY: The patient's past medical history is
significant for aortic stenosis with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of .6 cms.
History of colon cancer; status post colectomy; history of
non insulin dependent diabetes mellitus and
hypercholesterolemia.
MEDICATIONS: Medications at the time of admission to the
hospital included the following: Glucophage, Lipitor,
Atenolol, Aspirin.
ALLERGIES: No known drug allergies.
HOSPITAL COURSE: The patient remained on the CCU service and
he was optimized, as he was found to be a suitable candidate
upon surgical evaluation. On [**2167-3-31**], Mr. [**Known lastname 41531**] was
taken to the operating room and he [**Known lastname 1834**] a coronary
artery bypass graft times three, including left internal
mammary artery to the left anterior descending, saphenous
vein graft to the posterior descending artery and saphenous
vein graft to the diagonal. He also had an AVR repair with a
#19 mm [**Last Name (un) 3843**]-[**Doctor Last Name **] pericardial valve. He tolerated
the procedure well. He was transferred in stable condition
to the Intensive Care Unit.
Once in the unit, he continued to put more than 200 cc of
bloody drainage through his mediastinal and pleural tubes.
This ongoing bleeding went on for a couple of hours, without
decreasing in volume or amount and the decision was made to
take him back to the operating room for re-exploration. There
was no specific bleeding site identified.
After good hemostasis was confirmed, the patient was
transferred back again to the CSRU for further monitoring.
Overnight, he remained on pressors, requiring epinephrine,
Levophed, Milrinone, Propofol to keep good hemodynamic
parameters. He was transfused multiple times during the
course of the hospitalization.
By postoperative day two, he remained pressor dependent with
a hematocrit of 43.3 and he was noticed to have a K of 6.0.
His urine output fell and despite receiving simultaneous
doses of Lasix, he had no good renal response.
Over the course of that day, Mr. [**Known lastname 41531**] [**Last Name (Titles) 1834**] several
runs of ventricular tachycardia, requiring multiple
cardioversions. Lidocaine drip was started but, inspite of
all of this, the ventricular tachycardiac runs persisted.
The patient was started on hemodialysis for 50 minutes and
the decision was made to take him back to the catheterization
laboratory to further study him. Upon the catheterization,
he was found to have a 90% saphenous vein graft to R1
occlusion. This occlusion was ballooned open.
After this study, the patient returned to the CSRU for
further management and was started on Amudrip and pressors
including epinephrine, Levophed, a Lidocaine drip, Milrinone,
Neo-Synephrine and a bicarbonate drip to control his ongoing
acidosis.
Overnight, he continued to have runs of ventricular
tachycardia, requiring cardioversion, without improvement of
his overall status. Early in the morning of his postoperative
day #3, in an effort to control his renal ischemic acute
tubular necrosis, TVVHD was started.
Despite of all of the above, the patient continued to
deteriorate and his ongoing acidosis worsened. Finally,
around 4:10 p.m., the patient had an asystolic arrest and
ACLS resuscitation protocol was started.
Despite of chemical, electrical and mechanical stimulation,
the patient didn't respond. He was noticed to have non
spontaneous breathing. No pulse was palpable. There were no
audible heart sounds. No gag reflex. No pupillary or
coronary reflexes were evident.
The patient was pronounced dead by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
4:16 p.m. on [**2167-4-3**]. The family was notified and a post
mortem examination was rejected. The case was reported
routinely to the medical examiner and he waived the case.
The most likely cause of death was cardiac arrest, secondary
to cardiogenic shock.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern4) 26544**]
MEDQUIST36
D: [**2167-4-3**] 17:17
T: [**2167-4-9**] 04:42
JOB#: [**Job Number 23343**]
|
[
"428.0",
"250.00",
"424.1",
"272.0",
"414.01",
"410.71",
"785.51",
"443.9",
"998.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.61",
"88.53",
"37.22",
"36.15",
"36.12",
"34.03",
"35.21",
"39.61",
"88.55"
] |
icd9pcs
|
[
[
[]
]
] |
6651, 10409
|
5334, 6169
|
6192, 6633
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,592
| 180,169
|
27619
|
Discharge summary
|
report
|
Unit No: [**Numeric Identifier 67478**]
Admission Date: [**2110-4-29**]
Discharge Date: [**2110-4-30**]
Date of Birth:
Sex:
Service:
ADMISSION CHEST COMPLAINT:
1. Free intraperitoneal air.
2. Status post myocardial infarction.
3. Ischemic gut.
HOSPITAL COURSE: Mrs. [**Known firstname **] [**Known lastname 54752**] was a 79 year-old
Caucasian female who was referred from an outlying facility
having been approximately several days status post an acute
myocardial infarction. The patient experienced a low flow
state during this period of time. In addition she was
receiving steroid therapy for exacerbation of her chronic
lung disease. Prior to being transferred to the medical
Intensive Care Unit at the [**Hospital1 188**] the patient had undergone a CT scan which revealed
free intraperitoneal air. At this point in time the patient
had a stat transfer to the surgical service arranged. The
patient was then a direct admit to the trauma surgical
Intensive Care Unit where appropriate intravenous access was
achieved. Because of the nature of the patient's comorbidity
the family was cautioned that both intraoperative and
postoperative course were likely to be quite stormy.
The patient was taken to the operating room where upon
laparotomy an extension infarction of the colon was noted.
She underwent a total abdominal colectomy and an end
ileostomy. The patient was returned to the trauma surgical
Intensive Care Unit in critical condition. The patient was
maintained over the next 24 hours with extensive coverage
with inotropic agents and vasopressors. The patient
essentially made no meaningful physiologic recovery.
Approximately 12 hours after her surgical procedure an
extensive discussion was held with the family regarding the
fact that it will be unlikely that she will recovery. The
patient's family then asked the patient be made Do Not
Resuscitate and receive comfort measures. This was done. The
patient subsequently expired quietly.
[**First Name11 (Name Pattern1) 449**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 67332**]
Dictated By:[**Last Name (NamePattern1) 67333**]
MEDQUIST36
D: [**2110-8-14**] 17:16:26
T: [**2110-8-14**] 18:00:14
Job#: [**Job Number 67479**]
|
[
"557.0",
"562.11",
"410.71",
"567.21",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.20",
"45.8"
] |
icd9pcs
|
[
[
[]
]
] |
269, 2272
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,495
| 135,989
|
22166
|
Discharge summary
|
report
|
Admission Date: [**2186-6-25**] Discharge Date: [**2186-7-31**]
Date of Birth: [**2120-1-31**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Severe TR here for valve repair/replacement
Major Surgical or Invasive Procedure:
cardiac cath [**2186-6-26**]
TVR/RA reduction surgery via right thoracotomy [**2186-6-28**] ( 33 mm
CE pericardial valve)
PICC line [**2186-7-5**]
bronchoscopy [**2186-7-6**]
History of Present Illness:
Ms. [**Known lastname **] is a 66 yo F with h/o rheumatic mitral stenosis
s/p mechanical MVR ([**2165**]) on coumadin, right heart failure due
to severe TR and celiac disease who presents for heparin and
catheterization prior to tricuspid valve repair on [**6-28**]. The
patient presents with progressive TR and right heart failure
refractory to diuresis efforts. On review of old medical
records, TR was first mentioned in a report dated 07/[**2175**]. At
that time it was noted that she had a large right atrium and
significant TR, however she was asymptomatic and able to
maintain euvolemia with PO diuretics. However, she was recently
admitted to an OSH for diuresis due to increased peripheral
edema. Per the patients report, despite IV lasix, she was only
able to diurese 1-2lbs. MR [**First Name (Titles) **] [**Last Name (Titles) 461**] in [**Month (only) 116**], [**Month (only) **]
showed enlarged RV with severe TR and preserved LV function.
Over the past two months the patient reports increased weight
gain and LE edema. She has been taking lasix/metolazone daily
without any improvement in symptoms. Aside from the LE edema and
fatigue she denies any other symptoms. She does not have any
chest pain, palpitations, lightheadedness, dizziness, syncope or
presyncope. She does report SOB with ambulation however feels
that it is due to the exertion required to move her LE around.
This shortness of breath has been stable over the past month.
Per her report, her dry weight is 145lbs, recently up to 158lbs.
.
The patient's last dose of Coumadin was [**6-21**] and her INR today
was down to 1.7 per outside records (was 3.9 on Friday).
.
On review of symptoms, she reports occasional diarrhea and fecal
urgency especially in the morning. This has been stable since
she saw Dr. [**Last Name (STitle) **] in [**Month (only) 958**]. She follows a strict diet for
celiac sprue, however per Dr.[**Name (NI) 12202**] last note she may have a
refractory sprue. Biopsies on last colonoscopy were negative.
She reports a normal appetite with weight gain as above. She
denies any prior history of stroke, TIA, deep venous thrombosis,
pulmonary embolism, bleeding at the time of surgery, myalgias,
joint pains, hemoptysis, black stools or red stools. She denies
recent fevers, chills or rigors. She denies exertional buttock
or calf pain. All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea (sleeps with 1 pillow
baseline), palpitations, syncope or presyncope.
Past Medical History:
Mitral valve replacement, [**2165**] on coumadin. Treatment for
rheumatic MS. h/o MV commissurotomy in [**2152**].
Celiac sprue
Lactose Intolerance
Elevated LFTs
h/o AF prior to mechanical valve placement
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:
VS: T97.9, BP110/66, HR87, RR20, O2 97% on RA
63" 72 kg
Gen: WDWN elderly female in NAD, resp or otherwise. Oriented x3.
Mood, affect appropriate. Slightly anxious.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: JVP to angle of jaw.
CV: +RV heave, loud S1 (mech MV), normal s2, [**2-21**] holosystolic
murmur, [**12-24**] diastolic murmur. No rubs or gallops.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Soft, NTND, No HSM or tenderness. No abdominial bruits.
Ext: 3+ edema bilaterally to upper thighs. No femoral bruits.
Skin: Chronic venous stasis changes.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
.
Pertinent Results:
Admission Labs:
[**2186-6-25**] 02:45PM BLOOD WBC-5.0 RBC-3.53* Hgb-12.0 Hct-35.9*
MCV-102* MCH-34.0* MCHC-33.3 RDW-14.6 Plt Ct-119*
[**2186-6-25**] 02:45PM BLOOD PT-19.8* PTT-150* INR(PT)-1.9*
[**2186-6-25**] 02:45PM BLOOD Plt Ct-119*
[**2186-6-25**] 02:45PM BLOOD Glucose-119* UreaN-23* Creat-0.6 Na-137
K-3.7 Cl-101 HCO3-30 AnGap-10
[**2186-6-25**] 02:45PM BLOOD ALT-36 AST-58* LD(LDH)-326* CK(CPK)-53
AlkPhos-75 TotBili-1.1
[**2186-6-27**] 10:25AM BLOOD Lipase-34
[**2186-6-29**] 04:00AM BLOOD Lipase-15
[**2186-6-25**] 02:45PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2186-6-25**] 02:45PM BLOOD Albumin-2.6* Calcium-8.2* Phos-2.9 Mg-1.9
[**2186-6-25**] 02:45PM BLOOD TSH-5.0*
[**2186-6-26**] 06:34PM BLOOD Type-ART pO2-138* pCO2-43 pH-7.47*
calTCO2-32* Base XS-7 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**]
[**2186-6-28**] 08:43AM BLOOD Glucose-93 Na-137 K-3.3*
[**2186-6-26**] 06:34PM BLOOD Hgb-12.3 calcHCT-37 O2 Sat-97
[**2186-6-28**] 08:43AM BLOOD freeCa-1.05*
Studies:
[**2186-6-26**] C. Cath:
1. Coronary arteries are normal.
2. Severe tricuspid regurgitation with elevated right atrial
pressure.
3. Mild Pulmonary Hypertension.
4. No mitral stenosis.
Cardiology Report ECHO Study Date of [**2186-7-14**]
Left Ventricle - Ejection Fraction: >= 55% (nl >=55%)
LEFT ATRIUM: Marked LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated IVC (>2.5cm) with no
change with
respiration (estimated RAP >20 mmHg).
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size.
Suboptimal
technical quality, a focal LV wall motion abnormality cannot be
fully
excluded.
RIGHT VENTRICLE: Markedly dilated RV cavity. Moderate global RV
free wall
hypokinesis. Paradoxic septal motion consistent with prior
cardiac surgery.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta
diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Systolic
doming of aortic valve leaflets. Trace AR.
MITRAL VALVE: Bileaflet mitral valve prosthesis (MVR). Mild (1+)
MR. [Due to
acoustic shadowing, the severity of MR may be significantly
UNDERestimated.]
TRICUSPID VALVE: Bioprosthetic tricuspid valve (TVR). Increased
TVR gradients.
Mild [1+] TR. Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
[**2186-7-31**] 02:10AM BLOOD WBC-7.8 RBC-2.20* Hgb-7.6* Hct-23.5*
MCV-107* MCH-34.4* MCHC-32.2 RDW-19.2* Plt Ct-174
[**2186-7-30**] 05:25AM BLOOD WBC-8.4 RBC-2.25* Hgb-7.7* Hct-24.3*
MCV-108* MCH-34.2* MCHC-31.6 RDW-19.0* Plt Ct-158
[**2186-7-29**] 01:58AM BLOOD WBC-9.4 RBC-2.30* Hgb-8.0* Hct-24.2*
MCV-106* MCH-34.8* MCHC-33.0 RDW-20.0* Plt Ct-142*
[**2186-7-31**] 09:05AM BLOOD PT-15.9* PTT-44.8* INR(PT)-1.4*
[**2186-7-31**] 02:10AM BLOOD PT-15.1* PTT-111.1* INR(PT)-1.4*
[**2186-7-30**] 05:25AM BLOOD PT-12.6 PTT-33.6 INR(PT)-1.1
[**2186-7-29**] 03:48PM BLOOD PT-12.4 PTT-66.2* INR(PT)-1.1
[**2186-7-31**] 09:05AM BLOOD K-4.6
[**2186-7-31**] 02:10AM BLOOD Glucose-103 UreaN-30* Creat-0.4 Na-141
K-3.8 Cl-108 HCO3-28 AnGap-9
[**2186-7-30**] 05:25AM BLOOD UreaN-31* Creat-0.5 Cl-109* HCO3-29
Brief Hospital Course:
Ms. [**Known lastname **] is a 66 yo F with history of rheumatic valve s/p
MVR (87) on coumadin with severe TR and right heart failure here
for cardiac cath and TR repair. Admitted [**2186-6-25**].
Cath done [**2186-6-26**] prior to surgery. Underwent right
thoracotomy/TVR with Dr. [**Last Name (STitle) **] on [**6-28**]. Transferred to the
CSRU in stable condition on phenylephrine, propofol, vasopressin
and epinephrine drips. Extubated early the next morning.Drips
weaned over the next several days. Nutrition consult done for
history of celiac sprue. C. diff. culture sent for diarrhea, but
this was negative. PICC line placed for continued IV abx and
coumadin and heparin restarted for prior mechanical MVR/Afib. CT
scan of chest showedright effusion and bronchoscopy done on
[**7-6**] for thick secretions. Transferred to the floor on POD #12
to begin increasing her activity level and aggressive pulmonary
toilet. Tranferred back to the CSRU for hypercarbia and
decreased responsiveness without respiratory distress on [**7-12**]
early AM. BiPAP used intermittently. Right thoracentesis on [**7-14**]
and heparin drip restarted for subtherapeutic INR. Chest CT
repeated on [**7-17**] showed partial right lung collapse, and
aggressive pulmonary toilet continued. She was seen by
pulmonology for persistent hypoxia, aggresive diuresis and nebs
continued. Tube feedings and CPAP continued. She was reintubated
on [**7-24**]. Bronchoscopy on [**7-26**] showed moderate to severe
tracheomalacia. She was seen by surgery who performed a
tracheostomy and PEG on [**7-27**]. She was evaluated for passy-muir
valve, and is able to wear it for very short periods of time.
She was too fatigued to attempt swallow evaluation. She was
discharged to rehab on [**7-31**]. She was transfused 2 units PRBCs
prior to discharge.
Medications on Admission:
Diovan 160 mg daily
Lasix 40 mg a day
Metolazone 2.5 mg a day
Coumadin 4 mg a day alt with 2 mg a day
KCL supplement
MVI
Citracal
Immodium
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
4. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical TID (3 times a day) as needed: lower extremity.
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
13. Loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day) as needed.
14. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Six
(6) Puff Inhalation Q4H (every 4 hours).
15. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig:
One (1) Inhalation [**Hospital1 **] ().
16. Furosemide 20 mg IV BID
17. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: Eight Hundred (800) units/hour Intravenous ASDIR (AS
DIRECTED).
18. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for
1 doses.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
TVR/RA reduction via right thoracotomy
prior MVR [**2165**]
rheumatic heart disease
mitral stenosis s/p mitral commissurotomy [**2152**]
celiac sprue
lactose intolerance
A fib
Discharge Condition:
stable
stable
Discharge Instructions:
no lotions, creams, ointments or powders on any incision
no driving until cleared by surgeon
call for fever greater than 100.5, redness or drainage
no lifting greater than 10 pounds for 6 weeks
may shower over incisions and pat dry
Followup Instructions:
see Dr. [**Last Name (STitle) 7047**] in [**12-20**] weeks
see Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 24522**] 2 weeks
Already scheduled appointments:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], [**Name Initial (NameIs) **].D. Date/Time:[**2186-8-31**] 2:15
Completed by:[**2186-7-31**]
|
[
"482.9",
"398.91",
"458.29",
"518.81",
"427.31",
"997.3",
"519.19",
"271.3",
"518.0",
"391.1",
"V43.3",
"579.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.13",
"43.11",
"99.04",
"31.1",
"93.90",
"39.61",
"99.07",
"37.33",
"35.27",
"33.23",
"96.05",
"37.23",
"89.60",
"34.91",
"88.56",
"96.04",
"96.71",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
11182, 11254
|
7650, 9475
|
365, 543
|
11474, 11491
|
4493, 4493
|
11771, 12153
|
3511, 3593
|
9665, 11159
|
11275, 11453
|
9501, 9642
|
11515, 11748
|
3608, 4474
|
282, 327
|
571, 3141
|
4509, 7627
|
3163, 3370
|
3386, 3495
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,784
| 196,901
|
1818
|
Discharge summary
|
report
|
Admission Date: [**2113-8-26**] Discharge Date: [**2113-8-30**]
Date of Birth: [**2036-1-24**] Sex: M
Service: [**Hospital1 212**]
DIAGNOSES ON DISCHARGE:
1. Congestive heart failure exacerbation.
2. Atrial fibrillation with rapid ventricular response.
MEDICATIONS ON DISCHARGE:
1. Metoprolol 25 mg po b.i.d.
2. Zestril 40 mg po q.d.
3. Coumadin 4 mg q.h.s.
4. Lasix 20 mg b.i.d.
5. Glucophage 1000 mg b.i.d.
6. Iron gluconate and nitroglycerin sublingual prn.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 77-year-old male
with a history of congestive heart failure (ejection fraction
30%), coronary artery disease (status post myocardial
infarction times two), and paroxysmal atrial fibrillation
since [**2113-6-26**] (not cardioverted to [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 2966**]). He
presented to the [**Hospital6 256**]
Emergency Department on [**2113-8-26**] complaining of
shortness of breath and dry cough for two days. He also
noted one pillow orthopnea and paroxysmal nocturnal dyspnea.
He reported minimal pleuritic chest pain the night prior to
admission which he felt was due to coughing. It was
different from the chest pain he had experienced with his
previous myocardial infarctions. He denied nausea, vomiting
or diaphoresis. He reported chills and possible fever the
night prior to admission.
PAST MEDICAL HISTORY:
1. Paroxysmal atrial fibrillation since at least [**2113-7-27**], not cardioverted due to [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 2966**] on anticoagulation.
2. Congestive heart failure (transesophageal echocardiogram
on [**2113-6-26**] showed ejection fraction 30%).
3. Coronary artery disease, status post myocardial
infarction times two, status post mid left anterior
descending stent, [**2113-1-27**], plus left circumflex/obtuse
marginal stent [**2111-6-27**].
4. Noninsulin dependent diabetes mellitus.
5. Hypertension.
6. Gout.
7. Iron deficiency anemia plus pernicious anemia.
8. History of gastrointestinal bleed.
9. Hypereosinophilic syndrome.
ALLERGIES: The patient's allergies are aspirin, which causes
gastritis, and allopurinol causing rash.
SOCIAL HISTORY: The patient lives with his wife. Denies
tobacco or alcohol use.
PHYSICAL EXAM ON ADMISSION: His temperature was 100.4.
Heart rate 97 and irregular. Blood pressure 111/79.
Respiratory rate 21, saturating 97% on five liters nasal
cannula. General: The patient is sitting up in bed and
appears to be in mild respiratory distress. Head, eyes,
ears, nose and throat: Pupils equal, round and reactive to
light, oropharynx clear. Neck: Supple, no lymphadenopathy.
Chest: Crackles half way up from bases with diffuse
inspiratory and expiratory wheezes. Cardiovascular exam:
Irregularly irregular, no murmurs, rubs or gallops. Abdomen
was soft with normal active bowel sounds, minimal lower
abdominal tenderness. No guarding. Extremities: 2+ pitting
edema bilaterally, 2+ dorsalis pedis pulses. Skin: No
rashes. Neurological: Nonfocal.
PERTINENT LABORATORIES ON ADMISSION: White blood cell count
5.6, 76% polys, 8% lymphocytes, 5% monocytes and 10%
eosinophils. Hematocrit 34.1, platelet count 164,000. PT
18.8, PTT 36.9, INR 2.3. Chem-7 was normal with the
exception of glucose at 184. Urinalysis was negative.
Arterial blood gas was 7.48/32/88. CK was 222, CK-MB 4,
troponin I less than 0.3.
Chest x-ray showed no evidence of pneumonia or congestive
heart failure.
Electrocardiogram showed atrial fibrillation at 95 beats per
minute, left axis deviation, old Q wave in III and aVF seen
on electrocardiogram from [**2113-7-5**]. No significant ST
or T wave changes.
SUMMARY OF HOSPITAL COURSE:
1. Cardiovascular: The patient received 80 mg of Lasix
intravenously in the Emergency Department and subsequently
diuresed 3300 cc in three hours dropping his blood pressure
to 75/37. There was also reportedly a change in his mental
status after this diuresis and his temperature spiked to 101.
He was given gentamicin 100 mg intravenously and vancomycin 1
gram intravenously for question of sepsis. He received one
liter of normal saline boluses times three. Blood cultures
and urine cultures were sent. He was given diltiazem
intravenously times three in an attempt to control his heart
rate and was admitted to the Medical Intensive Care Unit for
further management.
In the Medical Intensive Care Unit, he ruled out by enzymes
times three. He remained in atrial fibrillation with rapid
ventricular response and was started on Metoprolol 12.5 mg.
He remained hemodynamically stable and was transferred to the
floor for further management. His condition improved and he
continued to receive his home dose of Lasix of 20 mg po
b.i.d. with good response. His Metoprolol was increased to
25 mg b.i.d. which kept his heart rate in the 80s to low
100s. It was determined that he was not eligible for
cardioversion at this time due to inadequate anticoagulation
over the past four weeks, so, the goal was to diurese and to
obtain better rate control with his atrial fibrillation.
This was accomplished and he was discharged at his baseline
status, saturating 98% on room air with minimal crackles on
his lung exam and much improved lower extremity edema.
2. Pulmonary: The patient had some inspiratory and
expiratory wheezes on exam, but was not responsive to
Atrovent nebulizers, and was likely cardiac asthma that
improved as he diuresed.
3. Anemia: He has a history of chronic anemia. He is on
iron and Vitamin B12. Hematocrit was 34.1 on admission and
dropped to a nadir of 28, but stabilized out in the low 30s.
4. Endocrine: His diabetes was controlled with fingersticks
q.i.d. and a regular insulin sliding scale as an inpatient.
He was restarted on his Glucophage on discharge.
5. Infectious Disease: His blood cultures and urine
cultures were negative. His antibiotics were not continued
and he did not spike any fevers for the rest of his hospital
course.
6. Fluid, electrolytes and nutrition: He was encouraged to
maintain a sodium restricted diet as dietary indiscretion was
partially responsible for this exacerbation. He did not
require any electrolytes repletions during his stay.
DISCHARGE CONDITION: He was discharged to home in good
condition with Physical Therapy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**First Name3 (LF) 10170**]
MEDQUIST36
D: [**2113-9-6**] 16:42
T: [**2113-9-6**] 16:42
JOB#: [**Job Number **]
|
[
"427.31",
"V45.82",
"428.0",
"250.00",
"401.9",
"412",
"280.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6261, 6594
|
299, 488
|
3717, 6239
|
172, 273
|
517, 1378
|
3085, 3688
|
1400, 2182
|
2199, 2279
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,148
| 114,469
|
29480
|
Discharge summary
|
report
|
Admission Date: [**2106-10-27**] Discharge Date: [**2106-11-8**]
Date of Birth: [**2033-5-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Chest/back pain
Major Surgical or Invasive Procedure:
CTA Torso/Neck/Head
History of Present Illness:
73 y/o male who presented to ED after multiple episodes of dull
pain which started between shoulder blades radiating to front of
chest with abdominal nausea. Rated most severe pain [**1-8**] lasting
5-10 minutes. Admitted to re-check type b aorta dissection via
CT.
Past Medical History:
Type B aortic dissection.
Coronary Artery Disease s/p Coronary Artery Bypass Graft 10 yrs.
ago
Hypertension
Hypercholesterolemia
Rheumatoid arthritis
Melanoma
Social History:
Lives with wife.
Cigs: none
ETOH: none
Family History:
DM
Physical Exam:
Elderly [**Male First Name (un) 4746**] in NAD
HEENT: NC/AT, PERLA, EOMI, poor dentition
Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids
2+ bilat.
Lungs: Clear to A+P
CV: RRR without R/G/M, nl s1, s2
Abd: +BS, soft, nontender without masses or hepatosplenomegaly
Ext: without C/C/E
Neuro: nonfocal, A&O x 3. MAE
Discharge
Gen NAD
Neuro: a/ox3 nonfocal
Pulm CTAB
Card: RRR no murmur/rub/gallop
Abd: soft, NT, ND +BS
Ext warm well perfused pulses +2
Pertinent Results:
[**2106-11-8**] 06:20AM BLOOD WBC-9.6 RBC-3.76* Hgb-11.4* Hct-31.9*
MCV-85 MCH-30.3 MCHC-35.7* RDW-13.4 Plt Ct-311
[**2106-10-26**] 07:20AM BLOOD WBC-11.2* RBC-4.34* Hgb-13.3* Hct-37.5*
MCV-86 MCH-30.5 MCHC-35.4* RDW-13.9 Plt Ct-160
[**2106-10-27**] 10:30AM BLOOD Neuts-81.9* Lymphs-10.4* Monos-5.8
Eos-1.8 Baso-0.1
[**2106-11-8**] 06:20AM BLOOD Plt Ct-311
[**2106-11-8**] 06:20AM BLOOD PT-13.5* PTT-30.4 INR(PT)-1.2*
[**2106-10-27**] 10:30AM BLOOD PT-12.8 PTT-26.2 INR(PT)-1.1
[**2106-10-26**] 07:20AM BLOOD Plt Ct-160
[**2106-11-8**] 06:20AM BLOOD Glucose-106* UreaN-18 Creat-1.1 Na-139
K-4.8 Cl-101 HCO3-27 AnGap-16
[**2106-10-26**] 07:20AM BLOOD Glucose-124* UreaN-16 Creat-1.1 Na-139
K-4.5 Cl-100 HCO3-30 AnGap-14
[**2106-10-28**] 06:35AM BLOOD ALT-11 AST-12 CK(CPK)-26* AlkPhos-115
TotBili-0.6
[**2106-10-27**] 07:29PM BLOOD ALT-15 AST-20 LD(LDH)-310* CK(CPK)-59
AlkPhos-132* Amylase-35 TotBili-0.6
[**2106-10-28**] 06:35AM BLOOD cTropnT-<0.01
[**2106-10-27**] 07:29PM BLOOD Lipase-18
[**2106-11-4**] 06:15AM BLOOD Mg-2.4
[**2106-10-28**] 06:35AM BLOOD Triglyc-105 HDL-47 CHOL/HD-2.9 LDLcalc-66
CTA chest [**10-27**]
IMPRESSION:
1. Aortic dissection involving the descending thoracic aorta
([**Location (un) 11916**] B, deBakey III). No extension to involve the ascending
aorta is evident.
2. History of prior CABG corroborated.
3. There is severe emphysema with a persistent left pleural
effusion.
4. There is cholelithiasis without evidence of cholecystitis.
[**11-2**] Echo
Left Atrium - Long Axis Dimension: *4.1 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.8 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *6.3 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.7 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 3.2 cm
Left Ventricle - Fractional Shortening: 0.32 (nl >= 0.29)
Left Ventricle - Ejection Fraction: >= 55% (nl >=55%)
Aorta - Valve Level: 3.1 cm (nl <= 3.6 cm)
Aorta - Ascending: *4.3 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.6 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.9 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A Ratio: 1.13
Mitral Valve - E Wave Deceleration Time: 133 msec
TR Gradient (+ RA = PASP): *27 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
systolic
function (LVEF>55%). Normal regional LV systolic function.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter. Moderately dilated ascending
aorta.
Descending aorta intimal flap/aortic dissection.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild mitral
annular
calcification.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Mild PA
systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions:
The left atrium is mildly dilated. The right atrium is
moderately dilated.
There is mild symmetric left ventricular hypertrophy with normal
cavity size
and systolic function (LVEF>55%). Regional left ventricular wall
motion is
normal. Right ventricular chamber size and free wall motion are
normal. The
ascending aorta is moderately dilated. While no clear dissection
flap is seen,
color Doppler imaging suggests a proximal descending aortic
dissection,
originating just distal to the origin of the left subclavian
artery. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are
structurally normal. There is no mitral valve prolapse. There is
mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Symmetric LVH with preserved global and regional
biventricular
systolic function. Moderately dilated ascending aorta.
Descending aortic
dissection.
[**11-2**] Stress Thallium
IMPRESSION: 1. Normal myocardial perfusion. 2. Normal LV cavity
size and
function.
[**11-4**] CTA head/neck
IMPRESSION:
1. Irregularity and narrowing along the V4 segment of the left
vertebral artery.
2. Mild/moderate right internal carotid artery stenosis at the
origin.
3. Atherosclerosis of bilateral carotids, most prominently at
the bulbs and cavernous portions.
4. Emphysema.
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname 8389**] was admitted for CT to
evaluate aorta. His blood pressure was closely managed and
cardiology was consulted. CT revealed no change in his Type B
Dissection of his Aorta from prior study. Cardiac enzymes were
followed with no increase suggestive of cardiac event. He was
further evaluated for endovascular stent and underwent
preoperative workup. He was transferred to the floor and pain
resolved. At this time declined surgery and was discharged home
a follow up CTA in 5 weeks and to call if pain returns.
Medications on Admission:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*0*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for back pain.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Type B aortic dissection.
Coronary Artery Disease s/p Coronary Artery Bypass Graft 10 yrs.
ago
Hypertension
Hypercholesterolemia
Rheumatoid arthritis
Melanoma
Discharge Condition:
Good
Discharge Instructions:
Follow medications on discharge instructions.
Call if pain reoccurs.
Followup Instructions:
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in 6 weeks ([**Telephone/Fax (1) 170**]) please call for
appointment
CAT SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2106-12-14**] 9am - do not eat
or drink anything 3 hours before. please go to [**Hospital Ward Name **] 4 at
[**Hospital1 18**]
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**] in [**1-1**] weeks please call for appointment
Completed by:[**2106-11-9**]
|
[
"492.8",
"V45.81",
"V10.82",
"441.01",
"714.0",
"272.0",
"413.9",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7796, 7802
|
6022, 6587
|
338, 360
|
8004, 8010
|
1414, 5999
|
8128, 8602
|
909, 913
|
7038, 7773
|
7823, 7983
|
6613, 7015
|
8034, 8105
|
928, 1395
|
283, 300
|
388, 655
|
677, 837
|
853, 893
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,651
| 136,221
|
12957
|
Discharge summary
|
report
|
Admission Date: [**2114-12-18**] Discharge Date: [**2115-1-4**]
Date of Birth: [**2038-4-8**] Sex: F
Service: MEDICINE
Allergies:
Daypro / Carafate / Procardia / Prilosec / Diflunisal
Attending:[**First Name3 (LF) 3963**]
Chief Complaint:
Initiation of chemotherapy.
Major Surgical or Invasive Procedure:
-PICC line placement on the R
-PICC line placement on the L
-R IJ central line placement
-Chemotherapy on [**2114-12-20**] and [**2115-1-4**].
History of Present Illness:
Mrs. [**Known lastname 39760**] is a 76 y/o F with history of autoimmune hepatitis,
diastolic CHF, hypertension, T2DM, as well as abdominal B cell
lymphoma, diagnosed after recent onset of abdominal pain. She
initially presented to NEBH ambulatory care [**2114-12-5**] for mild
abdominal pain, where, abdominal exam reportedly was notable for
a palpable mass. Labs that day were notable for hematocrit 30.5
(baseline 37-39) calcium of 13.1 (albumin 3.5), creatinine 1.8
(baseline 1.2-1.5), and BNP 333.
.
She underwent abdominal/pelvis CT scan, which revealed a large
soft tissue density surrounding the cecum and ascending colon
with significant stranding, initially believed to be a phlegmon
possibly [**1-23**] appendicitis or appendiceal rupture. There was
moderate concentric narrowing but no obstruction. CT also showed
a smaller, similar phlegmon anterior to the transverse colon. CT
Chest was negative for malignancy. She was admitted for surgical
evaluation and biopsy, and triaged to the ICU for intensive
fluid management in the setting of her severe diastolic CHF.
.
She underwent abdominal open surgery on [**12-10**], with biopsy of
her mass in multiple abdominal locations - diagnosis felt to be
large B cell lymphoma. As above, CT chest was negative for
malignant involvement. She did not undergo any other staging
studies. Patient was transferred for possible chemotherapy. Per
signout reported patient got prednisone 80 mg x 2 days [**12-17**],
[**12-18**] - but this is not listed in the discharge summary.
.
In regards to her hypercalcemia, she was treated with normal
saline and furosemide, with normalization of her serum calcium
levels. On day of transfer, her calcium was 9.8 with albumin of
2.2, suggesting mild hypercalcemia. She underwent TTE on [**12-13**]
that was reportedly not consistent with dCHF.
.
NEBH d/c summary reports today's exam notable for no fevers,
mild hypotension with systolic BPs in the 90s, regular heart
rhythm with rate in the 80s, and normal oxygen saturation. She
was reported as having a distended, slightly tender abdomen.
Labs today were notable for stable CBC, INR 1.3, creatinine 1.5,
and LDH 648. D/c summary also indicated that today's CXR was
unchanged, showing poor inspiratory effort, prominent hila,
basilar atelectasis bilaterally but no significant change from
prior chest x-rays. Discharge summary also reports a
supraventricular tachycardia 5 days ago treated with po
lopressor and diltiazem.
.
At time of [**Hospital1 18**] admission patient's on compliant is dysuria and
vaginal pain. Otherwise denies shortness of breath, chest pain
or abdoiminal pain.
Past Medical History:
Past medical history:
-Autoimmune hepatitis confirmed by biopsy in [**2099**] which was
treated with Azathioprine and prednisone. Recent hepatology note
indicates desire to transition from prednisone to budesonide.
Primary hepatologist is Dr. [**Last Name (STitle) **].
-Hypertension treated with metoprolol and Lasix
-osteoarthritis
-sleep apnea
-diabetes mellitus insulin-dependent, treated with Novolin and
regular insulin
-COPD
-possible pulmonary hypertension (This was not borne out by a
recent echocardiogram which although technically difficult, did
not show evidence, doppler or otherwise of diastolic
dysfunction)
-hiatal hernia treated with Nexium
-multiple allergies with intermittent use of Zyrtec
-hyperuricemia treated with urolic
-possible history of CHF, which has been treated with Lasix
-headaches treated with Fioricet.
.
Past Surgical History:
-oophorectomy and appendectomy in [**2063**]
-hysterectomy [**2085**]
-cholecystectomy [**2099**]
-bowel resection in [**2099**] as well
Social History:
A 35-pack-year, quit in [**2087**] and no alcohol. She is married.
Family History:
Unable to obtain at time of admission.
Physical Exam:
Upon admission:
GEN: NAD, patient complains in pain
HEENT: PERRLA, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII grossly intact. Moves all extremity.
At discharge:
VS: Tmax 97.7 / BP 87-131/58-82 / HR 79-90 / RR 20-24 / Sats
92-96% on 2L
Blood sugars: 165-218
Gen: NAD, more comfortable today
Skin: diffusely swollen, most on bilateral lower extremities and
some on R hand, skin on stomach is friable around abdominal
wound. abdominal wound has steri-strips over most of incision
but one area at apex and one at base of incision are opened and
packed with gauze. Area around wound is not indurated and there
is no significant surrounding erythema
Cardiac: RRR, S1, S2, no m/r/g, JVP not elevated
Pulm: CTAB in anterior and lateral fields, fair air movement
Abdomen: soft, NT, distended [**1-23**] to body habitus, positive bowel
sounds
Extremities: 3+ pitting edema up to mid-thigh bilaterally with
2+ pulses at BP and radial arteries
Neuro: A&Ox3, CN II-XII intact, language normal
Pertinent Results:
Upon admission:
[**2114-12-19**] 03:25AM BLOOD WBC-6.8 RBC-3.17* Hgb-10.4* Hct-32.2*
MCV-102*# MCH-32.9* MCHC-32.3 RDW-22.1* Plt Ct-271
[**2114-12-19**] 03:25AM BLOOD PT-13.5* PTT-21.1* INR(PT)-1.2*
[**2114-12-19**] 03:25AM BLOOD Glucose-139* UreaN-45* Creat-1.2* Na-139
K-5.2* Cl-98 HCO3-30 AnGap-16
[**2114-12-19**] 11:49AM BLOOD ALT-72* AST-91* AlkPhos-65 TotBili-0.7
[**2114-12-19**] 03:25AM BLOOD LD(LDH)-720*
[**2114-12-19**] 11:49AM BLOOD Albumin-3.0* Calcium-10.7* Phos-5.2*
UricAcd-6.1*
Imaging/pathology:
Bone Marrow Immunotyping ([**2115-12-18**]):
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield. CD45 bright, low side scatter
lymphoid events are less than 2% of total analyzed events.
B cells comprise 5% of lymphoid-gated events, and do not express
aberrant antigens. Clonality is difficult to assess due to scant
numbers, but appears polyclonal. T cells comprise 68% of
lymphoid gated events, and express mature lineage antigens.
INTERPRETATION
Non-specific T cell dominant profile; diagnostic
immunophenotypic features of involvement by non-Hodgkin lymphoma
are not seen in specimen. Correlation with clinical findings
and morphology (see S10-[**Numeric Identifier 39761**]) is recommended. Flow cytometry
immunophenotyping may not detect all lymphomas due to
topography, sampling or artifacts of sample preparation.
Chromosome analysis bone marrow ([**2115-12-18**]):
KARYOTYPE: 46,XX[20]
INTERPRETATION:
No clonal cytogenetic aberrations were identified
in metaphases analyzed from this unstimulated
specimen. This normal result does not exclude a
neoplastic proliferation.
Mosaicism and small chromosome anomalies may not be
detectable using the standard methods employed.
Note: FISH studies were not performed because assessment of
the specimen by Pathology showed no evidence of lymphoma.
Tissue Bone Marrow ([**2115-12-18**]):
Clinical: Lymphoma, NHL. Newly diagnosed DLBCL.
Pathology Slides ([**2115-12-20**]):
DIAGNOSIS: HIGH-GRADE B-CELL LYMPHOMA, DIFFUSE LARGE B CELL
TYPE, SEE NOTE.
ECHO ([**2115-12-19**]):
Conclusions
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF 70%). Right ventricular
chamber size and free wall motion are normal. There are focal
calcifications in the aortic arch. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. There
is borderline pulmonary artery systolic hypertension. There is
no pericardial effusion.
RUE U/S ([**2114-12-26**]):
IMPRESSION: Occlusive thrombus within the subclavian and
axillary veins
adjacent to a PICC. The cephalic, basilic, and paired brachial
veins are
patent.
Attempts to contact the medical team and nursing staff were
unsuccessful and so these findings were reported into the
radiology critical report dashboard.
CT of Abdomen/Pelvis ([**2114-12-27**]):
IMPRESSION:
1. Extensive wall thickening centered in the ileocecal region
but also
involving the ascending and proximal transverse colon.
Appearances may be due to lymphoma, typhilitis or colitis.
Comparison with any pre-treatment imaging would be extremely
helpful. No fluid collections seen.
2. Small bilateral pleural effusions.
3. Moderate amount of ascites.
4. Periportal edema noted.
5. Multiple small low-attenuation lesions noted in both kidneys.
6. Diffuse anasarca.
7. Extensive calcification of the abdominal aorta.
Final Addendum
CT images from [**Hospital6 2910**] dated [**2114-12-8**] have
now become
available for comparison. A large soft tissue mass in the right
lower
quadrant involving the ascending colon and terminal ileum is
significantly
decreased in size. The mass previously measured 13.4 x 13.3 cm
and currently measures 11.4 x 9.3 cm in a similar location. The
previously noted eccentric wall thickening in the transverse
colon has significantly improved. The wall measured previously
3.3 cm in largest thickness and currently measures 1.3 cm.
CXR Pa/Lat ([**2115-1-1**]):
IMPRESSION:
1. Mild residual pulmonary venous congestion, but improved
perihilar
infiltrates likely reflect improved pulmonary edema.
2. Basal atelectasis with possible small area of superimposed
consolidation at left base.
3. T9 compression as on prior CT exam.
4. Small basal pleural effusions.
5. Left PICC passes cranially, presumably into the left internal
jugular vein. The tip is excluded from the field of view.
Microbiology:
Urine Cx ([**2115-12-18**]):
**FINAL REPORT [**2114-12-22**]**
URINE CULTURE (Final [**2114-12-22**]):
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ =>32 R <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TETRACYCLINE---------- =>16 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
VANCOMYCIN------------ 1 S
Follow up Bcx, Ucx, and C diff toxins negative.
URINE CHEMISTRY:
Creat 99 / Na less than 10 / K 35 / Cl less than 10 / Calcium
1.32 / HCO3 less than 30 / OSM 585
Discharge Labs ([**2115-1-4**]):
WBC 15.9 / Hgb 9.5 / Hct 28.4 / Plts 141
Na 135 / K 4.5 / Cl 106 / HCO3 24 / BUN 26 / Cr 0.8 / Plts 202
Ca 7.7 / Mg 1.8 / Phos 2.9 / ALT 19 / AST 31 / LDH 442 / Alk
phos 222
INR 1.4
HIT Ab: negative
Pending:
Factor V Leiden
Blood Cx ([**12-29**] and [**1-2**])
Brief Hospital Course:
76 y/o female with diastolic CHF, T2DM, autoimmune hepatitis,
and newly diagnosed B cell lymphoma of the abdomen, transferred
from NEBH for initiation of chemotherapy.
.
#B cell lymphoma:
Diagnosed with pathology, cytology, and flow consistent with a B
cell lymphoma. Oncology preformed bone marrow today for - IPI
stage 5. Started with Solmedrol 100 mg IV dose X 1. Tumor
lysis labs were followed q8hours without issue, and bicarb D5W
75 cc/hr was also given with allopurinol. Echo revealed mild
diastolic CHF. She was transferred to the oncology floor on day
1 s/p solumedrol infusion without issue. She was started on CHOP
therapy cycle one on [**2114-12-20**]. Counts dropped as expected and
recovered again by [**2114-12-31**] with the aid of neupogen injections.
Pt required intermittent blood transfusions, although no plts
transfusions, while counts were low. Pt tolerated the chemo
fairly well although her hospital course was complicated by some
of the below issues. Pt was kept NPO during the first 11 days of
chemo over concerns that as her bowel mass shrunk she was at
risk for perforation of the bowel. Decision was made to give 2nd
cycle of CHOP, plus rituxan, on morning of discharge ([**2115-1-4**]),
because pt unable to receive rituxan at rehab center. Pt
discharged to [**Hospital3 **] in [**Hospital1 8**] with plans for
follow-up with Dr. [**Last Name (STitle) 3759**] on [**2115-1-10**] at 2pm.
.
# Atrial Fibrillation:
Pt had reported episode of Afib with RVR at NEBH before
transfer. On arrival in [**Hospital1 18**] ICU, pt was initially placed on
diltiazem and had dose uptitrated to control rate. After
transfer to floor still difficulty with rate control with rates
in 110-130s. Pt was switched to metoprolol and dose uptitrated
to 100mg metoprolol tartrate [**Hospital1 **] to good effect. At times pt
would get dehydrated and HR would bump up but these times
usually responded to small fluid boluses (500-1000mls NS.
.
# Delerium:
Pt had reported episode of delerium while at NEBH but was not
delerious at time of transfer to [**Hospital1 18**]. No issues with
initiation of chemotherapy but pt complained of intermittent
back pain from old known compression fracture and was given one
dose of IV dilaudid as at time had elevated LFTs and
questionable renal function. Pt became very delerious from
dilaudid. This cleared slowly over next three days, with the
help of IV haldol. By time of discharge pt alert and oriented x
3 and with no signs of delerium.
.
# COPD:
Pt with history of underlying lung disease of uncertain
severity. Initially pt was on 6L of nasal cannula in order to
keep sats in low-mid 90s. Unclear how much of this due to lung
disease and how much to other issues. Able to be titrated down
to 4L NC but not low in first week. Increased frequency of
albuterol and ipratropium and changed both to standing doses and
nebs and resulting improvement in sats so that pt only required
2L NC to keep sats in low to mid 90s.
.
# Febrile Neutropenia:
During pts count nadir from above CHOP, pt developed fevers. Due
to concern for abdominal source, started initially on Cefepime
and Metronidazole and then broadened to Vancomycin when fevers
persisted. Fevers went away after 48hrs and all culture data was
negative. Abx were stopped after counts recovered so that pt no
longer neutropenic.
.
# Diabetes Type II:
Pt with history of DM II and on insulin at home. With initiation
of chemo and accompanying steroids, pt had blood sugars very
difficult to control into 300s routinely with just ISS coveage.
Once TPN started, insulin was placed in TPN but sugars still
high so started on NPH and uptitrated to 8u am / 8u pm with
resulting sugars in mid 100s with 45 units regular insulin in
TPN.
.
# Abdominal Wound:
Ex-lap as part of DX at NEBH on [**12-10**]. General surgery at [**Hospital1 18**]
saw pt 12 days later and removed staples. Two seroma collections
opened up and drained serious fluid. Wounds were packed with
gauze with plan to let heal from inside out although healing
slow due to multiple medical issues. At time of D/C wound not
infected but still opened and packed at both superior and
inferior portion of wound.
.
# GERD:
Pt with no history of hiatal hernia and accompanying bad GERD
which caused significant intermittent abdominal discomfort. Pt
was started on [**Hospital1 **] IV PPI to help with this. PPI worked to good
effect and was titrated down to daily at time of D/C.
.
Medications on Admission:
Medications at home: per OMR [**10-31**] - patient unable to recall
AZATHIOPRINE [AZASAN] - 100 mg Tablet - 1 Tablet(s) by mouth
once
a day
BUDESONIDE [ENTOCORT EC] - 3 mg Capsule, Sust. Release 24 hr -
one Capsule(s) by mouth daily
CITALOPRAM - (Prescribed by Other Provider) - 10 mg Tablet - 1
Tablet(s) by mouth once daily Take with one 20mg tablet for dose
of 30
CITALOPRAM - (Dose adjustment - no new Rx) - 20 mg Tablet - 1
Tablet(s) by mouth once a day Take with one 10mg tablet for
total
of 30mg
ESOMEPRAZOLE MAGNESIUM [NEXIUM] - 40 mg Capsule, Delayed
Release(E.C.) - 1 Capsule(s) by mouth twice a day
FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 4
Tablet(s) by mouth q am and 2 q pm
INSULIN LISPRO [HUMALOG] - (Prescribed by Other Provider) - 100
unit/mL Solution - 80 units q am and 18 units q pm
METOPROLOL SUCCINATE - (Prescribed by Other Provider; Dose
adjustment - no new Rx) - 50 mg Tablet Sustained Release 24 hr -
3 Tablet(s) by mouth at bedtime Total of 350 mg daily
METOPROLOL TARTRATE - (Dose adjustment - no new Rx) - 100 mg
Tablet - 2 Tablet(s) by mouth once daily Total of 350 mg
REGULAR INSULIN SLIDING SCALE - (Prescribed by Other Provider) -
- as directed
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet - 1
Tablet(s) by mouth once a day
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 WITH D] - (Prescribed
by Other Provider) - 500 mg (1,250 mg)-400 unit Tablet - 1
Tablet(s) by mouth three times a day
MULTIVITAMIN - (Prescribed by Other Provider) - Tablet - 1
Tablet(s) by mouth once a day
POTASSIUM - (Prescribed by Other Provider) - Dosage uncertain
.
Meds on transfer:
-Insulin detemir 20 units subq in a.m. - novolin insulin sliding
scale
-hydroxyzine pamoate 25 mg p.o. p.r.n. itching
-albuterol ipratropium 1 vile DuoNeb q6h as needed for shortness
of breath
-metoprolol 100 mg po q 8 hours
-citalopram 30 mg p.o. daily
-senna docusate 8.6/50, Senokot-S 2 tabs as needed at bedtime
-econazole powder 2% b.i.d. topically to areas of rash
-heparin 5000 units subq q8h
-lorazepam 1 mg p.o. as needed daily
-febuxostat 80 mg p.o. daily
-Zofran 4 mg p.o. can be used as needed q6h for nausea
-Continue diltiazem 60 mg t.i.d. p.o.
-Maalox 30 mL as needed q6h for nausea or indigestion
-phosphate powder 1 package p.o. daily that is Neutrophos.
-re-started prednisone 5 mg a day - because on chronic dosing
prior to admission
Discharge Medications:
1. citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for oral thrush.
4. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day: Hold for sys BP < 90 and HR < 60.
5. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain or fever: Max of 2g acetaminophen
each day.
7. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash.
8. oxycodone 5 mg/5 mL Solution Sig: 2.5 mg PO Q8H (every 8
hours) as needed for severe pain: Please try to limit narcotic
use as patient is easily made delerious with narcotics.
9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
10. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
11. prednisone 50 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 4 doses: Give on Days 2, 3, 4, and 5.
12. enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
13. Sodium CITRATE 4% 3 mL DWELL TID
Please place in RIJ ports in palce of heparin
14. aprepitant 125 mg Capsule Sig: One (1) Capsule PO Q 24H
(Every 24 Hours) for 3 days.
15. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
16. pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous once a day.
17. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
18. haloperidol 1 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for agitation.
19. TPN Order
Volume(ml/d) 1800ml
Amino Acid(g/d) 75g/d
Dextrose(g/d) 300g/d
Fat(g/d) 40g/d
Trace Elements will be added daily
Standard Adult Multivitamins
NaCL 110 / NaAc 0 / NaPO4 40 / KCl 0 / KAc 35 / KPO4 25 / MgS04
14 / CaGluc 9
Insulin(units) 45
Total volume of solution per 24 hours.
20. Insulin Sliding Scale
Fingerstick q6hInsulin SC Fixed Dose Orders
Breakfast: NPH 8 units / Bedtime NPH 8 units
Insulin SC Sliding Scale Q6H Humalog
Glucose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol
71-150 mg/dL 0 Units
151-200 mg/dL 2 Units
201-250 mg/dL 4 Units
251-300 mg/dL 6 Units
301-350 mg/dL 8 Units
351-400 mg/dL 10 Units
> 400 mg/dL Notify M.D.
21. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
22. dextrose 50% in water (D50W) Syringe Sig: One (1)
Intravenous PRN (as needed) as needed for hypoglycemia protocol.
23. Neupogen 480 mcg/0.8 mL Syringe Sig: One (1) Injection once
a day: Please start on Sunday ([**2115-1-6**]).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] center
Discharge Diagnosis:
Primary Diagnosis:
- Abdominal B-cell Lymphoma
Secondary Diagnosis:
- Autoimmune Hepatitis
- Atrial Fibrillation
- Type II Diabetes
- Urinary Tract Infection
- COPD
- Delerium
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:
[**First Name8 (NamePattern2) **] [**Known lastname 39760**], it was a pleasure taking care of you during your
stay.
You were transfered to [**Hospital3 **] from [**Hospital6 17390**] for treatment of your abdominal lymphoma. You were
started on a chemotherapy regimen known as CHOP and you were
given the first round of this treatment on [**2115-12-20**] and the
second round on [**2115-1-4**]. You tolerated your chemo well with few
side effects and your blood counts had recovered by time of next
treament on [**2115-1-4**]. During you hospitalization, our general
surgeons removed your abdominal staples and opened to areas of
your wound that contained fluid. We have been packing this with
gauze and this should be continued at rehab. You also had both a
UTI and later a fever which were treated effectively with
anti-biotics. You had an episode of delerium during your stay
which was triggered by a narcotic medication. In the future you
should try to limit your use of narcotics as your body seems
very sensative to them and you may go into a delerium again.
You should follow-up with Dr. [**Last Name (STitle) 3759**] on [**2115-1-10**] as noted
below.
You should take the following medications:
-citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
-docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
-nystatin 100,000 unit/mL Suspension Five (5) ML PO QID PRN
thursh
-metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO BID
-polyethylene glycol 3350 17 gram/dose Powder 1 PO DAILY PRN
-acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for pain or fever: Max of 2g acetaminophen/day
-miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for rash.
-oxycodone 5 mg/5 mL Solution Sig: 2.5 mg PO Q8H (every 8 hours)
as needed for severe pain: Please try to limit narcotic use as
patient is easily made delerious with narcotics.
-albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
-ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H
(every 6 hours).
-prednisone 50 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24
hours) for 4 doses: Give on Days 2, 3, 4, and 5.
-enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q12H
(every 12 hours)
-Neupogen 480 mcg/0.8 mL Syringe Sig: One (1) Injection once
a day: Please start on Sunday ([**2115-1-6**]).
-TPN and Insulin as directed.
Followup Instructions:
Department: HEMATOLOGY/BMT
When: THURSDAY [**2115-1-10**] at 2:00 PM
With: [**First Name11 (Name Pattern1) 3750**] [**Last Name (NamePattern4) 3885**], NP [**Telephone/Fax (1) 3886**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2115-1-10**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3884**], MD [**Telephone/Fax (1) 3237**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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27,266
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47564
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Discharge summary
|
report
|
Admission Date: [**2198-11-22**] Discharge Date: [**2198-11-28**]
Date of Birth: [**2136-3-16**] Sex: F
Service: MEDICINE
Allergies:
Latex
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
Elective cardiac catheterization
Major Surgical or Invasive Procedure:
Cardiac Catheterization [**2198-11-22**]
R femoral artery pseudoaneurysm repair [**2198-11-23**]
IVC filter placement [**2198-11-25**]
History of Present Illness:
Ms. [**Known lastname 1924**] is a 62 year-old woman with a history of CAD s/p
NSTEMI in [**9-25**] who presented for catheterization on [**11-22**] and
who is now being transferred given worry for hematoma and
bleeding.
.
After NSTEMI in [**9-25**], she underwent cardiac catheterization
which a 90% stenosis of the LMCA and a 70% proximal RCA lesion.
On [**2197-10-20**] she underwent CABG x 3 with a LIMA to the LAD, SVG to
the OM and SVG to the RCA. Post operatively she had atrial
fibrillation and was started on Amiodarone. In addition she
developed a MRSA sternal wound
infection/high grade MRSA bacteremia and on [**2197-11-25**] she
underwent exploration of the sternal wound and sternal
debridement. Two days later she underwent sternal debridement
and bilateral pectoralis flaps.
.
Approximately 6 months prior to admission, she began to notice
that 4-5 minutes into her walks she would have to stop because
she was gasping for breath. She has also noticed similar
symptoms while doing her water aerobics, at times with
associated chest discomfort.
.
A stress test was done on [**2198-11-13**] and revealed apical ischemia
and septal hypokinesis with an LVEF of 61%. Given this, she was
referred for cardiac cath. On [**2198-11-22**] she underwent cath which
showed patent grafts. A POBA was done to the LAD.
.
Post-cath she had a failed mynx with pressure held. At
approximately 6pm, she moved her right leg and felt an acute
onset of groin pain. She was given a percocet, after which she
felt nauseated. After evaluation by the interventional fellow,
decision was made to transfer her to the CCU for observation.
.
On review of systems, she reports a history of prior [**Date Range **] in [**2182**]
at which time she experienced left facial numnbess/tingling. No
interventions were performed and this has not recurred. Also
reports bleeding after a tubal ligation when she was 25
year-old. She denies any deep venous thrombosis, pulmonary
embolism.
.
She has chronic joint pains, mostly in her knees and elbows.
Denies any hemoptysis, black stools or red stools. She denies
recent fevers, chills or rigors. She denies exertional buttock
or calf pain. Reports 20 pound weight gain over last 3 months;
for this she was evaluated for hypothyroidism and started on
replacement. All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS:
(-)Diabetes
(+)Dyslipidemia
(-)Hypertension
.
2. CARDIAC HISTORY:
-CABG ([**2197-10-20**]): LIMA -> LAD; SVG -> OM1; SVG -> RCA
-PCI ([**2197-10-17**]): LMCA 90% lesion -- no interventions
-PACING/ICD: None
.
3. OTHER PAST MEDICAL HISTORY:
- Remote [**Month/Day/Year **]
- History of MRSA/bacteremia requiring debridement/flap
- Chronic mid sternal chest pain related to prior chest
surgeries
- GERD
- Hypothyroidism
- Anxiety/Depression
- Arthritis
- Recurrent small bowel obstructions due to adhesions requiring
multiple surgeries
- History of TAH/BSO
- History of Laminectomy
- History of Resection of pilonidal cyst
- History of Cholecystectomy
- History of Hernia repair
Social History:
- Married with four children.
- Lives with: husband and daughter in [**Name (NI) **]
- Occupation: retired; previously worked as a secretary in a
[**Location (un) 86**] school
- ETOH: Several glasses of wine per night
- Tobacco: Quit in [**2196**] after 50 pack-years
Family History:
Brother had CABG in his 40??????s. Father had a stroke at age 58.
Physical Exam:
VS: BP=110/57 HR=80s RR=16 O2 sat=99% on room air
GENERAL: Lying in bed 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.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
Prior sternal wound noted but well-healed.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft. Is TTP over right groin with extension into lower
pelvis and to midline.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Pertinent Results:
Laboratory studies:
[**2198-11-22**] 06:44PM BLOOD Hct-34.9* Plt Ct-240
[**2198-11-23**] 03:07AM BLOOD WBC-5.7 RBC-3.32* Hgb-10.3* Hct-29.5*
MCV-89 MCH-31.1 MCHC-35.1* RDW-12.8 Plt Ct-224
[**2198-11-23**] 11:24PM BLOOD WBC-6.1 RBC-2.78* Hgb-8.7* Hct-25.1*
MCV-90 MCH-31.4 MCHC-34.8 RDW-13.5 Plt Ct-162
[**2198-11-25**] 04:21AM BLOOD WBC-4.7 RBC-2.41*# Hgb-7.4*# Hct-21.5*
MCV-90 MCH-30.8 MCHC-34.4 RDW-13.8 Plt Ct-170
[**2198-11-26**] 10:06AM BLOOD WBC-5.9 RBC-3.57*# Hgb-11.3*# Hct-30.7*
MCV-86 MCH-31.6 MCHC-36.7* RDW-14.7 Plt Ct-165
[**2198-11-28**] 07:30AM BLOOD WBC-5.4 RBC-3.67* Hgb-11.4* Hct-32.1*
MCV-87 MCH-31.0 MCHC-35.5* RDW-14.6 Plt Ct-255
.
[**2198-11-23**] 03:07AM BLOOD PT-12.4 PTT-23.9 INR(PT)-1.0
[**2198-11-25**] 04:21AM BLOOD PT-13.1 PTT-58.2* INR(PT)-1.1
.
[**2198-11-23**] 03:07AM BLOOD Glucose-105 UreaN-14 Creat-0.7 Na-139
K-4.0 Cl-107 HCO3-26 AnGap-10
[**2198-11-28**] 07:30AM BLOOD Glucose-101 UreaN-12 Creat-0.6 Na-139
K-4.1 Cl-104 HCO3-26 AnGap-13
[**2198-11-24**] 08:14AM BLOOD Glucose-62* UreaN-10 Creat-0.5 Na-138
K-3.7 Cl-106 HCO3-25 AnGap-11
.
[**2198-11-23**] 03:07AM BLOOD Calcium-8.0* Phos-3.7 Mg-1.9
[**2198-11-23**] 11:24PM BLOOD Calcium-6.7* Phos-1.8*# Mg-1.5*
[**2198-11-28**] 07:30AM BLOOD Calcium-8.6 Phos-2.7 Mg-1.7
[**2198-11-24**] 08:14AM BLOOD Albumin-3.3* Calcium-7.3* Phos-2.2*
Mg-1.8
.
[**2198-11-22**] 06:44PM BLOOD CK(CPK)-61
.
[**2198-11-28**] 06:21AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005
[**2198-11-28**] 06:21AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
Microbiology:
Nasal MRSA screen negative; BCx pending at time of discharge.
Imaging/Studies:
Cardiac Catheterization [**11-22**]:
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Patent LIMA and SVG's.
3. Moderate left ventricular diastolic dysfunction.
4. Moderate systemic arterial hypertension.
5. Successful POBA to the distal LAD (immediately post
anastomosis) via
LIMA.
6. Failed attempt to delived a Mynx closure device to the RCFA.
.
ECG [**11-22**]-
Sinus bradycardia. Baseline artifact. Non-specific anterior T
wave changes.
Compared to tracing #1 artifact is new.
TRACING #2
Read by: [**Last Name (LF) 2889**],[**First Name3 (LF) 2890**] K.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
54 158 86 446/435 69 -4 88
.
CT pelvis/abdomen [**11-22**]:
.
IMPRESSION: Moderately large hematoma centered primarily
anterior to the
bladder, likely with a predominantly intraperitoneal location,
also extending
into and expanding the right rectus sheath.
.
ECG [**11-23**]:
Sinus rhythm. Anterolateral ST-T wave changes. Consider
myocardial ischemia.
Compared to tracing #2 the ST-T wave changes are more pronounced
and the
baseline artifact is absent.
TRACING #3
Read by: [**Last Name (LF) 2889**],[**First Name3 (LF) 2890**] K.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
62 146 88 [**Telephone/Fax (2) 100535**]12
.
[**11-23**] CT abdomen/pelvis:
.
MPRESSION: Compared to the study done one day earlier, there has
been some
improvement in the size of the hematoma within the space of
Retzius no new
suspicious areas identified i.e., no findings to explain this
patient's
continued hematocrit drop.
.
Vascular u/s [**11-23**]:
IMPRESSION:
1. 2.2-cm pseudoaneurysm of the right common femoral artery at
the site of
puncture. Neck difficult to measure but thought to be very small
on the order
of [**1-21**] mm.
2. Right common femoral vein thrombosed near the site of
puncture.
.
U/S LE [**11-24**]:
IMPRESSION:
1. Focal thrombosis of the right common femoral vein as
identified on US from
[**2198-11-23**].
2. No left leg DVT.
.
CT abdomen/pelvis [**11-25**]:
IMPRESSION: Slight interval increase in size of a hematoma in
the space of
Retzius associated with a femoral vascular catheter, with
increased
retroperitoneal component and extension into the right inguinal
region.
.
ECG:
.
Sinus rhythm. ST-T wave abnormalities with predominantly T wave
inversions
in the anterolateral leads. Since the previous tracing of
[**2198-11-24**] atrial
premature beat is no longer present.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
74 150 92 396/420 -7 -5 158
Brief Hospital Course:
62 year old woman with known CAD, s/p CABG for severe LM
disease, complicated by a MRSA sternal wound
infection/bacteremia, who presented for an elective cardiac
catheterization (due to recent exertional symptoms and an
abnormal ETT) and eventually transferred to the CCU given
concern for post-catheterization bleeding.
.
# HEMATOMA. A failure of the mynx device to deploy during
closure s/p cath occured. The sheath was reportedly pulled w/o
complications. Post procedure HCT was found to drop from 34 to
29 and a CT pelvis was performed, a 6cm x
8cm pelvic hematoma with no RPB. Patient was thus transferred
to CCU for further care. HCTs were checked Q4H. Pt received 2U
PRBCs and there was no improvement in HCT. A repeat CT showed
no change. Given no response to transfusion and worsening groin
pain, in consultation w/ vascular team, it was agreed that
exploration of the groin was appropriate. An U/S of R femoral
A/V was performed showing 2.2-cm pseudoaneurysm of the right
common femoral artery near the site of
puncture for catheterization as well as suspicion for a R
femoral vein DVT. Plavix was stopped. A pseudoaneurysm repair
was performed on [**11-23**], successfully. A Right femoral DVT was
confirmed w/ LENI and heparin gtt was started. With this, HCT
began to drop, minimum of 21. A repeat CT showed slight
interval increase in size of a hematoma with increased
retroperitoneal component and extension into the right inguinal
region. At this time a decision with vascular, CCU teams and
patient was made to place an IVC filter and d/c heparin. IVC
filter was placed on [**11-25**] and heparin was d/c. Patient received
an additional 4 units of blood over next 48hours. HCT
eventually stabilized at ~ 30 and patient did not require
further transfusions. She remained relatively hemodynamically
stable througout this time, with minimum BPs reaching 85mmHg
systolic temporarily during dropping HCTs. Episodes of
hypotension were asymptomatic. BBK at this time was held.
Patient was maintained at bedrest until [**11-27**]. Hematoma was
stabilized w/ above management and HCT at time of discharge was
32.
.
# CAD: Known 3VD with prior CABG. After ETT showed apical
ischemia and a hypokinetic septum, performed for progressive
dyspnea, underwent cardiac cath which showed three vessel
coronary artery disease, patent LIMA and SVG's, moderate left
ventricular diastolic dysfunction and moderate PAH. She
underwent POBA to distal LAD. See above for failed mynx device
closure complications. She was continued on ASA. BBk was
temporarily withheld during episodes of hypotension. Plavix was
discontinued as pt. did not have a stent in place and had
developed a hematoma. Simvastatin was continued. She was
discharged home on ASA, Simvastatin and metoprolol 25mg [**Hospital1 **].
These doses should be optimized by outpatient cardiologist upon
follow up. Patient did not have chest pain, SOB or other angina
equivalent throughout hospitalization.
# CHF: EF of 60% on MIBI done last month, 40-50% on Echo from
[**2196**]. Pt. was not in HF throughout hospital stay.
.
# HYPOTHYRODISIM. Pt. was continued on home regimen of
Levothyroxine.
.
FEN/PPx. Pt. received cardiac diet, pain managment with tylenol
PRN and a bowel regimen.
.
CODE: Confirmed as DNR/DNI; discussed with patient at time of
transfer
Patient was discharged home in a hemodynamically stable
condition, w/ stable HCT and appropriate followup.
Contact person upon discharge: [**Name (NI) **] [**Name (NI) 1924**] (husband):
[**Telephone/Fax (1) 100536**]
Medications on Admission:
1. Aspirin 81mg daily
2. Simvastatin 40mg daily
3. Metoprolol Succinate 100mg daily
4. Levothyroxine 25mcg daily
5. Fosamax 70mg every Monday
6. Omeprazole 20mg daily
7. Colace 100mg daily
8. MVI
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week:
Every Monday.
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Lactulose 10 gram/15 mL Solution Sig: Thirty (30) ml PO once
a day as needed for constipation: as needed
.
Disp:*2 bottles* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Coronary artery disease
2. R femoral artery pseudoanerysm
3. R common femoral vein DVT
4. R groin hematoma
5. Retroperitoneal Bleed
Secondary Diagnoses
6. Hypothyroidism
7. Depression
8. Hypercholesterolemia
9. GERD
10. Osteoporosis
Discharge Condition:
Afebrile, hemodynamically stable, hematocrit stable
Discharge Instructions:
You were admitted to the hospital for cardiac catheterization.
After the catheterization you had a hematoma of the right groin.
A pseudoaneurysm was seen in the right femoral artery as well
as a blood clot in the common femoral vein. You were put on
heparin to thin your blood. You had the pseudoaneurysm repaired
on [**2198-11-23**]. You had continued bleeding after this surgery and
were found to have bleeding into your thigh and abdomen. You
required 6 units of blood in total. You had an IVC filter
placed on [**2198-11-25**] to prevent the blood clot from traveling into
your lungs. The heparin was stopped and you had no further
bleeding and blood counts were stable.
You should follow-up with your cardiologist and PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 10543**] in
the next 1-2 weeks. You should also follow up with Dr. [**Last Name (STitle) 1391**]
as listed below.
You should return to the hospital or seek medical attention with
any fevers > 101.4, chills, night sweats, chest pains, shortness
of breath, fast breathing or heart rate, sudden onset of
dizziness or weakness, arm or jaw numbness, abdominal pain,
bleeding in your bowel movements, increased pain, swelling or
discoloration of your right thigh or groin, or any other
symptoms that concern you.
Followup Instructions:
You should follow-up with your PCP and cardiologist, Dr. [**Last Name (STitle) 10543**]
in the next week.
Please follow up with Dr. [**Last Name (STitle) 1391**], your surgeon, on [**12-3**], 9am at [**Doctor First Name **], suite 5C in [**Last Name (un) 2577**] Building at
[**Hospital1 18**], [**2197**] for staple removal and evaluation of wound. Please
call ([**Telephone/Fax (1) 4852**] with any question.
Completed by:[**2198-11-30**]
|
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4,846
| 154,439
|
20165
|
Discharge summary
|
report
|
Admission Date: [**2111-10-5**] Discharge Date: [**2111-10-13**]
Date of Birth: [**2089-11-22**] Sex: M
Service: CSU
HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This 21-year-old male was
originally seen by the cardiac surgery team on [**2111-8-11**].
He had a known history of presenting to the __________
Emergency Room on the morning of [**2111-8-11**] complaining of
shortness of breath, headache and chest pain. He was
transferred to [**Hospital1 69**]
immediately for treatment. Echocardiogram in the emergency
room revealed 4 plus mitral regurgitation with a flail
leaflet and ejection fraction of 25 percent. In [**2111-10-21**], the patient had a gastrointestinal workup for rectal
bleeding. A heart murmur was noted at that time. He was
referred to his primary care physician for followup, but it
is unclear whether or not he did follow up. In [**2111-10-21**], he had an increase in cough. His chest x-ray revealed
cardiomegaly. Echocardiogram reportedly by Dr. [**Last Name (STitle) **] was
"abnormal," and the patient was referred to Dr. [**Last Name (STitle) 32622**] at
[**Hospital6 54206**]. The patient had not yet made
an appointment when he presented today on [**2111-8-11**]. He was
referred for evaluation of mitral valve replacement by Dr. [**Last Name (Prefixes) **].
PAST MEDICAL HISTORY: Rectal fissure 10 months ago.
Status post tonsillectomy.
Weight loss of 10 pounds in the past few months.
Multiple dental procedures over the past year.
SOCIAL HISTORY: He smoked one-half to one full pack per day
times two years, but quit two months ago. He admits to 3-4
beers per month and denied any recreational drugs. He is a
student currently at [**State 1558**] in [**Location (un) 86**].
He lives in [**Hospital1 **] with his mother.
MEDICATIONS AT HOME: Include albuterol inhaler p.r.n., but
since admission the patient was started on Lopressor,
captopril and digoxin.
ALLERGIES: No known allergies.
His electrocardiogram showed normal sinus rhythm with a left
bundle branch block. His chest x-ray showed no pulmonary
edema, but cardiomegaly. Echocardiography results as noted
prior. Cardiac catheterization performed on [**2111-8-12**]
showed an ejection fraction of 40 percent, anterobasal,
anterolateral, inferior and posterobasal hypokinesis, 4 plus
mitral regurgitation, normal coronaries, noted a cardiac
index of 3.2.
The patient was seen again for update examination on
[**2111-9-29**]. He was started on lisinopril in the interim
period between [**2111-8-11**] and being seen again on [**2111-9-29**].
PHYSICAL EXAMINATION: On examination, he was 6 feet 1 inches
tall, 140 pounds. Blood pressure 112/51. Pulse 78.
Respiratory rate 16. Sating 100 percent on room air. He
appeared not to be in any apparent distress and appeared to
be his stated age. He was alert and oriented times three.
His cranial nerves II-XII were grossly intact with no focal
deficits. His extraocular muscles were intact. His pupils
were equally, round and reactive to light and accommodation.
His neck was supple without any thyromegaly or
lymphadenopathy. He had no carotid bruits auscultated. His
heart was regular in rate and rhythm with an S1, S2 and a
grade [**3-26**] holosystolic murmur throughout his precordium. His
abdomen was soft, nontender and nondistended with positive
bowel sounds. His lungs were clear bilaterally without any
rhonchi or rales. His extremities were warm with no
cyanosis, clubbing, edema or varicosities. He had 2 plus
bilateral dorsalis pedis, posterior tibial, femoral and
radial pulses.
Hi[**Last Name (STitle) 54207**]trocardiogram showed 72 in sinus rhythm with left
axis deviation and intraventricular conduction defect. The
plan was the patient would come back in on [**2111-10-5**] for a
mitral valve repair versus placement with a tissue valve if
mitral valve repair was needed with Dr. [**Last Name (Prefixes) **].
Preoperative laboratories: White count 5.3. Hematocrit
41.6. Platelet count 197,000. PT 12.8. PTT 31.3. INR 1.0.
Urinalysis was negative. Glucose 68. BUN 16. Creatinine
0.8. Sodium 138. Potassium 4.4. Chloride 97. Bicarb 30.
Anion gap 12. ALT 44. AST 35. Alkaline phosphatase 58.
Total bilirubin 0.9. Total protein 7.7. Albumin 4.8.
Globulin 2.9. HB-A1C 4.9 percent.
Repeat preoperative chest x-ray on [**2111-9-29**] showed a normal
examination. Please refer to the final report dated
[**2111-9-29**].
Th[**Last Name (STitle) 1050**] was also seen on the day of admission,
[**2111-10-5**], by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7625**] from cardiac surgery prior
to his operation. On [**2111-10-5**], the patient underwent
mitral valve repair with a 30 mm [**Last Name (un) 3843**]-[**Doctor Last Name **] [**Doctor Last Name 405**]
Annuloplasty Band by Dr. [**Last Name (Prefixes) **]. He was transferred to
the Cardiothoracic Intensive Care Unit on a dopamine drop
with 5.0 mcg/kg per minute, Levophed drip 0.1 mcg/kg per
minute, Neo-Synephrine drip at 0.5 mcg/kg per minute,
propofol drip at 30 mcg/kg per minute and a vasopressin drip
at 0.04 units per minute.
On postoperative day one, the patient had a blood pressure of
98/47 and a heart rate of 79 in sinus rhythm, sating 97
percent with a cardiac index of 4.12. He was on a Levophed
drip at 0.035 mcg/kg per minute and a vasopressin drip at
0.04.
Postoperative laboratories: White count 13.6. Hematocrit
31.5. Platelet count 124,000. Potassium 4.5. BUN 7.
Creatinine 0.5. Blood sugar 102.
His incisions were clean, dry and intact. Chest tubes
remained in place. Cortisol level was sent off. Cardiology
consultation was requested. He was receiving intravenous
morphine for pain management. He was a-paced overnight at a
rate of 86. The patient still required Levophed over the
course of the first day. He had an initial patient
assessment done by Case Management.
On[**Last Name (STitle) 14810**]perative day two, his Levophed was weaned to off. He
remained on vasopressin drip at 0.04. He started his
aspirin. His hematocrit remained stable at 25.4 with a white
count of 9.6 and a creatinine of 0.6. His right IJ Cordis
and Swan remained in place. His heart was regular in rhythm.
His examination was otherwise unremarkable. His lungs were
clear with plans to pull his Swan-Ganz later in the day. A
diuresis was held at the time as was heparin as his platelet
count dropped. HIT screen was sent off. Platelet count
dropped to 80,000. Chest tubes were discontinued. The
patient was also seen by Dr. [**Last Name (STitle) **] from the [**Location (un) 86**] Adult
Congenital Heart Group at [**Hospital3 1810**]. The patient
remained on vasopressin at the time for his low SVR. An
endocrine consultation was also called requested by Dr. [**Last Name (Prefixes) **] for the patient's hyponatremia to rule out an Addison
crisis. They recommended that the patient probably had a
SIADH related to his pain and thoracic surgery as well as
some mild congestive heart failure and possible adrenal
insufficiency. Please refer to the endocrine consultation
note. The patient was also seen by Dr. [**Last Name (STitle) 54208**] from the
endocrine service. When patient's sodium on the 17th dropped
to 120 from 133 and 125, additional studies were done per
endocrine, and their recommendations were followed.
On postoperative day three, the sodium was increasing too
rapidly; so, the patient received a dose of GDAVP. Sodium
rose from 120-134. Hematocrit remained stable at 24.1 with a
normal white count. The patient was on no drips at the time.
Followup sodiums were done every four hours. Foley was
discontinued. The patient was seen again by the Bach
[**Hospital1 **] Group and daily by the endocrine attending.
The patient was also evaluated by physical therapy and
screened for his nutrition risks by the clinical nutrition
team on postoperative day four. He had no events over night
and continued on his aspirin. His creatinine remained stable
as did his white count and hematocrit. His sodium rose
slightly to 137. His sodium was stable. His examination was
unremarkable. His diet was advanced, and he continued to do
well. Central venous line was discontinued, and the patient
was transferred up to the floor. He was in sinus rhythm at
88 with a blood pressure of 107/51 off all pressor support.
Platelet count remained low on the 19th at 92,000.
Recommendations were evaluated by CT surgery, and endocrine
signed off on his care with recommendations to re-consult if
necessary. The patient was also seen by the staff
cardiologist in the [**Hospital1 **] Group. Dr. [**Last Name (STitle) 32622**]
recommended again aggressive pulmonary toilet, Ace inhibitor
and beta blockade, possible anticoagulation and eventual
Aldactone. The patient had a discussion with Dr. [**Last Name (STitle) 32622**]
about his need for cardiology followup. The patient was
transferred out to the floor on the 19th. Overnight, the
patient had some complaints of difficulty swallowing and
nasal congestion, and a nasal spray was ordered. Accupril
was increased. The patient remained in sinus rhythm, but
refused the Roxicet Elixir for pain management. He ambulated
three times during the day. His third walk showed much
improvement. He had no complaints of dizziness. He was also
started on his Niferex, vitamin C and folic acid and
continued to work with physical therapy daily. The patient's
pills were crushed in Jello. The following day, a swallowing
study was ordered to determine whether or not the patient was
at risk for aspiration.
On postoperative day five, he had some tachycardia while
ambulating, but in sinus rhythm in the 120s. Otherwise, he
had no events. He maintained a good blood pressure at 124/70
with an unremarkable examination with trace peripheral edema,
and incisions were clean, dry and intact. His ACE inhibitor
was increased with a goal of supraventricular tachycardia of
approximately 90. Foley remained in place with plans to
remove it the following day. The patient was seen again by
Dr.[**Name (NI) 54209**] service. Repeat labs were ordered on the
morning of the 20th. The patient declined HIV testing, and
the thiamine level was not available at the time of the note.
Stool was sent off for C. difficile. The patient also
continued to work with the incentive spirometer. Please
refer to Dr. [**Last Name (STitle) 54210**] note from [**Hospital3 1810**].
On postoperative day six, the patient voided without his
Foley and had no events over night. His examination was
unremarkable. His blood pressure monitoring continued. He
continued to work with physical therapy. A videoscopic
swallowing study was ordered for the 23rd. Bach cardiology
recommendations were appreciated and followed.
On postoperative day seven, his captopril was changed to
lisinopril. Toprol XL was added in. His white count was
stable at 5.2 with a hematocrit of 25.4 and a stable
creatinine at 0.9. Platelet count remained low at 88,000.
He was sating 96 percent on room air with a blood pressure of
90/50 in sinus rhythm at 82. Speech and swallowing
evaluation was done. Please refer to the final report dated
[**2111-10-12**]. Initial evaluation recommended a suggested diet
of thinned pureed foods and thin liquids until then with
medications crushed in applesauce. He had no difficulty
swallowing liquids. He was also screened by clinical
nutrition again. Videoscopic swallowing evaluation was
performed on [**2111-10-13**] in the morning. No aspiration
occurred during the examination. Please refer to the final
report. On the 23rd, the patient was discharged to home in
stable condition.
Di[**Last Name (STitle) **]e platelet count was 85,000 with a hematocrit of
28.7. The patient was given the instructions for the
following followup appointments. He was instructed to call
Dr. [**Last Name (STitle) 32622**] at [**Hospital3 1810**] for a followup
appointment in four weeks ([**Telephone/Fax (1) 54211**]. He was also
instructed to followup with his primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], in [**12-23**] weeks postoperatively ([**Telephone/Fax (1) 54212**]
and to followup with Dr. [**Last Name (Prefixes) **] in the office at one
month post discharge for his postoperative surgical visit
([**Telephone/Fax (1) 1504**].
DISCHARGE DIAGNOSES: Status post mitral valve repair.
Rectal fissure.
Status post tonsillectomy.
Congestive heart failure.
DISCHARGE MEDICATIONS:
1. Aspirin 81 mg enteric-coated p.o. once daily.
2. Percocet 5/325 one tablet p.o. p.r.n. every four hours for
pain.
3. Polysaccharide Iron Complex 150 mg p.o. once daily.
4. Vitamin C 500 mg p.o. twice daily.
5. Lisinopril 10 mg p.o. twice a day.
6. carvedilol 3.125 mg p.o. twice a day.
7. Colace 100 mg p.o. twice a day.
The patient was discharged to home in stable condition on
[**2111-10-13**].
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2111-10-27**] 11:31:03
T: [**2111-10-27**] 12:21:31
Job#: [**Job Number 54213**]
|
[
"E932.5",
"458.29",
"398.91",
"394.1",
"287.5",
"785.0",
"425.4",
"276.1",
"787.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.12"
] |
icd9pcs
|
[
[
[]
]
] |
12484, 12590
|
12613, 13272
|
1822, 2588
|
2611, 12462
|
1353, 1507
|
1524, 1800
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,749
| 101,735
|
24710
|
Discharge summary
|
report
|
Admission Date: [**2132-4-22**] Discharge Date: [**2132-5-2**]
Date of Birth: [**2090-7-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 552**]
Chief Complaint:
Dyspnea and hypoxia following resection of left renal mass
Major Surgical or Invasive Procedure:
L nephrectomy
Bronchoscopy
History of Present Illness:
This is a 41 year old man with a PMH significant for Factor V
Leiden mutation, who is now POD2 s/p resection of a left renal
mass, who had episodes of oxygen desaturation on the floor and
for whom a CT showed likely mucus plugging. He was transferred
to the [**Hospital Unit Name 153**] for planned bronchoscopy by the interventional
pulmonology service.
.
He originally presented with back pain and in the process of
workup for this got an MRI which incidentally showed a 2 cm left
renal mass. A CT scan confirmed the presence of the mass. He
came to Dr. [**Last Name (STitle) **] for urological follow-up, who scheduled and,
on [**4-22**], performed an open partial nephrectomy to resect the
mass. This included chest tube placement in the left; the chest
tube was pulled [**4-23**]. At midnight [**Date range (1) 62333**], he had a trigger on
the floor for hypoxia and fever, with temp 102.2 and O2
saturation of 87% on 3.5L NC. This increased to 92% with 5L NC
and use of an incentive spirometer. At that time, the covering
MD noted that he was "asymptomatic" without SOB, CP, dyspnea,
N/V, chills, or calf pain. An ABG at that time was 7.38/52/74 on
5L NC.
.
A PE protocol CT chest was ordered stat, and a provisional read
showed "Small left pneumothorax... [and] obstructive atelecatsis
of the left lower lobe and right middle and lower lobe due to
fillings of the lower lobe bronchi, most likely mucous plug."
.
An EKG done around that time appears to show diffuse T-wave
flattening compared to his earlier pre-op EKG but otherwise
without diagnostic focal changes.
.
On the floor today, he continued to be febrile for much of the
day, with Tmax of 102.8 at 1415; he continued to require oxygen
support of 5L NC with 40% facemask for much of the day, with
oxygen saturations in the mid 90s to this. He was also
tachycardic to the 110s-120s for most of the day.
Past Medical History:
Lower extremity DVT in [**2127**], diagnosed with heterozygous Factor
V Leiden mutation; on coumadin, followed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2805**]
Right leg vein stripping for varicose veins, [**2128**]
Essential tremor
Social History:
Professor [**First Name (Titles) **] [**Last Name (Titles) 20367**] at [**University/College **]. Married. Quit smoking
in [**2120**], was light smoker before then. 3 glasses of
alcohol/month. Denies recreational or IV drug use.
Family History:
Mother and sister with factor V Leiden mutation; sister w past
DVT
Physical Exam:
General Appearance: Well nourished, No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), ([**Year (4 digits) **] Sounds:
Bronchial: , Rhonchorous: diffusely)
Abdominal: Soft, Bowel sounds present
Extremities: Right: Absent, Left: Absent
Skin: Not assessed
Neurologic: Attentive, Responds to: Not assessed, Oriented (to):
x3, Movement: Not assessed, Tone: Not assessed
Pertinent Results:
[**2132-4-22**] 06:09PM GLUCOSE-131* UREA N-10 CREAT-1.3* SODIUM-142
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-24 ANION GAP-17
[**2132-4-22**] 06:09PM estGFR-Using this
[**2132-4-22**] 06:09PM MAGNESIUM-1.8
[**2132-4-22**] 06:09PM WBC-14.3*# RBC-4.64 HGB-13.8* HCT-39.9*
MCV-86 MCH-29.6 MCHC-34.5 RDW-13.9
[**2132-4-22**] 06:09PM PLT COUNT-157
[**2132-4-22**] 06:09PM PT-16.6* PTT-22.0 INR(PT)-1.5*
[**2132-4-22**] 11:45AM PT-16.6* PTT-29.3 INR(PT)-1.5*
[**2132-4-28**] 06:05AM BLOOD WBC-8.9 RBC-3.39* Hgb-10.1* Hct-29.8*
MCV-88 MCH-29.9 MCHC-34.1 RDW-13.8 Plt Ct-191
[**2132-4-27**] 04:30AM BLOOD WBC-11.6*# RBC-3.61* Hgb-10.8* Hct-31.9*
MCV-88 MCH-29.7 MCHC-33.7 RDW-13.7 Plt Ct-157
[**2132-4-28**] 06:05AM BLOOD Neuts-82.0* Lymphs-10.2* Monos-5.3
Eos-2.3 Baso-0.1
[**2132-4-28**] 06:05AM BLOOD PT-27.8* PTT-38.2* INR(PT)-2.8*
[**2132-4-27**] 05:10PM BLOOD PT-41.8* PTT-51.5* INR(PT)-4.6*
[**2132-4-27**] 04:30AM BLOOD Plt Ct-157
[**2132-4-27**] 04:30AM BLOOD PT-35.1* PTT-41.8* INR(PT)-3.7*
[**2132-4-26**] 03:28AM BLOOD Plt Ct-154
[**2132-4-28**] 06:05AM BLOOD Glucose-103 UreaN-14 Creat-1.3* Na-141
K-3.1* Cl-104 HCO3-28 AnGap-12
[**2132-4-27**] 05:10PM BLOOD Na-139 K-4.1 Cl-103
[**2132-4-27**] 04:30AM BLOOD Glucose-103 UreaN-16 Creat-1.4* Na-134
K-3.9 Cl-101 HCO3-23 AnGap-14
[**2132-4-26**] 03:28AM BLOOD Glucose-95 UreaN-14 Creat-1.3* Na-141
K-3.9 Cl-102 HCO3-29 AnGap-14
[**2132-4-25**] 04:32AM BLOOD ALT-26 AST-40 AlkPhos-64 Amylase-84
TotBili-1.0
[**2132-4-28**] 06:05AM BLOOD Calcium-7.9* Phos-2.4* Mg-2.3
[**2132-4-27**] 04:30AM BLOOD Calcium-8.0* Phos-2.1* Mg-2.0
[**2132-4-26**] 03:28AM BLOOD Calcium-8.0* Phos-2.0* Mg-2.0
[**2132-4-25**] 12:34PM BLOOD Type-ART pO2-67* pCO2-53* pH-7.40
calTCO2-34* Base XS-5
[**2132-4-25**] 05:54AM BLOOD Type-ART FiO2-100 O2 Flow-15 pO2-52*
pCO2-50* pH-7.42 calTCO2-34* Base XS-6 AADO2-630 REQ O2-100
Intubat-NOT INTUBA
CTA:
IMPRESSION:
1. Given a borderline suboptimal study, there is no pulmonary
embolism to the
segmental level.
2. Obstruction of the bronchus intermedius and all segmental
bronchi of the
left lower lobe, likely due to mucus plugging, causing complete
collapse of
the middle lobe, right lower lobe, and almost all the left lower
lobe.
3. New dependent opacities in the left upper lobe, lingula and
less in the
right upper lobe, could be due to aspiration.
4. Left thyroid hypodensity, should be evaluated by ultrasound
if not already
known.
5. Extensive post-operative changes of left partial nephrectomy.
6. Small left pneumothorax.
Echo
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve leaflets are structurally normal. No mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is a small pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal global and regional
leftventricular systolic function. Mild left ventricular
hypertrophy. Right ventricle could not be adequately assessed.
Brief Hospital Course:
41 yo M w PMHx of Factor V leiden mutation and DVT, L renal mass
sp partial L nephrectomy w post-op complications of fever,
hypoxia
.
#. Hypoxia - [**12-31**] to multiple etiologies. Initially thought to be
due to mucus plugging but the due to aspiration vs
hospital-acquired pneumonia with ?component of fluid overload.
Pt needed to be on bipap w high oxygen requirement which was
been weaned down to RA. Pt continues to do well on RA. is sp 7
day course of IV Vanc/Zosyn for HAP.
.
#. Cdiff colitis - continue oral vancomycin. Will tx for 2 weeks
p last abx dose. Low grade temps likely to resolving cdiff
colitis. Pt reports that diarrhea is getting better.
.
#. Hx of L renal mass sp partial nephrectomy - Urology
following. Wound site looks good. Path report from nephrectomy
shows angiomyolipoma, no cancer. Outpt FU w Dr. [**Last Name (STitle) **] at dc
next thursday
.
#. Hx of Factor V Leiden mutation and DVT - seen by heme preop
and coumadin w goal INR of [**12-31**].5 4-6 weeks post op. His INR was
supratherapeutic in ICU, so coumadin was held and vitamin K
given, Coumadin restarted at low dose. INR on day of dc was 1.9.
Discussed w primary hematologist and dc on coumadin alone at 2mg
MWF and 1mg T,T, Sat, [**Doctor First Name **] dose and INR check on monday
.
#. Anemia - likely from post-op blood loss.remained stable
throughout hospital stay around 30-31.
.
#. R flank discomfort - At one point pt complained of R flank
pain, likely MSK but was resolved at dc. UA only showed 13 RBC,
not concerning for renal stone. pain resolved on its own
.
# ?CKD- Baseline Cr ~1.2, given young age, nl for pt his age. Cr
flucutated but remained around 1.3 at dc.
.
.
Medications on Admission:
Home medications:
Warfarin 5 mg daily
Advil 600 mg prn ("occasionally")
Propranolol 20mg, prn ("very occasional" per pre-op med list)
for palpitations before presentations
Fish oil
MVI
.
Transfer medications:
cefazolin 2 g IV q8h
acetaminophen 650 pr q4H: prn fever
maalox 15-30 po qid:prn heartburn
dilaudid PCA 0.25 mg lockout 6 mins, basal 0, 1 hr max 2.5 mg
ondansetron 4 mg IV q4H: prn nausea
docusate sodium 100 mg po BID
diphenhydramine 25-50 mg q6h: prn pruritus or insomnia
Discharge Medications:
1. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 14 days.
Disp:*56 Capsule(s)* Refills:*0*
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
3. Warfarin 2 mg Tablet Sig: use as directed below Tablet PO
once a day: take 2mg (1tab) on M, W, F and 1mg on tues, thurs,
sat, sun ([**11-30**] tab).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
-SP L partial nephrectomy for renal mass - confirmed to be
angiomyolipoma
-Healthcare assoicated pneumonia
-C diff colitis
Discharge Condition:
Good
Discharge Instructions:
-You were admitted to the hospital for partial removal of Left
kidney due to a mass, which turned out not be cancer. After
surgery you developed complications of mucus plugging and
pneumonia. You also developed an infection of your bowel called
C diff colitis. You finished the course of IV antibiotics for
the pneumonia. You will need to take 2 additional weeks of oral
vancomycin for the Cdiff colitis. If at the end of the oral
antibiotic course you are still having diarrehea, abdominal pain
or fevers, you need to let your doctor know as you may need
additional antibiotics.
You have hx of factor V leiden mutation which makes you
vulnerable to form blood clots especially around surgery, so per
your hematologist, you have been placed on coumadin which will
be continued for about 4-6 weeks after your surgery. Please
follow up with them regarding INR checks and coumadin adjustment
Please call your doctor right away or return to ED for fevers,
chills, abdominal pain, chest pain, shortness of [**Last Name (LF) 1440**], [**First Name3 (LF) 691**]
concerning signs of infection at the incision site, worsening
diarrhea
Followup Instructions:
1. Urology, Provider: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. Phone:[**Telephone/Fax (1) 277**]
Date/Time:[**2132-5-8**] 3:30
2. PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 14477**], ph: [**Telephone/Fax (1) 25302**], Appt is on Tuesday, [**5-6**], 9:00 AM
3. Hematology, RN [**Doctor Last Name 9449**], ph: [**0-0-**]. Come to [**Hospital Ward Name 23**] 9,
have blood drawn for INR check and [**Doctor Last Name 9449**] will call you with
results
|
[
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"E878.8",
"008.45",
"E915",
"289.81",
"518.5",
"997.39",
"512.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"55.4"
] |
icd9pcs
|
[
[
[]
]
] |
9632, 9638
|
6975, 8652
|
372, 401
|
9805, 9812
|
3623, 6952
|
10986, 11534
|
2842, 2910
|
9187, 9609
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9659, 9784
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8678, 8678
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9836, 10963
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2925, 3604
|
8696, 8866
|
274, 334
|
8888, 9164
|
429, 2299
|
2321, 2580
|
2596, 2826
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,396
| 154,189
|
56129
|
Discharge summary
|
addendum
|
Name: [**Known lastname 6016**],[**Known firstname **] M Unit No: [**Numeric Identifier 6017**]
Admission Date: [**2108-12-9**] Discharge Date: [**2108-12-19**]
Date of Birth: [**2028-10-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1999**]
Addendum:
see below note
Chief Complaint:
The patient is an 80-year-old
male who presented to the ER today with the acute onset of
upper back pain that occurred during an episode of retching.
In brief, the patient
was eating a large [**Country 6018**] dinner this dinner. After finishing
his meal, he had 1 episode of vomiting at home. This episode
of vomiting was then followed by severe and unremitting back
pain. Given the concern for esophageal perforation, the patient
was
administered oral Gastrografin and the CT scan of the chest
was repeated. This study showed free extravasation of oral
contrast into the left pleural space, which was felt to be
consistent with Boerhaave syndrome.
Major Surgical or Invasive Procedure:
right thoracotomy for primary repair of esophageal perforation.
feeding jejunostomy and gastric tube
History of Present Illness:
In brief, the patient was eating a large [**Country 6018**] dinner this
dinner. After finishing his meal, he had 1 episode of vomiting
at home. This episode
of vomiting was then followed by severe and unremitting back
pain. Given the concern for esophageal perforation, the patient
was administered oral Gastrografin and the CT scan of the chest
was repeated. This study showed free extravasation of oral
contrast into the left pleural space, which was felt to be
consistent with Boerhaave syndrome.
Past Medical History:
Bradycardia s/p DDD
Colectomy for colon cancer 20 years ago
Treated for non operatively for small-bowel obstruction.
Social History:
Has 9 supportive daughters
Family History:
non-contributory
Physical Exam:
general: awake, alert and conversant,
Heent: unremarkable
chest: healing left thoracotomy incision. Chest tube sites x2
healing. JP drain site intact w/o erythema or draiange.
COR: RRR S1, S2
Abdomen : soft, round, NT, +BS. J_tube and G-tubes are intact
w/o erythema or drainge. Awell healed midline laparotomy scar
is noted.
extrem: no C/C/E
Pertinent Results:
BAS [**2108-12-17**]
Water soluable Conray contrast followed by thin barium was
administered orally. Multiple swallows in multiple projections
demonstrates contrast passing freely through the esophagus into
the stomach without evidence of holdup or extravasation.
IMPRESSION: No evidence of obstruction or contrast
extravasation.
CHEST (PA & LAT) [**2108-12-18**] 1:47 PM
FINDINGS: In comparison with the previous examination, the left
side of two chest tubes has been withdrawn. A small left-sided
pneumothorax with a gap width of [**2-4**] mm is seen. No depression
of the left-sided hemidiaphragm. All other radiographic changes
are unmodified.
IMPRESSION: Very small apical left-sided pneumothorax after
withdrawal of the two chest tubes. Otherwise unchanged.
[**2108-12-9**] WBC-9.5# RBC-3.93* Hgb-13.3* Hct-39.1 Plt Ct-271
[**2108-12-19**] WBC-5.9 RBC-2.94* Hgb-9.4* Hct-29.6 Plt Ct-407#
[**2108-12-9**] Glucose-192* UreaN-25* Creat-1.4* Na-138 K-3.9 Cl-102
HCO3-23
[**2108-12-18**] Glucose-144* UreaN-21* Creat-0.8 Na-143 K-3.6 Cl-106
HCO3-30
Brief Hospital Course:
Patient presented to the ER w/ abdominal pain after retching,
was diagnosed w/ esophageal perforation and was taken directly
to the OR for primary repair via left thoracotomy and then 4
days later for placement of feeding j-tube and G-tube. Two left
sided chest tubes and one JP drain were placed for drainage at
the time of the initial surgery. Due to soilage of the pleural
space the patient was placed on broad spectrum IV antibiotics
which were stopped on POD#8. Postoperatively the patient
remained intubated was admitted to the ICU for hemodynamic
monitoring and pulmonary management. In the initial post-op
period the patient required IVF to maintain hemodynamic
stability. He was extubated on POD#1 w/o difficulty. He had and
epidural for pain control, which was weaned to PCA then PO
Roxicet w/ good pain control.
Pt progressed well post operatively. The chest tubes were
d/removed on POD #8 w/ stable CXR. He was tolerated his TF at
goal of 90cc/he, passing stool and flatus and tolerated a clear
liquid diet. On telemetry on his SJ pacer showed evidence of
atrial undersensing and pacemaker induced tachycardia. The EP
service was consulted and they changed the atrial sensitivity to
0.3 mv, increased the PR-amp to 375 msec, decreased the AV delay
to 180 msec and turned on the auto detect mode of PMT. They
recommended he follow-up with his cardiologist in 1 week for
pacer interrogation. He also was found to have brief episodes of
atrial fibrillation and to increase his aspirin to 325 mg once
daily. He continued to work with physical therapy who
recommended home PT and was discharged on POD#9. He will
follow-up with Dr. [**First Name (STitle) **] as an outpatient.
Medications on Admission:
synthroid .1, digoxin .25, protonix 40, ASA 81, colace,
metamucil, dapson 50 (rash)
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mls PO BID (2
times a day).
Disp:*600 mls* Refills:*1*
2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
Disp:*480 ML(s)* Refills:*0*
3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO once a
day.
4. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO once a day.
5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
6. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 42**] VNA
Discharge Diagnosis:
GERD, bradycardia s/p pacer, hypothyroid, h/o SBO, colon CA
PSH: R colectomy
esophageal perforation with primary repair
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Name (NI) 6019**] office [**Telephone/Fax (1) 1477**] if you develop chest pain,
shortness of breath, fever, chills, productive cough, difficulty
swallowing, nausea, vomiting, abdominal pain, or any concerns
you may have.
You may shower on Friday. After showering, remove your chest
tube site dressings and cover the area with a clean bandaid
daily until healed.
No tub bathing or swimming for 4 weeks.
Continue to only take a clear liquid diet at home ( liquids you
can see through).
Take your tube feeds as directed through the jejunostomy feeding
tube. Flush the gastric tube daily with 50cc water otherwise
keep the gastric tube clamped.
If your feeding tube sutures become loose or break, please tape
tube securely and call the office [**Telephone/Fax (1) 1477**]. If your feeding
tube falls out, save the tube, call the office immediately
[**Telephone/Fax (1) 1477**]. The tube needs to be replaced in a timely manner
because the tract will close within a few hours.
Do not put any medication down the tube unless they are in
liquid form.
Flush your jejunostomy feeding tube with 50cc with water every 8
hours and before and after every feeding.
Staple removal when seen by Dr, [**Name (NI) **]
Followup Instructions:
You have a follow up appointment with Dr. [**First Name (STitle) **] on [**2109-1-3**]
9:30am on the [**Hospital Ward Name **] [**Hospital **] medical center [**Location (un) **].
Please arrive 45 minutes prior to your appointment for a chest
xray on the [**Location (un) **] radiology.
Follow-up with your cardiologist in 1 week for device
interrogation
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2000**] MD [**MD Number(2) 2001**]
Completed by:[**2108-12-19**]
|
[
"568.0",
"530.4",
"244.9",
"V10.05",
"530.81",
"511.9",
"427.31",
"V45.01",
"512.8",
"518.0",
"V45.72"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"54.59",
"43.19",
"96.6",
"42.89",
"46.39",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
5864, 5921
|
3428, 5119
|
1117, 1220
|
6086, 6093
|
2349, 3405
|
7355, 7871
|
1952, 1970
|
5253, 5841
|
5942, 6065
|
5145, 5230
|
6117, 7332
|
1985, 2330
|
426, 1079
|
1248, 1751
|
1773, 1892
|
1908, 1936
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,235
| 174,515
|
4437+55578
|
Discharge summary
|
report+addendum
|
Admission Date: [**2160-10-28**] Discharge Date: [**2160-11-2**]
Date of Birth: [**2114-10-13**] Sex: M
Service: [**Hospital Unit Name 196**]
HISTORY OF PRESENT ILLNESS: Patient is a 46-year-old male
with a complicated cardiac history including coronary artery
disease status post CABG x2 ([**2139**], [**2152**]), pericardial
constriction status post stripping, diastolic dysfunction,
stable angina (patient no longer an operative candidate per
Cardiothoracic Surgery). Patient also with history of
diabetes mellitus type 1, hypercholesterolemia, chronic renal
insufficiency, and chronic pleural effusion, who is admitted
to the [**Hospital Unit Name 196**] service on [**2160-10-28**] in decompensated heart
failure.
Patient complained of progressive shortness of breath and
pedal edema as well as an approximately 11 pound weight gain
over the past 2-3 weeks. While on the floor, diuresis was
attempted with Lasix and nesiritide, but patient's heart
failure was refractory to treatment, in addition he had
worsening renal failure and became hypotensive. He was
subsequently transferred to the CCU for PA catheterization
and further evaluation of hemodynamics/tailored CHF therapy.
Upon transfer, the patient denied complaints of chest pain,
shortness of breath, nausea, vomiting, abdominal pain,
lightheadedness, or dizziness, fever or chills.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post CABG '[**39**] with SVG to
LAD and D1 and CABG in '[**52**] with SVG to RCA, and pericardial
stripping secondary to constrictive pericarditis.
Catheterization [**1-20**] reveals 100% LAD lesion with
unsuccessful PTCA attempt, patent D1 and a subtotal D2.
Small [**Last Name (LF) 8714**], [**First Name3 (LF) **]-2 subtotally occluded status post PTCA with no
stent, SVG to RCA patent, and SVG to LAD/D1 totally occluded
proximally. Patient with collateral perfusion of LAD
territory. Catheterization [**1-20**] also revealed constrictive
physiology with RA approximately equal to PCWP approximately
20 mm Hg.
2. Chronic renal insufficiency, baseline creatinine of
1.4-1.8.
3. Diabetes mellitus type 1 complicated by retinopathy and
nephropathy.
4. CVA secondary to prior CABG.
5. Seizure disorder secondary to CVA.
6. Hyperlipidemia.
7. Gastritis.
8. PVD status post right toe amputation and right fem bypass.
9. Stable angina.
10. Chronic anemia.
HOME MEDICATIONS:
1. Imdur 90 q.d.
2. Lasix 160 q.a.m., 80 q.p.m.
3. Tegretol 300 t.i.d.
4. Zestril 10 q.d.
5. Lopressor 100 b.i.d.
6. Aspirin 325.
7. Protonix 40 q.d.
8. Lantus 20 q.a.m., 18 units q.p.m.
9. Humalog sliding scale.
10. Fluvoxamine 12.5 b.i.d.
11. Lipitor 10 q.d.
12. NTGSL prn, patient takes approximately one q.o.d.
ALLERGIES: Penicillin results in hives.
SOCIAL HISTORY: Patient lives with parents. No tobacco,
EtOH, or drugs. Currently on disability secondary to stroke.
FAMILY HISTORY: Dad with "[**Last Name **] problem", diabetes mellitus.
PHYSICAL EXAMINATION: Temperature 97.7, heart rate 93, blood
pressure 88/60, breathing 18, and satting 97% on room air.
General: Patient is alert, comfortable, and pleasant in no
acute distress. HEENT: Moist mucous membranes. Oropharynx
clear. Cardiovascular: Regular, rate, and rhythm, positive
S3, JVD difficult to assess. Lungs: Trace rales bilaterally
at bases. Abdomen: Positive bowel sounds, soft, nontender,
obese. Extremities: 3+ pitting edema bilaterally. Dorsalis
pedis 1+ bilaterally.
DATA: Chem-7: Sodium 117, potassium 4.7, chloride 83,
bicarb 25, BUN 60, creatinine 2.0. CBC: 8.3/28.8/421.
ECG: Normal sinus rhythm, normal intervals, normal axis,
flat T waves, no ST changes.
Echocardiogram: [**10-28**] EF 60%, E/A ratio 1.57, no evidence of
effusion or constriction, trivial MR.
HOSPITAL COURSE:
1. CHF: Patient was transferred to the CCU and had a PA
catheter placed without complication. Initial Swan numbers
revealed the following: CVP 22, PA 64/33, PCWP 30, CO/CI
equals 6.4/2.8, CR 475.
Given patient's etiology for hypotensive on the floor was
unclear and he was found to have elevated wedge pressure. He
was started on nesiritide drip, which he initially tolerated
well. Dopamine was added to increase renal perfusion and
enhance diuresis, however, patient became tachycardic and
experienced anginal symptoms which resolved upon
discontinuing dopamine. Patient's blood pressure remained
stable and given that his heart failure was secondary to
diastolic dysfunction, his beta blocker was titrated back on
board and increased as tolerated, as it was felt that slowing
his heart rate, increasing his filling time would improve his
cardiac function. Additionally, Lasix drip was added for
further diuresis. Patient's dry weight per family was noted
to be 205 pounds.
2. Coronary artery disease: Patient remained chest pain free
throughout stay except for episode of chest pain associated
with dopamine drip. He is known to have native LAD and SVG
to LAD occlusion with perfusion via collaterals. He is not
an operative candidate for CT surgery given substantial
mortality associated with third redo CABG, and patient with
longstanding diabetes. He was continued on aspirin, beta
blocker, and statin, Imdur, and prn NPG.
3. Hyponatremia: Etiology felt related to either SIADH
secondary to his SSRI or Tegretol or CHF. Urine electrolytes
were more consistent with SIADH picture, however, patient was
hypervolemic and urine electrolytes can be confounded in the
setting of diuretic therapy. Tegretol was felt to be an
unlikely etiology as this patient had been on this medication
for many years with no prior history of hyponatremia. His
SSRI was felt to be more a likely potential etiology. Thus a
psych consult was obtained for help with an appropriate
alternative if any.
Patient's sodium improved slowly over the course of his stay
with 1000 cc fluid restriction.
4. Renal: Patient with chronic renal insufficiency and
initially elevated creatinine. Once transferred to the CCU,
the patient's creatinine initially declined and then remained
stable at prior baseline value of even in the setting of
continued diuresis. Urinalysis was sent which was negative
for any evidence of ATN contributing to his renal disease.
5. Anemia: Patient required several transfusions while
in-house. He had no evidence of active bleeding, was guaiac
negative, and additionally had no evidence of hemolysis.
Iron studies were consistent with anemia of chronic disease
most likely secondary to longstanding renal failure.
6. Diabetes mellitus: Patient was initially maintained on
his home insulin regimen, however, his p.m. lantus had to be
decreased while in-house secondary to low fingersticks in the
a.m.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2160-11-2**] 16:51
T: [**2160-11-4**] 13:49
JOB#: [**Job Number 19055**]
Name: [**Known lastname 539**],[**Known firstname **] M Unit No: [**Unit Number 3100**]
Admission Date: [**2160-10-28**] Discharge Date: [**2160-11-7**]
Date of Birth: Sex:
Service:
SUMMARY OF HOSPITAL COURSE:
1. Congestive heart failure: The patient diuresed
approximately five liters over his hospital stay, possibly
more. He was only mildly fluid overloaded on the day of
discharge and was started on Zaroxolyn, in addition to his
home regimen of Lasix, by the time of discharge, and he is to
follow-up with a [**Hospital 3101**] clinic where they will likely DC the
Zaroxolyn.
2. Anemia: The patient did require transfusions in the
beginning of his admission, however, his hematocrit remained
stable. He was guaiac negative. Most likely, he has anemia
of chronic disease and Epogen should be considered on an
outpatient basis. There were no alterations to his previous
discharge summary.
DISCHARGE DIAGNOSES:
1. CHF exacerbation, acute on chronic.
2. Diabetes mellitus.
3. Anemia of chronic disease.
INSTRUCTIONS: The patient was instructed to weigh himself
every morning and to call if his weight is greater than three
pounds. Adhere to a 2 gram sodium diet and restrict his
fluid to one liter per day.
FOLLOW-UP: He is to follow-up with his primary care doctor,
Dr. [**Last Name (STitle) **], in one week. He is, also, to follow-up with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1313**] in the CHF service on [**11-28**]. To follow-up with
Dr. [**Last Name (STitle) 86**], Cardiology. He is to call to schedule an
appointment.
CONDITION ON DISCHARGE: Stable. The patient was diuresed 20
pounds during this admission. His ejection fraction is 55%.
DISCHARGE MEDICATIONS:
1. Isosorbide mononitrate SR, 90 mg PO q d.
2. Carbamazepine, 300 mg PO t.i.d.
3. Aspirin, 325, one PO q d.
4. Protonix, 40 mg PO q d.
5. Fluvoxamine, 12.5 mg PO b.i.d.
6. Lipitor, 10 mg PO q d.
7. Colace, 100 mg PO b.i.d.
8. Senna, one tablet PO b.i.d.
9. Lisinopril, 2.5 mg PO q d.
10. Lasix, 160 mg PO q a.m. and 80 mg PO q p.m.
11. Metoprolol, 75 mg PO b.i.d.
12. Glargine, 20 units in the morning and 10 units at night.
13. Zaroxolyn, 5 mg PO q d.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 297**], M.D. [**MD Number(1) 298**]
Dictated By:[**Last Name (NamePattern1) 3102**]
MEDQUIST36
D: [**2161-1-14**] 17:40
T: [**2161-1-14**] 19:46
JOB#: [**Job Number 3103**]
|
[
"458.29",
"780.39",
"285.29",
"253.6",
"511.9",
"413.9",
"250.41",
"428.0",
"414.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.13",
"89.68",
"99.04",
"89.64"
] |
icd9pcs
|
[
[
[]
]
] |
2897, 2954
|
7922, 8578
|
8725, 9465
|
3790, 7181
|
2401, 2759
|
7209, 7901
|
2977, 3773
|
188, 1371
|
1393, 2383
|
2776, 2880
|
8603, 8702
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,640
| 152,772
|
19883
|
Discharge summary
|
report
|
Admission Date: [**2126-2-22**] Discharge Date: [**2126-3-1**]
Date of Birth: [**2069-2-7**] Sex: M
Service: .
HISTORY OF PRESENT ILLNESS: This 57 year old white male has
known severe three vessel coronary artery disease. He was
scheduled to have a coronary artery bypass graft but missed
his appointment and presented to an outside hospital with
shortness of breath. His troponin were mildly elevated but
his CK were negative. His troponin elevation could have been
due to heart failure rather than acute ischemia. He
developed the gradual onset of shortness of breath the day
prior to admission which was not relieved with Lasix. He was
admitted to the outside hospital and started on heparin and
Integrilin and intravenous Nitroglycerin and was transferred
to the [**Hospital1 69**].
PAST MEDICAL HISTORY:
1. Significant for a history of coronary artery disease
status post myocardial infarction in [**2113**].
2. History of cardiomyopathy with an ejection fraction of
35%.
3. He had a positive stress test.
4. History of hypertension.
5. History of diabetes mellitus.
6. History of gastroesophageal reflux disease.
7. Status post deviated septum surgery.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg p.o. q. day.
2. Diovan 200 mg p.o. q. day.
3. Zantac 150 mg p.o. p.r.n.
4. Actos 30 mg p.o. q. day.
5. Lasix 40 mg p.o. p.r.n.
6. Nitroglycerin p.r.n.
7. Multivitamin p.r.n.
ALLERGIES: Question of an allergy to Lopressor and Imdur.
FAMILY HISTORY: Significant for coronary artery disease.
SOCIAL HISTORY: He lives alone; does not drink alcohol,
does not smoke cigarettes.
REVIEW OF SYSTEMS: His review of systems is unremarkable.
PHYSICAL EXAMINATION: On physical examination, he is a well
developed, well nourished white male in no apparent distress.
Vital signs are stable. He is afebrile. HEENT examination
normocephalic, atraumatic. Extraocular movements intact.
Oropharynx benign. Neck was supple with full range of motion
and no lymphadenopathy or thyromegaly. Carotids two plus and
equal bilaterally without bruits. Lungs had crackles half
the way up bilaterally. Cardiovascular examination with
regular rate and rhythm, normal S1 and S2 with no rubs,
murmurs or gallops. Abdomen was obese, soft, nontender, with
positive bowel sounds. No masses or hepatosplenomegaly.
Extremities were without cyanosis, clubbing or edema.
Neurological examination was non-focal.
LABORATORY: His cardiac catheterization of [**2125-11-27**]
revealed an 70% ostial left anterior descending lesion and
80% diffuse left circumflex lesion, 80% obtuse marginal 2
lesion; the right coronary artery had severe diffuse disease.
The ejection fraction was 30% with global hypokinesis and
apical akinesis.
Dr. [**Last Name (STitle) 1537**] was consulted and on [**2-22**], the patient underwent a
coronary artery bypass graft times four with left internal
mammary artery to the left anterior descending, reversed
saphenous vein graft to the diagonal, obtuse marginal and
patent ductus arteriosus. The patient tolerated the
procedure well and was transferred to the Surgical Intensive
Care Unit. He had some hypotension and he was transferred to
the CSRU on vasopressin and Neo-synephrine. The vasopressin
was weaned off the postoperative night and he was extubated
on postoperative day number one.
The Neo-Synephrine was weaned off on postoperative day number
two. His chest tubes were discontinued and he required
aggressive diuresis and pulmonary toilet. His creatinine
increased up to 1.7 on postoperative day number three. He
was also seen by [**Last Name (un) **] as he had elevated blood sugars and
remained on a drip. They felt that he should be started on
NPH 70/30 and Humalog sliding scale which he was.
On postoperative day four, he went into atrial fibrillation.
He was converted to sinus with amiodarone and Lopressor. He
transferred to the floor on postoperative day number four and
continued to improve. His creatinine did continue to
increase and had a peak of 2.6 but came back down to 2.0 and
then 2.2 on discharge.
Renal was following him and recommended discontinuing his
Lasix and on postoperative day number seven he was discharged
home in stable condition.
His labs on discharge are hematocrit of 28.5, white blood
cell count of 11.4, platelets 339,000. Sodium 131, potassium
4.9, chloride 97, carbon dioxide 23, BUN 82, creatinine 2.2,
blood sugar 109.
DISCHARGE MEDICATIONS:
1. Colace 100 mg p.o. twice a day.
2. Aspirin 325 mg p.o. q. day.
3. Percocet one to two p.o. q. four to six hours p.r.n.
4. Plavix 75 mg ;p.o. q. day.
5. Atenolol 12.5 mg p.o. twice a day.
6. Insulin 70/30, 40 units subcutaneously q. a.m. and 20
units subcutaneously q. p.m.
7. Humalog sliding scale.
DISCHARGE INSTRUCTIONS:
1. He will be followed by Dr. [**Last Name (STitle) **] in one to two weeks.
2. He will be followed by Dr. [**Last Name (STitle) 1537**] in four weeks.
3. Follow-up with [**Last Name (un) **] in one week.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Insulin dependent diabetes mellitus.
3. Atrial fibrillation.
4. Renal insufficiency.
[**Known firstname 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 6516**]
MEDQUIST36
D: [**2126-3-1**] 17:11
T: [**2126-3-1**] 19:46
JOB#: [**Job Number 53708**]
|
[
"414.01",
"593.9",
"427.31",
"458.29",
"410.81",
"250.01",
"412",
"E878.2",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"88.72",
"36.13",
"36.15",
"99.20"
] |
icd9pcs
|
[
[
[]
]
] |
1501, 1543
|
5030, 5417
|
4466, 4776
|
1222, 1483
|
4800, 5009
|
1713, 4443
|
1649, 1689
|
162, 816
|
838, 1196
|
1561, 1629
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,975
| 179,377
|
19974
|
Discharge summary
|
report
|
Admission Date: [**2178-7-6**] Discharge Date: [**2178-7-13**]
Date of Birth: [**2099-9-16**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Confusion, hypoxia, fever
Major Surgical or Invasive Procedure:
Intubation
Central line placement
A-line placement
Fecal disimpaction
History of Present Illness:
78 y/o male with Parkinson's, HTN, chronic lower back pain
secondary to spinal stenosis presents with one week of
obstipation, nausea/vomiting, anorexia, two days of increasing
confusion. According to the family, five days prior to
admission he began to be nauseated and vomited and over the next
few days was noted to be extremely constipated (non-compliant
with bowel regimen [**Name6 (MD) **] [**Name8 (MD) **] RN). He ate little and continued to
vomit occasionally. Three nights prior to admission he became
confused and this progressively worsened and he became weaker.
Two night prior to admission he was found to have a new oxygen
requirement and this increased over the next day, and he became
febrile.
In the ED, he was febrile to 102, hypotensive, tachypneic, and
confused and was intubated as his respiratory status continued
to decline. He was loaded with 6L IVF and was transiently on a
norepinephrine drip. Additionally in the ED he was noted to be
hyperkalemic with K+6.0 and peaked T-waves on ECG that resolved
with insulin +D50 and calcium gluconate Surgery was consulted
for possible small bowel obstruction. Evaluation revealed
severe fecal impaction, but no SBO. He was started empirically
on Vanco/Levofloxacin/Flagyl.
Past Medical History:
[**Last Name (un) 3562**] disease
Hypertension
Chronic lower back pain
Chronic renal insufficiency (baseline creat 1.2-1.5)
CAD
h/o melanoma s/p resection 20yrs ago
Gerd
BPH
Social History:
Lives at [**Hospital 100**] Rehab with his wife. A former International
Relations professor. independent in most ADLs
Family History:
son and daughter have renal cysts
Physical Exam:
t 102.1, bp 94/42, hr 64, rr 30, spo2 88%
100% on AC 550 x24 FiO2 1.0 PEEP 12
GEN: intubated, sedated
HEENT: PERRL, MM dry, ETT in place
Neck: supple, no JVD
CV: RRR, no mrg
Resp: coarse breath sounds throughout, bilateral rhonchi, no
crackles
Abd: distended, pain to deep palpation, decreased BS with
increased pitch
Ext: no edema
Neuro: PERRL, responds to voice, moves all extremities
Pertinent Results:
[**2178-7-6**] 08:15AM PLT SMR-NORMAL PLT COUNT-154
[**2178-7-6**] 08:15AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2178-7-6**] 08:15AM NEUTS-72* BANDS-18* LYMPHS-5* MONOS-3 EOS-0
BASOS-2 ATYPS-0 METAS-0 MYELOS-0
[**2178-7-6**] 08:15AM WBC-9.0 RBC-3.70* HGB-11.7* HCT-34.6* MCV-93#
MCH-31.5# MCHC-33.7 RDW-13.8
[**2178-7-6**] 08:15AM CK-MB-7
[**2178-7-6**] 08:15AM cTropnT-0.10*
[**2178-7-6**] 08:15AM ALT(SGPT)-3 AST(SGOT)-25 CK(CPK)-579* ALK
PHOS-96 AMYLASE-165* TOT BILI-0.5
[**2178-7-6**] 08:15AM GLUCOSE-193* UREA N-117* CREAT-6.7*#
SODIUM-129* POTASSIUM-6.0* CHLORIDE-96 TOTAL CO2-21* ANION
GAP-18
[**2178-7-6**] 08:29AM LACTATE-1.5
[**2178-7-6**] 08:45AM URINE RBC-[**2-7**]* WBC-0-2 BACTERIA-0 YEAST-RARE
EPI-0
[**2178-7-6**] 08:45AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-NEG
[**2178-7-6**] 08:45AM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2178-7-6**] 09:36AM K+-6.2*
[**2178-7-6**] 10:43AM LACTATE-1.8
[**2178-7-6**] 10:43AM TYPE-ART PO2-58* PCO2-42 PH-7.28* TOTAL
CO2-21 BASE XS-6
[**2178-7-6**] 12:00PM LACTATE-1.4 K+-5.0
.
Rads:
KUB [**7-6**]: IMPRESSION:
1) No definite evidence of obstruction.
2) Calcified renal cyst.
3) The upper abdomen including the hemidiaphragms were not
imaged. There is no free air seen in the portion of the abdomen
imaged.
.
CT Abd/Pelvis [**2178-7-6**]: IMPRESSION:
1) Dilated stool filled colon, particularly the rectosigmoid.
There is also apparent rectal wall thickening. The findings are
consistent with a fecal impaction.
2) Dense consolidation in both lower lobes which contain high
attenuation
material, suspicious for aspiration.
3) Extremely limited assessment of the abdomen due to
respiratory motion and beam hardening artifact from the
patient's arms.
4) Peripherally calcified cystic structure in the upper pole of
the right
kidney with Hounsfield units not consistent with a simple cyst.
This is
inadequately assessed without IV contrast. Further evaluation
with MRI could be considered. Two additional likely cysts in
the lower pole of the right kidney.
5) 7 mm non-obstructing right renal stone and tiny 1 mm
non-obstructing left renal stone.
.
Renal U/S: IMPRESSION:
1. No evidence of hydronephrosis on this limited exam.
.
CXR [**2178-7-12**] COMMENTS: Portable erect AP radiograph of the chest
is reviewed and compared with the previous study of [**2178-7-8**].
There is continued mild congestive heart failure with
cardiomegaly and small bilateral pleural effusion. There is
continued opacity in both lower lobes indicating aspiration
pneumonia. The patient has been extubated. The right jugular
IV catheter remains in place. The nasogastric tube terminates
in the gastric antrum. No pneumothorax is identified.
Brief Hospital Course:
78yo man with h/o CAD, HTN, Parkinson's Dz, chronic back pain
presented in sepsis, diagnosed with MRSA pneumonia and severe
fecal impaction. During his hospitalization the following
issues were addressed:
1. Sepsis: Sepsis was thought to be due to MRSA pneumonia vs
aspiration event in setting of partial small bowel obstruction
brought on by fecal impaction. He was treated with aggressive
iv fluids and required levophed initially to support blood
pressure. He was intubated for airway protection, and a right
subclavian central line was placed. Surgery service continued
to follow during the first few days of hospitalization but did
not feel he was obstructed causing his sepsis. He was treated
with Vancomycin for MRSA PNA ([**2178-7-13**] = day [**6-18**]). He also
completed a 7 day course of levofloxacin/metronidazole for
suspected GI source. Extubation was delayed due to copious
secretions; he was successfully extubated on [**2178-7-10**].
Additionally the patient failed the cortisol stimulation test
and was treated with hydrocortisone. This was discontinued on
day 5 as the patient was persistantly hypertensive at that time.
2. MRSA pneumonia: sputum grew MRSA. He was treated with
vancomycin and remained afebrile. Blood cultures were
nondiagnostic. He will complete this antibiotic course [**2178-7-20**].
Vancomycin was dosed according to level given his concurrent
renal failure. A trough shoudl be checked daily with goal
trough 15-20.
3. ARF: He presented with an acute renal failure on chronic
renal insufficiency. This was felt to be due to prerenal
etiology given his recent episodes of emesis and fever prior to
presentation. All nephrotoxic medications were held, and
creatine improved to near baseline with good urine output by the
time of discharge.
4. HTN: following extubation, the patient continued to be
hypertensive, requiring a nitroglycerin gtt for control. Oral
medications were titrated, and the gtt discontinued prior to
discharge. Goal SBP 140-150 was achieved on amlodipine 10mg
daily, Imdur 60mg daily, Metoprolol XL 50mg daily, and
Lisinopril 20mg daily. Lisinopril was restarted after
creatinine improved to baseline levels. Additionally,
hypertension improved with control of the patient's chronic
pain.
5. Hyperglycemia: patient was hyperglycemic in setting of
sepsis and with concurrent steroid use. He was treated with an
insulin gtt for tight glucose control. This was discontinued,
and he was placed on sliding scale prior to discharge. He was
not requiring supplemental insulin at the time of discharge.
6. Fecal impaction: The patient was severely impacted on
admission. He required repeated soap suds enemas and manual
disimpaction. He was discharged on a standing bowel regimen of
colace and senna consistent with his outpatient regimen. This
should be continued as long as he is on chronic narcotics.
7. Parkinson's disease: the patient's Sinemet was held on day
two for concern that it can cause ileus, leading to worsening
constipation and possible SBO. The dose was gradually titrated
back up in discussion with his outpatient neurologist. He was
on QID dosing at the time of discharge (home dose 6x/day).
8. FEN: While intubated he was on tubefeeds. Post-extubation
he had a bedside swallow exam which he passed. He was
tolerating a normal po diet at the time of discharge.
9. Health Maintenance: He was given pneumococcal vaccine.
9. Dispo: Patient was discharged to MACU. He is a full code.
Medications on Admission:
Atenolol 12.5mg daily
Sinamet 1 tab 6x/day
Neurontin 600mg daily
Zestril 40mg QAM, 10mg QPM
Zoloft 100mg daily
ASA 325mg daily
Colace 250mg daily
Finasteride 5mg daily
Imdur 15mg daily
Prevacid 30mg daily
Multivitamin daily
Nifedipine 60mg [**Hospital1 **]
Oxycodone SR 20mg [**Hospital1 **]
Senna 3tabs [**Hospital1 **]
Zocor 80mg daily
Tamsulosin 0.4mg daily
Tolterodine 4mg QHS
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
3. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
4. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
8. Imdur 60 mg Tablet Sustained Release 24HR Sig: One (1) Tablet
Sustained Release 24HR PO once a day.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
11. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
13. Vancomycin 500 mg Recon Soln Sig: 1000 (1000) mg Intravenous
Q 24H (Every 24 Hours) for 7 days.
14. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
15. Tolterodine Tartrate 4 mg Capsule, Sust. Release 24HR Sig:
One (1) Capsule, Sust. Release 24HR PO at bedtime.
16. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
17. Finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
Aspiration pneumonia
Sepsis
Altered Mental Status
Fecal impaction
Acute renal failure
Secondary:
Parkinson's disease
Hypertension
Chronic lower back pain
Discharge Condition:
Improved, oriented, stable off oxygen, with improving renal
function
Discharge Instructions:
Please return to the ED for fevers, shortness of breath,
vomiting, or other concerning symptoms.
Because of your medications you routine take, it is imperative
that you remain on the laxatives and stool softeners you have
been prescribed, taking them every day.
Followup Instructions:
Please see your primary care doctor in the next week. Call to
make an appointment.
Please see your neurologist in the next two weeks, call to make
an appointment.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"995.92",
"724.02",
"401.9",
"276.2",
"038.9",
"276.7",
"332.0",
"785.52",
"518.81",
"507.0",
"584.9",
"560.39",
"V10.82",
"482.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.6",
"38.91",
"96.04",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
10782, 10855
|
5360, 8858
|
297, 368
|
11052, 11122
|
2461, 5337
|
11433, 11727
|
1994, 2029
|
9290, 10759
|
10876, 11031
|
8884, 9267
|
11146, 11410
|
2044, 2442
|
232, 259
|
396, 1644
|
1666, 1841
|
1857, 1978
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,763
| 184,596
|
3208
|
Discharge summary
|
report
|
Admission Date: [**2203-10-19**] Discharge Date: [**2203-10-27**]
Date of Birth: [**2137-4-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ketorolac / Nalbuphine / Simvastatin / Atorvastatin / Crestor /
adhesive tape / Erythromycin Base / Green Pepper / Macrobid /
toridol
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
cough, frequent URI
Major Surgical or Invasive Procedure:
[**2203-10-19**]
Right thoracotomy, tracheoplasty with mesh,
right mainstem bronchus and bronchus intermedius
bronchoplasty with mesh, left mainstem bronchus bronchoplasty
with mesh, bronchoscopy with bronchoalveolar lavage.
History of Present Illness:
The patient is a 66-year-oldwoman who has severe, diffuse
tracheobronchomalacia with symptoms of cough, recurrent
infection and dyspnea. She underwent a stent trial and was
found to have a marked improvement in her symptomatology. She
was admitted to the hospital for tracheoplasty.
Past Medical History:
Aspiration of foregin object [**2200**] s/p intubation possibly c/b
tracheobroncheomalacia
1. Sarcoidosis
2. Diabetes
3. Hypertension
4. Hyperlipidemia
5. Pancreatic disease
- s/p cholecystectomy, [**2177**]
- s/p sphincterotomy, [**2177**]
- numerous ERCP
6. Chronic abdominal/back pain with history of detox
7. Osteoarthritis
8. Osteoporosis with compression fractures
9. Peptic ulcer disease
10. Gastroesophageal reflux disease
11. Depression
.
PAST SURGICAL HISTORY:
1. Appendectomy. [**2158**]
2. Right ankle pinning, [**2161**]
3. Total abdominal hysterectomy, [**2181**]
4. Kyphoplasy, [**2198**]
5. Rib fracture, thought secondary to coughing ([**1-5**])
6. Inguinal hernia repair
Social History:
No tobacco, drug use. Occasional alcohol use.
Lives in [**Location **] with her husband.
Family History:
Father: died of CVA
Mother: died of MI/COPD
Brother: died of MI (age 65)
Physical Exam:
Vital signs: HR 76 BP 142/69 RR 16 Oxygen saturation 100% RA
ADMIT 99.6,176/80, 15, 85, 94%3l
General Appearance: NAD, resting comfortably, audible gurgle.
Occasional non-productive cought
HEENT: MMM, O/P clear, sclera anicteric
Neck: trachea midline, no stridor, supple.
Chest: rhonchorus BS, with bibasilar diminunition. No crackles
Cardiovascular: reg rate, nl S1/S2, no MRG
Abdomen: soft, NT/ND, NABS, no HSM
Extremities: no CCE
Neurological: A&O x3,
Psychiatric: normal mood, no depression/anxiety
Skin: No rash, eruptions or erythema
Pertinent Results:
[**2203-10-19**] 08:39PM WBC-9.7# RBC-3.93* HGB-11.4* HCT-33.5* MCV-85
MCH-29.0 MCHC-34.1 RDW-13.3
[**2203-10-19**] 08:39PM PLT COUNT-210
[**2203-10-19**] 08:39PM GLUCOSE-264* UREA N-12 CREAT-0.4 SODIUM-132*
POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-21* ANION GAP-16
[**2203-10-24**] CXR :
1. Persistent but improved mild pulmonary edema compared to
prior study on
[**2203-10-23**].
2. Right pleural thickening or loculated effusion is stable.
Brief Hospital Course:
Mrs. [**Known lastname 15036**] was admitted to the hospital and taken to the
Operating Room where she underwent tracheoplasty via a right
thoracotomy. See formal op note for details. She tolerated the
procedure well and returned to the SICU in stable condition.
She was extubated and able to clear her airway but was closely
monitored in the ICU and received vigorous pulmonary toilet. She
had an epidural catheter which provided her adequate pain relief
and she improved after her chest tubes were removed. She was
briefly diuresed in the ICU as she had some marginal O2
saturations with fluid overload on her chest xray.
Following transfer to the Surgical floor her epidural was
removed and her pain control was poor. She had multiple
adjustments with her oral narcotics and improved on MS Contin
with Dilaudid for breakthrough and eventually Gabapentin. She
was able to ambulate and use her incentive spirometry but was
never completely able to wean from oxygen. Her room air
saturations decreased to 84% with ambulation but rebounded to
95% on 1 liter of oxygen. Her lungs had occasional scattered
wheezes on the right and clear breath sounds on the left. Her
legs were without ed ama. She remained on bronchodilators. She
will require home O2 for a short time as she recovers from her
surgery and increases her activity.
Her recent gastritis by EGD was stable as she remained on PPI's
and was tolerating a diabetic diet without difficulty. Her
biopsy's were negative (esoph/gastric) along with a negative
HPylori. She was having daily BM's as well.
She did have complaints of dysuria after her catheter was
removed and also had a positive urinalysis. She was treated
with 3 days of Cipro and eventually her culture grew > 100K
enterococcus. She remained afebrile with a normal WBC and will
have a repeat UC when she follows up with her PCP in [**Name Initial (PRE) **] week or
2.
Her blood sugars remained stable on her pre op dose on Lantus
and Metformin. She did have some hyponatremia and initially had
some salt tabs then was instructed to cut back on her water
intake. She will have follow up electrolytes when she sees her
PCP. [**Name10 (NameIs) **] was not taking Lasix routinely prior to her admission.
After a prolonged hospital stay she was discharged to home on
[**2203-10-27**] and will follow up in the Thoracic Clinic in 2 weeks.
Medications on Admission:
Citalopram 40', voltaren 1% gel'''', tricor 145', percocet
7.5-325 prn, insulin lispro, metformin 500'', nortriptyline
150', pravastatin 40', ramipril 10', VitD', B12', colace
ALL: crestor, erythromycin, green pepers, adhesive bandages,
simvastatin, atorvastatin, macrobid, nalbuphine
Discharge Medications:
1. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) puffs Inhalation four times a day as needed for shortness of
breath or wheezing.
Disp:*1 MDI* Refills:*1*
2. fenofibrate micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
3. nortriptyline 25 mg Capsule Sig: One [**Age over 90 1230**]y (150) mg
PO HS (at bedtime).
4. ramipril 5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily).
5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): on for
12 hours/off for 12 hours.
Disp:*10 Adhesive Patch, Medicated(s)* Refills:*2*
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
11. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q12H (every 12 hours).
Disp:*60 Tablet Extended Release(s)* Refills:*0*
12. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. 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:*2*
14. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for irritation.
15. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
Disp:*100 Capsule(s)* Refills:*2*
16. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
17. hydromorphone 2 mg Tablet Sig: 2-3 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*150 Tablet(s)* Refills:*0*
18. insulin glargine 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous at bedtime.
19. insulin regular human 100 unit/mL Solution Sig: 0-12 units
Injection four times a day as needed for per sliding scale.
20. Oxygen
Oxygen continuous at 1 liter a minute Please evaluate for
pulse.
( Room air saturations 84-85% )
Dx tracheobronchialmalacia
Discharge Disposition:
Home With Service
Facility:
VNA of Southern [**Location (un) 3844**]
Discharge Diagnosis:
Severe, diffuse tracheobronchomalacia.
UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, cough or chest pain
-Incision develops drainage or increase redness
Pain
-No driving while taking narcotics
-Take stool softners with narcotics and make sure that you stay
regular
-Try to decrease the Dilaudid as your pain improves either by
decreasing the amount or increasing the interval.
Activity
-Shower daily. Wash incision with mild soap & water, rinse, pat
dry
-No tub bathing, swimming or hot tubs until incision healed
-No lotions or creams to incision site
-Walk 4-5 times a day as tolerated.
Oxygen
-You will still need to wear oxygen at 1 liter a minute when
you're walking and also on an as needed basis.
-You will likely be able to wean it off in a week or 2.
-The VNA will help assess your respiratory status.
-Continue to use your incentive spirometer 10 times an hour
while awake.
Followup Instructions:
Call Dr. [**First Name (STitle) 1511**] for a follow up appointment in [**11-28**] weeks to
follow blood sugars, repeat a urine culture and follow
electrolytes
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2203-11-10**] at 2:00 PM
With: [**Name6 (MD) 1532**] [**Name8 (MD) 1533**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please report to the Radiology Department on the [**Location (un) **] of
the [**Hospital Ward Name 23**] Building for a chest xray 30 minutes prior to your
appointment.
Department: OTOLARYNGOLOGY-AUDIOLOGY
When: THURSDAY [**2203-12-22**] at 1 PM
With: [**Name6 (MD) 15040**] [**Last Name (NamePattern4) 15041**], MD [**Telephone/Fax (1) 41**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 895**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2203-10-27**]
|
[
"272.4",
"276.1",
"041.04",
"599.0",
"715.90",
"311",
"577.9",
"519.19",
"533.90",
"733.00",
"401.9",
"530.81",
"V13.51",
"250.00",
"135",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"33.48",
"31.79"
] |
icd9pcs
|
[
[
[]
]
] |
7900, 7971
|
2920, 5294
|
422, 649
|
8058, 8058
|
2448, 2897
|
9176, 10163
|
1798, 1872
|
5630, 7877
|
7992, 8037
|
5320, 5607
|
8209, 9153
|
1455, 1675
|
1887, 2429
|
363, 384
|
677, 962
|
8073, 8185
|
984, 1432
|
1691, 1782
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,223
| 191,292
|
52744
|
Discharge summary
|
report
|
Admission Date: [**2172-7-6**] Discharge Date: [**2172-7-9**]
Date of Birth: [**2105-4-12**] Sex: M
Service: NMED
Allergies:
Penicillins / Meperidine
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 67 year old man with a history of dementia,
depression, hypertension, and left CEA 3 weeks ago now
presenting
with an episode of shaking witnessed by sister and worrisome for
a seizure. As per the sister, on the day of admission to the
OSH, the patient was complaining of abdominal pain and went to
bed early. She checked on him later in the night and thought
him
to be restless in the bed, moving about and unable to sleep.
She checked on him again about an hour later and found him nude
in the now-urine soaked bed. His clothes were also soaked in
urine and on the floor next to the bed. Of note, the patient is
incontinent of urine and stool (less often) at baseline. As per
the sister, he only had one eye open and kept saying "turn it
on"
and "I want that barrel over there" while pointing to a chair in
the corner. A few moments later, he started grimacing, became
very stiff, then started shaking all four extremities in a
rhythmic fashion with clenched fists. At that point, the sister
called for an ambulance and the patient was brought to the OSH.
At the OSH, he was loaded with phenytoin, ativan, ceftriaxone
and
transferred to [**Hospital1 18**] for further management.
In our ED, the patient was febrile to 102.8, hypertensive to
214/136 and minimally responsive to painful stimuli. He was
started on a nitro drip for blood pressure control and
transferred to the MICU. There an LP was performed which showed
0 wbc, 0 rbc, 15% polys, 45% lymphs, 40% monos. He was started
on vanco and acyclovir. He was subsequently transferred to the
neurology service for further management.
Past Medical History:
NIDDM diet controlled
CAD
HTN
hypercholesterolemia
AAA
throat CA s/p resection/XRT
seizure disorder
depression
Parkinson's Dz
Social History:
worked as a security guard, lives with nephew and sister. walks
unaided. HCP [**Name (NI) **] [**Name (NI) 6955**] (nephew) [**Telephone/Fax (1) 108794**].
current smoker, 1 pack per day hx for "many years"
ETOH dependency, stopped 25 years ago
No drug use
Family History:
mother: intracranial bleed 72 yr old
Physical Exam:
Vitals: T=99.0 BP=114/60 P=98 R=18 SaO2=98%
General: Well nourished, in no acute distress
Neck: supple, carotid bruit on right
Lungs: decreased breath sounds at the bases
CV: rr, 2/6 systolic murmur
Abdomen: non-tender, non-distended, bowel sounds present
Ext: warm, no edema; good pulses
Neurologic Examination:
Mental Status: Awake and alert, cooperative with exam, normal
affect
Oriented to person, place, month but not president
Attention: Can say months of year forward and backward in 50 sec
Language: Fluent, no dysarthria, no paraphasic errors, naming
intact
Fund of knowledge normal
Registration: [**3-4**] items, Recall [**2-4**] items at 3 minutes with
prompting
No apraxia, No neglect
[**Location (un) **] intact
Cranial Nerves: Visual fields are full to confrontation. Pupils
equally
round and reactive to light, 4 to 2 mm bilaterally. Extraocular
movements intact, no nystagmus. Facial sensation and mild right
facial droop. Hearing intact to finger rub bilaterally. Tongue
midline, no fasciculations. Sternocleidomastoid and trapezius
normal
bilaterally.
Motor:
Normal bulk and tone bilaterally
No tremor.
D T B WF WE FiF [**Last Name (un) **] IP Gl Q H AF AE TF TE
Right 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Left 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Mild right pronator drift
Sensation was intact to Light touch, pin prick, temperature
(cold), vibration, and proprioception
Reflexes: B T Br Pa Pl
Right 2 2 2 2+ 1
Left 2 2 2 2+ 1
Grasp reflex absent
Plantar reflex was withdrawal
FNF slower on right, rapid alternating
movements slowed on right
Pertinent Results:
Cbc: 13.3>36.6<172
Inr: 1.2
Chem: 140/2.9 99/29 19/0.7 133
AST:23 ALT:13 AK:104 TB:1.1
C/M/P: 9.4/1.5/2.4
Cxr [**2172-7-7**]: bibasilar densities
Head MRI [**2172-7-6**]: (From OMR)
Severely limited examination due to motion artifact. Bilateral
white matter and cortical hyperintensities in the posterior
frontal and parietal regions with a more prominent area in the
left posterior temporal region. These are suspicious for
infarction occuring after [**2172-5-31**]. However, these areas appear
normal on the diffusion weighted images and thus do not
represent
acute infarction.
[**2172-7-5**] 11:50PM CEREBROSPINAL FLUID (CSF) PROTEIN-77*
GLUCOSE-138
[**2172-7-5**] 11:50PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-0 POLYS-15
LYMPHS-45 MONOS-40
Brief Hospital Course:
The patient was managed on the neurology service for his
possible seizure activity in the setting of a recent stroke. He
underwent an EEG on [**2172-7-8**] that showed abnormally slowed
background rhythms. He had a carotid ultrasound performed which
showed no significant stenosis as well on [**2172-7-8**]. Over the
course of his 3 day admission his neuro exam changed slightly in
that the weakness in his lower extremity improved slightly but
his memory impairments remained. He was discharged on day 4 in
stable condition.
Medications on Admission:
Protonix 40 QD
ASA 81 QD
Donepezil 15 QD
Lopressor 25 [**Hospital1 **]
Colase
Quetiapine 200 QD
Aricept 10 QD
Nardil 30/45
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).
2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO HS
(at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
3. Donepezil Hydrochloride 10 mg Tablet Sig: One (1) Tablet PO
HS (at bedtime).
4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO QD (once a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
7. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*2*
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
1. subacute stroke
2. seizure
Discharge Condition:
Stable, steady on feet.
Discharge Instructions:
Please return to nearest ER if symptoms of shaking, headache, or
visual disturbance occur. Please take medications as
prescribed.
Followup Instructions:
Provider: [**Name10 (NameIs) **] STUDY Where: CC CLINICAL CENTER RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2172-9-23**] 10:00
Please follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1007**] in
[**3-5**] weeks as needed.
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2172-8-22**]
|
[
"414.01",
"401.9",
"997.02",
"331.82",
"E878.8",
"507.0",
"294.11",
"311",
"780.39"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"88.49"
] |
icd9pcs
|
[
[
[]
]
] |
6591, 6640
|
4863, 5394
|
301, 307
|
6714, 6739
|
4081, 4840
|
6918, 7350
|
2399, 2438
|
5567, 6568
|
6661, 6693
|
5420, 5544
|
6763, 6895
|
2453, 2747
|
240, 263
|
335, 1957
|
3200, 4062
|
2786, 3184
|
2771, 2771
|
1979, 2107
|
2123, 2383
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,629
| 101,878
|
14481
|
Discharge summary
|
report
|
Admission Date: [**2112-7-6**] Discharge Date: [**2112-7-15**]
Date of Birth: [**2112-7-6**] Sex: M
HISTORY OF PRESENT ILLNESS: Baby boy [**Known lastname 10208**] was delivered at
37-6/7 weeks weighing 3010 g and was admitted to Neonatal
Intensive Care Unit from Labor and Delivery for respiratory
blood group, antibody negative, received RhoGAM at 20 and 28
weeks, hepatitis B surface antigen negative, rapid plasma reagin
nonreactive, Rubella immune, afebrile, with rupture of membranes
seven hours prior to delivery. She had chronic abruption
observed in house early in her pregnancy.
Spontaneous vaginal delivery . Apgar scores were 8 and 9. He
received blow-by oxygen only. He was transferred to the Newborn
episode in the newborn nursery at about 3 hours of life.
Measurements revealed birthweight 3010 g (which was the 50th
percentile), length of 50 cm (which was the 75th percentile), and
a head circumference of 33.5 (which was also the 50th
percentile).
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed a pale, pink, nondysmorphic male with palate intact.
Bilaterally equal breath sounds. No murmur. In respiratory
distress. The abdomen was soft and nontender with a 3-vessel
cord. No hepatosplenomegaly. Back and spine were normal.
Hips were stable. Red reflex was present. Anterior fontanel
was open and flat and molding of the head was also noted.
The child was placed on CPAP for respiratory support. He also
received a bolus of IV normal saline for poor perfusion.
HOSPITAL COURSE:
1. RESPIRATORY: Intubated after around 12 hours of
life and received one dose of surfactant for persistent
respiratory distress and oxygen requirement, self- extubated
within the next 12 hours and remained on CPAP since then. He was
taken off CPAP to nasal cannula on [**7-11**]. He remained
intermittently tachypneic and on nasal cannula oxygen until [**7-13**]. By [**7-14**] he was oxygenating well in room air except with
bottle feeding. Spent 24 hours nursing exclusively with no
desaturations prior to discharge.
2. CARDIOVASCULAR: No murmurs. No issues. Blood pressure
was stable.
3. FLUIDS/ELECTROLYTES/NUTRITION: He was initially started
on D-10-W at 60 cc/kilo per day, and the first set of
electrolytes were sodium of 143, potassium of 3.6, chloride
of 107, and bicarbonate of 22. Feedings advanced once
respiratory status stabilized. Difficulty oxygenating with
bottle feeds prior to discharge as noted above. Currently, he is
breast feeding ad lib; parents counseled re: feeding cues,
expected frequency/duration of feeds, signs of milk transfer.
Discharge weight 2835 g (4.5% below birthweight).
4. INFECTIOUS DISEASE: He received ampicillin and
gentamicin for seven days based on respiratory distress and
prolonged distress, presumed pneumonia. The complete blood count
showed a white blood cell count of 17.9 (73 neutrophils and 2
bands). Blood cultures remained negative.
5. GASTROINTESTINAL: He is on full feeds and tolerating
them. No abdominal distention. Blood sugar has been stable.
The initial bilirubin was 6/0.3 on day two, peaked at
15.8/0.9 on day five and responded well to phototherapy, down to
9.7/0.7 day six at which time lights were discontinued with a
rebound of 7.6/0.4 on day seven. His blood group was A negative,
and Coombs was negative.
6. NEUROLOGICAL: No issues.
7. HEMATOLOGY: His initial hematocrit was 51, and a
platelet count of 299. WBC diff as noted above. Pink and well
perfused at discharge.
8. GENITOURINARY: Underwent circumcision [**7-14**] with subsequent
suture placement by Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] for persistent bleeding a
few hours later. Wound/suture site is clear without sign of
infection or bleeding at discharge.
Passed hearing screen in both ears. Passed car seat test.
Received hepatitis B vaccine [**2112-7-14**]. State screen sent per
routine.
Discharged home in stable condition with parents, to follow up
with primary pediatrician Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3450**] in [**Location (un) **] on [**2112-7-16**] at
10am.
Discharge diagnoses:
1. Respiratory distress syndrome, resolved.
2. Presumed pneumonia, resolved.
3. Status post sepsis evaluation with negative blood cultures.
4. Exaggerated physiologic hyperbilirubinemia, resolved.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] 50-563
Dictated By:[**Name8 (MD) 42804**]
MEDQUIST36
D: [**2112-7-12**] 16:35
T: [**2112-7-12**] 16:39
JOB#: [**Job Number 42805**]
|
[
"779.3",
"V30.00",
"V29.0",
"998.11",
"E878.8",
"774.6",
"769",
"V50.2",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.55",
"93.90",
"96.6",
"96.71",
"96.04",
"64.0",
"99.15",
"99.83"
] |
icd9pcs
|
[
[
[]
]
] |
4194, 4640
|
1555, 4172
|
148, 1537
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,096
| 118,682
|
4367
|
Discharge summary
|
report
|
Admission Date: [**2160-3-20**] Discharge Date: [**2160-4-7**]
Date of Birth: [**2104-7-14**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
abdominal pain, nausea, vomiting, decreased PO intake
Major Surgical or Invasive Procedure:
exploratory laparotomy [**2160-3-26**]
History of Present Illness:
The patient is a 55y man with a history of EtOH cirrhosis who
experienced nausea and vomiting for 24 hours prior to
presentation. He had decreased appetite and PO intake as well as
dizziness. He denied fever or chills.
Past Medical History:
#. Alcoholic cirrhosis, not on transplant list
- complicated by ascites and hepatic encephalopathy
- doses of his diuretics reduced due to hypotension
- undergoes paracentesis approximately every 2 weeks
- intermittently nadolol due to hypotension previously
#. UGIB [**2-9**] secondary to gastric vacices
#. Hepatic sarcoidosis
#. Abdominal and inguinal hernia (s/p bilateral inguinal
herniorrhaphies)
#. CKD
#. history of HSP
#. Anemia
#. Gout
#. History of colon adenoma - 6mm adenomatous polyp by biopsy
[**3-8**]
Social History:
Patient lives with wife but is not working, lives in [**Name (NI) 745**]. He
performs all ADLs but does not drive. He is married with a good
social support system. He has two children living in [**State **].
Tobacco: None
ETOH: Prior alcoholic, No Etoh since [**Month (only) **] (6 months)
Illicts: No drug use
Family History:
Father w/ HTN, early CAD, alcoholism. Brother with alcoholism.
Mother w/ HTN.
Physical Exam:
On Admission:
VS: 98.1 88 77/48 18 100%
General: NAD
Cardiac: RRR, S1 S2
Lungs: CTA bilaterally
Abd: Soft, distended, faint bowel sounds, diffuse tenderness to
palpation
Extr: Bilateral lower extremity edema
Pertinent Results:
labs day of admission:
[**2160-3-20**] 08:05AM WBC-9.9# RBC-2.82* HGB-9.1* HCT-26.8* MCV-95
MCH-32.2* MCHC-33.9 RDW-17.2*
[**2160-3-20**] 08:05AM ETHANOL-NEG
[**2160-3-20**] 08:05AM AMMONIA-27
[**2160-3-20**] 08:05AM ALBUMIN-2.7* CALCIUM-9.3 PHOSPHATE-4.8*
MAGNESIUM-2.1
[**2160-3-20**] 08:05AM cTropnT-0.02*
[**2160-3-20**] 08:05AM ALT(SGPT)-25 AST(SGOT)-55* CK(CPK)-36* ALK
PHOS-124* TOT BILI-3.1*
[**2160-3-20**] 08:05AM GLUCOSE-97 UREA N-40* CREAT-1.6* SODIUM-133
POTASSIUM-5.3* CHLORIDE-103 TOTAL CO2-19* ANION GAP-16
[**2160-3-20**] 08:30AM ASCITES WBC-5075* RBC-[**2076**]* POLYS-54*
LYMPHS-3* MONOS-30* MESOTHELI-3* MACROPHAG-10*
[**2160-3-20**] 12:38PM PT-21.2* PTT-45.3* INR(PT)-2.0*
CT ABDOMEN W/O CONTRAST [**2160-3-22**] 11:58 AM
IMPRESSION: Large amount of ascites with associated findings of
cirrhosis as described.
Distended fluid and air-filled loops of small and large bowel,
most consistent with ileus. However, early partial small bowel
obstruction could have a similar appearance. Findings discussed
with Dr. [**First Name4 (NamePattern1) 1439**] [**Last Name (NamePattern1) **] at time of interpretation. Continued close
clincal follow-up advised. If clinically indicated, repeat
imaging could be obtained.
Right basilar airspace opacity which may be related to
aspiration, pneumonia, or less likely atelectasis.
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2160-3-24**] 5:02 PM
IMPRESSION:
Suboptimal examination; however no definite evidence of
pulmonary embolism is identified. Bilateral infiltrates likely
representing aspiration pneumonia. Large amount of abdominal
ascites. This finding is better assessed on CT scan dated
[**2160-3-22**]. There are several calcified mediastinal lymph nodes
likely representing sequelae of previous granulomatous disease.
CT ABDOMEN W/O CONTRAST [**2160-3-26**] 12:14 AM
IMPRESSION:
1. Small bowel distention, mural thickening, pneumatosis, and
mesenteric venous gas, consistent with bowel ischemia. Massive
ascites, unchanged.
Right lower lobe consolidation consistent with pneumonia and
atelectasis minimally improved. Findings consistent with portal
hypertension and cirrhosis, unchanged. Calcified mediastinal and
hilar lymph nodes consistent with prior granulomatous disease.
Large right-sided hydrocele unchanged.
CHEST (PORTABLE AP) [**2160-4-5**] 12:34 AM
IMPRESSION: Mild interval increased atelectasis and elevation in
the right hemidiaphragm when compared to prior study. No
pneumothorax.
Brief Hospital Course:
Patient was admitted with SBP and distened abdomen consistent
with ileus, encephalopathy and was started on antibiotics.
Originally abdominal distension resoleved and NFGT was d/c'd.
NGT had to be reinserted when patient re-developed abdoinal
distension. A Abdominal CT was performed at that time which
showed dilated small bowel and air in the mesenery and portal
vein consistent with ischemic gut. The patient was taken to the
OR for exploration. On exploration he was found to have 12L of
ascites and fibrinous exudate on the bowel. No evidence of
obstruction, ischemia or open perforation. JP was left in the
abdomen for ascites leak control. The patient was maintained on
levofloxacin and flagyl post operatively for SBP and question of
pre op aspiration PNA for 1 week. Subsequently transitioned to
cipro for SBP prophylaxis. 3 days prior to discharge he
developed increasing WBC and hypotenion with elevated Cr. He was
cultured and JP drain was analyzed and contained 1500WBC with
80% polys consistent with SBP with no growth on culture at this
time. The patient was started on vanco and zosyn empirically. He
was given albumen bolus taper for 3 days for SBP treatment. Also
was noted to have g+ cocci growth from his central line which
grew staph epidermidis, question of contamination. The CVL was
removed. Patient was started on tube feeds through a
[**Last Name (un) **]-duodenal tube placed by EGD. On AM of [**4-7**] the patient
accidently d/c'd the NG feeding tube. The patient is putting out
3-4L ascites through the JP daily which is being replaced 1/2cc
per cc with NS. His baseline weight was maintained at 70-71 kg.
The plan was to D/C JP drain after 2 weeks post op to ensure
fascial healing to minimize risk of ascites leak through the
midline incision. 1 day ago pt was noted to have drop in HCT
from 30 to 22 with no evidence of gross bleeding. He has brown
BMs that are guaiac positive. he received 3u PRBCs and 1 bag
platelets with appropriate response. Currently he is tolerating
a regular diet and has normal bowel funtion. He is afebrile and
the incsion has a stapled closure with no evidence of leakage,
erythema or edema. He has a JP with serous drainage.
Medications on Admission:
rifaximin 400 mg TID
Colchicine 0.6mg daily
Hexavitamin
Lactulose 30ml titrated to 4-5BM /day
Lasix 20mg daily
Nadolol 20gm daily
Spironolactone 100mg daily
Protonix 40mg daily
Zinc
Vit A
Calcium carbonate 500mg [**Hospital1 **]
Cholecalcierol 400u Daily
albuterol PRN
Acetaminophen PRN
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
2. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
3. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
5. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
6. Hydromorphone 2 mg/mL Syringe Sig: 0.25 mg Injection Q3H
(every 3 hours) as needed for pain.
7. Vancomycin 1000 mg IV Q 12H
8. Piperacillin-Tazobactam Na 4.5 g IV Q8H
9. Albumin 25% (12.5g / 50mL) 75 gm IV ONCE Duration: 1 Doses
Start tomorrow DAY 2
1g/kg
10. Albumin 25% (12.5g / 50mL) 50 gm IV ASDIR Start: [**2160-4-7**]
0.5 mg/kg
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 18824**]
Discharge Diagnosis:
ETOH Cirrhosis
Ileus
Encephalopathy
Intractable ascites
SBP
Discharge Condition:
fair
Discharge Instructions:
Please call [**Telephone/Fax (1) 673**] if questions re: [**Hospital 18**] hospital course
or call Dr.[**Name (NI) 6670**] office 617-632-****
Followup Instructions:
Transfer to [**Hospital6 18824**]
|
[
"507.0",
"427.32",
"427.89",
"560.1",
"584.9",
"567.23",
"571.2",
"572.2",
"789.59",
"572.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"54.11",
"99.15",
"99.61",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
7714, 7762
|
4378, 6565
|
367, 407
|
7866, 7873
|
1870, 4355
|
8065, 8102
|
1543, 1623
|
6902, 7691
|
7783, 7845
|
6591, 6879
|
7897, 8042
|
1638, 1638
|
274, 329
|
435, 655
|
1652, 1851
|
677, 1197
|
1213, 1526
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,801
| 171,118
|
54576
|
Discharge summary
|
report
|
Admission Date: [**2151-6-14**] Discharge Date: [**2151-6-16**]
Service: MEDICINE
Allergies:
Cipro Cystitis
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Fever/Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
88 yo M h/o CAD s/p CABG, prostate cancer s/p XRT, HTN who
presents from [**Hospital 100**] Rehab with one day of nausea/vomiting of
billious emesis, chills and rigors. He is s/p laparoscopic
cholecystectomy on [**4-24**] with a course complicated by
post-op hypotension, new onset afib s/p cardioversion currently
on coumadin, and Klebsiella UTI treated with Unasyn. Notably, at
[**Hospital 100**] Rehab, heart rates recorded in 120s-140s with hypoxia
90-92% on 3L. Patient does not remember the events of the day.
.
In the ED, initial vs were: 102.1 109 145/67 24 91% 3L. Oriented
x 2. On physical exam RUQ tenderness to palpation. Wound without
evidence of infection. Due to RUQ pain and emesis, an NG tube
was placed with relief of symptoms. Labs notable for UA showing
wbc >182, lactate of 2.3. CT abd/pelvis showed consolidation
with pleural effusions concerning for aspiration PNA and
improving colitis. RUQ u/s showed no abscess. Surgery was
consulted and did not feel any acute surgical issue was present.
Patient was given 3 liters of IVFs, 1 gram vanc, 500 flagyl,
zosyn with c/f RUQ abscess. With concern for aspiration,
levoquin was added. Also received 4 mg morphine, zofran,
compazine and tylenol. He is coming to MICU b/c he is notably
desaturating to 85% with ambulation. VS prior to transfer: 79
107/53 23 97% 5L. Has 2 PIVs for access.
.
Upon arrival to the MICU, patient is requesting his NG tube be
removed as it is bothering his throat. He has no further
complaints at this time.
Past Medical History:
Past Medical History:
- Hypertension
- CAD and h/o MI and CABG in [**2139**] at [**Hospital1 2025**]
- Prostate CA (s/p XRT), urethral stricture - Evaluation on
[**2149-4-29**] revealed a negative bone scan as well as CT scan for
metastatic disease. Per urology hormonal therapy could be
started in the next 2 years.
Past Surgical History:
- Stenting x 3 at [**Hospital1 18**] for CAD and MI in [**10-15**]
- CABG in [**2139**] at [**Hospital1 2025**]
- Melanoma on his back resected in [**2124**] at [**Hospital1 2025**]
- Right inguinal hernia repair 2mo ago [**Hospital1 2025**]
- Left inguinal hernia repair
Social History:
Lives in [**Location 583**] with his wife. Stopped smoking in [**2088**].
Occasional EtOH use. No recreational drugs.
Family History:
Father: "Heart Problems" Lived to 91
Mother: [**Name (NI) **], Lived to 70
Physical Exam:
On admission:
Vitals: T: 97.2 BP: 115/73 P: 88 R: 22 O2: 96% on 5 liters
General: Alert, oriented x 3, pale, thin, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, decreased breath
sounds bilaterally.
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, steri-strips
in place at site of recent CCY
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
On discharge:
General: Alert, oriented x 3, pale, thin, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: decreased coarse breath sounds bilaterally, no wheezes or
rales
CV: Regular rate and rhythm, nl S1/S2, holosystolic ejection
murmur at LSB
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly,
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission labs:
---------------
[**2151-6-13**] 11:10PM BLOOD WBC-9.5 RBC-3.84* Hgb-11.0* Hct-34.4*
MCV-90 MCH-28.6 MCHC-32.0 RDW-17.5* Plt Ct-575*
[**2151-6-13**] 11:10PM BLOOD Neuts-86.2* Lymphs-7.8* Monos-1.9*
Eos-3.8 Baso-0.4
[**2151-6-13**] 11:10PM BLOOD PT-25.9* PTT-28.6 INR(PT)-2.5*
[**2151-6-13**] 11:10PM BLOOD Glucose-131* UreaN-23* Creat-0.9 Na-139
K-4.4 Cl-103 HCO3-25 AnGap-15
[**2151-6-13**] 11:10PM BLOOD ALT-42* AST-27 AlkPhos-111 TotBili-0.3
[**2151-6-13**] 11:10PM BLOOD Lipase-52
[**2151-6-14**] 01:07PM BLOOD Lipase-17
[**2151-6-13**] 11:10PM BLOOD cTropnT-0.03*
[**2151-6-14**] 06:04AM BLOOD CK-MB-3 cTropnT-0.03*
[**2151-6-14**] 01:07PM BLOOD CK-MB-3 cTropnT-0.02*
[**2151-6-14**] 06:04AM BLOOD Calcium-8.0* Phos-2.9 Mg-1.5*
[**2151-6-16**] 03:33AM BLOOD calTIBC-168* Ferritn-200 TRF-129*
[**2151-6-13**] 11:14PM BLOOD Lactate-2.3*
[**2151-6-14**] 06:20AM BLOOD Lactate-2.1*
[**2151-6-14**] 01:45PM BLOOD Lactate-3.1*
[**2151-6-15**] 05:00AM BLOOD Lactate-1.5
.
Discharge labs:
---------------
[**2151-6-16**] 03:33AM BLOOD WBC-15.2* RBC-2.86* Hgb-8.7* Hct-25.4*
MCV-89 MCH-30.3 MCHC-34.1 RDW-15.6* Plt Ct-330
[**2151-6-16**] 03:33AM BLOOD Neuts-83.5* Bands-0 Lymphs-10.0*
Monos-4.0 Eos-2.3 Baso-0.3
[**2151-6-16**] 03:33AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
[**2151-6-16**] 03:33AM BLOOD Glucose-91 UreaN-14 Creat-0.8 Na-136
K-3.4 Cl-105 HCO3-22 AnGap-12
[**2151-6-14**] 01:07PM BLOOD CK(CPK)-36* Amylase-38
[**2151-6-16**] 03:33AM BLOOD Calcium-7.5* Phos-4.6*# Mg-2.0 Iron-19*
[**2151-6-16**] 03:33AM BLOOD calTIBC-168* Ferritn-200 TRF-129*
.
Imaging:
---------
[**6-13**] CXR:
1. Borderline heart failure, improved.
2. Small bilateral, layering pleural effusions, and mild basal
atelectasis, left greater than right, improved.
.
[**6-14**] RUQ U/S:
Status post cholecystectomy. CBD measuring between 6 and 9 mm
without filling defects. No intrahepatic biliary ductal
dilatation. No fluid collections.
.
[**6-14**] CT abd:
1. Bibasilar consolidation, worrisome for aspiration pneumonia.
Bilateral
pleural effusions, smaller than on the prior CT.
2. Persistent, but improved inflammatory stranding around the
ascending colon where there are numerous diverticula. Findings
suggestive of improved colitis or diverticulitis.
3. Status post cholecystectomy without fluid collection in the
gallbladder
fossa. CBD dilation without filling defects. No intrahepatic
biliary ductal dilatation.
4. NG tube tip with its in the stomach, however, the tube has
flexed back
upon itself in the first portion of the duodenum.
5. Bladder diverticulum, renal cyst stable.
6. Prior granulomatous disease in the spleen and liver.
7. Stable fluid collection inferior to the heart may be a
pericardial cyst.
.
Brief Hospital Course:
88 yo M h/o CAD s/p CABG, prostate cancer s/p XRT, recent lap
chole [**5-18**], presenting from [**Hospital 100**] Rehab with N/V and and
hypoxia.
.
# Fever/ Leukocytosis: patient was febrile on admission to 102
and was recently discharged after having cholecystectomy. He was
slightly tachycardic and hypertensive. His WBC was elevated to
20 on admission with no bands and he reported nausea but not
other localizing symptoms of infection. NG tube was placed for
relief of symptoms given mild tenderness in RUQ on palpation.
Surgery was consulted and did not feel any acute surgical issue
was present. He was started on vanco and zosyn for broad
coverage of possible intra-abdominal source given recent
operation. RUQ U/S was done and did not show any duct dilatation
or fluid collections. A CT abdomen was done and showed
persistent but improved colitis in ascending colon, post-chole
findings with no fluid collections or CBD dilation, and
bibasilar lung consolidation concerning for aspiration pneumonia
with bilateral pleural effusions improved from prior CT. U/A on
admission showed >180 WBCs with few bacteria and many
leukocytes. On hospital day 2, WBC rose to 24.3 with 20% bands
and infectious disease was consulted. He was started on PO
vancomycin for empiric coverage of C diff given recent
hospitalization though he was not having diarrhea, and evidence
of colitis on CT. Blood and urine cultures showed no growth at
time of discharge. Stool C diff toxin was negative. His WBC
trended down to 15 and he remained afebrile. He should complete
a 5-day course of vanco/zosyn IV and a 10-day course of PO
vancomycin.
.
# Hypoxia: Pt had mild SOB on admission and was desaturating to
85% with ambulation. On transfer to the MICU, he was 97% on 5L
nasal cannula. CXR and CT abdomen showed opacities at the lower
bases suggestive of aspiration and bilateral pleural effusions
which were improved from prior. He was treated as above with
vanco/zosyn which would have covered pneumonia. His hypoxia
improved steadily and at time of discharge he was saturating
96-7% on room air. He had no evidence of aspiration on swallow
evaluation. His lasix, which had recently been decreased to 20mg
daily from 20mg [**Hospital1 **] prior to admission, was being held given
hypotension to SBP 110, but should be restarted once his blood
pressure improves. As above, he should complete a 5-day course
of vanco/zosyn (last day = [**2151-6-17**]).
.
# SVT - patient had an episode of supraventricular narrow
complex tachycardia shortly after admission with HR to 150's
which lasted for a few minutes, he was given adenosine and SVT
converted to sinus. He remained in sinur rhtythm for the
remainder of the hospitalization with HR ranging in the 70-80s.
Of note, patient has a fib and was cardioverted on [**5-31**] and
there was no documented a fib on this admission.
.
# Anemia - HCT trended down from 39 in [**5-/2151**] to 25-26. He had
no evidence of bleeding. RDW is elevated and iron studies showed
low iron with Fe/TIBC ratio >10% with normal ferritin, which
suggests a combination of iron deficiency anemia and anemia of
chronic inflammation. HCT should be trended daily and he should
consider initiating iron supplementation after the acute phase
of his illness resolves. He will call to schedule an appointment
with his PCP.
# CAD: s/p CABG: Carvedilol, losartan and lasix were held in the
setting of hypotension (SBP 100s). These should be restarted as
an outpatient once his hypotension improves. Aspirin and statin
were continued per home dose.
.
# Afib: patient has been in sinus rhythm throughout admission
except brief episode of SVT as described above. He is s/p
cardioversion on [**5-31**] in most recent admission for post-op afib.
His INR was supratherapeutic at 3.4 and his coumadin was held at
time of discharge. He should have his INR checked daily and
coumadin restarted (home dose 0.5mg daily) with goal INR [**3-11**]. He
will need to follow up with his PCP or cardiologist to stop
anticoagulation post-cardioversion as an outpatient.
.
Medications on Admission:
Tramadol 25 mg PO Q6H as needed for pain.
senna 8.6 mg PO BID
bisacodyl 10 mg Daily as needed for constipation.
acetaminophen 650 mg PO Q6H as needed for fever.
albuterol sulfate Nebulization One INH Q6H as needed for
wheeze.
camphor-menthol 0.5-0.5 % One QID as needed for itching.
ranitidine HCl 150 mg One PO DAILY
furosemide 20 mg PO daily
carvedilol 3.125 mg PO BID
Losartan 100 mg PO DAILY
simvastatin 20 mg One PO DAILY
aspirin 81 mg PO DAILY
Coumadin 0.5 mg daily to maintain INR 2.0-3.0.
Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 8 days.
5. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): hold for sbp < 100 or HR < 60.
6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Zosyn 4.5 gram Recon Soln Sig: 4.5 grams Intravenous every
eight (8) hours for 4 doses: To be started 0000 [**2151-6-17**].
9. vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg
Intravenous every twelve (12) hours for 3 doses: To be started
[**2140**] tonight [**2151-6-16**] .
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
UTI
Aspiration
Colitis
Secondary:
CAD
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 27928**],
You were admitted to the [**Hospital1 18**] ICU for nausea, fever, and low
oxygen. We found a possible infection in your urine and lungs,
and scans of your abdomen did not show any complications after
your cholecystectomy. We treated you with antibiotics and you
improved.
You should continue all of your medications with the following
important changes.
1. Continue vancomycin 1000 mg IV every 12 hours for three more
doses. Last dose: the evening of [**2151-6-17**].
2. Continue Zosyn 4.5 mg IV every 8 hours for 4 more doses
starting midnight tonight [**2151-6-17**].
3. Continue vancomycin po (by mouth) 125 mg every 6 hours for 8
more days. This should be stopped [**2151-6-24**].
4. HOLD coumadin dosing until INR < 3. Goal INR [**3-11**].
5. HOLD Losartan 100 mg daily until acute infection has resolved
and blood pressures are stable.
6. HOLD lasix 20 mg daily until acute infection has resolved and
blood pressures are stable.
***You should continue anticoagulation with coumadin until at
least [**2151-6-30**] as this is one month past your cardioversion.
Further management should be discussed with your PCP [**Name Initial (PRE) **]/or
cardiologist at this time***
Followup Instructions:
You should follow up with your primary care doctor once you
leave the rehab facility.
You should call cardiology at [**Telephone/Fax (1) 62**] to make an
appointment regarding your anticoagulation in the next [**2-7**]
weeks.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2151-6-16**]
|
[
"427.31",
"V10.82",
"507.0",
"V58.61",
"599.0",
"280.9",
"427.89",
"V45.81",
"V10.46",
"008.45"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12090, 12156
|
6578, 10632
|
243, 249
|
12276, 12276
|
3794, 3794
|
13701, 14095
|
2570, 2647
|
11180, 12067
|
12177, 12255
|
10658, 11157
|
12459, 13678
|
4795, 6555
|
2144, 2418
|
2662, 2662
|
3286, 3775
|
190, 205
|
277, 1781
|
3810, 4779
|
2676, 3272
|
12291, 12435
|
1825, 2121
|
2434, 2554
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,332
| 104,924
|
40913
|
Discharge summary
|
report
|
Admission Date: [**2120-4-24**] Discharge Date: [**2120-4-27**]
Date of Birth: [**2092-9-12**] Sex: M
Service: MEDICINE
Allergies:
Effexor
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
acute mental status changes and agitation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
27 yo M with PMHx of polysubstance of abuse, bipolar disorder,
transfer from [**Hospital1 **] for AMS. He was there on a section 12
for lamictal 100mg OD on [**4-19**] after presenting with lethargy and
nausea to [**Hospital3 **]. His tox was found to be positive
for Cannibis. Per report he has taken [**9-14**] pills in an
intentional overdose but denied SI but was reportedly
disorganized and not a reliable historian. He was treated with
haldol, ativan, risperidone, benadryl, and cogentin. On the
first few days after admission, he became more clear and was
able to participate in thepary, however is mental status began
to decompensate yesterday. He was referred here for confusion
and worsening mental status. There was a question of what or not
he might have ingested drugs over the weekend (from visitors).
Vitals signs at bornewood notable for [**2120-4-23**] HR 136 am and
100pm and [**2120-4-24**] 136am 100 pm. Prior to transfer BP 97.2 115/81
117 20 97%.
In the ED, 98.5 84 120/76 18 98% RA. Reported initial
improvement in mental status and plan for discharge. However,
when EMS arrived to take the patient back to [**Hospital1 **], he
became very agitated. He was given ativan 2mg and haldol 5mg but
continued to be aggitated. He appeared confused and was having
auditory and visual hallucinations. Pulse transiently 151 prior
to physostigmine. Tox c/s thought he had anticholinergic
toxicity symptoms including dry skin and garbled speech. Thought
he improved to physostigmine 2mg over 5 minutes. Speech cleared.
Then agitated in angry way which was different. Thought this was
diagnostic. VS prior to transfer 76 117/82 18 97%RA. Normal head
CT. Labs normal. Tox wants to old all antipsychotics, use
benzos. In 4 points and ativan prior to sedation.
In the ICU, patient was agitated and whimpering. He wanted to
get out of his restraints. Still not oriented to person, place
or time.
Past Medical History:
-polysubstance abuse->dependent on cannabis
-depression
-?bipolar disorder
Social History:
Smoke [**12-3**] ppd, marijuana 1 joint per day. Periodic alcohol use.
Family History:
Unknown
Physical Exam:
Exam on Admission:
VS: Temp: 96.7 BP: 126/73 HR:85 RR:13 O2sat 96% on RA
GEN: agitated and trying to get out of restraints
HEENT: PERRL, EOMI, anicteric, dryMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: tachycardia, RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters, multiple piercings and
tattoos
NEURO: Purposeful movement, AAOx0, could not participate in
formal exam
Exam on discharge:
GEN: calm, A/Ox3 man sitting in chair, in NAD
HEENT: EOMI, anicteric, MMM
RESP: CTA b/l with good air movement throughout
CV: RRR, normal S1 and S2, no m/r/g
ABD: soft, nontender, nondistended, +b/s
EXT: no c/c/e.
SKIN: no rashes/no jaundice, multiple piercings and tattoos
Mental Status: A/Ox3, talkative, answers questions with poor
insight
Pertinent Results:
[**2120-4-24**] 03:22PM URINE HOURS-RANDOM
[**2120-4-24**] 03:22PM URINE HOURS-RANDOM
[**2120-4-24**] 03:22PM URINE GR HOLD-HOLD
[**2120-4-24**] 03:22PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2120-4-24**] 03:22PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.010
[**2120-4-24**] 03:22PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2120-4-24**] 10:10AM GLUCOSE-103* UREA N-8 CREAT-0.8 SODIUM-140
POTASSIUM-3.5 CHLORIDE-103 TOTAL CO2-28 ANION GAP-13
[**2120-4-24**] 10:10AM estGFR-Using this
[**2120-4-24**] 10:10AM ALT(SGPT)-16 AST(SGOT)-21 ALK PHOS-56 TOT
BILI-1.0
[**2120-4-24**] 10:10AM LIPASE-21
[**2120-4-24**] 10:10AM ALBUMIN-4.8 CALCIUM-10.5* PHOSPHATE-3.9
MAGNESIUM-2.0
[**2120-4-24**] 10:10AM AMMONIA-21
[**2120-4-24**] 10:10AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2120-4-24**] 10:10AM WBC-6.9 RBC-4.77 HGB-14.6 HCT-41.8 MCV-88
MCH-30.7 MCHC-35.1* RDW-12.4
[**2120-4-24**] 10:10AM NEUTS-66.1 LYMPHS-26.5 MONOS-5.6 EOS-1.4
BASOS-0.4
[**2120-4-24**] 10:10AM PLT COUNT-289
EKG: sinus arrhythmia at 79bpm, borderline right axis, NI, TWF
in V1, TWI in V3 and III, otherwise no Q waves or ST deviations.
Imaging:
CT head: Normal non-contrast head CT.
CXR [**4-26**]: Current study demonstrates no evidence of radiopaque
foreign bodies seen on the previous examination. Heart size is
normal. Mediastinum is normal. Azygos lobe, anatomical variant
is noted. Lungs are essentially clear. There is no appreciable
pleural effusion or pneumothorax seen.
Brief Hospital Course:
27 yo M with history of polysubstance of abuse, bipolar
disorder, and a mood disorder who was transfered from [**Hospital1 **]
for acute mental status changes.
# Toxic metabolic encephalopathy: Likely secondary to alcohol
withdrawal. The patient's acute mental status changes were
initially thought to be due to delirium in the setting of
possible anticholinergic syndrome from benadryl and congentin in
addition to other psych meds. In support of this, he was
reported to improve with physostigmine. The patient was also
treated with a total of 60mg Valium over 24 hours, with
resolution of his agitation. It subsequently became clear that
the patient drinks a very large amount of alcohol, and in
retrospect, it seemed likely that his symptoms may have also
been due to EtOH withdrawal. Toxicology followed the patient
in-house as did Psychiatry. He continued to receive 5mg Haldol
[**Hospital1 **] PRN for agitation. His mental status improved to baseline.
He had a 1:1 sitter throughout his hospital stay. Section 12
was filed by psychiatry and he is being discharged to inpt
psychiatry at [**Hospital1 18**].
#Polysubstance abuse: Per report, the patient has a history of
benzo abuse and likely alcohol abuse. He has poor insight. He
was placed on a CIWA scale with 5mg of Valium given for CIWAs >
10. His valium was self-tapered in this way. He was continued
on MVI, thiamine, folate, and a nicotine patch throughout his
hospitalization.
# Anxiety/mood disorder: The patient's mood is likely unstable
at home given a recent possible overdose to "sleep off his
emotions." Psychiatry followed throughout his hospitalization,
and recommended an inpatient psychiatric hospitalization for
further management. He was not started on any standing
psychiatric medications during this hospitalization. He was
only given haldol for agitation as above.
# Radiodense foreign body: On radiograph, the patient was
observed to have a curvilinear radiodensity overlying his
abdomen, which was gone on repeat x-ray. The patient denied
having swallowed anything. A search of his skin did not reveal
any evidence of a foreign body, making it possible that this
finding was something external to him. He did not complain of
abdominal pain and was otherwise asymptomatic.
Medications on Admission:
No prescription medications prior to admission to [**Hospital1 **]. He
had not seen a PCP in years.
Medications at [**Hospital1 **]:
-risperidone 2mg [**Hospital1 **]
-Ativan 1mg q4h prn
-nicotine patch
-ibuprofen 400mg q4 prn
-haldol 5mg PO q4hr prn
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 18**] [**Hospital1 **] 4
Discharge Diagnosis:
Primary Diagnosis:
Anticholinergic toxicity
Secondary diagnoses:
Polysubstance Abuse
Mood Disorder, NOS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with confusion and agitation.
It was likely from either withdrawal from alcohol or
benzodiazepines or an anticholinergic toxicity. We may never
know exactly what it was. You improved with proper treatment.
Because of your overdose, we had the psychiatrists see you.
They wanted to make some changes to your medications and watch
you for the next few days while receiving these medications.
- Please take take only the medications recommended by the
psychiatrists.
We made the following changes to your medications:
We STARTED thiamine, folate, multivitamin and nicotine patch.
Followup Instructions:
Please follow up with your new primary care physician [**Name Initial (PRE) 176**] [**12-3**]
weeks after discharge. Please follow up with your mental health
providers as directed by your inpatient mental health team.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2120-4-27**]
|
[
"966.3",
"E849.9",
"292.81",
"E855.0",
"349.82",
"304.31",
"305.1",
"300.02",
"E855.4",
"971.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8020, 8084
|
5132, 7405
|
309, 315
|
8232, 8232
|
3460, 4770
|
9023, 9393
|
2453, 2462
|
7708, 7997
|
8105, 8105
|
7431, 7685
|
8383, 8907
|
2477, 2482
|
8170, 8211
|
8936, 9000
|
228, 271
|
343, 2248
|
3096, 3370
|
4779, 5109
|
8124, 8149
|
2496, 3077
|
8247, 8359
|
2270, 2347
|
2363, 2437
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,986
| 166,640
|
19503
|
Discharge summary
|
report
|
Admission Date: [**2180-1-18**] Discharge Date: [**2180-1-26**]
Date of Birth: [**2104-2-15**] Sex: F
Service: PODIATRY
Allergies:
Naproxen
Attending:[**First Name3 (LF) 17242**]
Chief Complaint:
Somnolence
Major Surgical or Invasive Procedure:
TEE with Cardioversion
History of Present Illness:
Ms. [**Known lastname 52947**] is a 75 yo F w/PMHx sx for DM2, PVD, hypertension,
dyslipidemia, atrial flutter, and TB s/p LUL resection who
presented after surgery [**2180-1-18**] for left Charcot foot. Patient
was noted to have somnolence and decreased O2 sats as well as
metabolic acidosis after the procedure and was admitted to the
[**Hospital Unit Name 153**] for closer monitoring. Patient also noted to have
metabolic acidosis as well.
.
MICU course: In the [**Hospital Unit Name 153**] she was found to be in aflutter and
CHF. Was Diuresed with Lasix with some relief. Renal is
following for ? of new onset RTA with protenuria. She remained
tachycardic to 110-120's with evidence of fluid retention.
Cardiology consulted, and TEE [**2180-1-21**] with successful d/c
cardioversion of her Afib. + some concerns of mental status
change in the ICU.
.
Patient has no complaints. She denies nausea, vomiting, SOB,
chest pain, palpitations, lightheadedness, diarrhea, dysuria.
She reports that her shortness of breath is much improved from
admission to the ICU. She reports her baseline ADL's as able to
ambulate around her house independently. She has been limited
the past 2 months by her foot disease.
Past Medical History:
DM II with neuropathy
PVD
hx hypertension
hx dyslipdemia
hx atrial fibrillatiion
hx TB s/p LUL resection [**2129**]
hx diverticulosis/p bowel resection [**2169**]
hx osteo arthritis
hx arrythmia s/p AV node ablation
s/p TAH, s/p c-section
s/p spinal surgery
s/p rt. hip surgery
s/p rt. EIA endartectomy with patch angioplasty w dacron
s/p b/l foot surgeries
Social History:
married lives with spouse, denies tobacco use, admits to
drinking heavily: 1 bottle of wine to a pint of vodka per day
per her and husband.
.
Family History:
unknown
Physical Exam:
VS: HR 118. BP 147/94. O2sat 100% on 3L NC. Tc 96.2.
Gen: well appearing. NAD.
HEENT: Thick neck. No carotid bruits. MMM.
Hrt: Irreg irreg. 3/6 SEM at RUSB.
Lungs: Expiratory wheezing at left base. No rales or rhonchi.
Abd: Soft. Nontender. Nondistended. Normoactive BS. No
organomegaly. Well healed midline incision.
Ext: 2+ pitting edema to knees bilaterally. Both feet and shins
wrapped, with dressings CDI.
Neuro: Alert and oriented to self, place, president, not to year
([**2132**]). Able to move all extremities.
Pertinent Results:
[**2180-1-18**] 09:30AM BLOOD WBC-6.8 RBC-3.35* Hgb-10.4* Hct-33.3*
MCV-99* MCH-30.9 MCHC-31.1 RDW-20.1* Plt Ct-206
[**2180-1-22**] 06:55AM BLOOD WBC-5.9 RBC-3.24* Hgb-10.0* Hct-32.5*
MCV-100* MCH-30.9 MCHC-30.8* RDW-19.8* Plt Ct-224
[**2180-1-22**] 06:55AM BLOOD Plt Ct-224
[**2180-1-22**] 06:55AM BLOOD PT-25.7* PTT-35.7* INR(PT)-2.6*
[**2180-1-21**] 06:10AM BLOOD PT-24.5* PTT-38.0* INR(PT)-2.5*
[**2180-1-19**] 06:33AM BLOOD PT-28.1* PTT-41.7* INR(PT)-2.9*
[**2180-1-18**] 09:30AM BLOOD Glucose-121* UreaN-41* Creat-1.5* Na-144
K-5.5* Cl-119* HCO3-13* AnGap-18
[**2180-1-22**] 06:55AM BLOOD Glucose-99 UreaN-37* Creat-1.5* Na-144
K-4.5 Cl-113* HCO3-22 AnGap-14
[**2180-1-20**] 09:10AM BLOOD TotProt-6.1* Albumin-3.1* Globuln-3.0
Calcium-8.4 Phos-3.0 Mg-2.1 UricAcd-8.2* Iron-34 Cholest-142
[**2180-1-20**] 09:10AM BLOOD calTIBC-277 VitB12-1214* Folate-7.1
Ferritn-275* TRF-213
[**2180-1-20**] 09:10AM BLOOD Triglyc-90 HDL-59 CHOL/HD-2.4 LDLcalc-65
[**2180-1-20**] 02:20PM BLOOD PTH-162*
Surface ECHO [**2180-1-21**]: Left ventricular hypertrophy with moderate
global left ventricular systolic dysfunction (?metabolic,
long-standing tachycardia). Moderate calcific aortic stenosis.
Moderate tricuspid regurgitation. Elevated left and right-sided
intracardiac filling pressures. Moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2179-11-5**],
left ventricular systolic function has significantly declined.
Severity of tricuspid regurgitation has increased, and pulmonary
hypertension is now identified.
.
TEE ECHO [**2180-1-21**]:
The left atrium is moderately dilated. Mild spontaneous echo
contrast is seen in the body of the left atrium and left atrial
appendage. No thrombus is seen in the body of the left atrium or
left atrial appendage. No spontaneous echo contrast or thrombus
is seen in the body of the right atrium or the right atrial
appendage. A very small secundum atrial septal defect is present
(?postprocedural). Overall left ventricular systolic function is
normal (LVEF>55%).
There are complex (>4mm) atheroma in the descending thoracic
aorta. The aortic arch is not well seen. The aortic valve
leaflets are severely thickened/deformed. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is a
trivial/physiologic pericardial effusion.
.
ECG [**2180-1-21**]: NSR, AV block, + new T-wave inversions inferiorly
and V1-V3 after cardioversion
.
[**2180-1-22**] CXR: The lungs are hyperinflated and the diaphragms are
flattened. There is marked cardiomegaly. There are diffusely
increased interstitial markings. There are small bilateral
pleural effusions, larger on the left. Multichamber
cardiomegaly and small effusions. Some of the interstitial
marking prominence could represent an atypical distribution of
CHF. Differential diagnosis
includes chronic lung disease, the possibility of an infectious
interstitial infiltrate is considered much less likely. Known
calcified nodes not wellvisualized radiographically. Compared
with [**2180-1-18**], there has been improvement in the CHF findings.
Brief Hospital Course:
75 yo F w/PMHx sx for DM2, HTN, PVD, hyperlipidemia admitted for
left Charcot foot repair, noted to have somnolence and metabolic
acidosis after procedure, now admitted to the [**Hospital Unit Name 153**] for closer
monitoring.
.
#. Respiratory distress. Patient with mild hypoxia and minimal
oxygen requirement, with CXR c/w fluid overload [**2180-1-18**]. Patient
also with nongap metabolic acidosis with compensatory
respiratory alkalosis. On the medical floor, the patient was
diuresed with Lasix IV with good response and negative 1 l per
day. However, oxygen saturation did not improve. Patient
remained 91-93% on RA and would desaturate to 84% with activity.
This may be due to progressive interstitial lung disease in
addition to CHF. She was switched to oral Lasix and continued to
diuresis well. She worked with physical therapy but refused to
attempt the stairs saying that they were very different from the
stairs at her home. Multiple conversations were held with the
patient and her husband regarding her oxygen levels with
ambulation. The patient felt well and expressed the desire to
leave the hospital. They both felt confident that she would be
able to ambulate up the stairs at their home with help from her
husband if necessary. She is being discharged with home O2 for
ambulation.
.
# Cardiac: Evaluated and managed by the cardiology service
. Vessels: No hx of CAD, does have HTN/Dyslipidemia, + evidence
of new T-wave inversions after cardioversion
- Beta-blocker continued and tolerated
- No statin necessary as HDL 60, LDL 65
- started ASA therapy
. Pump: Surface Echo with + evidence of EF 35%, but > 55% on TEE
- Pump function continued to do well status post cardioversion
- Lasix Diuresis as above
. Rhythm: Patient has known hx of atrial fibrillation/flutter,
cardioversion [**11-9**] and then again today [**2180-1-21**].
- rhythm controlled with beta-blocker
- coumadin initiated
.
#. Chronic Kidney Disease: Patient appears to be near baseline
Cr.
Concern for RTA with elevated Proteinuria which is in neprotic
range, concern for possible multiple myeloma so renal service
consulted. Nephrotoxic medications avoided, all meds renally
dosed if necessary. Good urine output throughout admission. SPEP
negative and UPEP with multiple proteinaceous bands, with
predominance of albumin. Renal feels that patient needs a renal
biopsy to fully evaluate for suspicion of amyloid nephropathy.
Biopsy scheduled [**2180-3-2**]. Patient instructed to hold ASA and all
NSAIDS starting [**2-21**] and to hold coumadin one week prior to
biopsy.
.
#. S/p foot surgery. Patient did well with wet to dry dressings
and was followed by the podiatry service. Pain controlled with
percocet, morphine as needed.
.
#. EtOH use. Patient with hx heavy alcohol use. Patient given
MVI/folate/thiamine and placed on CIWA scale although did not
require any benzodiazepines throughout stay. Liver function
tests within normal limits.
.
#. Anemia. Stable at patient's baseline.
.
Patient discharged home with home O2, VNA for INR checks, and
home PT.
Medications on Admission:
Medications at home:
Metoprolol 62.5 mg tid
Warfarin 5 mg qhs
Amlodipine 10 mg qd
Sertraline 10 mg qd
Meprobamate 400 mg qhs
Ambien 10 mg qhs
Percocet 5/325 prn
Ferrous gluconate 225 mg [**Hospital1 **]
.
Meds on transfer to [**Hospital Unit Name 153**]:
Morphine prn pain
Oxycodone-acetaminophen 1-2 tabs q4-6 prn
Amlodipine 10 mg qd
Promethazine 6.25 to 12.5 mg IV prn
Sertraline 100 mg qd
Haloperidol prn
Vancomycin 1000 mg IV qd
Heparin 5000 SC tid
Warfarin 5 mg/7.5 mg PO HS
Metoprolol 62.5 mg PO qd
Zolpidem Tartrate 5-10 mg PO qhs PRN
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Warfarin 5 mg Tablet Sig: 1.5 Tablets PO DAYS (TU,TH).
Disp:*30 Tablet(s)* Refills:*2*
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime):
Take this dose Sunday, monday, wednesday, friday, and saturday.
Disp:*30 Tablet(s)* Refills:*2*
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous twice
a day.
Disp:*10 * Refills:*2*
10. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
11. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*
13. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
14. medical
Patient will need home oxygen at 2 liters by nasal cannula when
ambulating.
15. Outpatient Lab Work
Please check INR and fax results to primary care physician
16. Norvasc 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 18346**]
Discharge Diagnosis:
Aortic Stenosis
Congestive Heart Failure
Hypertension
Diabetes Mellitus
Atrial fibrillation
PVD
Discharge Condition:
Good
Discharge Instructions:
You were evaluated in the hospital for your foot surgery.
During this admission you were found to have somnolence and it
was determined that you had congestive heart failure.
Initially, your heart was in an abnormal rhythm and required
elctrical cardioversion. You were then treated with Diuretics
for fluid retention.
.
We made changes to your medication regimen, most notably your
coumadin, and you should take your medications as prescribed.
You will need to take lovenox shots as you were taught in the
hospital for a total of 5 days after leaving the hospital. You
should discuss your medication regimen with your primary care
doctor.
.
While admitted, your kidney function was found to be abnormal
with high levels of proten in your urine. You were evaluated by
the nephrologists who determined that you need a kidney biopsy.
The biopsy was scheduled for [**2180-3-2**]. You should stop taking all
aspirin and NSAID medications, like ibuprofen or advil, 10 days
prior to the biopsy, so [**2180-2-21**]. Also, one week prior to the
biopsy, you should stop all anticoagulation, like coumadin.
.
You were also found to have low oxygen saturations with physical
activity during your hospital stay. This may be due to either
progressive lung disease or congestive heart failure although
your oxygen requirements did not change with diuresis. You will
need to have oxygen when doing physical activity including
housework, walking, etc.
Weigh yourself daily and adhere to a low sodium diet.
.
See your own doctor right away or go to the ER if any problems
develop, including the following:
* Your chest pain or chest discomfort lasts longer than 5
minutes.
* Your chest pain or chest discomfort gets worse in any
way.
* You have angina and your chest pain or chest discomfort
is worse, lasts longer than usual or comes on with less
activity than usual.
* You have angina and your chest pain or chest discomfort
is not relieved by your usual medicines.
* You develop any shortness of breath, sweats, dizziness,
throwing up or nausea with your chest pain or chest
discomfort.
* Your chest pain or chest discomfort moves into your
arm, neck, back, jaw or stomach.
* Anything else that worries you.
Even if you feel better and have no further chest pain or chest
discomfort, follow-up with your own doctor this week.
The Emergency Department is open 24 hours a day for any
problems.
Followup Instructions:
You should follow-up with your regular doctor in [**12-7**] weeks. You
should call and schedule an appointment.
.
You should follow-up with Dr. [**Last Name (STitle) **] in Podiatry in one week.
You should call [**Telephone/Fax (1) 543**] to schedule an appointment.
.
You should follow-up with Dr. [**Last Name (STitle) **] in Cardiology in [**12-7**]
weeks. You should call [**Telephone/Fax (1) 285**] to schedule an appointment.
[**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) 15351**] DPM 48-114
|
[
"V58.61",
"272.4",
"291.81",
"780.09",
"250.60",
"427.31",
"996.78",
"V12.01",
"585.9",
"401.9",
"707.12",
"428.0",
"E879.8",
"424.1",
"799.02",
"276.4",
"303.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"78.68",
"88.72",
"78.67",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
11088, 11140
|
5833, 8891
|
281, 306
|
11280, 11287
|
2671, 5810
|
13795, 14347
|
2106, 2115
|
9483, 11065
|
11161, 11259
|
8917, 8917
|
11311, 13772
|
8938, 9460
|
2130, 2652
|
231, 243
|
334, 1549
|
1571, 1930
|
1946, 2090
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,454
| 115,782
|
6923
|
Discharge summary
|
report
|
Admission Date: [**2165-6-25**] Discharge Date: [**2165-7-4**]
Date of Birth: [**2095-5-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
[**First Name3 (LF) 26058**] Mitral leaflet, CAD
Major Surgical or Invasive Procedure:
Cardiac Catheterization
[**2165-6-27**] CABGx1 (SVG->OM), Mitral Valve Replacement (pericardial)
History of Present Illness:
70 y.o. female with HTN, CAD, recent PCI in [**2163**] w/ stent to
RCA, 2 days s/p discharge from [**Hospital Unit Name 196**] presents with dypsnea and
found to have acute mitral regurgitation. She was in her USOH
after her discharge from [**Hospital1 18**] 2 days ago (during which time a
pMIBI demonstrated a reversible inf/lat defect without cardiac
cath). She then quickly became markedly dyspneic and was unable
to lie flat. She presented to the ER where SBP 155, HR 112, O2
was 80% on RA and 100% on CPAP. She was given 180 IV lasix,
morphine and nitro with marked improvement in dyspnea. She was
admitted to the CCU on 2 liters O2 and a bedside echo
demonstrated severe 4+ MR [**First Name (Titles) 151**] [**Last Name (Titles) **] posterior mitral leaflet.
Past Medical History:
1. HTN
2. CAD s/p stenting (see below)
3. DM
4. s/p hip and [**Last Name (un) **] fracture secondary to fall, recently
d/c'ed from Rehab
5. former smoker
Echo [**9-17**]:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular ejection fraction is normal
(LVEF 60%); the basal segments of the inferior free wall and
posterior wall are hypokinetic. No masses or thrombi are seen in
the left ventricle. There is no ventricular septal defect. Right
ventricular
chamber size and free wall motion are normal. There are focal
calcifications in the aortic arch. The aortic valve leaflets (3)
are mildly thickened but not stenotic. 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 left ventricular inflow pattern suggests impaired
relaxation. There is no pericardial effusion.
.
Cath [**9-17**]:
1. Selective coronary angiography showed a right dominant
system with two vessel disease. The LMCA was without significant
disease. The stent in the proximal LAD was widely patent without
flow limiting stenosis. The distal LAD had a 50% stenosis. The
LCX had a 40% stenosis in its mid segment and a 60% stenosis in
its distal portion. The RCA had a patent stent proximally. The
mid RCA was subtotally occluded.
2. Successful PCI of the mid-RCA with a 3.0 x 33 mm Cypher DES.
Final angiography demonstrated no dissections, no residual
stenosis, and TIMI-3 flow.
Social History:
Patient is a housewife. She lives at home with her husband, and
her son and daughter's family live in the same house. Patient
smoked [**12-16**] PPD for 33 years, and she quit 18 years ago.
Family History:
Mother died of an MI at 86.
Father died of an accident
Sister has history of premature CAD
Physical Exam:
BP: 104/55, HR:112, RR:18, O2:100% on CPAP
Gen: HEENT MMM. lips slightly dry. No JVD. neck supple. No
appreciable lymphadenopathy. Sclerae anicteric
LUNGS: CTA B/L. No R/W/C
CV: S1 S2. Grade III/VI Systolic murmur best heard at LSB
radiating to apex and to the back.
ABD: soft NT/ND. BS +
EXT: 1+ peripheral pulses. mild ankle swelling. No C/C/or other
pedal edema.
NEURO: A/O x 3. Motor [**4-18**]. [**Last Name (un) **]:GI to LT. CN II-XII GI.
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2165-7-3**] 05:25AM 28.8*
[**2165-7-2**] 05:59AM 6.9 3.13* 9.5* 27.3* 87 30.4 34.8 13.9
290
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2165-7-3**] 05:25AM 3.9
[**2165-7-2**] 05:59AM 112* 9 0.3* 135 3.9 98 301 11
Brief Hospital Course:
After surgery was able to be transferred to the SICU in critical
but stable condition on epi, milrinone and neo. She was
extubated by post operative day one. He drips were weaned to off
and she was transferred to the step down unit by post op day
four. She had no complications post operatively and was ready
for discharge to rehab.
Medications on Admission:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ranitidine HCl 75 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
7. Avandia 4 mg Tablet Sig: One (1) Tablet PO once a day.
8. Glucophage 500 mg Tablet Sig: One (1) Tablet PO twice a day.
9. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
10. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Medications:
1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours).
Disp:*120 Capsule, Sustained Release(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
Disp:*45 Tablet(s)* Refills:*2*
7. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
12. 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*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 246**] Nursing Center - [**Location (un) 246**]
Discharge Diagnosis:
CAD, MR, EF 40%
s/p PCIx3
DM
hyperlipidemia
HTN
Discharge Condition:
Good.
Discharge Instructions:
No driving or lifting until follow up appointment with surgeon
or while taking pain medication.
Call with temperature greater than 100.5, redness or drainage
from incision, weight gain more than 2 pounds in one day or five
in one week.
[**Month (only) 116**] shower, wash incision with mild soap and water, pat dry. No
creams, lotions, powders, no baths.
Followup Instructions:
Dr. [**Last Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) 26056**] 2 weeks
Dr. [**Last Name (STitle) 26059**] 2 weeks
Completed by:[**2165-7-4**]
|
[
"414.01",
"428.0",
"410.72",
"424.0",
"401.9",
"V45.82",
"518.82",
"250.00",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.23",
"37.61",
"39.61",
"93.90",
"37.23",
"97.44",
"36.11",
"38.93",
"88.72",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
6585, 6676
|
3983, 4318
|
335, 434
|
6768, 6775
|
3615, 3960
|
7178, 7332
|
3040, 3132
|
5156, 6562
|
6697, 6747
|
4344, 5133
|
6799, 7155
|
3147, 3596
|
247, 297
|
462, 1234
|
1256, 2817
|
2833, 3024
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,154
| 168,626
|
54531
|
Discharge summary
|
report
|
Admission Date: [**2128-4-18**] Discharge Date: [**2128-4-22**]
Date of Birth: [**2055-10-11**] Sex: M
Service:
HISTORY OF THE PRESENT ILLNESS: This is a 73-year-old
gentleman, who presented with a cerebrovascular accident on
the [**2128-2-1**]. He developed left hand and foot
numbness. He also had repeated episodes of left facial droop
and left hand tingling; most recent being seven days before
and also for possible carotid stenting.
PAST MEDICAL HISTORY:
1. Hypercholesterolemia for the last twenty years.
2. Cerebrovascular accident on the [**1-28**]. Diabetes mellitus.
4. Bilateral carotid stenosis.
MEDICATIONS ON ADMISSION:
1. Coumadin
2. Actos.
3. Avelide.
4. Pravachol.
5. Celexa.
6. Colace.
ALLERGIES: The patient had no drug allergies.
PHYSICAL EXAMINATION: On examination the temperature was
98.4, heart rate 67, blood pressure 120/68; oxygen saturation
95 on room air. Neurological examination was normal.
On admission, the Coumadin was held and he was started on IV
heparin for angiography and he was started on daily aspirin and
Plavix in preparation for possible stent placement.
Angiogram was done on the [**2128-4-20**] and also left
carotid bifurcation stenting was performed. The patient
tolerated the procedure well. He was in the ICU overnight for
monitoring. He was transferred to the floor the next day. He
was started on Plavix and aspirin.
The rest of his hospital course was uneventful, and he was
discharged on the [**2128-4-22**]. He was instructed to
continue the Plavix and aspirin. Heparin was discontinued as
was the Coumadin. He was advised to followup with Dr. [**Last Name (STitle) 1132**]
in three weeks. He was discharged home in stable condition.
FINAL DIAGNOSIS: Bilateral carotid stenosis status post
left carotid bifurcation stent placement.
[**Location (un) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D.
Dictated By:[**Name8 (MD) 7075**]
MEDQUIST36
D: [**2128-4-22**] 11:50
T: [**2128-4-22**] 12:30
JOB#: [**Job Number 111563**]
|
[
"438.89",
"250.00",
"782.0",
"433.30",
"V58.61",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"39.90",
"39.50"
] |
icd9pcs
|
[
[
[]
]
] |
662, 787
|
1757, 2092
|
810, 1738
|
484, 636
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,915
| 123,002
|
15144
|
Discharge summary
|
report
|
Admission Date: [**2192-6-13**] Discharge Date: [**2192-6-28**]
Date of Birth: [**2137-7-9**] Sex: M
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 44143**] is a gentleman who is
suffering from micrometastatic esophageal cancer with
dysphagia. He had undergone test treatment with
chemotherapy, but instead chose to undergo
esophagogastrectomy for failure to relieve his progressive
dysphagia. Micrometastases were seen by PET scan.
EXAMINATION: The patient is a thin male in no apparent
distress. Cervical examination reveals no adenopathy. Eye
examination reveals the sclerae are anicteric. Lungs are
clear. Heart is regular without murmur. Thorax shows no
asymmetry or lesions. Abdomen is without mass. The
extremities have no edema. He does have clubbing, but states
that this has been present throughout his life. Skin shows
no lesions or cyanosis. Neurologically is grossly nonfocal
and intact and appropriate mental status.
LABORATORY: On admission, the patient's white count was 10.7
with a hematocrit of 36, PT 13.1, PTT 20.3, platelets 174,
INR 1.1. BUN and creatinine were 14 and 1.2, respectively.
At the time of discharge, the patient's white count was 11.7,
with a hematocrit of 33.0, platelet count 208. His BUN and
creatinine were 28 and 1.0, respectively. Otherwise, his
electrolytes were normal.
HOSPITAL COURSE: The patient was admitted on [**6-13**] and
underwent an [**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **] esophagogastrectomy. He was taken to
the Cardiothoracic Surgical Intensive Care Unit
postoperatively where he remained intubated and sedated. He
was started on enteral nutrition with tube feeds, and was
also on inotropes in the ICU. He did develop a pneumonia
which was treated with antibiotics, and upon resolution the
patient was transferred to the regular floor where he did
well. The only notable problem was a few episodes of
agitation which were relieved by change in patient's
medication regimen.
In terms of procedures, the patient underwent percutaneous
tracheostomy, [**Doctor Last Name 12351**] [**Doctor Last Name **] esophagogastrectomy, feeding
jejunostomy, and bronchoscopy. He was in good condition at
the time of discharge.
DISCHARGE DIAGNOSIS: 1) Esophageal cancer, status post
esophagogastrectomy. 2) Pneumonia. 3) Intermittent atrial
fibrillation/ventricular tachycardia. 4) Status post
myocardial infarction.
DISCHARGE MEDICATIONS: 1) albuterol sulfate ipratropium
inhaler, 2) ibuprofen 400 mg 1 q 6 h, 3) ranitidine, 4)
aspirin, 5) captopril 12.5 mg po tid, 6) amiodarone 200 mg 2
tablets po bid, 7) percocet 525/5 ml, [**5-5**] ml po q 4-6 h as
needed.
FOLLOW-UP: He is supposed to follow-up with Dr. [**Last Name (STitle) 952**] in 2
weeks.
FOLLOW-UP INSTRUCTIONS: As given in the patient handout.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Last Name (NamePattern1) 44144**]
MEDQUIST36
D: [**2192-6-28**] 12:03
T: [**2192-6-28**] 11:11
JOB#: [**Job Number 44145**]
cc:[**Hospital6 44146**]
|
[
"518.5",
"997.1",
"197.7",
"196.1",
"516.8",
"151.0",
"276.2",
"428.0",
"427.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"33.29",
"33.21",
"43.99",
"46.39",
"96.72",
"46.51",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
2494, 2809
|
2298, 2470
|
1409, 2276
|
183, 1391
|
2834, 3173
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,611
| 184,054
|
26236
|
Discharge summary
|
report
|
Admission Date: [**2179-6-16**] Discharge Date: [**2179-6-24**]
Date of Birth: [**2112-1-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
CHF, increasing DOE
Major Surgical or Invasive Procedure:
AVR/cabg x1 [**2179-6-17**] (21mm St. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 9041**] porcine valve, SVG
to OM)
History of Present Illness:
67 yo male with metastatic renal cell CA, s/p left nephrectomy,
found to have AS in [**2171**]. He was followed by serial echos and
had increasing DOE with CHF. Hospitalized in [**4-26**] with [**Date Range **]
heart failure. Recommended for AVR so pt. could undergo newer
treatments for metastatic disease. Cath revealed 80% OM 1, 80%
OM 2, RCA 90%. Prior echo showed marked LVH, EF 60-65%, severe
AS, mild to moderate MR, mild TR, [**Doctor Last Name **]. Referred for AVR/CABG.
Past Medical History:
1) HTN
2) Hyperlipidemia
3) Gout
4) Aortic stenosis - ECHO [**2177-6-19**] (1.1 area, 24 mean gradient)
5) CRI
PSHX
1) Cataract surgery
2) Knee arthroscopy
ONCOLOGIC HISTORY:
[**2171**] - Mr. [**Known lastname 64996**] presented with hematuria and clot retention. A
CT scan revealed a 7 cm x 6 cm x 5 cm left renal clear cell
cancer with focal sarcomatoid features, grade III-IV with no
capsular perivascular, or renal vein invasion.
[**10/2176**]-CT scan revealed development of 1 cm left lung nodule in
the left lung pleural-based density at the costophrenic angle.
There was also a new 10 cm mass in the left adrenal gland.
[**5-/2177**] - developed a left parotid gland mass and increased
adrenal
mass as well as lung nodules. FNA of the left parotid mass was
nondiagnostic.
[**2177-10-27**] - underwent superficial parotidectomy and pathology
was
consistent with metastatic renal cell carcinoma. He was
ineligible for the sorafenib/bevacizumab trial and for high-dose
IL-2 given his ventricular tachycardia in ETT.
[**1-/2178**] - Started off protocol sorafenib with PR. However, his
left
parotid mass demonstrated enlargement during the interval
between
[**2178-4-20**] and [**2178-6-20**] during which his remainder of systemic
disease got smaller.
[**7-/2178**] - 2400 cGy of radiation via CyberKnife over a 3-day
period
to the left parotid mass.
[**3-27**] - Sorafenib discontinued due to disease progression.
[**2179-4-27**] - Started on Perifosin protocol 06-408
sleep apnea with CPAP x 3 years
Social History:
Social history is significant for the absence of current tobacco
use, but quit 35 yrs ago (smoked 2ppd for 20 yrs). There is no
history of alcohol abuse, but drinks occasionally, wine and
beer.
Family History:
Mother with MI at 55, father with MI at 40, died at 50 from MI.
Brother with CABG x 3 approximately 10 yrs ago.
Physical Exam:
Admission
Ht 5'4" Wt 180#
Gen:NAD
VS: HR 54 RR 18 right 135/64 left 124/70
HEENT: PERRL/EOMI, scar below left ear healed
neck supple, with full ROM
Pulm: CTAB anteriorly (on bedrest post-cath)
CV: RRR 3/6 SEM; murmur transmits to carotids bilat
Abd: soft, NT, ND, no palpable masses, + BS
Ext:warm, well-perfused;1+ LLE non-pitting edema;no varocisities
noted.
Pulses: 2+ bilat Fem/DP/PT/Radial
Neuro: nonfocal exam, alert and oriented x 3
Discharge
VS: 98.8 71SR 100/56 18 92%/RA
Gen: NAD
Neuro: A&Ox3 nonfocal
Pulm: CTA bilat
CV: RRR Sternum stable, incision CDI
Abdm: soft, NT/ND/+BS
Ext: warm, trace edema bilat
Pertinent Results:
[**2179-6-21**] 06:30AM BLOOD WBC-6.6 RBC-3.03* Hgb-9.8* Hct-28.5*
MCV-94 MCH-32.2* MCHC-34.2 RDW-15.2 Plt Ct-170#
[**2179-6-21**] 06:30AM BLOOD Plt Ct-170#
[**2179-6-20**] 06:15AM BLOOD Glucose-114* UreaN-22* Creat-1.5* Na-132*
K-4.0 Cl-93* HCO3-31 AnGap-12
[**2179-6-20**] 06:15AM BLOOD Calcium-8.5 Phos-4.3 Mg-2.4
[**2179-6-16**] 01:55PM BLOOD %HbA1c-5.9
Hematology
Test Name Value Units Reference Range
[**2179-6-24**] 07:05AM
BASIC COAGULATION (PT, PTT, PLT, INR)
PT 14.6* sec 10.4 - 13.1
PERFORMED AT WEST STAT LAB
INR(PT) 1.3* 0.9 - 1.1
PERFORMED AT WEST STAT LAB
Test Name Value Units Reference Range
[**2179-6-24**] 07:05AM
RENAL & GLUCOSE
Glucose 97 mg/dL 70 - 105
PERFORMED AT WEST STAT LAB
Urea Nitrogen 28* mg/dL 6 - 20
PERFORMED AT WEST STAT LAB
Creatinine 1.6* mg/dL 0.5 - 1.2
PERFORMED AT WEST STAT LAB
Sodium 135 mEq/L 133 - 145
PERFORMED AT WEST STAT LAB
Potassium 4.8 mEq/L 3.3 - 5.1
PERFORMED AT WEST STAT LAB
Chloride 98 mEq/L 96 - 108
PERFORMED AT WEST STAT LAB
Bicarbonate 29 mEq/L 22 - 32
PERFORMED AT WEST STAT LAB
Anion Gap 13 mEq/L 8 - 20
ESTIMATED GFR (MDRD CALCULATION)
Estimated GFR (MDRD equation)
Using this patient's age, gender, and serum creatinine value
of 1.6,
Estimated GFR = 43 if non African-American (mL/min/1.73 m2)
Estimated GFR = 52 if African-American (mL/min/1.73 m2)
For comparison, mean GFR for age group 60-69 is 85 (mL/min/1.73
m2)
GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure
Cardiology Report ECHO Study Date of [**2179-6-17**]
PATIENT/TEST INFORMATION:
Indication: avr/cabg
Status: Inpatient
Date/Time: [**2179-6-17**] at 09:24
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW1-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) 1112**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
MEASUREMENTS:
Left Ventricle - Inferolateral Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.5 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 50% to 55% (nl >=55%)
Aorta - Ascending: 3.2 cm (nl <= 3.4 cm)
Aorta - Descending Thoracic: 2.4 cm (nl <= 2.5 cm)
Aortic Valve - Peak Gradient: 54 mm Hg
Aortic Valve - LVOT Diam: 1.9 cm
Aortic Valve - Valve Area: *0.6 cm2 (nl >= 3.0 cm2)
Mitral Valve - Mean Gradient: 3 mm Hg
Mitral Valve - MVA (P [**12-22**] T): 4.7 cm2
INTERPRETATION:
Findings:
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LV WALL MOTION: basal anterior - normal; mid anterior - normal;
basal
anteroseptal - normal; mid anteroseptal - normal; basal
inferoseptal - normal; mid inferoseptal - normal; basal inferior
- normal; mid inferior - normal; basal inferolateral - normal;
mid inferolateral - normal; basal anterolateral - normal; mid
anterolateral - normal; anterior apex - normal; septal apex -
normal; inferior apex - normal; lateral apex - normal; apex -
normal;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Normal descending aorta
diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: ?# aortic valve leaflets. Severely
thickened/deformed aortic
valve leaflets. Severe AS (AoVA <0.8cm2). Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to
moderate ([**12-22**]+) MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. No TEE related complications. The TEE probe was
passed with assistance from the
anesthesioology staff using a laryngoscope. The patient was
under general
anesthesia throughout the procedure.
Conclusions:
Pre-CPB: No spontaneous echo contrast is seen in the left atrial
appendage. Right ventricular chamber size and free wall motion
are normal. There are simple atheroma in the descending thoracic
aorta. The number of aortic valve leaflets cannot be determined.
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. Mild to moderate ([**12-22**]+) mitral regurgitation
is seen. There is no pericardial effusion.
Post-CPB: A prosthetic aortic valve is in place. Leaflets cannot
be
individually discerned. C.O. is 5.5, but a large residual
gradient (40) exists across the valve. No [**Male First Name (un) **]. Aorta intact. MR
is 1+. Good biventricular systolic fxn. Other parameters as
pre-bypass.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD on [**2179-6-18**] 10:24.
[**Location (un) **] PHYSICIAN:
([**Numeric Identifier 64997**])
RADIOLOGY Final Report
CHEST (PA & LAT) [**2179-6-20**] 9:57 AM
CHEST (PA & LAT)
Reason: r/o intrathoracic bleed
[**Hospital 93**] MEDICAL CONDITION:
67 year old man with AS, CAD
REASON FOR THIS EXAMINATION:
r/o intrathoracic bleed
STUDY: PA and lateral chest, [**2179-6-20**].
HISTORY: 67-year-old man with aortic stenosis. Evaluate for
intrathoracic bleed.
FINDINGS: Comparison is made to the previous study from [**2179-6-18**].
Median sternotomy wires and surgical skin staples are again
seen. There is stable cardiomegaly. There is improved aeration
at the left retrocardiac region since the previous study. There
is an unchanged 3 cm mass in the right upper lobe which is
better evaluated on the previous chest CTs.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: SUN [**2179-6-20**] 2:40 PM
Brief Hospital Course:
Admitted [**6-16**] and cath done revealing AS and CAD. Underwent
AVR/cabg x1 with Dr. [**Last Name (STitle) **] on [**6-17**]. Transferred to the CSRU in
stable condition on neosynephrine and propofol drips. Extubated
that afternoon and chest tubes removed on POD #1. Beta blockade
and diuretics started and pt transferred to the floor on POD #2
to begin increasing his activity level. Pacing wires removed
without incident. Pt had intermittent episodes of Atrial
fibrillation requiring beta blockade titration, amiodarone and
anticoagulation. Over the next several days the patients
activity was advanced, his INR monitored and coumadin dose
adjusted. On POD7 the patient was discharged home. His INR is to
be followed by [**Name (NI) 64998**] coumadin clinic, 1st visit Monday [**6-28**].
Medications on Admission:
allopurinol 200 mg daily
metoprolol 200 mg daily
lasix 20 mg daily
lipitor 20 mg QPM
norvasc 10 mg daily
ASA 325 mg daily
essiac one ounce daily
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] HH and Hospice
Discharge Diagnosis:
CAD/AS s/p AVR/cabg x1
metastatic renal cell carcinoma s/p left nephrectomy
diastolic CHF
HTN
elev. lipids
left knee gout
prior knee arthroscopy
prior bil.cataract surgeries
prior left carpal tunnel surgery
prior left parotidectomy with Cyberknife radiation
Discharge Condition:
stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
no driving for one month
no lifting greater than 10 pounds for 10 weeks
no lotions, creams, ointments, or powders
call surgeon for fever greater than 100.5, redness, or drainage
shower daily and pat dry incisions, no baths
Followup Instructions:
see Dr. [**First Name (STitle) **] in [**1-23**] weeks
see Dr. [**Last Name (STitle) 171**] in [**1-23**] weeks
see Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**],
see your oncologist Dr. [**Last Name (STitle) 1729**] in [**1-23**] weeks
Pt to call for all appointments
Completed by:[**2179-6-24**]
|
[
"274.9",
"V10.52",
"V15.82",
"414.01",
"285.29",
"593.9",
"272.4",
"401.9",
"780.57",
"V45.61",
"428.0",
"197.0",
"198.89",
"424.1",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"39.61",
"88.56",
"37.22",
"88.53",
"35.22",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
10288, 10354
|
9300, 10093
|
297, 440
|
10658, 10667
|
3499, 5015
|
11039, 11363
|
2711, 2825
|
8559, 8588
|
10375, 10637
|
10119, 10265
|
10691, 11016
|
5041, 8342
|
2840, 3480
|
238, 259
|
8617, 9277
|
468, 950
|
8374, 8522
|
972, 2484
|
2500, 2695
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,566
| 162,451
|
23483
|
Discharge summary
|
report
|
Admission Date: [**2163-2-17**] Discharge Date: [**2163-3-1**]
Date of Birth: [**2121-9-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2163-2-18**] CABGx4(LIMA->LAD, SVG->OM, PDA, distal LCX seq)
History of Present Illness:
44 yo M came to ED with SOB and increased cardic enzymes earlier
this month, treated for pneumonia. Could not get cardiac cath
due to elevated creatinine, and was sent home with appointment
for cath. Again went to PCP with SOB. Was admitted for cath, was
fluid overloaded for awaited diuresis prior to cath on [**2-17**]
which showed 3VD and he was referred for CABG.
Past Medical History:
1)CAD/Systolic Congestive Heart Failure/Ischemic Cardiomyopathy
2)Type II DM - diabetic Neuropathy, Nephropathy, and Retinopathy
3)PVD - s/p bilateral TMA, s/p fem [**Doctor Last Name **] bypass, s/p fem ant
tibial bypass
4)History of Pancreatitis - s/p surgery
5)Gout
6)Hyperlipidemia
7)History of Recurrent LE Cellulitis
Social History:
Active smoker, [**2-2**] pack per day. Denies ETOH. Disabled
Family History:
Denies premature CAD.
Physical Exam:
NAD HR 81 RR 21 BP 143/70
Gen: NAD
HEENT: EOMI, PERRLA
Neck: Supple, FROM
Lungs CTAB
Heart RRR
Abd: Distended soft, nontender
Extrem with 2+ edema, bilateral TMAs, right DP/PT pulses
dopplerable
Neuro: Intact, MAE, A&O x 3
Pertinent Results:
[**2-27**] CXR: Two views. Comparison with [**2163-2-25**]. A small right
pleural effusion and moderate left pleural effusion are again
demonstrated. There is consolidation in the left lower lobe as
noted previously. The patient is status post median sternotomy
and CABG as before. Mediastinal structures are unchanged in
appearance. The bony thorax is grossly intact. A right internal
jugular catheter remains in place.
Echo [**2-18**]: PREBYPASS: 1. No atrial septal defect is seen by 2D
or color Doppler. There is severe regional left ventricular
systolic dysfunction with severe hypokinesia of the inferior and
inferoseptal walls.. Overall left ventricular systolic function
is severely depressed (LVEF= 30 %). 2. RV shows mild global free
wall hypokinesis. 3. There are simple atheroma in the descending
thoracic aorta. 4.The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. 5.The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. Post
Bypass: 1. Patient is being a- paced and receiving an infusion
of Norepinephrine and Milrinone.
2. LV function slightly improved. RV function slightly improved.
3. Aorta intact post decannulation.
[**2163-2-18**] Carotid Ultrasound and Vein Mapping: 1. No significant
right ICA stenosis (graded as less than 40%). 2. 40-59% left ICA
stenosis. 3. Bilateral greater saphenous vein harvest, lesser
saphenous veins appear patent.
[**2163-2-18**] Aterial Upper Extremity Study: Radial artery
compression eliminates all waveforms on both the right and the
left, i.e., at the first and fifth digit. Compression of the
ulnar artery on both the left and right failed to have any
effect on the waveforms of the first or fifth digit. IMPRESSION:
Findings as stated above which indicate bilateral radial artery
dominance.
[**2163-2-17**] 05:48PM BLOOD WBC-9.2 RBC-3.37*# Hgb-9.9*# Hct-29.9*
MCV-89 MCH-29.3 MCHC-33.1 RDW-15.4 Plt Ct-340
[**2163-2-20**] 01:30AM BLOOD WBC-13.2* RBC-2.76* Hgb-8.1* Hct-24.1*
MCV-87 MCH-29.3 MCHC-33.5 RDW-14.8 Plt Ct-190
[**2163-2-23**] 05:13AM BLOOD WBC-7.6 RBC-3.32* Hgb-9.9* Hct-28.6*
MCV-86 MCH-29.9 MCHC-34.7 RDW-15.3 Plt Ct-236
[**2163-3-1**] 04:50AM BLOOD WBC-14.4* RBC-3.30* Hgb-9.2* Hct-28.4*
MCV-86 MCH-28.0 MCHC-32.6 RDW-14.3 Plt Ct-538*
[**2163-2-17**] 05:48PM BLOOD PT-12.1 PTT-27.0 INR(PT)-1.0
[**2163-2-23**] 05:13AM BLOOD PT-12.7 PTT-29.7 INR(PT)-1.1
[**2163-2-17**] 05:48PM BLOOD Glucose-132* UreaN-41* Creat-1.9* Na-137
K-4.7 Cl-101 HCO3-28 AnGap-13
[**2163-2-21**] 03:06AM BLOOD Glucose-101 UreaN-54* Creat-3.3* Na-136
K-4.9 Cl-103 HCO3-22 AnGap-16
[**2163-3-1**] 04:50AM BLOOD Glucose-98 UreaN-79* Creat-2.8* Na-134
K-4.9 Cl-94* HCO3-30 AnGap-15
[**2163-2-27**] 06:30AM BLOOD Calcium-8.7 Phos-3.2# Mg-1.9
Brief Hospital Course:
Mr. [**Known lastname 55810**] was admitted under cardiac surgery and underwent
preoperative evaluation. Carotid ultrasound revealed mild to
moderate carotid disease while vein mapping showed patent lesser
saphenous vein(see result section). Arterial upper extremity
study indicated bilateral radial artery dominance. Other than
his chronic renal insufficiency, preoperative evaluation was
otherwise unremarkable and he was cleared for surgery. On
[**2-18**], Dr. [**First Name (STitle) **] performed 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. He was
intermittently transfused to maintain hematocrit near 30% and
was slow to wean from inotropic support. He temporarily required
a Lasix drip for effective diuresis. He was noted to have
episodes of atrial fibrillation and was started Amiodarone and
beta blockade. He had further decline in renal function. His
creatinine peaked to 3.3 on postoperative day three. He
otherwise made gradual improvements and eventually transferred
to the SDU on postoperative day five. His renal function
gradually improved. He remained in a normal sinus rhythm without
further episodes of atrial fibrillation. He was started on
antibiotics for urinary tract infection on post-op day ten. He
appeared to be doing well and on post-op day eleven was
discharged home with VNA services and the appropriate follow-up
appointments.
Medications on Admission:
lantus 100 QAM, HISS, plavix 75', tricor 145', pletal 100",
lipitor 40', ASA 325', Albuterol prn
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. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
Disp:*30 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
Take 400mg qd for 1 week. Then 200mg qd until stopped by
cardiologist.
Disp:*60 Tablet(s)* Refills:*1*
8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
9. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
10. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
12. Insulin Glargine 100 unit/mL Solution Sig: One Hundred (100)
units Subcutaneous once a day.
Disp:*3000 units* Refills:*0*
13. Insulin Lispro 100 unit/mL Solution Sig: sliding scale units
Subcutaneous four times a day.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
Systolic Congestive Heart Failure
Postoperative Atrial Fibrillation
Carotid Disease
PMH:
Chronic Renal Insufficiency
Type II DM - diabetic Neuropathy, Nephropathy, and Retinopathy
PVD - s/p bilateral TMA, s/p fem [**Doctor Last Name **] bypass, s/p fem ant tibial
bypass
History of Pancreatitis
Gout
Discharge Condition:
Good
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon or while taking narcotic
pain medicine.
Followup Instructions:
Dr. [**Last Name (STitle) **] 2 weeks - call for appt
Dr. [**First Name (STitle) **] 4 weeks - call for appt
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2163-4-14**]
9:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2163-4-14**] 10:00
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2163-3-1**]
|
[
"997.1",
"599.0",
"250.40",
"998.0",
"250.50",
"707.03",
"413.9",
"357.2",
"518.5",
"414.01",
"250.60",
"585.9",
"V49.73",
"428.22",
"428.0",
"362.01",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"38.93",
"36.13",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7590, 7605
|
4295, 5880
|
295, 360
|
8009, 8015
|
1480, 4272
|
8367, 8852
|
1199, 1222
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6027, 7567
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7626, 7988
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5906, 6004
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8039, 8344
|
1237, 1461
|
236, 257
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388, 757
|
779, 1105
|
1121, 1183
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,035
| 168,760
|
14741
|
Discharge summary
|
report
|
Admission Date: [**2187-11-13**] Discharge Date: [**2187-11-15**]
Date of Birth: [**2120-10-20**] Sex: F
Service: RADIOLOGY
Allergies:
Sulfa (Sulfonamides) / Amoxicillin / Percocet
Attending:[**First Name3 (LF) 25590**]
Chief Complaint:
renal artery angioplasty complicated by thrombus
Major Surgical or Invasive Procedure:
angioplasty [**2187-11-13**] complicated by renal artery thrombosis,
status post 24 hour ICU stay for thrombolysis with tPA and
heparin.
angioplasty re-attempt [**2187-11-14**], no intervention (procedure
aborted secondary to suboptimal approach)
History of Present Illness:
Pt is a 67 yo female with DMII, HTN, renal artery stenosis, who
is s/p angioplasty yesterday with resultant thombus in renal
artery noted on angiogram, s/p tPA and heparin in MICU, observed
overnight with Hct stable, VSS. She went back to IR again today
for possible restenting, however, the approach was felt to be
not adequate for stenting, procedure aborted. Plan by IR was to
have pt watched overnight, discharged in AM, to follow up at a
later date for re-stenting.
.
As far as her history of HTN and RAS, the pt reports she has
always had elevated blood pressure. It was first noted when she
was pregnant and over the years since her BP has consistently
been elevated, up to 220/110 [**First Name8 (NamePattern2) **] [**Last Name (un) **] records. Until 10 years
ago, BPs were in the 180s-190s/90s on a hefty medication regimen
and more medications were subsequently added (not noted which
[**First Name8 (NamePattern2) **] [**Last Name (un) **] records). BPs diastolic improved, but systolics
remained elevated 160s-170s.
.
In [**2184**], pt underwent angioplasty without stenting of her right
kidney as she was found to have renal artery stenosis, thought
[**1-3**] FMD. BP improved to the 120s systolic, but this lasted only
1 month. Later, an angiogram in [**3-/2185**] showed no large vessel
stenosis in renal aa. but right kidney was 9.1 cm and left one
was 11.7 cm. She had an abdominal CT scan for eval of abd pain
in [**4-/2186**] showing an atrophic right kidney (unclear the size).
Repeat MRA at the end of [**Month (only) 359**] demonstrated beading and
narrowing of right renal artery with extension in to the
branches. Her serum creatinine has been in the range of
0.7-0.9. She has had no albuminuria on [**Last Name (un) **].
.
Yesterday, around noon, a thrombus was noted on angiogram.
Simultaneously, pt also had a vasovagal episode, was put in
trendelenberg, given IVF, and give one mg of atropine. She was
given [**2181**] units of intra-arterial heparin, and 11 mg of tPA in
divided doses.
.
She was completely stable overnight, with hcts 28 to 30 the last
24 hours. Her VSS. She is being called out to the medical
floor in stable condition. Her ROS is negative for:
CP/SOB/palpitations. No nausea/vomiting/abd pain/constipation.
No numbness or tingling in extremities or weakness. Has been in
lying position since IR procedure, sheath removed at 1pm. Pt
able to sit up to 30 degrees at 6pm. C/o intermittent low back
pain from lying down for 'so many hours.' She is also c/o
hunger, wants to eat.
Past Medical History:
Diabetes mellitus
Hypertension
s/p H pylori eradication (had allergy to amoxicillin then);
repeat endoscopy cx showed gone
s/p ovarian cyst removal at age 16
s/p hysterectomy at 30
s/p CCY in [**2177**]; ovarian pathology seen and s/p oophorectomy
s/p fixation of hernia after laporotomy
s/p melanoma in situ removed from left shoulder-two months ago
Bilateral cataracts
Social History:
Married, four children. Lives in [**Location **], MA. Never smoked.
No alcohol. No IVDA.
Family History:
Mother- DM, HTN, CHF, died in her 80s. Father-died in 60s with
MI, DM. Brother died at age 39, MI and DM. Both paternal and
maternal grandmothers had [**Name2 (NI) **].
Physical Exam:
VS: Tm: 98.6 Tc: 98.6 BP: 138/43 RR: 16 O2sat: 95-99% RA. I/O
[**Telephone/Fax (1) 43382**] for net negative 779.
Gen: Well appearing CF in NAD. WNWD. AOX3, [**Location (un) 1131**] a book.
Pleasant and cooperative.
HEENT: PERRL, EOMI. No scleral icterus. MMM, OP clear.
Neck: no lymphadenopathy, no JVP appreciated.
CV: RRR S1 and S2 audible, no murmurs, rubs or gallops
Lungs: CTAB anteriorly
Abd: Soft, NT ND, obese, positive bowel sounds, no masses. No
organomegaly. Midline lower scar present and RUQ scar present.
Back: could not examine as patient must lie flat
Ext: WWP, DP/radial/PT 2+ bilaterally, no edema, right groin
with catheter removed, bandaid in place, minimal bleeding. No
palpable hematoma. No bruits.
Pertinent Results:
[**2187-11-13**] 07:42AM WBC-5.2 RBC-3.96* Hgb-12.8 Hct-34.4* MCV-87
MCH-32.3* MCHC-37.1* RDW-13.8 Plt Ct-247
[**2187-11-13**] 03:09PM WBC-9.1# RBC-UNABLE TO Hgb-11.7* Hct-34*
MCV-UNABLE TO MCH-UNABLE TO MCHC-UNABLE TO RDW-UNABLE TO Plt
Ct-240
[**2187-11-13**] 05:39PM Hct-31.7*
[**2187-11-13**] 08:00PM Hct-30.9*
[**2187-11-14**] 05:57AM Hct-28.7*
[**2187-11-14**] 11:04AM WBC-10.1 RBC-3.39* Hgb-11.0* Hct-28.8* MCV-85
MCH-32.3* MCHC-38.0* RDW-13.7 Plt Ct-235
[**2187-11-14**] 05:47PM WBC-9.7 RBC-3.46* Hgb-11.3* Hct-30.3* MCV-88
MCH-32.6* MCHC-37.2* RDW-13.8 Plt Ct-264
[**2187-11-15**] 05:30AM WBC-9.8 RBC-3.22* Hgb-10.6* Hct-28.4* MCV-88
MCH-32.7* MCHC-37.2* RDW-13.5 Plt Ct-233
[**2187-11-13**] Glucose-191* UreaN-14 Creat-0.7 Na-142 K-3.8 Cl-108
HCO3-25 AnGap-13
[**2187-11-15**] Glucose-125* UreaN-12 Creat-0.9 Na-140 K-4.4 Cl-106
HCO3-25 AnGap-13
.
Radiology:
MRA kidney with and without contrast [**2187-9-27**]-
1. Beaded appearance of the right main renal artery extending
into two main branch vessels, suggestive of fibromuscular
dysplasia. Greater than 50% stenosis is noted at the main branch
point, which is approximately 2.5 cm from the aorta.
2. Patent left main and left lower pole accessory renal
arteries.
3. Marked parenchymal tissue loss of the right lower pole,
likely from prior ischemic insult.
4. 11-mm cystic lesion in the pancreatic head. Differential
includes
pseudocyst or possible intraductal papillary mucinous tumor
(IPMT). A followup study in six months is recommended to ensure
stability.
5. Narrowed celiac ostium is likely from expiratory compression
and is of little concern in the absence of related symptoms;
please correlate clinically.
.
Abd CT: right kidney with 2 x 2 cm lesion (Area of the right
kidney with increased contrast accumulation and irregular
cortex, which may represent an intraparenchymal hematoma or
reperfusion injury. No other hematoma).
.
[**2187-11-14**] RENAL ANGIOGRAM REPORT
IMPRESSION: Follow up angiography after overnight thrombolysis
demonstrated good renal artery perfusion with no evidence of
residual thrombus. There is beading of the distal main renal
artery and its proximal branch vessels consistent with
fibromuscular dysplasia as was demonstrated on the prior
angiogram from yesterday.
The patient should return to their antihypertensive regimen as
was being taken prior to the procedure.
Brief Hospital Course:
Impression/Plan: Pt is a 67 yo female with DM, HTN, renal artery
stenosis, who is s/p renal artery angioplasty complicated by
right renal artery thrombus, also s/p re-attempt today at
stenting, aborted procedure [**1-3**] suboptimal approach. Plan by IR
is to discharge and take back for follow up appt for another
attempt at stenting after the [**Holiday **] holidays (per pt
preference).
.
1. Renal artery thrombus- The patient was taken to the ICU for
tPA and heparin thrombolysis of the renal artery thrombus that
complicated her initial angioplasty on [**2187-11-13**]. The pt
tolerated the heparin and tPA without complications. The
following day, she was taken back to Interventional Radiology
for a re-look with possible restenting/angiogram, and it was
noted the thrombus was resolved, however the approach was
technically suboptimal (see report), and the procedure was
aborted. The plan is to have the pt return as an outpatient at
her convenience to have the procedure attempted again. She was
given the phone numbers for which to schedule an appt with IR.
She is currently with normal renal function, no CKD, with a
baseline creat of 0.7. Her right groin site was without
hematoma, bleeding or bruit. The sheath was removed without
complications.
.
2. Low Back Pain- Her back pain was believed to be secondary to
lying flat for several hours while her procedures was being
done. Her pain was musculoskeletal in nature, improved with
positional changes. Abdominal CT ruled out retroperitoneal
bleed. H/o apendectomy and cholecystectomy in the past. Pain
relieved with tylenol, and resolved by discharge.
.
3. Diabetes mellitus: She was restarted on her outpt regimen of
humalog 75/25 with 8 units at breakfast and 18 units at
dinnertime. Her blood sugars were stable and she was tolerating
po well.
.
4. HTN- well controlled. Etiology: secondary to renal artery
stenosis [**1-3**] FMD.
We continued her atenolol 100mg po qd, and restarted her
valsartan 320mg po qAM and 160mg po qPM, and her HCTZ 25mg po qd
after her procedure. Essentially, she is on the same
medications for blood pressure as she was on prior to procedure.
Her first procedure was complicated by a thrombus, so no
stenting. Her second procedure was a suboptimal approach,
therefore aborted.
.
5. Acute blood loss Anemia: The patient's Hct was stable the
last 48 hours, ranging from 28 to 30. Most likely secondary to
procedural blood loss. Her CT Abd was neg for RP bleed. Her
vital signs have been completely stable. She has no symptoms
and is ambulating well without complaints.
.
6. pancreatic cyst: The pt was noted on imaging to have an 11mm
pancreatic cyst, an incidental finding. Repeat imaging was
recommended for 6 months from now. The patient was given a
report of her imaging, and a copy of the report was given to her
to bring to her PCP's office in 7 days (an appointment was
scheduled for her). She was explained that it is important for
her to follow up and have repeat imaging, as the lesion could
possibly be benign, although a malignant lesion is a possibility
as well. Her PCP's office was called and notified. She has an
appointment in 1 week.
.
7. Prophylaxis: She was placed on pneumoboots and her home PPI.
ASA was held in the setting of tPA, but then restarted.
.
8. Code Status: full code
Medications on Admission:
Atenolol 100 mg qday
Humalog 75/25 [**Hospital1 **] up to 40 units
Diovan 320 mg qday
Diovan 160 mg qpm
Lipitor 20 mg qday
Promega 2 tid
Protonix 40 mg qday
MVI
Flonase 50 mcg 2 sprays qday
HCTZ 25 mg qday
ASA 81 mg- held 4 days prior to procedure
Discharge Medications:
1. 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*
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
4. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Atenolol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Valsartan 160 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
Disp:*30 Tablet(s)* Refills:*2*
7. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
Disp:*60 Tablet(s)* Refills:*2*
8. Humalog Mix 75-25 75-25 unit/mL Suspension Sig: Ten (10)
units Subcutaneous qAM at breakfast: Inject 10 units
subcutaneously qAM. .
Disp:*qs 1 vial* Refills:*2*
9. Humalog Mix 75-25 75-25 unit/mL Suspension Sig: Twenty (20)
units Subcutaneous qHS at dinnertime: Inject 20 units humalog
subcutaneously at dinnertime. .
Disp:*qs 1 vial* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Renal artery stenosis secondary to fibromuscular dysplasia
status post angioplasty complicated by thrombus status post
alteplase
2. Acute blood loss anemia
3. Hypertension
4. Diabetes mellitus
5. Low back pain
Discharge Condition:
Stable
Discharge Instructions:
You need to have a follow up abdominal CT since the one you had
here incidentally revealed an 11-mm cystic lesion in the
pancreatic head. You should see your PCP regarding this, who
can arrange for an outpatient Abd CT.
If you experience any chest pain, shortness of breath, numbness,
weakness in your right leg, bleeding from right groin site,
please report to the emergency room immediately.
Please take all of your medications.
Please follow up with your Primary Care Physician (see info
below).
Followup Instructions:
1. You have an appointment with Dr. [**First Name (STitle) **] (Dr.[**Name (NI) 43383**]
associate at the same office). Your appt is for 11:00 am on
Monday, [**11-19**]. Her office number is: [**Telephone/Fax (1) 31979**].
2. You should bring a copy of the CAT scan report to your
doctor so that she can schedule a follow up Abd CT to evaluate
the incidental finding of pancreatic mass seen on CT.
Completed by:[**2187-11-17**]
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21,623
| 110,420
|
321
|
Discharge summary
|
report
|
Admission Date: [**2187-3-26**] Discharge Date: [**2187-4-5**]
Date of Birth: [**2105-12-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2972**]
Chief Complaint:
LLQ Pain and BRBPR
Major Surgical or Invasive Procedure:
none
History of Present Illness:
81 y/o M w/ h/o AAA s/p repair, colon ca s/p sigmoidectomy,
diverticulitis, prostate cancer, and non-small cell lung cancer
p/w 4 days of LLQ pain. Patient states that for the past four
days he has had a band like abdominal pain across his lower
abdomen. On day of admission his home health aide noted bright
red blood in his stools and so patient referred to the ED.
.
In the ED, initial vs were: VS 97.8 106 129/83 18 100%. Patient
with BRB on DRE and mild LLQ pain (intermittent). HR improved
with 1L NS. CT A/P done in ED showed no acute abdominal
pathology c/w patient's symptoms. Patient was observed and had
one further episode of BRBPR in the ED prior to ICU transfer.
Repeat Hgb went from 10.9 on arrival to 8.2 (baseline Hgb
[**11-19**]).
.
On arrival to the ICU, patient comfortable with stable VS. On
further questioning, denies any recent f/c/n/v/ns/diarrhea/
constipation/weight gain or weight loss/chest pain/syncope or
other complaints. Denies melena.
Review of systems:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath, or wheezing. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
Past Medical History:
1) Non Small Cell Lung Cancer: found during [**5-13**]
hospitalization, s/p LUL lobectomy [**2183-7-28**], complicated by left
recurrent laryngeal nerve palsy.
2) Abdominal Aorta Aneurysm: s/p repair [**5-13**]
3) Colon Carcinoma: s/p sigmoid colectomy [**2171**]
4) Prostate cancer: s/p radical prostatectomy [**2169**]
5) 3 vessel CAD w/ hx remote MI in [**2164**] - no stents
6) Hypercholestermia
7) h/o recurrent small bowel obstructions
8) Diverticulitis
9) HTN
10) Hypercholesterolemia
11) Squamous cell cancer of face surgically resected and getting
XRT.
Social History:
Lives alone but has a HHA/VNA. Son is nearby.
He has two children and seven grandchildren.
Previously he worked for the electric company as a street lamp
worker. Habits: 20 pack year smoking history, quit 20 years
ago. Quit alcohol 50 years ago, drank scotch "for a long time."
Denies any
other drug use. Not currently sexually active.
Family History:
His son is a diabetic. Brother died of myocardial infarction in
his 70s. He had a brother with a myocardial infarction in his
80s. His mother died of cardiogenic shock in her 80s. His father
also died from "heart problems."
Physical Exam:
On admission:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Labs on Admission:
[**2187-3-26**] 06:25PM BLOOD WBC-8.2 RBC-3.30* Hgb-9.7* Hct-27.9*
MCV-84 MCH-29.2 MCHC-34.6 RDW-16.1* Plt Ct-203
[**2187-3-26**] 06:25PM BLOOD PT-13.1 PTT-22.8 INR(PT)-1.1
[**2187-3-27**] 12:29AM BLOOD WBC-7.0 RBC-3.34* Hgb-9.9* Hct-28.2*
MCV-84 MCH-29.6 MCHC-35.1* RDW-16.0* Plt Ct-145*
[**2187-3-27**] 12:40AM BLOOD Hct-26.2*
[**2187-3-27**] 09:41AM BLOOD Hct-27.9*
[**2187-3-26**] 06:25PM BLOOD Glucose-135* UreaN-28* Creat-1.2 Na-137
K-4.8 Cl-103 HCO3-21* AnGap-18
.
Imaging:
[**2187-3-26**] CT Abdomen/Pelvis
Impression:
1. Status post sigmoid colectomy and prostatectomy. No
small-bowel
obstruction. Moderate fecal load, limiting the evaluation of
intraluminal
colonic mass but no obstructing mass is noted. No colonic wall
thickening. No acute diverticulitis.
2. Right inguinal hernia with a loop of non-obstructed small
bowel.
Fat-containing left inguinal hernia.
3. Interval progression of T12 compression fracture since [**2183**]
with now
almost complete loss of vertebral height, but minimal
retropulsion into the spinal canal.
4. Stable left adrenal nodule. Cholelithiasis without acute
cholecystitis. Unchanged increased lung base interstitial
marking suggestive of pulmonary fibrosis.
5. Status post AAA repair with persistent thrombosed [**Female First Name (un) 899**].
6. If clinical concern remains high for colonic mass, recommend
followup with colonoscopy.
.
[**2187-3-27**] CXR
Cardiac size is top normal. There is no change in diffuse
emphysema and
peripheral reticular abnormality, left greater than right,
consistent with
pulmonary fibrosis. There is evidence of loss of volume in the
left lung
consistent with left upper lobe wedge resection. Mild increase
opacity of the left lower lobe is likely atelectasis. There is
no pneumothorax or pleural effusion. There are no new lung
abnormalities suggestive of pneumonia.
.
[**2187-3-28**]: colonoscopy: Diverticulosis of the whole colon. Large
amount of old blood and clots were seen throughout the colon,
but not in the terminal ileum. This is likely a right-sided
diverticular bleed. No active, ongoing bleeding at present.
Limited view of mucosa given extensive old blood.
Brief Hospital Course:
Acute blood loss anemia [**1-9**] GIB: The patient was initially
admitted to the MICU for a GI bleed. Serial hematocrits were
stable after receiving 2 units of PRBCs from [**3-26**]
(admission)-[**3-27**] and he was transitioned to the regular medical
floor. Pt was maintained with 2 large bore IVs, active type and
screen, consented and crossmatched. His home aspirin and
antihypertensives were held. GI was consulted and recommended
colonoscopy for the morning on [**2187-3-28**]. Colonoscopy showed
multiple diverticuli and bleeding (see above). Overnight on
[**5-3**] pt had 2 episodes large volume BRBPR with HR in 110s.
Pt recieved 2U of PRBCs and did not have further bleeding until
[**3-30**] when he started to have melanotic stools. His hematocrit
was trending down and he was transfused to a hematocrit of >28.
His melana resolved and GI felt an EGD would not be necessary at
this time. It was felt his melana was residual blood from his
previous bleed. In total pt recieved 6 [**Location 2984**] throughout
hospitalization.
# Dementia: continued namenda
# Hypertension: lisinopril and metoprolol were held. They were
held upon discharge as well and based on patient's outpatient
blood work and blood pressure readings, the decision should be
made in the outpatient to restart these medications.
# CAD: aspirin was held
# SC nodule: pt was noted to have a small subcutaneous nodule
very low in LLQ. Pt stated that it had been present for many
years (though pt is variable historian). Management deferred to
primary care provider.
# Prostate/Lung/Colon/Skin cancer: management deferred to outpt
providers.
# HLD: continued lipitor
Medications on Admission:
Lipitor 10mg daily
lisinopril 5mg daily
metoprolol 25mg [**Hospital1 **]
namenda 10mg [**Hospital1 **]
aspirin 81mg daily (started in last 3-4 weeks)
Discharge Medications:
1. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Outpatient Lab Work
Please check Hematocrit [**Last Name (LF) 2974**], [**4-6**] and send results to
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**0-0-**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
primary: rectal bleeding
secondary: htn, hypercholesterolemia
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Discharge Instructions:
You were admitted for bleeding for bloody bowel movements. You
had a colonoscopy which showed out-pouchings of your colon
(called diverticulosis) without active bleeding or polyps. The
bleeding initially probably came from one of those outpouchings
but we could not tell which one. After your colonoscopy, you
started having bleeding in your stool again. This time the
bleeding slowed down considerably. Your blood levels remained
stable. It was felt the minimal blood in your stool was residual
blood from your previous bleed. You should follow up with your
outpatient doctor for a re-check of your blood level.
You also had some difficulty with shortness of breath. A CT scan
was performed that did not show any acute concerning causes of
shortness of breath. This may be due to underlying lung disease.
Your oxygen levels were normal while walking. You should follow
up with your doctor for further managment.
When you go home please continue your home medications with the
following changes:
1. HOLD Lisinopril 5 daily
2. HOLD Metoprolol 25 mg [**Hospital1 **]
3. HOLD Aspirin 81 mg daily
****These two medications should be re-adjusted at your follow
up visit on [**Hospital1 766**]. Your blood pressure was not elevated and
with concern for bleeding, these were not re-started.***
4. START Protonix 40 mg twice a day. This will help decrease the
acid in your stomach.
It is important that you keep all of your doctor's appointments.
Followup Instructions:
You have the following appointment arranged for you:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] B.
Appointment: [**Last Name (LF) 766**], [**4-9**], at 3:00 PM at Location: CARDIOLOGY
ASSOCIATES OF GREATER [**Location (un) **]
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**0-0-**]
The GI doctors [**Name5 (PTitle) 2985**] they did not need to follow up with you. If
you ever need to see them in the future the number to call
Phone: [**Telephone/Fax (1) 2986**] . The doctor you saw in the hospital was
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2987**], MD.
|
[
"414.01",
"255.9",
"285.1",
"574.20",
"V10.05",
"V10.46",
"412",
"272.0",
"V45.89",
"518.89",
"V10.11",
"550.92",
"401.9",
"173.3",
"562.12",
"294.8",
"515"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
7869, 7924
|
5504, 7154
|
333, 339
|
8030, 8077
|
3309, 3314
|
9607, 10246
|
2569, 2794
|
7354, 7846
|
7945, 8009
|
7180, 7331
|
8140, 9584
|
2809, 2809
|
1361, 1590
|
275, 295
|
367, 1342
|
3328, 5481
|
8092, 8116
|
1634, 2198
|
2214, 2553
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,486
| 123,243
|
12981+56415
|
Discharge summary
|
report+addendum
|
Admission Date: [**2164-5-1**] Discharge Date: [**2164-5-11**]
Date of Birth: [**2108-5-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
PEA arrest
Major Surgical or Invasive Procedure:
[**2164-5-7**]
1. Coronary artery bypass grafting x4 with reverse
saphenous vein graft from the aorta to the posterior
left ventricular coronary artery; reverse saphenous vein
graft from aorta to the first obtuse marginal coronary;
as well as reverse saphenous vein graft from the aorta
to the first diagonal coronary artery as well as a free
left internal mammary artery from the proximal vein
graft to the first diagonal to the distal left anterior
descending coronary artery.
2. Epiaortic duplex scanning.
3. Endoscopic left greater saphenous vein harvesting.
History of Present Illness:
55 y/o M with CAD s/p stents, [**Hospital 23051**] transferred from [**Hospital1 9191**] after hypoxia and PEA arrest. Per family, the patient
was driving at 2am to pick up his daughter. [**Name (NI) **] en route, he
stopped by the side of the road to urinate. While urinating he
became incontinent of stool, and developed acute onset of
dyspnea, and fell to the ground. ststing " I can't breathe and I
feel like I'm going to die". EMS was called. BS 276 in the
field. Per family report, while being transported to [**Hospital1 **] the
patient arrested and was resucitated by EMS. However, there was
no documentation of this in EMS log. Rhythm strip from
ambulance showed ST depressions V3-V5. No evidence of
hyperkalemia on EKG, PR and QTc within normal limits. Pt was
tachycardiac to 117 with sat of 80-87% on 100% NRB.
.
On arrival to the OSH, he was bradycardic at 40, O2 75%,
underwent CPR for two minutes, epinephrine X2, atropine 1 amp
X1, HCO3 2 amps. Post arrest his HR was in the 120's and blood
pressure in the 140s, and he was placed on nitro gtt. At [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] his ekg showed anterolateral ST depressions, in setting of
hyperkalemia and respiratory acidosis. CXR showed fluid overload
and he was given 40mg lasix IV. BNP 97. Initial blood gas at
OSH, 6.87/73/76 satting 100% on NRB. Repeast [**Doctor Last Name **] 50 minutes
later 6.91/88/95 now intubated. UA negative He was transferred
to [**Hospital1 18**] ED because apparently his records are here.
.
In the ED here vitals were: 123 117/87 100% on FiO2 100%.
EKG showed sinus tachycardia with rightward axis, st depressions
in I, V3-V5. CT head was normal, CTA torso was remarkable for
large bilateral aspirations but no PE or aortic dissection.
Cards was consulted in the ED and felt ekg changes were likely
secondary to hypoxia and acidemia, and given no evidence STEMI,
VF, or VT, cath was not indicated at this time and MICU
admission was appropriate. Labs showed K of 6.8, lactate of 3.3.
He was given vancomycin and zosyn. He was started on the arctic
sun cooling protocol as well, and transferred to the MICU.
.
In the MICU, patient's CK and troponin continued to rise. ECHO
showed severaly depressed EF of 20%, both left and right
ventricular dilitation, and inferolateral akinesis and mid to
distal anteroseptal and apical akinesis with hypokinesis
elsewhere.
Past Medical History:
myocardial infarction/cardiac arrest, acute systolic heart
failure, coronary artery disease, s/p coronary artery bypass
this admission
PMH:
coronary artery disease, s/p 2 stents ([**2143**]) and 1st MI at age
42, diabetes mellitus with diabetic nephropathy,
Hypertriglyceridemia, hypertension, h/o pancreatitis from
hypertriglyceridemia, gastroesophageal reflux disease
Social History:
Lives with: wife and daughter
Occupation: auto mechanic
Tobacco: 1/2ppd x 40 yrs.
ETOH: none
Family History:
Father - deceased 71yrs, with CAD and DM
Mother - [**Name (NI) **], diet-controlled DM, HTN
Physical Exam:
Pulse: 95 Resp: 18 O2 sat: 97%3L
B/P Right: 121/69 Left:
Height: 5'[**63**]" Weight: 89kg
General:
Skin: Dry [x] intact [x] no rash
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [] rales at bases
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 [] no edema or varicosities
Neuro: Grossly intact x
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: Left:
no bruits appreciated
Pertinent Results:
Admission Labs:
[**2164-5-1**] 06:20AM BLOOD WBC-31.3* RBC-5.53 Hgb-15.9 Hct-48.8
MCV-88 MCH-28.8 MCHC-32.6 RDW-14.7 Plt Ct-299
[**2164-5-1**] 06:20AM BLOOD Neuts-87* Bands-5 Lymphs-3* Monos-5 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2164-5-1**] 06:20AM BLOOD PT-11.8 PTT-19.2* INR(PT)-1.0
[**2164-5-1**] 06:20AM BLOOD Fibrino-365
[**2164-5-1**] 06:20AM BLOOD Glucose-540* UreaN-22* Creat-1.3* Na-140
K-7.4* Cl-102 HCO3-24 AnGap-21*
[**2164-5-1**] 01:16PM BLOOD Calcium-9.0 Phos-4.2 Mg-1.9
[**2164-5-2**] 04:34PM BLOOD Triglyc-292* HDL-16 CHOL/HD-6.2
LDLcalc-25
Cardiac Enzymes
[**2164-5-1**] 01:16PM BLOOD CK(CPK)-2044*
[**2164-5-1**] 09:24PM BLOOD ALT-118* AST-249* LD(LDH)-658*
CK(CPK)-[**2151**]* AlkPhos-55 TotBili-0.2
[**2164-5-2**] 05:25AM BLOOD CK(CPK)-1747*
[**2164-5-3**] 04:42AM BLOOD CK(CPK)-934*
[**2164-5-4**] 01:20PM BLOOD ALT-57* AST-44* CK(CPK)-478* AlkPhos-44
Amylase-88 TotBili-0.4 DirBili-0.2 IndBili-0.2
[**2164-5-1**] 06:20AM BLOOD cTropnT-0.48*
[**2164-5-1**] 06:20AM BLOOD CK-MB-94* MB Indx-10.5*
[**2164-5-1**] 01:16PM BLOOD CK-MB-277* MB Indx-13.6* cTropnT-1.71*
[**2164-5-1**] 09:24PM BLOOD CK-MB-250* MB Indx-12.5* cTropnT-3.02*
[**2164-5-2**] 05:25AM BLOOD CK-MB-219* MB Indx-12.5* cTropnT-3.12*
[**2164-5-3**] 04:42AM BLOOD CK-MB-86* MB Indx-9.2* cTropnT-1.71*
Urine Studies
[**2164-5-1**] 06:20AM URINE RBC-0-2 WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-0-2
[**2164-5-1**] 06:20AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2164-5-1**] 06:20AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.010
CTA Chest [**2164-5-1**] - . No evidence of aortic dissection or
pulmonary embolism. 2. Bilateral lower lobe consolidation,
suggestive of massive aspiration. 3. Fatty liver. 4. Right
adrenal nodule, likely adrenal adenoma
CT Head [**2164-5-1**] - No acute ICH
ECHO [**2164-5-1**] - The left ventricular cavity is dilated. Overall
left ventricular systolic function is severely depressed (LVEF=
20 %) with inferolateral akinesis and mid to distal anteroseptal
and apical akinesis with hypokinesis elsewhere. The right
ventricular cavity is dilated with mild global free wall
hypokinesis. The aortic valve is not well seen. There is no
aortic valve stenosis. The mitral valve leaflets are
structurally normal. No mitral regurgitation is seen. There is a
trivial/physiologic pericardial effusion. There is at least mild
pulmonary artery systolic hypertension
Bilateral Lower Extremity Doppler US [**2164-5-2**] - No evidence of
DVT in the lower extremities bilaterally
Cardiac Cath [**2164-5-4**] - 1. Coronary angiography in this right
dominant system demonstrated left main and three vessel CAD. The
LMCA had an ostial 60% stenosis and diffuse mild narrowing. The
LAD had diffuse 80% proximal and mid stenoses and 60% mid-distal
stenosis. The LCx had a diffuse 99% stenosis that tracked back
to the LMCA. The RCA had a mid 60% stenosis.
2. Limited resting hemodynamics revealed normal systemic
arterial blood
pressure with SBP 114mmHg and DBP 73mmHg.
Brief Hospital Course:
55M who was admitted with PEA arrest and NSTEMI. He was
successfully cooled with the Arctic Sun and extubated with
return
of excellent mental status. Echo showed biventricular
dilatation and EF 20% with multiple wall motion abnormalities.
Cath revealed severe three vessel coronary artery disease. He
is
on broad spectrum antibiotics for aspiration pneumonia, which
improved significantly within 2-3 days.
Mr. [**Known lastname 39793**] was transferred to the cardiac surgery service for
coronary artery bypass after undergoing the routine preoperative
workup. The patient was brought to the operating room on
[**2164-5-7**] where the patient underwent coronary artery bypass x 4.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. Vancomycin was
used for surgical antibiotic prophylaxis given his preoperative
stay of greater than 24 hours. 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. Coumadin was initiated for atrial
fibrillation. 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. Coumadin follow up with Dr. [**Last Name (STitle) **] was
set up and VNA is to call INR levels to [**Telephone/Fax (1) 21566**] for
Coumadin dosing instructions (goal INR 1.5-2.5) for left atrial
thrombus. The patient was cleared for discharged to home in
good condition with appropriate follow up instructions.
Medications on Admission:
Cialis 10mg po prn
Clindamycin 300mg po daily
Diazepam 5mg Po bid
Gemfibrozil 600mg po bid
Glyburide 10mg po daily
Hydrocodone-acetominophen 1 tablet q4h prn pain (not on PCP
[**Name Initial (PRE) **])
Lisinopril 10mg po daily
Metformin 850mg TID
Metoprolol 50mg po bid
MVI
Omeprazole 20mg po daily.
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
2. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO Q12H (every 12 hours) for 5
days.
Disp:*20 Tablet Sustained Release(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. 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*
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever/pain.
7. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
11. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
12. Metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
13. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
14. Warfarin 2.5 mg Tablet Sig: as directed for ventricular
thrombus Tablet PO once a day for 3 months: Goal INR 1.5-2.5
3 months of therapy.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
myocardial infarction/cardiac arrest, acute systolic heart
failure, coronary artery disease, s/p coronary artery bypass
this admission
PMH:
coronary artery disease, s/p 2 stents ([**2143**]) and 1st MI at age
42, diabetes mellitus with diabetic nephropathy,
Hypertriglyceridemia, hypertension, h/o pancreatitis from
hypertriglyceridemia, gastroesophageal reflux disease
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 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:
Surgeon Dr. [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**]
Please call to schedule appointments
Primary Care Dr. [**Last Name (STitle) 21565**],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 21566**] in [**12-31**] weeks
Cardiologist Dr. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2164-7-18**] 9:00 in [**12-31**] weeks
Labs: PT/INR for Coumadin ?????? indication Left atrial thrombus
Goal INR 1.5-2.5
First draw : [**2164-5-12**]
Results to Dr. [**Last Name (STitle) **]
Phone [**Telephone/Fax (1) 21566**] fax [**Telephone/Fax (1) 39794**]
OVER WEEKEND PLEASE CALL [**Telephone/Fax (1) 3183**] with INR Results
**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:[**2164-5-11**] Name: [**Known lastname 7165**],[**Known firstname 126**] Unit No: [**Numeric Identifier 7166**]
Admission Date: [**2164-5-1**] Discharge Date: [**2164-5-11**]
Date of Birth: [**2108-5-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1543**]
Addendum:
To clarify patient was anticoagulated for left ventricular
thrombus not for atrial fibrillation as indicated in discharge
summary. Target INR should be [**2-1**].
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2164-5-14**]
|
[
"414.01",
"410.71",
"412",
"583.81",
"305.1",
"530.81",
"427.5",
"276.7",
"428.21",
"272.1",
"428.0",
"584.9",
"435.2",
"250.40",
"507.0",
"518.81",
"276.2",
"V45.82",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.13",
"96.71",
"37.22",
"36.15",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
14665, 14880
|
7776, 9766
|
330, 927
|
12330, 12486
|
4699, 4699
|
13188, 14642
|
3882, 3976
|
10116, 11837
|
11937, 12309
|
9792, 10093
|
12510, 13165
|
3991, 4680
|
280, 292
|
955, 3361
|
4715, 7753
|
3383, 3755
|
3771, 3866
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,584
| 174,497
|
31963
|
Discharge summary
|
report
|
Admission Date: [**2147-8-21**] Discharge Date: [**2147-8-23**]
Date of Birth: [**2067-3-4**] Sex: M
Service: MEDICINE
Allergies:
Augmentin
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
C1 fracture, hypertensive urgency
Major Surgical or Invasive Procedure:
Hard C collar placed for C1 fracture
History of Present Illness:
80 M with CABG, HTN, DM2, was leaving a friend's house after
dinner in the dark, tripped on the back stairs, and had
mechanical fall. No dizziness, palpitations, chest
pain/pressure, SOB, seizures, confusion before falling, patient
describes the fall as "thinking there was a stair where there
was no stair". He fell on his left forehead and left hip, no
LOC. He immediately got up by himself from the ground, thought
he was fine and got in his friend's car to be driven home,
noticed that he couldn't bend his head down well, friend drove
him to OSH for assessment.
At OSH, CT head was negative, CT C spine showed C1 fracture. One
hour after his fall, he vomited x1, no blood, had no abdominal
pain at the time. Has chronic constipation, cannot remember last
BM. Was transferred here for ortho spine fracture consultation.
When he arrived at [**Hospital1 18**] ED, ortho assessed patient, placed him
in hard collar, admitted to ortho for observation, but he was
hypertensive to 220s, HR 60-70s, and he was placed to MICU
service instead. In the ED, he was placed on nitro gtt with
difficulty controlling his SBP in 190s.
Past Medical History:
DM2 x 40 years with neuropathy, nephropathy
Hypertension
Hyperlipidemia
Depression
s/p CABG [**49**] years ago
Leg claudication with walking
COPD - diagnosed 15 years ago, quit smoking since diagnosis
Benign tremor
Social History:
Lives alone in 1 bdrm apartment at [**Location (un) 74908**]in [**Location (un) 1456**],
independent living retirement community. No ETOH, 50 pky smoking
history but quit 15 years ago, no illicit drugs. Has close
girlfriend and son. Worked as psychology professor [**First Name (Titles) **] [**Last Name (Titles) **], now
retired.
Family History:
Noncontributory.
Physical Exam:
VS: 96.4 / 180/95 / 75 / 18 / 98% RA
GENERAL: Articulate, very mildly demented, speaks and answers
questions clearly
HEENT: Cannot assess JVD or LAD because of hard C collar, L>R
eye ecchymosis, OP clear, dry mm
LUNGS: CTA B
HEART: RRR, no m/r/g
ABDOMEN: Soft, obese, +BS, ND, NT
EXTR: Rash of multiple flat maculopapular circular brown plaques
1x1 cm on legs, both hands shaking but not pill-rolling,
amputated right first toe
NEURO: Cannot assess gait, [**4-1**] motor, decreased sensation in
feet
Pertinent Results:
[**2147-8-21**] 10:07AM POTASSIUM-5.2*
[**2147-8-21**] 06:03AM COMMENTS-GREEN TOP
[**2147-8-21**] 06:03AM K+-5.6*
[**2147-8-21**] 02:50AM GLUCOSE-208* UREA N-35* CREAT-1.6* SODIUM-139
POTASSIUM-5.2* CHLORIDE-104 TOTAL CO2-26 ANION GAP-14
[**2147-8-21**] 02:50AM estGFR-Using this
[**2147-8-21**] 02:50AM ALT(SGPT)-12 AST(SGOT)-23 LD(LDH)-247
CK(CPK)-275* ALK PHOS-116 AMYLASE-79 TOT BILI-0.4
[**2147-8-21**] 02:50AM LIPASE-26
[**2147-8-21**] 02:50AM CK-MB-12* MB INDX-4.4 cTropnT-0.03*
[**2147-8-21**] 02:50AM ALBUMIN-3.7 IRON-78
[**2147-8-21**] 02:50AM calTIBC-307 FERRITIN-100 TRF-236
[**2147-8-21**] 02:50AM TSH-5.0*
[**2147-8-21**] 02:50AM FREE T4-1.2
[**2147-8-21**] 02:50AM WBC-13.7* RBC-4.16* HGB-13.1* HCT-37.8*
MCV-91 MCH-31.5 MCHC-34.6 RDW-14.4
[**2147-8-21**] 02:50AM NEUTS-89.7* BANDS-0 LYMPHS-7.2* MONOS-2.7
EOS-0.3 BASOS-0.2
[**2147-8-21**] 02:50AM PLT SMR-NORMAL PLT COUNT-197
[**2147-8-21**] 02:50AM PT-11.9 PTT-24.7 INR(PT)-1.0
CT C-spine:
IMPRESSION:
1. Fractures across the right anterior arch of C1 and central
right posterior arch of C1, with 5 mm of distraction of the
right anterior arch fragments, as well as mild atlanto-occipital
offset on the right.
CT Head:
IMPRESSION:
1. No acute intracranial hemorrhage or mass effect.
2. Incompletely visualized fracture of the C1 vertebral body,
please refer to the cervical spine CT for full details.
XR L femur:
IMPRESSION: No evidence of fracture.
CXR:
IMPRESSION: 2 areas of increased opacification bilaterally with
prominence of the left hilum. Comparison with previous films is
essential. If these are not available, CT should be obtained.
Brief Hospital Course:
80 M with CABG, HTN, DM2, s/p mechanical fall, here with C1
fracture and hypertensive urgency.
# C1 fractures:
CT C-spine showed fractures across the right anterior arch of C1
and central right posterior arch of C1, with 5 mm of distraction
of the right anterior arch fragments, as well as mild
atlanto-occipital offset on the right. Ortho recommended wearing
hard C collar for three months with no surgery, and followup in
one week after discharge with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**]. His phone number
is [**Telephone/Fax (1) 3573**]. Please call his office to schedule an
appointment.
# Hypertensive urgency:
Patient was found to have SBP 220s in ED, had not taken his home
antihypertensive regimen. In the ED, he was placed on nitro gtt
with SBP 140s, and patient was transferred to the MICU. Nitro
gtt was titrated off and patient was transitioned to home
regimen of ramipril and Toprol with SBP 120-130s. His blood
pressures remained elevated and he was started on norvasc 5mg.
The norvasc was just increased to 10mg daily today (only got 5mg
this [**Last Name (un) 44550**] prior to leaving for rehab). Please titrate up his
metoprolol as needed for futher blood pressure control.
# Mechanical fall:
CT head was negative for fracture or hemorrhage. CT C spine
showed C1 fractures. XR L femur was negative for fracture.
Possible etiology of fall includes strict mechanical fall in the
evening dark, infection, cardiogenic syncope, retinopathy
etiology. EKG shows TWI V1-V4, 0.5-1mm STE III, 1mm STD I and L,
RBBB, with no previous EKG for comparison and cardiac enzymes
were cycled. Patient was maintained on ASA, metoprolol, and
statin. Patient states recent ophthalmology appointment for
diabetic retinopathy was normal, but it was recommended that
patient follow up regularly in case vision was contributing
factor to fall.
# Cardiac:
Patient has history of CABG years ago. EKG showed anterolateral
ischemic changes, RBBB, previous EKG was not available for
comparison and was rechecked. Patient was maintained on ASA,
metoprolol, statin. TTE was not available in [**Hospital1 18**] records.
Cardiac rhythm was NSR 60-70s. Patient was asymptomatic
throughout admission with no chest pain/pressure, no shortness
of breath.
# Diabetes mellitus, presumed type 2:
He reports DM2 diagnosed 40 years ago. He was maintained on ISS.
His home regimen is lantus 40 units QAM, Novolog 12-20 units per
meal. If his sugars are elevated at rehab, his insulin sliding
scale should be increased.
# Hyperkalemia/chronic sinusitis:
Patient reported that he takes potassium iodide tablets for
chronic sinusitis daily. He was advised to stop taking potassium
iodide as an outpatient and was told that his potassium was
elevated likely due to this medication.
# Chest Opacifications
Chest X ray on [**2147-8-21**] noted two opacifications in the left
upper lobe. Patient should have a follow-up chest CT performed
as an outpatient.
Medications on Admission:
Ramipril 10 daily
Toprol XL 50 [**Hospital1 **]
Lipitor
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO BID (2 times a day).
7. Carbidopa-Levodopa 25-100 mg Tablet Sig: .5 Tablet PO DAILY
(Daily).
8. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
9. Simethicone 80 mg Tablet, Chewable Sig: 0.5 Tablet, Chewable
PO QID (4 times a day) as needed.
10. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
11. Ramipril 5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily).
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
13. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed.
14. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **] Hospital
Discharge Diagnosis:
C1 fracture
Hypertensive urgency
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted after a fall with a fracture of your cervical
spine. It is important that you wear the cervical collar for
three months. You will need to see Dr [**Last Name (STitle) 363**] next week. His
phone number is [**Telephone/Fax (1) 3573**]. Please call his office to
schedule an appointment.
You should not drive with this collar on.
While you were in the hospital your blood pressure was elevated.
We added new medication called norvasc which you will need to
take daily.
You should also talk with your primary care physician about
obtaining [**Name Initial (PRE) **] chest CT to follow-up abnormalities on his CXR.
Please call if you have any further pain, lightheadedness,
dizziness, confusion or any other concerning symptoms.
Followup Instructions:
You should follow up with the Orthopedic Surgeon Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 363**], [**Telephone/Fax (1) 3573**], early next week. Please call his office
to schedule an appointment.
|
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52,269
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40609
|
Discharge summary
|
report
|
Admission Date: [**2119-6-11**] Discharge Date: [**2119-6-22**]
Service: MEDICINE
Allergies:
amiodarone
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
elective corevalve
Major Surgical or Invasive Procedure:
Percutaneous aortic valve replacement
Endotracheal intubation
Central line
History of Present Illness:
86 year old woman with severe AS (valve area = 0.4, peak
gradient 100), LVEF 55%, PAF, Amiodarone lung toxicity,
pulmonary fibrosis, pacemaker for tachybrady syndrome,
scleroderma/CREST syndrome and severe pulmonary hypertension.
Patient was ADL independent at home untill her most recent
admission to [**Hospital1 18**] in [**4-/2119**] with small bowel obstruction and
pneumonia compicated by left basilic vein DVT from a PICC line
which was replaced prior to her discharge on [**2119-5-25**]. She was
started on Vanco + Cefepim [**5-21**], she had negative blood cultures
and sputum grew MRSA, Cefepim was given for 5 days and Vanco
for 10 days (last dose 5/11). Patient was worked up during her
admission for aortic valve procedure to treat her critical AS.
She is now readmited electively from rehab for the procedure.
Antibiotics for pneumonia have been completed and patient is
afebrile. Bowel obstruction has since resolved and patient is
tolerating soft diet. Coumadin was discontinued on [**2119-6-7**] and
switrched to fundaparinaux. She does report frequent loose
stools, repeated assays for C. diff have been negative.
.
Untill her recent admission patient had been ADL independent and
taking care of her demented [**Age over 90 **] year old husband at home. She
dressed, cooked and shopped on her own and got cleaning help
once weekly. She did have base-line DOE and was not able to walk
more than 20 paces without stopping. She has had significant
unintentional weight loss over the past 4-5 years. She was on
oxygen at home for hypoxia attributed to her chronic pulmonary
fibrosis. She has chronically low systolic blood pressure,
running 70-90's. She had intermittent dizziness upon standing.
She had orthopnea X 1 pillow. Nocturia X2. She denies leg
swelling. At rehab she was able to walk upto 10 paces with
walker and had to stop d/t SOB. She reports an episode of
epigastic/lower anterior chest pain yesterday after a meal which
she attributes to her scleroderma related GERD. Pain was
continous for 2 hours and resolved with analgesia. ECG was
checked and was reportedly unchanged. She denies any chronic
angina.
GU: voiding spontaneously, occasional inconteince.
.
Hct on [**6-8**] --27.7 . No evidence of bleeding. Hct initally was
around 33 at rehab, but has trended down to 27-28 and has
remained stable since [**6-1**].
.
On review of systems, she denies prior history of stroke, TIA,
pulmonary embolism, bleeding at the time of surgery, cough,
hemoptysis, black stools or red stools. Denies recent fevers,
chills or rigors.
.
Cardiac review of systems - notable for absence of paroxysmal
nocturnal dyspnea, ankle edema, palpitations, syncope or
presyncope
Past Medical History:
1. Aortic stenosis (valve are = 0.8)
2. Left ventricular systolic dysfunction with ejection fraction
of 45-55%.
3. Paroxysmal atrial fibrillation.
4. Amiodarone lung toxicity.
5. Pulmonary fibrosis, on home oxygen. PHTN (PAP = 80)
6. Tachybrady syndrome, status post permanent pacemaker.
7. History of breast cancer.
8. Gastroesophageal reflux disease.
9. Scoliosis.
10. Diverticulosis.
11. Hypothyroidism.
12. Basal cell carcinoma.
13. Left rotator cuff tendinitis and partial tear in [**2119**].
14. Scleroderma with GI manifestations and lung manifestations,
but without renal manifestations.
15. Severe pulmonary hypertension.
16. left basilic vein thrombosis, PICC induced [**5-/2119**]: Left
basilic vein thrombosis: PICC induced during previous admission
[**5-31**], considered superficial thrombosis. PICC on left pulled and
no anticoagulation was indicated
17. s/p left shoulder injury with rotator cuff tear [**2119**]
18. partial SBO [**4-/2119**]
Social History:
Retired, a registered nurse [**First Name (Titles) **] [**Last Name (Titles) 88870**]. Until her previous
admission in [**4-/2119**] patient reports she had been ADL independent
and taking care of her demented [**Age over 90 **] year old husband at home. She
dressed, cooked and shopped on her own and got cleaning help
once weekly. She did have base-line DOE and was not able to walk
more than 20 paces without stopping. She has been in rehab since
her discharge on [**2119-5-25**], There she was able to walk up to 10
paces with walker.
.
Her 4 kids live in the area. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20246**] (daughter) is her HCP
(tel: [**Telephone/Fax (1) 88871**]).
.
.
-Tobacco history: ~ 50 pack years, stopped in
-ETOH: untill recently used to drink one vodka-[**Doctor Last Name 6654**] with
olive per evening.
-Illicit drugs: none
Family History:
Mother with breast CA.
Physical Exam:
On Admission:
VS: T= 95.6...BP=109/49...HR=69...RR=20...O2 sat= 97%
GENERAL: cachectic, frail appearing woman, NAD, tachypneic to 25
with speech dyspnea, A+OX3. Appropriate affect.
HEENT: PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no thyromegaly, no carotid bruits, JVD to the
angle of the Jaw.
HEART: Irregularly irregular, 3/6 SEM max at LUSB with out
radiation to the carotids. no RG.
LUNGS: faint crackles to the scapulas bilaterally, rare
scattered exp wheezes.
ABDOMEN: normal bowel sounds, Soft/NT/ND, no masses or HSM, no
rebound/guarding mid lower abdomen, left knee, right sholder
Skin: surgical scars
EXTREMITIES: WWP, trace pre-tibial edema, no c/c, vertical
surgical scar over left knee
NEURO: Awake, A&Ox3, CNs II-XII grossly intact. motor 4-5/5
throughout, sensory intact except for loss of proprioception in
3rd through 5th toes of right foot.
Lines: PICC right arm - no erythema, tenderness, discharge or
swelling.
Pulses r/l: radial -/-; brachial ++/+; TP +/+; DP -/-
.
On discharge:
expired
Pertinent Results:
On admission:
[**2119-6-11**] 04:40PM BLOOD WBC-5.7 RBC-3.05* Hgb-9.7* Hct-30.7*
MCV-101* MCH-31.9 MCHC-31.8 RDW-15.5 Plt Ct-334
[**2119-6-11**] 04:40PM BLOOD PT-14.8* PTT-29.7 INR(PT)-1.3*
[**2119-6-11**] 04:40PM BLOOD Glucose-100 UreaN-15 Creat-0.7 Na-141
K-5.2* Cl-106 HCO3-28 AnGap-12
[**2119-6-11**] 04:40PM BLOOD ALT-13 AST-14 LD(LDH)-230 AlkPhos-91
TotBili-0.4
[**2119-6-14**] 03:07AM BLOOD Lipase-28
[**2119-6-11**] 04:40PM BLOOD CK-MB-3 proBNP-[**Numeric Identifier 88872**]*
[**2119-6-11**] 04:40PM BLOOD Albumin-3.0* Calcium-8.5 Phos-4.2 Mg-2.2
Iron-23*
.
[**6-14**] TTE: FOCUSED STUDY. Overall left ventricular systolic
function is normal (LVEF>55%). An aortic CoreValve prosthesis is
present. Mild (1+) aortic regurgitation is seen. There is no
pericardial effusion.
.
[**6-20**] TTE:
The left atrium is elongated. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). The right ventricular cavity is markedly dilated
with moderate global free wall hypokinesis. An aortic CoreValve
prosthesis is present. The prosthetic aortic valve leaflets
appear normal The transaortic gradient is normal for this
prosthesis. A mild (1+) anterior paravalvular aortic valve leak
is present. The mitral valve leaflets are mildly thickened.
Moderate (2+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is severe pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normally-functioniong CoreValve aortic prosthesis
with mild paravalvular regurgitation. Normal global and regional
left ventricular systolic function. Severe pulmonary
hypertension with dilated right ventricle with moderate global
systolic dysfunction. Moderate mitral regurgitation.
Compared with the prior study (images reviewed) of [**2119-6-15**],
estimated PA pressures are higher still and RV appears slightly
more dilated. The other findings are similar.
.
On [**2119-6-22**]
[**2119-6-22**] 03:33AM BLOOD WBC-17.5* RBC-2.68* Hgb-8.3* Hct-25.5*
MCV-95 MCH-30.8 MCHC-32.3 RDW-21.0* Plt Ct-89*
[**2119-6-22**] 02:06AM BLOOD PT-20.1* PTT-90.9* INR(PT)-1.8*
[**2119-6-22**] 03:33AM BLOOD Glucose-178* UreaN-94* Creat-4.8* Na-142
K-4.8 Cl-108 HCO3-14* AnGap-25*
[**2119-6-22**] 02:06AM BLOOD ALT-62* AST-132* AlkPhos-109*
Amylase-610* TotBili-0.5
[**2119-6-22**] 02:06AM BLOOD Lipase-1540*
[**2119-6-20**] 04:16AM BLOOD proBNP-[**Numeric Identifier 4732**]*
[**2119-6-22**] 06:14AM BLOOD Type-ART Temp-37.8 pO2-103 pCO2-34*
pH-7.30* calTCO2-17* Base XS--8 Comment-AXILLARY T
[**2119-6-22**] 06:14AM BLOOD Lactate-6.7*
Brief Hospital Course:
86 year old woman with severe AS (valve area = 0.4, peak
gradient 100), LVEF 55%, PAF, Amiodarone lung toxicity,
pulmonary fibrosis, pacemaker for tachybrady syndrome,
scleroderma/CREST syndrome and severe pulmonary hypertension who
was admitted electively for core-valve placement, expired on
[**2119-6-22**].
.
# Critical AS: valve area = 0.4, peak gradient 100. Patient not
deemed a surgical candidate for surgery due to her
co-morbidities therefore scheduled for core-valve on [**6-13**].
Patient with uneventful pre-operative course. Intra-procedure
patient plavix loaded. Procedure complicated by inability to
pull right groin shealth necessitating open closure per
vasculature. Patient extubated and transferred to the CCU.
Follow-up TTE demonstrated stable, properly placed corevalve.
.
# PUMP: CHF, EF 45% per OSH. TTE prior to procedure 55%.
Post-procedure, TTE demonstrated overall normal left ventricular
systolic function, (LVEF>55%). An aortic CoreValve prosthesis is
present. Mild (1+) aortic regurgitation is seen. There is no
pericardial effusion. Patient was continued on metoprolol,
digoxin.
.
#. ATRIAL FIBRILLATION: Pre-opertively patient had been on
coumadin which had been transitioned to lovenox and subsequently
switched to fondaparinaux.
-- RATE CONTROL:
Patient rate controlled with digoxin and metoprolol.
-- ANTICOAGULATION:
Pre-opertively patient had been on coumadin which had been
transitioned to lovenox and subsequently switched to
fondaparinaux
Patient initially anticoagulated post-procedure with heparin IV
however due to concern for HIT, heparin was stopped and
argatroban started. HIT antibody returned negative and patient
restarted on heparin gtt on [**6-20**].
.
# Hypotension. Post-procedure patient noted to be hypotension
with MAPS in 50s and SBPs in 80s necessitating pressure support.
Initial hypotension attributed to fluid shifts s/p core valve
and blood pressure augmented with neo. Neo resulted in
pronounced peripheral vasoconstriction with resulting left
extremity cyanosis. However patient persistently hypotension
thought secondary to probable sepsis. Patient started on broad
spectrum antibiotics and decision made to aggressively hydrate
with IVF and transition pressure support to levophed and
vasopression. On [**6-21**], the patient became increasingly
hypotensive requiring pressor support with levophed,
vasopressin, and dopamine. Despite pressors, lactate continued
to climb into the 7 range until aggressive measures were
withdrawn.
.
# Thrombocytopenia. Platlets with precipitous drop while
hospitalized; ~300 pre-procedure with nadir in the 60s.
Differential diagnosis at that time included sepsis, DIC
medication side effect and HIT. DIC labs negative. Patients 4 T
score ~6 (especially after UE US with evidence of new left
brancial thrombosis). Concern for HIT prompted transition to
argatroban and send out of the HIT antibody. On [**6-20**] HIT
returned negative and patient transitioned back to IV heparin.
Likely drop reflective of underlying infectious process as HIT
ruled out and DIC labs negative.
.
# Acute Kidney Injury. Patient with elevation in creatinine and
decrease in urine production post-corevalve. CT with evidence of
renal infarct thought to have occurred intra-procedure. Etiology
to [**Last Name (un) **] likely multifactorial in setting of renal infarct as well
as hypovolemia in setting of hypotension. Patients kidney
function was monitored daily, medications were renally dosed.
The patient remained oliguric for several days and became net +
13L. Cr stabilized around 4.8 and urine output improved
transiently on a lasix gtt before the patient began to
deteriorate and urine output again declined.
.
# Peripheral vasoconstriction/left hand cyanosis. Post-procedure
patient with complaints of numbness and tingling in left hand.
Decision made to pull left axillary arterial line after which
symptoms subsided. Patient with hypotension s/p procedure
necessitating augmented pressure support with neo. Additional
vasoconstriction in setting of neo in a patient with scleroderma
likely resulted in aggravated peripheral vasoconstriction of
left hand. Pressors transitioned from neo to vasopression with
some improvement in perfusion.
.
# Elevated LFTS. Likely secondary to shocked liver in the
setting of hypotension and sepsis. LFTs stabilized and began to
slowly trend down after initiation of broad spectrum antibiotics
and normalization of blood pressure.
.
#. CAD. Left cath undertaken in [**4-/2119**] as part of work-up for
core-valve demonstarted left dominant system with singel vessel
disease: ~50-70% lesion in OM1. Patient without complaints of
chest pain in house. Continued on ASA 81 as well as BB.
.
# Lung disease. Pateint with history of extensive interstitial
pulmonary fibrosis secondary to to amiodarone exposure vs
scleroderma vs radiation injury (got radiation for breast cancer
in the past. Per chart biopsy, baseline home oxygen 2-3L.
Pre-procedure chest CT and severe pulmonary HTN on RHC which
showed PA systolic pressure of 80mmHg in the presence of nopmal
wedge pressure (16mmHg). Post-extubation patient continued on
home nebulizer treatments. On [**6-21**], the patient acute desaturated
to the 80s. She was deep suctioned with improvement in her sats.
There was concern that the patient was not protecting her airway
because of altered mental status and she was again intubated on
[**6-21**].
.
# Provoked Left basilic vein thrombosis. PICC induced during
previous admission [**5-31**], considered superficial thrombosis.
Monitored clinically in house
.
# Scleroderma: Clinically suspected on past admission on the
basis of her ILD and chronic GERD complaints. Rheumatology were
consulted and serology showed positive [**Doctor First Name **] + Anticentromere ab
with neg SCL70, RNA ab and B2 glycoprotein. Impression was of
CREST syndrome. No systemic therapy was started. Patient
continued on PPI for treatment of GERD
.
# Nutrition. Post-procedure course complicated by extubation
necessitating intubation. Of note patient is significantlly
cachectic with hypoalbuminemia (Alb = 2.7 [**2119-5-21**]) likely [**2-22**]
to her various chronic diseases and poor PO intake. There was
concern for mesenteric ischemia post-procedure because of
complaints of abdominal pain, and TPN was started.
.
# Hypothyroidism: TSH [**4-/2119**] = 2.6. Patient continued on home
[**Year (4 digits) **] 75mcg
.
On [**6-22**], the patient was re-intubated for altered mental status
and inability to protect her airway. The patient was noted to
have oliguria, worsening lactic acidosis, evidence of
pancreatitis and persistent respiratory failure. Discussions
about goals of care were held with the patient's family -
including her daughter who served as her HCP. The decision was
made to transition the patient to comfort measures only. She
passed away shortly after pressors were discontinued on the
morning of [**2119-6-22**].
Medications on Admission:
digoxin 125 mcg Tablet 1 Tablet(s) by mouth once a day
levalbuterol HCl [Xopenex] 0.63 mg/3 mL Solution for
Nebulization
inh four times a day
levothyroxine 75 mcg Tablet 1 Tablet(s) by mouth once a day
metoprolol tartrate 25 mg Tablet 1 Tablet(s) by mouth q8hrs
omeprazole 20 mg Capsule, Delayed Release(E.C.) 1 Capsule(s) by
mouth twice a day
potassium chloride 10 mEq Capsule, Extended Release 1 Capsule(s)
by mouth once a day
aspirin 81 mg Tablet, Delayed Release (E.C.)
1 Tablet(s) by mouth once a day
cholecalciferol (vitamin D3) 2,000 unit Tablet
1 Tablet(s) by mouth once a day
Arixtra SQ 2.5 mg QD
Lidoqain patch was started in rehab on [**6-10**]
Sucralfat 1g QID
in rehab also got: Zolpidem, guiafenasine, maalox, glycolax,
ondasternon
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiopulmonary arrest
Severe aortic stenosis s/p percutaneous aortic valve replacement
Atrial fibrillation
Pulmonary fibrosis
Tachybrady syndrome
Hypothyroidism
Scleroderma
Pulmonary hypertension
Discharge Condition:
Expired
Discharge Instructions:
Patient made comfort measures only on [**2119-6-22**] after developing
cardiogenic shock and multi-system organ failure. This was in
the setting of having received a percutaneous aortic valve
replacement on [**2119-6-13**].
Followup Instructions:
None
|
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"511.9",
"428.0",
"V45.01",
"518.81",
"038.9",
"427.31",
"E878.8",
"E879.0",
"577.0",
"424.1",
"496",
"287.5",
"V70.7",
"782.5",
"998.0",
"244.9",
"V10.83",
"427.5",
"570",
"414.01",
"E849.7",
"V58.61",
"996.72",
"995.91",
"427.81",
"584.5",
"997.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"99.15",
"38.91",
"38.18",
"00.40",
"37.23",
"35.22",
"88.42",
"96.04",
"99.60",
"35.96",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
16400, 16409
|
8638, 15575
|
237, 314
|
16650, 16660
|
6009, 6009
|
16932, 16940
|
4919, 4943
|
16372, 16377
|
16430, 16629
|
15601, 16349
|
16684, 16909
|
4958, 4958
|
5980, 5990
|
179, 199
|
342, 3030
|
6023, 8615
|
3052, 4014
|
4030, 4903
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,463
| 140,827
|
10519
|
Discharge summary
|
report
|
Admission Date: [**2178-5-24**] Discharge Date: [**2178-5-28**]
Date of Birth: [**2115-11-3**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
pancreatitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
62M with history of liver transplant [**2174**] presents to ED with
abdominal pain, nausea and vomiting after falling down 14 stairs
1 day prior to admission. Transferred from [**Hospital3 3583**]
where CT showed severe peripancreatic fluid and fat stranding
involving pericolic gutters and question of pancreatic
laceration. His lipase was 10,684 and amylase was 1431.
Past Medical History:
alcoholic cirrhosis
s/p cadaveric liver transplanct [**8-26**] ([**Doctor Last Name **]/[**Doctor Last Name 497**])
CMV viremia
HTN
DM
hernia
h/o VRE/MRSA
Social History:
+EtOH abuse
denies tobacco use
Physical Exam:
NAD
CTAB
RRR
soft mildly tender, nondistended
Pertinent Results:
[**2178-5-28**] 04:45AM BLOOD WBC-3.1* RBC-3.14* Hgb-10.6* Hct-30.8*
MCV-98 MCH-33.7* MCHC-34.3 RDW-16.9* Plt Ct-133*
[**2178-5-24**] 03:45AM BLOOD WBC-6.0# RBC-3.56* Hgb-12.6*# Hct-37.4*#
MCV-105* MCH-35.5* MCHC-33.8 RDW-15.0 Plt Ct-187
[**2178-5-24**] 03:45AM BLOOD Neuts-88.7* Bands-0 Lymphs-8.5* Monos-2.7
Eos-0.1 Baso-0
[**2178-5-28**] 04:45AM BLOOD Plt Ct-133*
[**2178-5-27**] 05:00AM BLOOD PT-11.9 PTT-22.4 INR(PT)-1.0
[**2178-5-24**] 03:45AM BLOOD PT-11.6 PTT-20.2* INR(PT)-1.0
[**2178-5-25**] 04:14PM BLOOD Ret Aut-3.4*
[**2178-5-28**] 04:45AM BLOOD Glucose-118* UreaN-16 Creat-1.3* Na-138
K-4.6 Cl-106 HCO3-23 AnGap-14
[**2178-5-24**] 03:45AM BLOOD Glucose-190* UreaN-43* Creat-2.4* Na-138
K-4.9 Cl-101 HCO3-20* AnGap-22
[**2178-5-27**] 05:00AM BLOOD ALT-21 AST-25 AlkPhos-79 Amylase-82
TotBili-0.7
[**2178-5-24**] 03:45AM BLOOD ALT-35 AST-47* AlkPhos-124* Amylase-1724*
TotBili-1.0
[**2178-5-24**] 03:45AM BLOOD Lipase-1732*
[**2178-5-28**] 04:45AM BLOOD Calcium-7.9* Phos-2.5* Mg-1.6
[**2178-5-24**] 03:45AM BLOOD Albumin-4.0 Calcium-8.9 Phos-6.7*#
Mg-1.5*
[**2178-5-24**] Hand X-ray: No acute fracture or dislocation.
[**2178-5-24**] tib-fib x-ray: Focal soft tissue swelling. No fracture.
[**2178-5-24**] MRI Abd: 1) Findings consistent with pancreatitis. No
duct disruption is noted to suggest injury. No masses are
present. There is ascites and peripancreatic fluid present.
2) Decreased signal within the liver with accompanying findings
suggestive of hemosiderosis.
[**2178-5-24**] CXR: No acute cardiopulmonary process.
[**2178-5-24**] EKG: Sinus rhythm
Borderline low voltage
Borderline left axis deviation
Consider left atrial abnormality
[**2178-5-25**] Abd CT: 1. Findings consistent with pancreatitis. No
evidence for hemorrhage or necrosis. No peripancreatic fluid
collections.
2. Status post liver transplant.
3. Small amount of simple ascites throughout the abdomen and
pelvis.
Brief Hospital Course:
62M admitted to SICU with pancreatitis after suffering a fall
from 14 stairs. Hand and tib-fib films ruled out any trauma or
injury to the extremities. Outside CT showed severe
peripancreatic fluid and fat stranding involving pericolic
gutters and question of pancreatic laceration. Secondary to an
elevated Cr, a contrast CT could not be performed and an MRI
abdomen was performed to further evaluate for pancreatic injury.
This showed no ductal injury. Pt remained stable overnight and
only complained of mild abdominal pain. He was kept NPO, given
IVF, and bolused as needed to maintain adequate urine output.
Pt remained stable and his amylase and lipase enzymes decreased
steadily during his hospital stay. He transferred to the floor
on HD3. On HD4, pt was started on sips which were slowly
advanced to regular diet. By HD5, pt was tolerating a regular
diet, pancreatic enzymes had normalized, and abdominal pain was
resolved. He was discharged on [**2178-5-28**] in stable condition.
He was continued on his outpatient immunosuppression regimen of
prograf [**3-27**], cellcept [**Pager number **] [**Hospital1 **], and bactrim SS qd upon admission.
His prograf levels were found to be elevated and he was
titrated down to a level of [**2-26**].
Medications on Admission:
Prograf [**3-27**]
cellcept [**Pager number **] [**Hospital1 **]
bactrim qd
glipizide 2.5'
actonel 35 qwk
SSI
metoprolol 50"
tramadol 50"
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatitis s/p liver transplant
Discharge Condition:
Good
Discharge Instructions:
-Resume your regular medications.
-Take all new medications as directed.
-Do not drive while taking narcotics.
-You may shower.
Please call your doctor or return to the ER if you experience:
-Fever (> 101.4)
-Inability to eat/drink or persistent vomiting
-Increased pain
-Other symptoms concerning to you
Followup Instructions:
[**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2178-7-15**] 9:00
Completed by:[**2178-5-28**]
|
[
"518.0",
"V11.3",
"577.0",
"401.9",
"789.5",
"250.00",
"E849.0",
"V42.7",
"E880.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
4424, 4430
|
2971, 4236
|
326, 333
|
4508, 4515
|
1041, 2948
|
4870, 5006
|
4451, 4487
|
4262, 4401
|
4539, 4847
|
975, 1022
|
274, 288
|
361, 734
|
756, 912
|
928, 960
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,353
| 103,861
|
8053
|
Discharge summary
|
report
|
Admission Date: [**2158-12-12**] Discharge Date: [**2158-12-22**]
Date of Birth: [**2097-4-14**] Sex: M
Service: SURGERY
Allergies:
Adhesive / Nut Flavor / Percocet / Roxicet
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Abdominal pain and melena x 2days
Major Surgical or Invasive Procedure:
Antrectomy with Billroth II gastrojejunostomy - [**2158-12-12**].
History of Present Illness:
61 year old male with h/o duodenal ulcer, s/p lap nissen [**10-3**]
for GERD, has had non-healing duodenal ulcer since [**5-4**]. Has
been treated with PPIs, avoidance of NSAIDs (although remains on
aspirin), and work-up for HPylori and gastrinoma negative. For
approximately 10 days, he developed epigastric abdominal pain
followed by melena 2 days ago, presented for outpatient EGD
today, where an actively bleeding ulcer with visible vessel was
identified in the posterior duodenal bulb. The site was
injected with epinephrine with diminution but not cessation of
the bleeding. General surgical consult placed from the
endoscopy suite for possible operative management of the
persistent bleed.
.
No episodes of tachycardia or hypotension during or after the GI
procedure. Patient denies current lightheadedness or dizziness.
No chest pain. Mild shortness of breath, improved with sitting
upright. Moderate epigastric abdominal pain radiating to (R)UQ
of abdomen.
Past Medical History:
PMHx: h/o duodenal ulcer, paroxysmal AFib s/p ablation,
nephrolithiasis, anxiety
.
PSHx: Mini-Maze [**5-4**] ([**Doctor Last Name 914**]), excision lipoma (R) thigh [**2-3**]
([**Doctor Last Name **]), Lap Nissenfundoplication, lysis of adhesions and
incisional hernia repair [**10-3**] ([**Doctor Last Name **]), multiple (R) knee
arthroscopy (including [**9-1**]), umbilical incisional hernia
repair, lap cholecytectomy [**2149**], (L) shoulder replacement
approximately 10y ago with revision approximately 5y ago.
Social History:
Patient married with teenage daughter. Lives [**1-27**] the year in
[**Hospital1 6687**] and [**1-27**] the year in the [**Location (un) 4398**] of [**Location (un) 86**]. He is a
CFO of a wine company. Denies smoking. Denies drinking any ETOH
since he had his Nissen fundoplication
Family History:
Non-contributory
Physical Exam:
On Admission:
VS: HR 78, BP 128/75, 18, 100 on 2L NC
GEN: A&Ox3, NAD, lying slightly uncomfortably on stretcher
LUNGS: CTAB
COR: RRR
ABD: Soft, tender epigastrically/RUQ without rebound or
guarding. Well-healed incisions without hernia.
EXTREM: WWP sans edema
On discharge:
Afebrile/VSS
GEN: A&Ox3, NAD
LUNGS: CTAB
COR: RRR
ABD: Soft, appropriately tender along incision. Incision c/d/i
with steristrips in place. JP site with dressing c/d/i.
EXTREM: WWP, no edema, 2+dp
Pertinent Results:
On Admission:
[**2158-12-12**] 08:57PM GLUCOSE-151* UREA N-43* CREAT-1.0 SODIUM-141
POTASSIUM-4.4 CHLORIDE-109* TOTAL CO2-23 ANION GAP-13
[**2158-12-12**] 08:57PM CALCIUM-8.0* PHOSPHATE-3.4 MAGNESIUM-1.5*
[**2158-12-12**] 08:57PM HCT-37.7*
[**2158-12-12**] 07:28PM GLUCOSE-130* LACTATE-1.2 NA+-139 K+-4.1
CL--113*
[**2158-12-12**] 07:28PM HGB-12.6* calcHCT-38
[**2158-12-12**] 07:28PM freeCa-1.01*
[**2158-12-12**] 05:49PM TYPE-ART PO2-205* PCO2-34* PH-7.45 TOTAL
CO2-24 BASE XS-0
[**2158-12-12**] 05:49PM GLUCOSE-98 LACTATE-0.9 NA+-140 K+-4.8 CL--106
[**2158-12-12**] 05:49PM HGB-12.8* calcHCT-38
[**2158-12-12**] 05:49PM freeCa-1.09*
[**2158-12-12**] 04:30PM PT-14.1* PTT-28.0 INR(PT)-1.2*
[**2158-12-12**] 03:20PM GLUCOSE-104 UREA N-43* CREAT-1.0 SODIUM-141
POTASSIUM-4.7 CHLORIDE-110* TOTAL CO2-25 ANION GAP-11
[**2158-12-12**] 03:00PM WBC-5.4 RBC-4.31* HGB-12.1* HCT-37.2* MCV-86
MCH-28.1 MCHC-32.6 RDW-18.6*
[**2158-12-12**] 03:00PM NEUTS-65.9 LYMPHS-29.0 MONOS-3.3 EOS-1.2
BASOS-0.6
[**2158-12-12**] 03:00PM PLT COUNT-188
.
IMAGING:
[**2158-12-13**] Abdominal X-Ray:
There is a tube ending with its tip in the gastric fundus,
likely the NGT. However, the tube cannot be followed superiorly
above the GE junction secondary to poor exposure of this
radiograph. Repeat film with focus on the upper abdomen is
recommended.
.
[**2158-12-14**] ECG:
Sinus rhythm. Left atrial abnormality. Low precordial lead
voltage. Compared to the previous tracing of [**2158-6-12**] no
diagnostic interim change.
Intervals Axes:
Rate PR QRS QT/QTc P QRS T
73 154 98 394/416 9 -7 0
.
[**2158-12-14**] Abdominal X-Ray: There is no evidence of free air,
ileus, small or large bowel obstruction.
.
[**2158-12-16**] CHEST PORT. LINE PLACEM:
Right PICC tip in the upper SVC. Moderate cardiomegaly is stable
since [**2158-4-26**]. Aside from atelectasis in the bases of the
lungs, greater on the left base, the lungs are clear. There is
no pneumothorax or large pleural effusion. NG tube tip is out of
view below the diaphragm.
.
[**2158-12-19**] UGI SGL CONTRAST W/ KUB:
..............
Brief Hospital Course:
The patient was admitted to the General Surgical Service for
evaluation of the aforementioned problem. On [**2158-12-12**], the
patient underwent antrectomy with Billroth II gastrojejunostomy,
which went well without complication (reader referred to the
Operative Note for details). After a brief, uneventful stay in
the PACU, the patient arrived on the floor NPO with an NG tube
to low intermittent suction, on IV fluids and IV Protonix Q12,
with a foley catheter and JP to bulb suction in place, and a
Morphine PCA for pain control. He recived two doses on IV
Cefazolin peri-operatively. The patient was hemodynamically
stable.
.
Post-operative pain was initially inadequately controlled with
the Morphine PCA, which was changed to a Dilaudid PCA with
subsequent dose adjustment with improved pain control. When
tolerating clear liquids, the PCA was discontinued and he was
converted to oral pain medication with continued good effect.
.
A PICC line was placed, and the patient was started on TPN on
POD#4 due to expected prolonged NPO status post-operatively. An
abdominal x-ray on POD#2 revealed no evidence of free air,
ileus, small or large bowel obstruction. An Upper GI study with
contrast and KUB revealed normal emptying of the stomach. The NG
tube was discontinued on POD#8. The patient was started on sips
of clears on POD#8, which was progressively advanced as
tolerated to a bariatric stage 3 diet by POD#9 TPN was
discontinued on POD#10 The foley catheter discontinued the
morning of POD#7. The patient subsequently voided without
problem. The JP was discontinued on POD#9.
.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirrometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. The patient's blood sugar was monitored
regularly throughout the stay; sliding scale insulin was
administered when indicated. Labwork was routinely followed;
electrolytes were repleted when indicated.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a bariatric
stage 3 diet, ambulating, voiding without assistance, and pain
was well controlled. He was discharged home with services for
nutritional support. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
1. ASA
2. Celexa
3. Xanax
Discharge Disposition:
Home With Service
Facility:
CareGroup VNA
Discharge Diagnosis:
Duodenal ulcer with hemorrhage
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**6-4**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently [**Month/Year (2) **] the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Completed by:[**2158-12-22**]
|
[
"532.40",
"V45.3",
"577.8",
"338.18",
"300.00",
"V43.61",
"V13.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.15",
"44.43",
"43.7"
] |
icd9pcs
|
[
[
[]
]
] |
7477, 7521
|
4918, 7401
|
337, 405
|
7596, 7596
|
2791, 2791
|
2266, 2284
|
7542, 7575
|
7427, 7454
|
7741, 8260
|
8276, 8813
|
2299, 2299
|
2574, 2772
|
264, 299
|
433, 1409
|
2806, 4895
|
7610, 7717
|
1431, 1949
|
1965, 2250
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,179
| 156,818
|
52802
|
Discharge summary
|
report
|
Admission Date: [**2168-12-10**] Discharge Date: [**2168-12-23**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Chest tube placement
VATS
Intubation
History of Present Illness:
This is an 87 F with h/o htn, asthma, gerd, IBS, gait d/o who
initially p/w fever, SOB, s/p fall X 2 with generalized
weakness. She was admitted on [**2168-12-10**] for increasing SOB, fevers
and s/p fall. Initial imaging-Head CT negative, initial CXR
found to have a large L-sided pleural effusion. Per Chest CT
noted to have loculated pleural effusion and lungs that appeared
to be tacked to pleural surface. Diagnostic Thoracentesis
(5-10cc) clear fluid grew out Strep Milleri, sensitivities
pending. She was started on Levo ([**12-11**]) and Flagyl([**12-12**]) for LLL
PNA. She's remained febrile although fever curve trending down.
Per CT surge she underwent a VATS on [**12-15**]. Intra-op 1 liter of
straw colored fluid removed from L-pleural space, partial lung
decortication & removal of pleural fibrin, also ~400cc estimated
blood loss. 2 Chest Tubes were placed in L pleural space-left to
water suction. She received 1 UPRBC intra-op. She was extubated
post operatively but remained on Neosynephrine for low SBP.
.
PACU Course: Pt was mentating well, only c/o some chest
discomfort at site of L Chest tubes. She denied any
CP/Palpitations. Her SOB seemed improved to her. She denied any
N/V/Abdominal pain. No diarrhea. No dysuria. No HA/Confusion.
.
Past Medical History:
Hypertension
Asthma
GERD
IBS
RLS
Gait disorder
Spinal stenosis
Shingles with residual neuralgia
LE neuropathy
UTI 2 months ago
Colonoscopy last year without concern for cancer
Hyperlipidemia
Insomnia
2 back surgeries for spinal stenosis ([**2164**], [**2166**])
Social History:
lives alone in an [**Hospital3 **] facility. Walks with a
walker. Former smoker (quit 20 yrs ago, 18 pack years)-1ppevery
3 days x15years; no ETOH
.
Family History:
Mother with breast ca in 80s and father with [**Name2 (NI) 499**] ca in 80s.
Physical Exam:
Vitals: T: 98.1 P: 86 BP: 130/60 R: 20 SaO2: 94% on 4L
General: Awake, alert, NAD.
HEENT:PERRL, EOMI, dry MM
RESP: Diffuse rhonchi w/diminished BS b/l L base>R, no
expiratory/inspiratory wheezing
CV: Reg, Nml S1S2, no M/R/G
Abdomen: soft, NT/ND, + bowel sounds, no rebound/guarding
Extremities: no C/C/E, warm, 1+DP pulses b/l
Skin: abrasion on forehead
Neurologic: A&O X3, No focal deficits, CN II-XII intact
Pertinent Results:
[**2168-12-10**] 01:24PM PT-14.8* PTT-33.1 INR(PT)-1.3*
[**2168-12-10**] 01:07PM LACTATE-1.4
[**2168-12-10**] 12:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2168-12-10**] 12:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2168-12-10**] 12:30PM URINE RBC-0 WBC-0 BACTERIA-OCC YEAST-NONE
EPI-<1
[**2168-12-10**] 12:30PM URINE HYALINE-<1
[**2168-12-10**] 12:15PM GLUCOSE-147* UREA N-28* CREAT-1.0 SODIUM-130*
POTASSIUM-3.6 CHLORIDE-90* TOTAL CO2-24 ANION GAP-20
[**2168-12-10**] 12:15PM estGFR-Using this
[**2168-12-10**] 12:15PM CK(CPK)-404*
[**2168-12-10**] 12:15PM cTropnT-<0.01
[**2168-12-10**] 12:15PM CK-MB-5
[**2168-12-10**] 12:15PM WBC-25.9*# RBC-3.29* HGB-10.8* HCT-29.5*#
MCV-90 MCH-32.7* MCHC-36.4*# RDW-13.2
[**2168-12-10**] 12:15PM NEUTS-92.1* BANDS-0 LYMPHS-4.0* MONOS-3.6
EOS-0.2 BASOS-0
[**2168-12-10**] 12:15PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2168-12-10**] 12:15PM PLT SMR-NORMAL PLT COUNT-333
EKG: V1-RSR', NSR, TWI V3-no new changes, No ST-T segment
changes
.
Radiologic Data:
[**12-10**] CT C-spine
IMPRESSION: No acute fracture. Degenerative changes. Loss of
normal cervical lordosis is likely positional due to patient's
spine collar.
[**12-10**] CT head:
IMPRESSION: No intracranial hemorrhage or mass effect. No
fracture
identified.
[**12-10**] CT pelvis:
IMPRESSION:
1. Grade 2 anterolisthesis of L4 on L5. This is increased
compared with prior exam dated [**2162-6-28**], at which time it was
grade 1. The acuity of this displacement is not clearly defined
on the CT scan.
2. Small left pleural effusion with compressive atelectasis at
the left lower lobe.
3. Dense atherosclerosis.
.
[**12-10**] CXR (PA/Lat)
IMPRESSION: Large left pleural effusion. Associated left lower
lobe
consolidation could be secondary to compressive atelectasis,
however, an underlying pneumonia cannot be excluded. .
.
CHEST PORT. LINE PLACEMENT [**2168-12-21**] 3:38 PM
Right PICC line has been placed, with tip terminating in the mid
superior vena cava. Cardiac silhouette remains enlarged. CHF has
improved. Left retrocardiac consolidation is also slightly
improved. A moderate left and small right pleural effusions are
unchanged.
IMPRESSION: Right PICC line terminates in superior vena cava.
Brief Hospital Course:
Ms. [**Known lastname **] is an 87 year old woman with history of asthma, HTN,
GERD, and gait disorder who presented with falls, fever, and
found to have LLL PNA with loculated parapneumonic effusion
requiring VATS decortication. Hospital course was complicated by
post-operative hypotension requiring pressors and admission to
the MICU. She was stabilized and moved to the general medical
floor for further treatment of cultures growing Strep Milleri.
.
#) Community Acquired Pneumonia with Loculated Parapneumonic
effusion:
Strep Milleri from diagnostic thoracentesis. She was treated
initially with levofloxacin and metronidazole and underwent
VATS-decortication and chest tube placement. Given
post-operative hypotension, antibiotic coverage was broadened to
Clindamycin/Vancomycin/Ciprofloxacin. Upon stabilization and
transfer to the floor her she was changed to vancomycin. Strep
Milleri did not successfully grow in culture and sensitivity
data was not able to be obtained. PICC line was placed for
planned 14 day course of vancomycin. She has 7 days remaining of
vancomycin therapy at time of discharge.
.
.
#)Mediastinal Lymphadenopathy:
The patient's initial chest CT noted mediastinal
lymphadenopathy. Though this is likely reactive in the setting
of parapneumonic effusion, an interval chest CT should be
obtained 1 month following discharge.
.
#. Hypotension:
Most likely in setting of volume loss and volume shifts as 1L
fluid was removed from VATS in addition to 400cc blood loss
intra-op. Pt responded well to IV fluids in PACU w/transient
period off NEO once arrived to MICU. No evidence of cardiac
etiology-no EKG changes, no changes in cardiac enzymes. No
tachycardia, no CP, or changes in O2 require to suggest PE.
Lactate level was not elevated. Pt was weaned from pressors
without incident.
.
#) Asthma:
No PFT data available on admission, with history seemed more
consistent with chronic obstructive lung disease. We maximized
therapy with singulair, pulmicort neb, ipratropium nebulizer,
albuterol nebulizer. If not already obtained, the patient should
have outpatient PFT's to guide management in the future.
.
#) Fall:
CT head on admission without any evidence of bleeding. No focal
neurological deficits.
.
#) Anemia:
Iron studies consistent with acute inflammatory state. Had 1
Unit PRBC transfused intraoperively. Pt's hematocrit was
trending upwards at time of discharge. Stools guaiac negative.
.
#) Hyperglycemia:
Patient had elevated BG's in the setting of acute infection as
no history of diabetes. We measured her finger sticks QID, and
maintained humalong sliding scale as needed. At time of
discharge she did not have an insulin requirement.
.
#) Hyperlipidemia: we continued atorvastatin
.
#) Chronic back pain: we continued neurontin
.
#) Code Status:
The patient is Full code (discussed w/patient in MICU and
w/grandaughter-HCP [**Doctor First Name 6480**]
.
#) Communication: HCP [**Name (NI) 6480**] [**Name (NI) 108883**] (Grand daughter) ([**Telephone/Fax (1) 108884**]; ([**Telephone/Fax (1) 108885**]; [**Name (NI) **] [**Name (NI) **] (son) ([**Telephone/Fax (1) 108886**]; ([**Telephone/Fax (1) 108887**].
Medications on Admission:
Atenolol 50 mg q.d.
Neurontin 300 mg four pills four times a day
Singulair 10 mg at nighttime
Lipitor 10 mg at night
Trazodone 50 mg bedtime
Nexium 40 mg daily
hydrochlorothiazide 12 1/2 mg a day
Dicyclomine 10 mg po before meals
Vicodan 1 q 4 hrs prn pain
Pulmicourt (0.5 mg) 1 neb [**Hospital1 **]
Duoneb q 4-6 hrs prn
Centrum Silver
B complex
Oscal
vitamin C.
Discharge Medications:
1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Budesonide 0.5 mg/2 mL Solution for Nebulization Sig: One (1)
ML Inhalation [**Hospital1 **] ().
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. Dicyclomine 10 mg Capsule Sig: Two (2) Capsule PO TID BEFORE
MEALS ().
11. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QID (4
times a day).
12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q2H (every 2
hours) as needed.
13. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB.
14. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO Q4H (every 4 hours): Patient may refuse, hold for
sedation.
15. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
16. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
17. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
18. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
19. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
20. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours) for 7 days.
21. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): Only while not ambulating for DVT
prophylaxis.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary: Community Acquired Pneumonia
Secondary:
Asthma
Coronary artery diseas
Hyperlipidemia
Hypertension
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted after a fall and found to have a severe
pneumonia that required placement of a chest tube for drainage.
You were given intravenous antibiotics and medicines to help
support your blood pressure in the ICU. On the general medicine
floor we gave you antibiotics and continued with breathing
treatments.
.
Please take all of your medications as prescribed.
.
Call Dr. [**Last Name (STitle) **] if you experience any fevers, chills,
shortness of breath, severe wheezing, fatigue, worsening
weakness, numbness or tingling.
Followup Instructions:
Please see Dr. [**Last Name (STitle) **] within a week of discharge from rehab
You should have a CT scan of your chest within the next
1-2months to follow up a scan here that showed enlargement of
some lymph nodes.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
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"401.9",
"530.81",
"458.29",
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"787.91",
"511.9",
"780.52",
"486",
"724.00",
"272.4",
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] |
icd9cm
|
[
[
[]
]
] |
[
"33.22",
"96.05",
"38.93",
"34.51",
"34.04",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10532, 10598
|
4976, 8138
|
232, 270
|
10750, 10760
|
2558, 3917
|
11343, 11656
|
2034, 2113
|
8551, 10509
|
10619, 10729
|
8164, 8528
|
10784, 11320
|
2128, 2539
|
181, 194
|
298, 1564
|
3926, 4953
|
1586, 1850
|
1866, 2018
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,047
| 155,347
|
34733
|
Discharge summary
|
report
|
Admission Date: [**2159-6-22**] Discharge Date: [**2159-7-31**]
Date of Birth: [**2105-2-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9853**]
Chief Complaint:
Chest Pain/Dissection
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is a 54yo male with who presented on [**6-21**] to an OSH
with low back pain and HTN (BP 220/120) and was found to have a
type B aortic dissection on CTA. He was started on Esmolol and
Nipride gtt and then transferred to [**Hospital1 18**] for further
management.
On [**6-22**] the patient was noted to be more confused and agitated.
including confusion and agitation. On [**6-23**] he was intubated for
airway protection. During this time he also had low-grade
fevers. On [**6-24**], the patient was started on Ampicillin,
Vancomycin, and Ceftriaxone to empirically treat for bacterial
meningitis in the setting of fevers and mental status changes.
He also had a lumbar puncture with OP 44 mmHg, 1 WBC, Prot 52,
and Gluc 68. Based on these results, his antibiotics were
stopped and he remained on Vancomycin since he was found to have
GPCs in his blood cultures.
Past Medical History:
Aortic aneurysm, type B
Social History:
Patient has fiance, rides bike to work at a grocery store daily.
Physical Exam:
vitals T 99.4 BP AR 58 RR 11 O2 sat
vent MMV FI02 0.30 MV 4 [**3-26**]
Gen: Sedated, responsive to sternal rub
HEENT: ETT in place, PERRLA
Heart: RRR, no m,r,g
Lungs: CTAB
Abdomen: Soft, NT/ND, +BS
Extremties: No edema, 2+ DP/PT pulses bilaterally
Pertinent Results:
Relevant Imaging:
1)TTE ([**6-22**]): The left atrium is dilated. There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF 70%). The ascending aorta is mildly
dilated. The aortic arch is mildly dilated. There are focal
calcifications in the aortic arch. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened.
2)TEE ([**6-23**]): Type B aortic intramural hematoma.
3)CT head ([**6-23**]): 1. No acute intracranial process. 2. Chronic
lacunar infarct involving the right caudate and anterior limb
internal capsule and left subinsular region. 3. Extensive
opacification of bilateral ethmoid, maxillary, and frontal
sinuses.
4)MRI ([**6-24**]): Numerous bilateral supratentorial infarctions
probably combination of watershed and embolic ischemia.
Extensive sinonasal polyposis.
5)CT head ([**6-25**]): No evidence of hemorrhage. Possible acute left
middle cerebral artery infarction.
6)Renal ultrasound ([**6-27**]): 1. Asymmetry in the peak systolic
velocities of the main renal arteries, with the left measuring
considerably slower than the right. 2. No hydronephrosis. 3.
Trace free fluid in the abdomen.
Brief Hospital Course:
Mr. [**Known lastname **] is a 54yo male with recent type B aortic dissection
who is being transferred to the MICU for further managment of
his acute medical issues.
1)Aortic dissection: Patient presented to OSH with low back pain
and hypertension. Imaging confirmed diagnosis of type B
dissection. He was then transferred to [**Hospital1 18**] vascular surgery
ICU for further management. He was started on a Labetolol gtt
for blood pressure control with goal SBP<130. He was continued
on this drip upon transfer to the MICU. In the MICU, he was
started on oral Labetolol which was titrated up to 800mg PO Q6H
as he was being weaned off the drip. In addition, he was started
on Captopril, Hydralazine, Norvasc, and Clonidine. The patient
had to go back on the drip several times given poor control of
his blood pressure. He was continued on ASA 325mg daily.
Vascular surgery did not feel that he needed any further imaging
of his aorta or kidneys. As Mr. [**Known lastname 79608**] requirements for BP
medication has decreased, he is now being discharged on
Labetalol 300mg TID, Clonidine 0.1mg patch, and Lisinopril 20mg.
His pressures were maintained well below 130s for several days
prior to discharge on this regimen.
2)Stroke: Patient noted to have progressive global decline in
mental status after being transferred to [**Hospital1 18**]. MRI confirms
innumerable infarcts in both hemispheres involving
supratentorial/infratentorial and corpus collosum. Thought to be
embolic source but TTE/TEE were unrevealing. Also concerned
about an infected aortic aneurysm showering septic emboli. ID
was consulted but did not feel that he had an infected aortic
aneurysm. Neurology was consulted and recommended medical
management with Aspirin. [**Hospital1 **] listed amphetamine use on the
differential of potential causes, and it is important to note
that urine was initially positive for amphetamines.
3)Fevers: Patient noted to have low grade fevers associated with
mental status changes upon transfer to [**Hospital1 18**]. He has GPCs in his
blood cultures which is thought to be [**12-23**] an a-line. He also had
a TTE and TEE which did not suggest endocarditis. He also had an
LP which is not consistent with bacterial meningitis. He was
started on Vancomycin for his a-line infection. His blood
cultures also grew out strep viridans which would be concerning
for endocarditis but his TTE and TEE were negative. An infected
aortic aneurysm would also be concerning but after talking with
ID and vascular surgery they did not feel that this was the
case.
4)Respiratory: Patient was intubated on [**6-23**] for airway
protection in the setting of acute mental status changes. He was
then extubated a few days into his hospital course and has been
maintaining excellent oxygen saturations on room air.
5)Renal failure: Patient presented with Cr of 1.9 on admission;
peaked to 2.4 and slowly coming down to 1.7. There was some
concern that the dissection was effecting his kidneys. He had a
renal ultrasound which showed no dissection of the renal
arteries. This was confirmed with vascular surgery.
6)EKG changes: Patient has impressive EKG changes with ST
depressions in lateral leads V3-V6 on admission to [**Hospital1 18**].
Cardiology was consulted and felt that these changes occurred in
the setting of demand ischemia. He also had elevated CK and
troponins. He was continued on ASA 325mg daily and enzymes were
no longer followed.
7)Anemia: Patient presented with Hct~36.5 on admission. Slowly
decreased to 24 during his MICU stay. Unclear etiology. There
was some concern that he was bleeding around or into his aorta.
This was low on the differential given his stable hemodynamics.
His Hct was trended daily and, after reaching a nadir of 22,
began trending up without intervention. Likely Anemia of
Chronic Disease.
====================================================
Upon transfer to the medicine floor, the patient's overall
functional status consistently improved. He progressed from
being A&OxO to A&Ox2. His speech became more fluent, his left
side neglect resolved, although he still has some difficulty
with coordination of his extremities. His blood pressure
medications were slowly reduced and he ultimately settled within
the taget range of SBP<130 set by vascular.
An MRA of his renal arteries was done because doppler ultrasound
suggested assymmetric flow. The MRA was suboptimal secondary to
movt and claustrophobia, but it did also show assymmetric flow.
It should be repeated at some later time when the patient is
better able to cooperate. The dissection will have to be
serially imaged as per vascular surgery's reccommendations. The
pt has an appointment with them on [**8-7**].
Medications on Admission:
None
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)).
4. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTHUR (every Thursday).
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Labetalol 300 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Location (un) 686**]
Discharge Diagnosis:
Primary:
- Type B aortic dissection
- Accelerated hypertension
- CKD stage III
- Anemia NOS
- Non-thrombotic troponin elevation
- Coagulase negative staph aureus line sepsis
- Innumerable small acute infarcts bilateral cerebral
hemispheres.
- Paroxysmal sinus tachycardia NOS
- Vitamin B12 deficiency
Discharge Condition:
stable
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were initially admitted to the hospital for severe low back
pain and very high blood pressure. A CT scan at an outside
hospital showed that you had a dissection of the aorta. You were
transfered to the Intensive Care Unit of [**Hospital1 **]
were your blood pressure was brought under control. You were
seen by vascular surgery and they deemed that no surgical
intervention was indicated. While in the ICU, you became
acutely confused and agitated. You were intubated to protect
your airway.
An MRI of the brain showed inumerable small infarcts (strokes)
of unclear origin. The possibility that these may have been the
result of an infected clot was entertained, but the infectious
disease specialists thought that was very unlikely. You did
develop an infection of one of the arterial lines in your arm
that was treated successfully with antibiotics. You later
developed a mild case of pneumonia also successfully treated
with antibiotics.
You were transferred to the medicine service for management of
your labile blood pressure in anticipation of a placement into
rehab. The neurology team feels that your prognosis is very
good with aggressive rehabilitation.
We slowly reduced the doses of blood pressure medicine you were
taking as your blood pressure improved. Currently, it is well
managed with lisinopril, clonidine, amlodipine, and labetalol.
An MRI of your kidneys showed that one of the kidney arteries
may be partially occluded. This was not an optimal study because
you could not stop moving while inside the machine. This test
should be repeated at your convenience when you are ready to do
so.
You need to follow-up with vascular surgery on [**8-7**].
Appointment information is below. They will make reccomendations
regarding how often you should be scanned to monitor your
aneurysm.
You also have an appointmet with neurology listed below.
You should return to the hospital if you experience severe
abdominal or back pain such as the pain that first brought you
to the hospital. You should establish care with a primary care
physician. [**Name10 (NameIs) **] you do not have one, you can establish care at
[**Hospital3 **], by calling [**Telephone/Fax (1) 250**]. You can request an appt
with Dr. [**First Name (STitle) **] [**Name (STitle) **], or any other physician if you
prefer.
Followup Instructions:
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2159-8-7**] 9:00
.
VASCULAR SURGERY: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2159-8-7**] 9:45
.
NEUROLOGY: DRS. [**Name5 (PTitle) 162**] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2159-9-17**] 4:00
Completed by:[**2159-7-31**]
|
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icd9cm
|
[
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[]
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[
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icd9pcs
|
[
[
[]
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8455, 8522
|
3033, 7759
|
337, 344
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8868, 8877
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1676, 1676
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11278, 11704
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7814, 8432
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8543, 8847
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,997
| 147,502
|
37938
|
Discharge summary
|
report
|
Admission Date: [**2159-6-8**] Discharge Date: [**2159-6-19**]
Date of Birth: [**2085-11-1**] Sex: M
Service: MEDICINE
Allergies:
Quinapril / Rosiglitazone / Spironolactone
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Altered mental status, respiratory failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
73 year old male with history of Parkinson's disease, CKD(Cr bl
4), CHF 25-30%, and recent intracranial hemorrhage (ICH)
presenting with worsening hallucinations. Pt transferred from
[**Hospital1 **] for concerns of worsening head bleed. Recently
admitted to [**Hospital1 112**] [**5-27**] with head bleed 1 week after fall. Treated
for PNA and UTI and discharged 9 days ago although family does
not feel patient had recovered. He was treated with CTX and
azithro and discharged on levaquin which the family could only
get filled as moxiflox and nitrofuratoin. Labs there were
notable on admission for WBC 2.32 Plts 117 Cr of 4.89 BUN 80 and
80/4.63 with WBC of 2.08 Plts 104 on discharge [**5-30**]. His UCx
grew beta hemolytic strep [**5-28**]. Also of note, pt was admitted to
[**Hospital1 **] 5 weeks ago for lethargy and started on levothyroxine
at that point.
.
He saw his PCP 1 week ago for hallucinations and was started on
seroquel which reportedly made him worse and was stopped. Today
family noted him to have increased confusion, agitation, and
hallucinations including seeing mice and bunnies running around
the floor in past 3 days. At OSH found CT read as new small
acute hemorrhage in right upper subinsular area and interval
resolution of previously noted small hemorrhage in the left
centrum semi-ovale. Also found to be hypothermic to 92.9,
bradycardia (55-60) with pressures holding at 140s-150s. No
rigors or fevers. Urine, blood pending. No headache or meningeal
signs. Asterixis suggestive of encephalopathy.
.
Upon arrival to the ED, 93.6 57 138/91 18 100%2L. Pt denies any
complaints. FSBS 135. Blood, urine sent. Put on warming blankets
and repeat head CT ordered. Neurology felt c/w encephalopthy.
Head bleed very small and prob HTN related and needs sepsis w/u.
BP goal less than 160/90. Labs notable for Cr 4.3(bl 4), wbc
2.2. Given zosyn and vanc for empiric sepsis. CXR showed right
middle/lower lobe infiltrate vs volume overload. Given
Haloperidol for CT scan.
.
Upon arrival to the ICU, patient was noted to be alert and
nor responsive with twitching motions and internal rotation of
left arm. Question of seizure prompted eval by neuro who said
myoclonic jerks. Family also confirmed this was a change. Had
received haldol downstairs prior to coming up. Family reports
ongoing cough and hallucination (picking at paper towel last
night) and a fall last night as well.
.
ROS: Review of systems:
(+) Per HPI, rest of could not be obtained [**2-7**] mental status
Past Medical History:
-Parkinson's
-CKD
-CHF EF 20-25%[**4-14**]
-anemia
-HTN
-spinal stenosis
-BPH
-DM since [**2146**]
-Vit B12 def
-CAD
-gout
-HL
-Chronic LE edema
.
Social History:
Social History: Retired insurance adjustor and lives with his
wife and son in [**Name (NI) 84792**]. Denies smoking or alcohol use.
Family History:
father died of MI in 70s, son died of bone cancer at 13
Physical Exam:
VS: Temp:96.4 BP: 162/58 HR:77 RR:18 O2sat 95%2L
GEN: eyes closed, only responsive to sternal rub, twitching
movements of all extremities, with internal rotation of left arm
HEENT: pinpoint pupils and minimally reactive, EOMI, anicteric,
dryMM, op without lesions, no supraclavicular or cervical
lymphadenopathy, jvd difficult to assess [**2-7**] habitus, no carotid
bruits, no thyromegaly or thyroid nodules
RESP: poor air movement, decreased BS and b/l bases
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c, 3+edema to b/l ankles, dopplerable distal pulses
B/L
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx0, hallucinating. Cn II-XII intact. Myotonic jerking
and cogwheel rigidity throughout, 2+reflexes throughout, no
clonus, could not participate in remainder of exam [**2-7**] mental
status, +asterixis
Pertinent Results:
[**2159-6-8**] 11:06PM URINE HOURS-RANDOM UREA N-360 CREAT-51
SODIUM-77 POTASSIUM-22 CHLORIDE-68
[**2159-6-8**] 07:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2159-6-8**] 07:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-300
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2159-6-8**] 07:30PM URINE RBC-<1 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-1
[**2159-6-8**] 07:30PM URINE HYALINE-1*
[**2159-6-8**] 07:30PM URINE MUCOUS-RARE
[**2159-6-8**] 07:18PM LACTATE-0.7
[**2159-6-8**] 04:15PM GLUCOSE-127* UREA N-63* CREAT-4.3* SODIUM-141
POTASSIUM-4.0 CHLORIDE-99 TOTAL CO2-30 ANION GAP-16
[**2159-6-8**] 04:15PM estGFR-Using this
[**2159-6-8**] 04:15PM IRON-80
[**2159-6-8**] 04:15PM calTIBC-237* VIT B12-967* FOLATE-5.5
FERRITIN-317 TRF-182*
[**2159-6-8**] 04:15PM TSH-6.1*
[**2159-6-8**] 04:15PM WBC-2.2* RBC-4.03* HGB-10.8* HCT-34.4* MCV-86
MCH-26.8* MCHC-31.3 RDW-17.0*
[**2159-6-8**] 04:15PM NEUTS-71.3* LYMPHS-20.4 MONOS-5.9 EOS-1.8
BASOS-0.6
[**2159-6-8**] 04:15PM PLT COUNT-100*
[**2159-6-8**] 04:15PM PT-14.4* PTT-33.3 INR(PT)-1.2*
.
EKG upon ED admission: NSR at 55bpm, LAD, NI, late RWP, TWI in
V2-V4, I, avL with Q in III and avF, no ST deviations, compared
to [**2159-5-27**] ant TWI are now.
EKG upon admission to unit NSR at 75 bpm, compared to ED the TWI
in V2-V4 have righ which may be lead placement as unchanged from
5/22/11/
.
Imaging: [**6-8**] CXR: Right-sided pulmonary airspace opacity with
effusion concerning for pneumonia.
.
[**6-8**] CT head Right-sided pulmonary airspace opacity with effusion
concerning for pneumonia.
.
[**6-8**] [**Hospital1 **]: At OSH found CT read as new small acute
hemorrhage in right upper subinsular area and interval
resolution of previously noted small hemorrhage in the left
centrum semi-ovale.
.
CT head [**Hospital1 112**] [**5-27**]: similary appearance of punctate focus of
hyperattenuation within the left corona radiate which may
represent punctate hemorrhage, but is nonspecific.
CXR [**Hospital1 112**] [**5-27**]: RLL opacity
.
Micro: BCx pending, Ucx pending
Brief Hospital Course:
73 year old male with history of Parkinson's disease, CKD(Cr bl
4), CHF 25-30%, and recent ICH presenting with worsening
hallucinations. The patient's altered mental that was felt to
be related to an encephalopathy, exacerbated by pneumonia and by
sedating medications given in the emergency department. The tiny
foci of question intracranial hemorrhage were not felt to be
contributing and later scans showed no change, suggestiing this
was more likely calcifcation than bleed. The patient was treated
for pneumonia as below. The neurology service was consulted and
recommended MRI, which the patient refused and follow-up CT was
performed instead, which was stable. The patient waxed and
waned throughout his course in terms of attention, agitation,
orientation and hallucinations. He was intermittently agitated
and physically combative to staff. Seroquel caused him to be
nearly unresponsive. After discussion with neurology, including
his movement specialist, chemical restraints were avoided at
this point in favor of soft mechanical restraints. He
intermittently required soft restraints for agitation. His
mental status did not improve with treatment of his pneumonia,
he was given vancomycin and zosyn for 8 days, and holding
sedating medications. He had a PEA arrest on [**6-19**], was
intubated, extubated per the family's wishes and expired several
hours later.
.
#RLL infiltrate: The patient was treated with vancomycin and
Zosyn IV for 8 days, with resolution of symptoms.
.
#CKD: Per report Cr 4.0 at baseline, etiology unclear/unknown
but likely component of DM, HTN. The creatinine was 4.3 on
admission and increased throughout hospitalization to a peak of
7.0 on [**6-16**], thought to be due to reduced po intake causing
intravascular volume depletion and pre-renal acute renal
failure. There was no evidence of obstruction. He was given
gentle IV fluids to support his renal function. The family had
discussed renal replacement therapy with his outpatient
nephrologist and were not interested in this.
.
#CHF: EF 25-30%, etiology unclear but likely ischemic given Q
waves on EKG. Intravascularly dry but overall body hypervolemic.
Held lasix and coreg in setting of likely infection. Given
increased Cr and no signs of worsening volume overload on exam,
lasix continued to be held. Coreg was reintroduced on hospital
day 2.
.
#Parkinson's disease: Continued carbadopa/levodopa. Requip
tapered and discontinued per outpatient neurologist Dr. [**Last Name (STitle) **].
.
#End of life discussions: On three occasions, family meetings
were held with the care team and the patient's wife, his sons
were also sometimes present. The family had a strong desire to
see the patient come home that was expressed. Reversible causes
of his mental status were addressed by completing eight days of
HAP treatment, witholding sedating medication. His stage V
renal failure at baseline had worsened, but the family did not
wish to pursue renal replacement therapy. As he continued to
show non-improvement, the patients' family expressed interest in
moving to comfort care. At the family meeting on [**6-18**] with his
wife, we discussed that he was unlikely to return to his
pre-hospitalization baseline. His wife was seeking to bring him
home with hospice service. At the time, code status was
discussed and she was leaning toward DNR/DNI/CMO, but wished to
discuss it with her sons first.
.
#PEA Arrest: In the early morning of [**6-19**], the patient's nurse
noted the patient jerking. Such jerking motions had been seen
the previous morning and after neurology evaluation were thought
to be myoclonic jerks secondary to his renal failure. At the
bedside, the nurse found the patient to be pulseless and a code
was called. The patient was intubated and transferred to the
MICU. There his family were called to the bedside, he was
extubated per their wishes and he expired two hours later.
Medications on Admission:
Medications at home:
-coreg 3.125 [**Hospital1 **]
-doxazosin 4mg [**Hospital1 **]
-allopurinol 100mg daily
-norvasc 5mg daily
-requip 1mg TID
-synthroid 0.025 qday
-[**Doctor Last Name **]-levo 50mg QID
-finisteride 0.05mg daily
-lipitor 40mg qhs
-iron qday
-zetia 10mg daily
-asa 81 mg daily
-procrit prn
-VitD
-B12
Discharge Medications:
patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnosis:
Pneumonia
Secondary Diagnosis:
Delirium
Discharge Condition:
patient expired
Discharge Instructions:
patient expired
Followup Instructions:
patient expired
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"403.91",
"584.9",
"583.81",
"427.5",
"428.0",
"332.0",
"285.21",
"272.4",
"276.50",
"349.82",
"486",
"250.40",
"274.9",
"284.1",
"333.2",
"428.22",
"276.0",
"780.39",
"585.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"99.60"
] |
icd9pcs
|
[
[
[]
]
] |
10615, 10624
|
6294, 10206
|
345, 352
|
10727, 10744
|
4178, 6271
|
10808, 10952
|
3215, 3273
|
10575, 10592
|
10645, 10645
|
10232, 10232
|
10768, 10785
|
10253, 10552
|
3288, 4159
|
2809, 2878
|
263, 307
|
380, 2790
|
10695, 10706
|
10664, 10674
|
2900, 3049
|
3081, 3199
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,034
| 168,995
|
971
|
Discharge summary
|
report
|
Admission Date: [**2196-10-20**] Discharge Date: [**2196-10-22**]
Date of Birth: [**2135-2-26**] Sex: M
Service: [**Hospital1 **]
CHIEF COMPLAINT: Syncope, hematemesis.
HISTORY OF PRESENT ILLNESS: The patient is a 61 year-old
male with a history of NASH cirrhosis, type 2 diabetes
mellitus and esophageal varices who was transferred to [**Hospital1 1444**] from [**Hospital3 3765**] after
being found down on bathroom floor. The patient has no
recollection of the event, but states he believes he fell
after getting up to urinate. The patient's wife found him on
the floor with coffee ground emesis and dark stool. EMS
arrived and found his blood sugar to be 24. He was given two
ampules of D50 at the scene. The patient had a further
episode of coffee ground emesis in the ambulance. At
arrival at [**Hospital3 3765**] the patient's fasting blood
sugars was 59. His hematocrit was 42.9. Although the
patient was confused regarding the details of the event, the
patient did note that he felt better after receiving the
glucose. He was transferred to [**Hospital1 188**] for a MICU admission.
Upon further questioning the patient states that he has noted
increased abdominal girth over the last one to two days and
ten minutes of sharp right sided chest pain on the day prior
to admission. The patient states that he felt the pain was
most likely secondary to muscle strain and denies any
association with shortness of breath, dizziness, nausea,
vomiting or diaphoresis. The patient has been taking his
insulin as per his routine with his last dose being the night
prior to admission. The patient has not been compliant with
his diuretics over the past few days as he has ran out of his
prescription. The wife states that she has noted some
yellowing of the patient's eyes as well as decreased po
intake on the day prior to admission.
PAST MEDICAL HISTORY:
1. NASH cirrhosis, the patient is currently on the liver
transplant list. He had on episode of ascites in the past.
Liver failure is complicated by esophageal varices status
post banding in [**2195-10-31**].
2. Insulin dependent diabetes.
3. Status post left nephrectomy and embolization for
ASK-UPMCK kidney.
MEDICATIONS ON ADMISSION:
1. Insulin 50 units NPH b.i.d., 20 units regular b.i.d.
2. Lasix 40 mg po q.d.
3. Aldactone 100 mg po q.d.
4. Inderal 10 mg po t.i.d.
5. Vitamin E.
6. Protonix 40 mg po q.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient denies the use of tobacco,
alcohol or drugs. He is married and lives with his wife. [**Name (NI) **]
is the owner of a computer chip company.
FAMILY HISTORY: No history of cancer or liver disease.
PHYSICAL EXAMINATION ON ADMISSION: The patient was
hemodynamically stable with a blood pressure of 104/63 and a
pulse of 70. Respiratory rate 18. The patient was 100% on 3
liters nasal cannula. In general, the patient was sitting up
in no acute distress. His sclera were anicteric. His chest
was clear to auscultation bilaterally. There was spider
angiomata and gynecomastia. Cardiovascular examination was
normal with a regular rate and rhythm. There was a soft 2
out of 6 systolic ejection murmur in the left upper sternal
border without radiation. The abdomen was soft, mildly
distended, nontender with normoactive bowel sounds. Rectal
examination revealed light brown stool that was hemoccult
negative. The patient had no costovertebral angle
tenderness. His extremities had no edema except trace edema
in the left lower extremity to the ankles.
LABORATORY EXAMINATION ON ADMISSION: White blood cell count
6.2, hematocrit 35.8 decreased from outside hospital
measurement of 42.9, platelets 109, sodium 140, potassium
3.3, chloride 109, bicarb 25, BUN 7, creatinine 0.7, glucose
137, PT 12.8, PTT 32.8, INR 1.4. Liver function tests were
within normal limits. The patient had 6 to 10 white blood
cells on urinalysis.
HOSPITAL COURSE: The patient is a 61 year-old man with known
esophageal varices and liver failure presents with coffee
ground emesis. The patient was admitted to the medical
Intensive Care Unit for management of presumed upper
gastrointestinal bleed. His Intensive Care Unit course is as
described below.
1. Gastrointestinal bleed: During the course of his
Intensive Care Unit stay the patient exhibited no evidence of
active bleeding. His hematocrit was 35 on admission and
remained stable with a nadir of 32.2. The patient had
esophogastroduodenoscopy done, which indicated grade one
(minor) esophageal varices and portal gastropathy. No
additional banding was indicated. At the time of transfer to
the floor unit, the patient denied any symptoms of
hematemesis, fatigue or lightheadedness.
2. Hypoglycemia: The patient was hypoglycemic at the time
of his episode and when transferred to the [**Hospital3 3765**]
as described above. Per the patient's wife report the
patient's diet was decreased on the days prior to admission.
The patient took his normal dose of insulin regardless. The
patient was started on a dextrose drip with blood sugars
ranging less then 150 generally. He was transitioned to an
insulin sliding scale and blood sugars have remained below
250 generally. His outpatient insulin regimen was
discontinued until sugars were within normal limits.
3. Increased abdominal girth: The patient had been
noncompliant with diuretics for one week prior to admission.
After restarting diuretics abdominal girth decreased.
4. Chest pain: The patient described chest pain one day
prior to admission. The patient's cardiac enzymes were
cycled and found to be negative.
Given the patient's stability in the MICU the patient was
transferred to the floor for continued monitoring. His
course was as follows.
1. Upper gastrointestinal bleed: The patient had no further
episodes of gastrointestinal bleeding. His hematocrit
remained stable. He was hemodynamically stable. He
continued beta blocker therapy for known varices. He was
discharged to home on his outpatient medications.
2. Hypoglycemia: Once the patient was tolerating regular
diet, insulin therapy was reinitiated. The patient had one
episode of hypoglycemia with a nadir of 47 on [**2196-10-22**]. The
patient has no history of prior hypoglycemic episodes despite
being on his outpatient regimen for over four months.
However, given the initial episode and inpatient episode of
hypoglycemia the patient's outpatient regimen was adjusted.
Per the medical attendings recommendation p.m. NPH dose was
decreased to 40 units and a.m. dose of regular insulin was
held. Other then the described hypoglycemic episode the
patient's blood sugars remained in good control.
MEDICATIONS ON DISCHARGE: The patient will continue his
outpatient medications. The insulin doses were adjusted as
described above.
FOLLOW UP: The patient was instructed to follow up with Dr.
[**First Name8 (NamePattern2) 1312**] [**Last Name (NamePattern1) 6457**] in seven to ten days.
CONDITION ON DISCHARGE: The patient was asymptomatic,
hemodynamically stable, tolerating a regular diet.
DISCHARGE DIAGNOSES:
1. Upper gastrointestinal bleed.
2. Hypoglycemia.
3. Insulin dependent diabetes.
4. Cirrhosis.
5. Esophageal varices.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Last Name (NamePattern1) 6458**]
MEDQUIST36
D: [**2197-5-17**] 04:53
T: [**2197-5-25**] 11:19
JOB#: [**Job Number 6459**]
|
[
"572.3",
"571.5",
"573.3",
"578.9",
"456.21",
"250.80",
"789.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
2641, 2702
|
7110, 7480
|
6716, 6824
|
2231, 2450
|
3937, 6689
|
6836, 6982
|
165, 188
|
217, 1868
|
3583, 3919
|
1890, 2205
|
2467, 2624
|
7007, 7089
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,419
| 182,003
|
6107
|
Discharge summary
|
report
|
Admission Date: [**2121-7-21**] Discharge Date: [**2121-7-28**]
Date of Birth: [**2061-5-14**] Sex: M
Service: MEDICINE
Allergies:
Haloperidol / Valium
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
coffee ground emesis
Major Surgical or Invasive Procedure:
upper endoscopy [**7-21**]
History of Present Illness:
60 yo M with Hx of CVA admitted to [**Hospital1 **] 4 for suicidal ideation
(w/ no plan or attempts) was noted to have coffee ground emesis
twice this evening. On initial evalution by med consult:
afebrile, with lying BP=127/95, HR=119 & sitting BP=141/104,
HR=125, in NAD. Quantity of emesis unknown but he was found with
dried blood on his gown and hands.
.
He had originally been transferred to [**Hospital1 **] 4 from the [**Hospital1 **]
Group Home reporting thoughts of suicide to staff. He reported
that recently both his mother and an aunt were hospitalized with
medical conditions. He stated that in this context, he became
depressed and began having delusional beliefs. He denied
paranoid delusions and auditory or visual hallucinations.
.
Prior to transfer, T&S sent, 2 PIVs placed, IV PPI given, 2L NS
given. Labs drawn prior to transfer notable for a stable Hct at
42.6 and leukocytosis of 17.
.
On arrival, somnolent but easily arousable and oriented x3.
Denies ever having had bloody emesis.
Past Medical History:
- Paranoid Schizophrenia
- Left frontoparietal stroke ([**2114**])- maintained on ASA and
plavix
- Seizures
- Tardive dyskinesia
- Constipation, bowel/bladder incontinence
- Migraines
- COPD
Social History:
Lives at [**Hospital1 **] [**Hospital1 1426**] [**Hospital3 400**].
Contacts include father, [**Name (NI) **] [**Name (NI) 23919**] [**Telephone/Fax (1) 23921**] and aunt, [**Name (NI) **]
[**Name (NI) **], [**Telephone/Fax (1) 23922**].
Family History:
-aunt with scoliosis
-father with seizures and hepatitis
-mother with ? aneurysm, stroke, heart valve replacement
Physical Exam:
VS: HR 96 BP 119/63 SaO2 94% RA
Gen: cooperative, anxious elderly man lying in bed in NAD
HEENT: anicteric sclerae, EOMI, pupils reactive to light.
surgical pupil OS (s/p PE:PCIOL). Very dry mucous membranes
CV: RRR nl S1, S2 no murmurs
Lungs: CTAB no wheezes
Abd: +BS, soft, ND diffusely tender to palpation esp RUQ
Ext: 2+ pulses B/L DP and PT
Neuro: A&Ox3 but poor insight. able to spell world forwards and
backwards, unable to perform serial 7's. Able to repeat a
sentence, speech somewhat tangential and repetitive. Concerned
he
is not "getting the right medications for his condition"
R-sided facial droop (possibly residual from L-sided CVA)
Strength: [**5-13**] UE and LE B/L
Cerebellar: FNF intact, gait not assessed
Pertinent Results:
Labs on Admission [**2121-7-21**]
WBC-17.4*# RBC-4.60 Hgb-14.8 Hct-42.6 MCV-93 MCH-32.3* Plt
Ct-242
PT-11.7 PTT-23.7 INR(PT)-1.0
Glucose-177* UreaN-33* Creat-1.8* Na-129* K-4.3 Cl-91* HCO3-25
AnGap-17
ALT-20 AST-19 AlkPhos-73 Amylase-73 TotBili-0.5
Lipase-33
Calcium-9.9 Phos-4.5 Mg-2.5
.
.
.
.
.
.
Other Studies:
[**2121-7-21**] CXR: Generally low lung volumes and more pronounced
elevation of the right hemidiaphragm than the left are
longstanding. There is no evidence of aspiration, no pneumonia
or atelectasis. Lungs are essentially clear. Heart size normal.
No pleural abnormality.
[**2121-7-21**] EGD: Grade 4 esophagitis with spontaneous bleeding was
seen in the lower third of the esophagus. Cold forceps biopsies
were performed for histology at the lower third of the
esophagus. Normal stomach. Normal duodenum.
Brief Hospital Course:
This is a 60 yo M with Hx of CVA admitted to [**Hospital1 **] 4 for suicidal
ideation (w/ no plan or attempts) was noted to have coffee
ground emesis twice this evening without prior Hx of GI bleed.
.
# Upper GIB: The patient has no history of gastric, hepatic, or
esopheal pathology. No predisposing medications. 2 peripheral
IV's in place. Pt typed and screened. Hemodynamically stable.
Initial tachycardia was concerning, but orthostatic signs were
negative. Stable Hct can be misleading as it was drawn soon
after episode and patient had not received volume in the
interim. The patient has an active type and scree. The patient's
coffee ground emesis resolved quickly with NG tube and lavage.
An IV PPI [**Hospital1 **] was started. IV PPI [**Hospital1 **] was changed to PO PPI [**Hospital1 **]
on [**7-23**].
.
# Psych: Per the psychiatry team, the patient is Section 12'd
and does not require a 1:1 sitter. Continuing
citalopram/olanzapine. Mental status at baseline per [**Hospital1 **] 4
team. Restarted trileptal.
.
# Hx of CVA: re-started ASA/ Plavix as per GI team's recs.
.
# urinary retention: when foley was pulled initially pt had
difficulty voiding. bladder scan at the time revealed 870cc
residual. straight cath was attempted but this met w/
resistance. Urology was consulted and they recommended
re-instating the foley catheter and starting pt on 0.4mg flomax
daily. the foley was left in place from [**7-25**] to [**7-28**] as per
urology's recs and it was removed on [**7-28**]. He passed his voiding
trial and was accepted for transfer to [**Hospital1 **] 4.
Medications on Admission:
Home medications:
zyprexa 25mg at night
citalopram 10mg once daily
trileptal 600mg qhs plus
asa 325mg once daily
bisacodyl every other day
detrol 1mg [**Hospital1 **]
robitussin 1 tsp QID
plavix 75mg once daily
miralax once daily
spiriva
symbicort
vit b12
Discharge Medications:
zyprexa 25mg at night
citalopram 10mg once daily
trileptal 600mg qhs plus
asa 325mg once daily
bisacodyl every other day
detrol 1mg [**Hospital1 **]
robitussin 1 tsp QID
plavix 75mg once daily
miralax once daily
spiriva
symbicort
vit b12
Discharge Disposition:
Extended Care
Discharge Diagnosis:
PRIMARY: hematemesis
SECONDARY: Depression/ SI, paranoid schizophrenia, seizure
disorder
Discharge Condition:
stable
Discharge Instructions:
You came to the psych floor of the hospital on [**7-17**] with suicidal
thoughts and abdominal pain. You had one episode of vomiting but
otherwise did well until [**7-21**] when you vomited some blood. You
went to the intensive care unit and had an upper endoscopy
performed by the GI doctors. They found a small bleed in your
lower esophagus and some yeast. We treated you for the yeast
with some anti-fungals. You did well in the ICU and came to the
general medicine floors on [**7-22**]. You continued to do well with
no further episodes of bleeding but had some problems retaining
urine.
Please come back to the hospital if you have any of the
following symptoms: shortness of breath, chest pain, severe
abdominal pain, blood in your stool or urine.
Your medications have been changed as follows:
Flomax 0.4mg PO daily
Followup Instructions:
MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3708**]
Specialty: Gastroenterology
Date and time: [**2121-8-15**] 9:00am
Location: [**Location (un) 830**] [**Hospital Unit Name 1825**] [**Location (un) **]
Phone number: [**Telephone/Fax (1) 463**]
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2121-7-28**]
|
[
"276.1",
"333.85",
"345.90",
"295.32",
"112.84",
"E947.9",
"600.01",
"564.00",
"V62.84",
"346.90",
"785.0",
"276.9",
"530.82",
"438.83",
"492.8",
"788.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
5731, 5746
|
3578, 5161
|
301, 329
|
5878, 5886
|
2730, 3555
|
6759, 7159
|
1852, 1968
|
5468, 5708
|
5767, 5857
|
5187, 5187
|
5910, 6736
|
1983, 2711
|
5205, 5445
|
241, 263
|
357, 1366
|
1388, 1580
|
1596, 1836
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,015
| 149,744
|
30002
|
Discharge summary
|
report
|
Admission Date: [**2117-4-1**] Discharge Date: [**2117-4-11**]
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 1436**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **] yo M, recently transferred from OSH to neurosurgical ICU on
[**4-1**] for subdural hematoma following a fall.
The patient states that he had 2 falls before the
hospitalization. He fell initially at home in the middle of the
night when he turned off the lights before getting into bed and
fell over the walker. He had imaging which showed a L elbow
fracture and went to short term rehab. He then had another fall
at rehab which was unwitnessed, found face down, although awake
and alert, not remembering how the fall happened. He was brought
to [**Hospital **] Hospital and found to have a left sided subdural
hematoma and was transferred to Neuro ICU for observation. His
aspirin was discontinued and he was started on prophylactic
antiseizure regimen.
Serial cardiac markers were checked to evaluate his fall, noted
to be elevated, cardiology consulted and recommended transfer to
[**Hospital Unit Name 196**].
Repeat head CT showed stable subdural hematoma.
The patient denies any chest pain or SOB during this
hospitalization. He notes a mild non-productive cough with some
rib discomfort when coughing. No recent fevers, chills, n/v.
Past Medical History:
CAD MI X4 - the pt states last MI was about 18 mos ago, denies
prior hx of cardiac cathetirization or stenting.
Cardiomyopathy
COPD
DJD of c-spine
Social History:
Normally lives alone, independent, but in short term rehab uses
walker. Stopped smoking and drinking 10 years ago. Has 2
daughters which are involved.
Family History:
n/a
Physical Exam:
98.2, BP 125/41, HR 68, RR 18, O2 sat 98% on 2L NC
The patient has a visible laceration on his L zygomatic bone, no
discharge.
The patient was oriented to person, place and time. The
patient's mood and affect were generally inappropriate.
.
There was no xanthalesma and conjunctiva were pink with no
pallor or cyanosis of the oral mucosa. The neck was supple with
no JVD. The carotid waveform was normal. 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 normal
S1 and the S2 was normal. There were no rubs, murmurs, 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, femoral or carotid
bruits. Inspection and/or palpation of skin and subcutaneous
tissue showed no stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: DP 2+ PT 2+ femoral 2+ popliteal 1+
Left: DP 2+ PT 2+ Femoral 2+ popliteal 1+
Pertinent Results:
[**2117-4-1**] 12:33PM BLOOD WBC-5.3 RBC-3.63* Hgb-11.6* Hct-33.2*
MCV-92 MCH-32.0 MCHC-35.0 RDW-13.1 Plt Ct-185
[**2117-4-4**] 06:50AM BLOOD WBC-6.5 RBC-3.66* Hgb-11.2* Hct-34.4*
MCV-94 MCH-30.6 MCHC-32.5 RDW-13.1 Plt Ct-257
[**2117-4-1**] 12:33PM BLOOD Neuts-78.7* Lymphs-12.2* Monos-8.4
Eos-0.5 Baso-0.1
[**2117-4-1**] 12:33PM BLOOD Glucose-132* UreaN-48* Creat-1.7* Na-142
K-5.0 Cl-106 HCO3-23 AnGap-18
[**2117-4-3**] 07:00AM BLOOD ALT-17 AST-28 LD(LDH)-215 CK(CPK)-123
AlkPhos-83 TotBili-0.6
[**2117-4-1**] 12:33PM BLOOD CK-MB-NotDone cTropnT-0.14*
[**2117-4-2**] 10:48AM BLOOD CK-MB-10 MB Indx-5.4 cTropnT-0.27*
[**2117-4-4**] 06:50AM BLOOD CK-MB-21* MB Indx-9.1* cTropnT-0.52*
[**2117-4-4**] 06:50AM BLOOD Digoxin-0.8*
[**2117-4-2**] 12:36AM BLOOD Phenyto-12.9
.
AP PELVIS AND TWO VIEWS LEFT HIP: There are prominent
degenerative changes within the lower lumbar spine. Sacroiliac
joints and pubic symphysis are normally aligned. The coccyx is
largely obscured due to overlying soft tissue. Femoral heads
articulate well with bilateral acetabuli. No fracture or
malalignment is identified. There are prominent vascular
calcifications.
IMPRESSION: No fracture or malalignment identified.
.
THREE VIEWS, LEFT ELBOW: An appropriate lateral view was
obtained. The bones appear well mineralized. A tiny ossific
density lesion overlying the distal humerus, on the lateral film
only, is likely the sequela of prior trauma. The joint spaces
are preserved. The bones are normally aligned. The surrounding
soft tissues are unremarkable.
IMPRESSION: No new fracture or malalignment.
.
CT OF THE HEAD WITHOUT CONTRAST DATED [**2117-4-1**].
HISTORY: [**Age over 90 **]-year-old man with subdural hematoma, status post
fall; evaluate intracranial hemorrhage.
TECHNIQUE: Contiguous 5-mm axial tomographic sections were
obtained from the skull base through the vertex and viewed in
brain and bone window on the workstation.
FINDINGS: No prompting outside hospital study is available to
me. There is a small right frontotemporal scalp subgaleal
hematoma with no underlying skull fracture. There is an acute
contre-coup subdural hematoma layering over the left cerebral
convexity, with relatively slight mass effect and flattening of
the subjacent gyri. There is resultant very slight, perhaps
2-mm, rightward shift of the normally midline structures with no
evidence of [**Age over 90 71613**] herniation or ventricular trapping or
obstruction. The subdural hematoma measures roughly 7.5 mm in
maximal thickness (2:18). No other acute intracranial hemorrhage
is identified. There is symmetric slight prominence of the
bifrontal extraaxial CSF spaces, with a somewhat flattened
appearance to the subjacent gyri, which raises the possibility
of underlying chronic, thin subdural collections, perhaps
related to previous hematomas.
No skull fracture is seen elsewhere. The included portions of
the paranasal sinuses, as well as the mastoid air cells and
middle ear cavities are clear. Incidentally noted is extensive
calcification of the cavernous and supraclinoid segments of both
internal carotid arteries, as well as a solitary punctate
calcification located in a right parietovertex sulcus (2:20).
This is non-specific, but may be seen with old, healed
neurocysticercosis.
IMPRESSION:
1. Acute, perhaps superimposed on chronic, left subdural
hematoma, layering over the cerebral convexity. There is only
minimal mass effect and shift of the midline structures, with no
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 71613**] herniation.
2. No other acute intracranial hemorrhage.
3. Right frontotemporal scalp hematoma with no underlying skull
fracture.
4. Possible evidence of old, healed neurocysticercosis.
COMMENT: These findings (as well as a CD with images of outside
hospital CT cervical spine) were reviewed with Dr. [**First Name (STitle) **],
Emergency Department, at the time of this dictation.
.
Repeat head CT:
FINDINGS: The evolving left convexity subdural hematoma is less
dense than on the prior study and slightly smaller with a
maximum diameter of 6.5 mm. No new hyperdense component. As
mentioned previously, there are more chronic appearing subdural
collections likely hematomas in the bifrontal and right
convexity, which are unchanged. The acute on chronic left
convexity subdural continues to exert some mass effect on the
adjacent parenchyma without definite shift of midline
structures. No new acute hemorrhage is appreciated.
IMPRESSION: Left convexity acute on chronic subdural hematoma
appears slightly less prominent. No other short interval change.
.
EKG with STE in V1-V4 (appears somewhat chronic)
.
Eccho: 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 with
anteroseptal/anterior
akinesis/hypokinesis, anteroalteral hypokinesis and
inferior/inferolateral
akinesis/hypokinesis. Right ventricular chamber size is normal.
Right
ventricular systolic function is borderline normal. The aortic
valve leaflets
(3) are mildly thickened. There is no aortic valve stenosis.
Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to
moderate ([**12-29**]+) mitral regurgitation is seen. The tricuspid
valve leaflets are
mildly thickened. 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, EF 25%
Brief Hospital Course:
Patient is a [**Age over 90 **] yo M prior hx CAD s/p MI, subdural hematoma
following a fall and noted to have elevated cardiac markers.
.
# STEMI - Initially transferred from SICU to medicine for
elevated troponins with unclear symptoms of angina and a
non-diagnostic in the setting of LVH and has not changed over
the last 24 hrs. However he has increasing troponins concerning
for acute ischemic event. Heparin drip very high risk given
recent subdural hematoma. Otherwise ischemia was treated with
rate control with beta blockade and BP was controlled with
hydralazine. Pt was placed on ASA and anxiety was limited with
benzodiazepines. Ecchocardiogram revealed EF 25% with
extensive anterior, anteroseptal, inferior hypo/akinesis (see
report). After his ischaemic episode he went into florid
pulmonary edema.
.
# CHF - Initially patient had minimal signs volume overload on
exam but signs of overload on CXR but after his Cardiac event he
went into florid pulmonary edema with RR in the 40's. He was
placed on a NTG drip, his BB was decreased, and he was diuresed
agressively with lasix with resultant resolution of CHF.
.
# Rhythm: Mr. [**Known lastname **] had been in NSR until the day prior to
discharge when he went into a flutter and then a fib. He was
not a candidate for anticoagulation so he was rate controlled
with metoprolol. He converted back to NSR the following day and
remained in sinus at time of discharge. Consider
anticoagulation in the future if he has further recurrences of
afib.
.
# COPD: With many years of smoking though no known medications
at home. Treated with nebs.
.
# HTN - cont BB, changed atenolol to metoprolol given his renal
dysufnction. No ACE-I for now given renal dysfunction, but
afterload reduction with hydralazine.
.
# Subdural hematoma - appears stable continue phenytoin for
seizure ppx. Continue neuro checks. Neurosurgery has signed off
as patient has improved hematoma on repeat CT. Should follow up
with neurosurgery in 4 weeks with another CT head.
.
# CRI - unknown baseline, increased from Cr 1.7 on admission to
2.7. This was stable for at least a week despite agressive
diuresis.
.
# Code: DNR/DNI. This was confirmed with the patient and family
in-house.
Medications on Admission:
ASA 325mg daily
Hydralyzine 10mg PO daily
Digoxin 0.125
Atenolol 25mg PO daily
Nitroglycerin patch 0.6
Zantac 150mg daily
MVI daily
Discharge Medications:
1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
10. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
11. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: [**12-29**] Tablet,
Sublinguals Sublingual PRN (as needed) as needed for chest pain.
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Cepacol 2 mg Lozenge Sig: [**12-29**] Lozenges Mucous membrane PRN
(as needed) as needed for cough.
15. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for dyspnea, nausea.
16. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
17. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
19. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
20. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
21. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 6594**] Nursing and Rehab
Discharge Diagnosis:
left acute on chronic subdural hematoma
ST elevation myocardial infarction (heart attack)
Congestive heart failure
atrial fibrillation
severe arthritis
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital with bleeding around your
brain and were later found to have a heart attack, congestive
heart failure, and atrial fibrillation. You should [**Name6 (MD) 138**] and MD
or return to the ER if you develop any of the following: chest
pain, shortness of breath, significant headache unaffected by
ibuprofen or tylenol, inability fo urinate or move your bowels,
nausea/vomiting, severe abdominal pain, temp>101F, New onset of
tremors or seizure, any confusion or change in mental status,
any numbness, tingling, weakness in your extremities, or any
other concerning symptoms.
Followup Instructions:
follow-up with Dr. [**Last Name (STitle) **] in 4 weeks with a head CT at that time
call [**Telephone/Fax (1) 2731**] for an appointment you should stay on Dilantin
until that time.
Have your primary care check your dilantin level for a goal of
[**10-11**] 1 week after discharge
.
Please see your primary care doctor in 1 week
|
[
"414.01",
"410.71",
"584.9",
"427.32",
"721.0",
"E888.9",
"585.9",
"427.31",
"403.90",
"496",
"852.21",
"428.0",
"414.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13240, 13304
|
8881, 11113
|
226, 233
|
13500, 13509
|
3235, 7169
|
14163, 14494
|
1775, 1780
|
11296, 13217
|
13325, 13479
|
11139, 11273
|
13533, 14140
|
1795, 3216
|
178, 188
|
261, 1420
|
7178, 8858
|
1442, 1591
|
1607, 1759
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,593
| 127,185
|
41725+58466
|
Discharge summary
|
report+addendum
|
Admission Date: [**2175-7-29**] Discharge Date: [**2175-8-1**]
Date of Birth: [**2157-3-15**] Sex: M
Service: NEUROSURGERY
Allergies:
Milk
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
fall from tree
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 18-year-old right handed man who was brought to [**Hospital1 18**]
after a fall from a tree. Patient was sitting on the windowsill
on the [**Location (un) 1773**] of his building and reached for a tree
branch at which time he fell and struck his head on the
sidewalk. Bystanders reported loss of consciousness for
approximately 1-2 minutes. On arrival EMS found patient to be
awake alert and confused, complaining of headache.vPatient was
asking repetitive questions per EMS. He had brain CT that showed
showed multiple occipital condyle fractures and small right
temporal hemorrhage
Past Medical History:
Appendectomy
Social History:
He denies any drugs use, alcohol or tobacco use.
Family History:
He denies any family history of cancer or blood clots.
Physical Exam:
PHYSICAL EXAMINATION:
T98. BP 144/70 P90 R12 O2 sat 98%/RA. Patient is alert, awake
and
oriented times 3. There is no right-left confusion. His
calculation ability is intact. His language is fluent with good
comprehension, naming, and repetition. Recent recall is intact.
His pupils are equal and reactive to light, 4 mm to 2 mm
bilaterally. Extraocular movements are full. Visual fields are
full to confrontation. Funduscopic examination reveals sharp
disks margins. His face is symmetric. Facial sensation is
intact.
His hearing is intact bilaterally. His tongue is midline. Palate
elevates in the midline. Sternocleidomastoids and upper trapezii
are strong. He does not have a pronator drift. His muscle
strength is [**3-30**] bilaterally. His muscle tone is normal. Reflexes
are +3 and symmetric. His toes are downgoing. Sensory
examination is intact to touch and proprioception. No visual or
tactile extinction. Coordination is normal. His gait is
deferred.
Romberg not tested. General examination. His skin has full
turgor. HEENT is unremarkable. Neck is supple and there is no
bruit. Cardiac examination reveals regular rate and rhythms.
His
lungs are clear. His abdomen is soft. His extremities do not
show
clubbing, cyanosis, or edema.
At time of discharge he was neurologically intact.
Pertinent Results:
LABORATORY:
[**2175-7-29**] Na 140 K 3.6 Cl 100 CO2 27 BUN 16 CREAT 1.1 GLC 103
[**2175-7-29**] WBC 6.5 HGB 12.7 PLT 249
IMAGING:
[**2175-7-29**] CT/brain showed bilateral occiput fx extending toward
though not
involving either occipit or temporal bones (terminating in
foramen magnus) and 1 cm rounded hyperdensity in inferior aspect
right frontal lobe,
[**2175-7-29**] CTA stable hyperdensity in inferior aspect of R frontal
lobe- layering SAH vs evolving contusion.
2. Head CTA: no stenosis, occlusion, aneusym, hemorhage.
[**7-31**] CT Head- IMPRESSION:
1. Expected evolution of right frontal contusion
2. 4-mm hyperdensity in the left frontal lobe is more
conspicuous than on the prior study, likely reflects a tiny left
frontal contusion.
3. Unchanged bilateral skull base fractures.
Brief Hospital Course:
Mr. [**Known lastname 90663**] was admitted to the TICU and monitored closely. He
remained neurologically intact. On [**2175-7-30**] his cervical collar
was removed as he had no point tenderness or difficulty with
flexion extension. He had staples placed for posterior scalp
laceration in ED which were CDA. He was transferred to the
floor and diet and activity advanced. On [**7-31**] he had an increased
headache therefore a CT was obtained but stable and revealed
some resolution of the previously seen hemorrhage. He remained
in the hospital for pain and nausea medication. He was stable
and discharged to home on [**2175-8-1**].
Medications on Admission:
None
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
3. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Basilar skull fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge 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.
?????? If you have been prescribed Keppra for anti-seizure medicine,
take it as prescribed until finished
Followup Instructions:
Follow-Up Appointment Instructions
* You have staples that need to be removed in 7 days, this can
be done at PCP or call [**Name (NI) 90664**] office for appt.
??????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 without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
??????We recommend you see Dr [**First Name (STitle) **] in the Traumatic Brain Injury
(TBI) clinic the phone number is [**Telephone/Fax (1) 6335**]. If you have any
problems booking this appointment please ask for [**First Name8 (NamePattern2) 16367**] [**Last Name (NamePattern1) 16368**].
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2175-8-1**] Name: [**Known lastname 14304**],[**Known firstname 14305**] Unit No: [**Numeric Identifier 14306**]
Admission Date: [**2175-7-29**] Discharge Date: [**2175-8-1**]
Date of Birth: [**2157-3-15**] Sex: M
Service: NEUROSURGERY
Allergies:
Milk
Attending:[**First Name3 (LF) 1698**]
Addendum:
Meclizine was helping the patient's nausea and he was given a
prescription for this at time of discharge.
Discharge Disposition:
Home
[**Name6 (MD) **] [**Name8 (MD) 1041**] MD [**MD Number(2) 1709**]
Completed by:[**2175-8-1**]
|
[
"801.22",
"873.0",
"E884.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.59"
] |
icd9pcs
|
[
[
[]
]
] |
6359, 6489
|
3239, 3878
|
283, 289
|
4370, 4370
|
2421, 3216
|
5013, 6336
|
1031, 1087
|
3933, 4274
|
4324, 4349
|
3904, 3910
|
4521, 4990
|
1102, 1102
|
1124, 2402
|
229, 245
|
317, 912
|
4385, 4497
|
934, 948
|
964, 1015
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,154
| 180,663
|
47940
|
Discharge summary
|
report
|
Admission Date: [**2137-8-13**] Discharge Date: [**2137-9-2**]
Date of Birth: [**2079-8-1**] Sex: M
Service: SURGERY
Allergies:
Neurontin
Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Central venous access line placement
Intubation
[**2137-8-14**] Left wrist aspiration and washout
[**2137-8-21**] Left transmetatarsal amputation revision, Right 5th ray
amputation
[**2137-8-28**] Right transmetatarsal amputation
History of Present Illness:
58 year old male with multiple medical problems including
chronic diastolic CHF and ESRD on hemodialysis and severe
vascular disease presented to the ED on [**2137-8-12**] with left wrist
cellulitis. He had recently fallen while at rehab after his left
TMA and fractured the left wrist. Of noted he had missed 2
dialysis sessions secondary to transportation issues.
Past Medical History:
PVD, chronic diastolic CHF with LVEF >55% by TTE [**2-/2134**],
exercise MIBI in [**2-/2134**] with no reversible defects, CKD on
hemodialysis, hypertension, type 2 diabetes, alcohol abuse,
chronic anemia, prior left leg DVT (previously on warfarin),
peripheral neuropathy requiring long-term percocet/oxycodone
use.
Past Surgical History:
[**2131-7-5**]: LLE angio, AK-[**Doctor Last Name **] stenting
[**2131-10-26**]: I&D LLE abscess
[**2132-2-7**]: STSG to LLE ulcers
[**2132-5-19**]: RLE angio showing SFA occlusion
[**2132-5-20**]: R Fem-AK [**Doctor Last Name **] bypass with PTFE
[**2132-5-22**]: R second toe amp
[**2133-6-16**]: Left 2nd and 3rd toe debridements
[**2134-7-20**]: LUE AV graft
[**2136-3-8**]: LLE angio, SFA stent, 2nd, 3rd toe amps
[**2136-3-12**]: amp site debridement, VAC
[**2136-6-1**]: R heel debridement
[**2137-1-30**]: r 4th toe amp
[**4-8**]: L TMA
[**2137-6-28**]: RLE angio
Social History:
Lives at home with fiancee. Retired. Denies ETOH consumption,
and denies recreational drug use.
Family History:
Diabetes mellitus in both parents.
Physical Exam:
On admission:
Vitals: T: 97.8 BP:131/71 P: 133 R: 24 O2: 98RA
General: Uncomfortable, tremulous, only responds ??????yes?????? to
calling his name
HEENT: Sclera anicteric, MM dry, oropharynx clear tongue not
obstructing airway, PERRL 3??????2 mm bilaterally
Neck: supple, JVP not elevated, no LAD
CV: tachycardic and slightly irregular by radial pulse but
moaning and very difficult to hear heart sounds
Lungs: Clear to auscultation bilaterally, some coarse expiratory
wheezes, no crackles anteriorly. No accessory muscle use.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: bilateral foot dressings are c/d/i. Trace pitting edema
bilaterally. Left wrist also dressed c/d/i. ; left ue avf
without abnormalities
Neuro: Responds ??????yes?????? sometimes when calling his name. Otherwise
does not follow commands. Does orient to voice intermittently by
opening his eyes and looking toward the voice. Tremulous.
Cranial nerves with equal and reactive pupils 3mm to 2mm with
light. Face looks symmetrical. Difficult to asses muscle
strength but tone and bulk are normal. Reflexes are 2+ at the
patellae bilaterally and 2+ in the right bicep. Unable to
assess sensation, gait.
On discharge:
General: AOx3, NAD
HEENT: PERRLA
Neck: supple, JVP not elevated
Lungs: CTAB
CV: RRR, no m/r/g
Abdomen: soft, NT/ND, +BS, no guarding
Ext: warm, no edema, left wrist casted, right and left foot in
dressings, wounds c/d/i without erythema or drainage.
Pertinent Results:
[**2137-9-2**] 09:50AM BLOOD WBC-6.4 RBC-3.07* Hgb-8.7* Hct-27.3*
MCV-89 MCH-28.5 MCHC-32.0 RDW-16.8* Plt Ct-185
[**2137-9-2**] 09:50AM BLOOD Plt Ct-185
[**2137-8-24**] 05:14AM BLOOD PT-13.3* PTT-29.5 INR(PT)-1.2*
[**2137-9-2**] 09:50AM BLOOD Glucose-135* UreaN-34* Creat-4.9* Na-130*
K-4.5 Cl-91* HCO3-29 AnGap-15
Radiology
CT abdomen [**8-14**]
IMPRESSION:
1. Mild stranding and fluid around the left common femoral
graft origin. No
enhancing lesions to suggest abscess.
2. New left lower lobe and right middle lobe pulmonary nodules
measuring up
to 11 mm are concerning for infection, a full chest CT is
recommended to
evaluate the extent of this process.
3. Widely patent bifemoral grafts.
4. Cholelithiasis.
5. Nodular contour of the liver suggestive of cirrhosis.
6. Splenomegaly and parasplenic varices indicative of chronic
portal
hypertension.
Cardiology: Echo [**8-14**]
IMPRESSION: Moderate symmetric LVH. Septal hypokinesis. There is
a calcified mass on the posterior leaflet of the mitral valve,
this was present on prior study. It could be consistent with a
healed vegetation or calcification from another cause.
Neurology: EEG [**8-14**]
IMPRESSION: Abnormal EEG due to the occasional slowing of the
background and
bursts of generalized slowing. These findings suggest a
widespread
encephalopathy. Metabolic distort disorders are most common
causes.
Nevertheless, the background was very difficult to discern or
characterize.
Also, there were no areas of prominent focal slowing. There were
no
definitely epileptiform abnormalities.
Micro
[**8-13**] Blood cx
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
[**8-14**] Wrist aspirate cx
STAPH AUREUS COAG +. MODERATE GROWTH OF TWO COLONIAL
MORPHOLOGIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Blood Culture, Routine (Final [**2137-8-24**]): NO GROWTH.
Brief Hospital Course:
Mr. [**Known lastname 732**] is a 58 year old male with multiple medical problems
including ESRD on HD (T/th/Sat), HepC, severe PVD s/p multiple
interventions, HTN, DM2 who presented on [**8-13**] with left wrist
cellulitis and weakness/malaise after missing HD for one week.
He was admitted to the general medicine floor on antibiotics and
was brought to HD urgently in the AM, though he developed acute
agitation, and atrial fibrillation with RVR in the 140s. He was
transferred to the MICU for HD. His heart rate was controlled
with diltiazem gtt which has since been transitioned to PO dilt
with good control to the 100-110's. He was intubated for airway
protection and possible OR debridement of a worsening left foot
infection from a recent transmetatarsal amputation. His
antibiotics were expanded to vancomycin/cefepime. His blood
cultures later returned positive for MSSA and so he was
transitioned to cefazolin, the likely source of his left wrist
septic joint as aspiration of the joint fluid by hand surgery
revealed MSSA as well. A TTE showed valvular calcification and
wall motion abnormalities (attributed to sepsis/uremia) but no
vegetations were found to explain the bacteremia. He [**Month/Year (2) 1834**] a
bedside debridement of the vascular wound while intubated. He
was extubated on [**8-15**]. His mental status was poor following
extubation but has improved since that time and he has been AOx3
for some time now. CT of his head revealed no intracranial
lesions and EEG was consistent with toxic metabolic
encephalopathy. Over the next several days he was continued on
cefazolin and continued to receive HD on T/thurs/S as his wrist
and left foot were monitored by hand and vascular surgery
respectively. On [**8-22**] he was taken to the OR for a revision of
the left TMA as his wound had begun to dehiss. He also [**Month/Year (2) 1834**]
a right 5th ray amputation for a gangrenous appearing toe. He
tolerated the procedure well and was started on levofloxacin
following sensitivities of the MSSA from his wrist joint
aspiration. On [**2137-8-24**] he was seen by PT who recommended bed
exercises. He continued to do well until he was noted to have
some necrosis over the R foot wound edge the wound was debrided
and he was subsequently went back to the OR for a right TMA on
[**2137-8-28**]. Since that time he has continued on cefazolin with HD
and Levaquin and has been followed by PT. His CVL was removed on
[**2137-8-31**]. At thime of discharge, he was afebrile, his pain was
well controlled, he was voiding and tolerating a regular diet.
He is to continue his antibiotics until [**2137-9-11**]. Follow up has
been scheduled with Dr. [**Last Name (STitle) **] on [**2137-9-19**]. Please call
61/-[**Telephone/Fax (1) **] to schedule an apointment with Dr. [**First Name (STitle) 1022**] in [**1-28**] weeks
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from Patient.
1. Albuterol Inhaler [**1-28**] PUFF IH Q4H:PRN sob
2. Amlodipine 5 mg PO DAILY
hold for SBP<100
3. Atorvastatin 80 mg PO DAILY
4. Carvedilol 6.25 mg PO BID
hold for SBP<100, HR<60
5. Clopidogrel 75 mg PO DAILY
6. darbepoetin alfa in polysorbat *NF* 100 mcg/mL Injection QHD
7. HydrALAzine 25 mg PO Q6H
hold for SBP<100
8. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
hold for sedation or RR<10
9. Tiotropium Bromide 1 CAP IH DAILY
10. Nephrocaps 1 CAP PO DAILY
11. Aspirin 325 mg PO DAILY
12. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Nephrocaps 1 CAP PO DAILY
2. HydrALAzine 25 mg PO Q6H
hold for SBP<100
3. Tiotropium Bromide 1 CAP IH DAILY
4. darbepoetin alfa in polysorbat *NF* 100 mcg/mL Injection QHD
5. Albuterol Inhaler [**1-28**] PUFF IH Q4H:PRN sob
6. Carvedilol 6.25 mg PO BID
hold for SBP<100, HR<60
7. Atorvastatin 80 mg PO DAILY
8. Aspirin 325 mg PO DAILY
9. Clopidogrel 75 mg PO DAILY
10. Lactulose 30 mL PO QID
Titrate to [**3-31**] BM per day
11. Nicotine Patch 21 mg TD DAILY
12. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
13. CefazoLIN 1 g IV POST HD
14. Levofloxacin 250 mg PO Q48H
15. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
hold for sedation or RR<10
RX *oxycodone 10 mg 1 tablet(s) by mouth Q6hrs Disp #*30 Tablet
Refills:*0
16. Diltiazem 60 mg PO QID
hold for HR <60 and SBP < 100
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Septic arthritis of left wrist
MSSA bacteremia
left foot osteomyelitis
respiratory failure
chronic renal failure
post operative anemia requiring transfusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 732**],
It was our pleasure caring for you. You were admitted to [**Hospital1 1535**] for altered mental status during
your hemodialysis session. You were brought to the ICU where you
were intubated and received antibiotics to treat the bacteria
found in your bloodstream. The hand specialists found that your
wrist was infected. In addition the vascular surgeons found that
your foot was also infected, so you were taken for surgery to
clean out your wrist joint and your foot. You were given
antibiotics to treat these infections. You ultimatily required
transmetatarsal amputation of both feet.
During your hospitalization, you also developed an abnormal
heart rhythm, which we think you developed because of your
infections. We treated you with medications to slow your heart
rate and blood-thinning medications to reduce your risk of
stroke.
ACTIVITY:
?????? On the side of your amputation you are non weight bearing for
4-6 weeks.
?????? You should keep this amputation site elevated when ever
possible.
?????? You may use the opposite foot for transfers and pivots.
?????? No driving until cleared by your Surgeon.
?????? No heavy lifting greater than 20 pounds for the next 3 weeks.
BATHING/SHOWERING:
?????? You may shower when you get home
?????? No tub baths or pools / do not soak your foot for 4 weeks from
your date of surgery
WOUND CARE:
?????? Sutures / Staples may have been removed before discharge. If
they are not, an appointment will be made for you to return for
staple removal.
?????? When the sutures are removed the doctor may or may not place
pieces of tape called steri-strips over the incision. These will
stay on about a week and you may shower with them on. If these
do not fall off after 10 days, you may peel them off with warm
water and soap in the shower.
CAUTIONS:
?????? If you smoke, please make every attempt to quit. Your primary
care physician can help with this. Smoking causes narrowing of
your blood vessels which in turn decreases circulation.
DIET:
?????? Low fat, low cholesterol / if you are diabetic ?????? follow your
dietary restrictions as before
CALL THE OFFICE FOR: [**Telephone/Fax (1) 28502**]
?????? Bleeding, redness of, or drainage from your foot wound
?????? New pain, numbness or discoloration of the skin on the
effected foot
?????? Fever greater than 101 degrees, chills, increased redness, or
pus draining from the incision site.
Please continue your levofloxacin and cefazolin until [**2137-9-11**]
Followup Instructions:
Provider: [**Name10 (NameIs) 5536**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 5537**] Date/Time:[**2137-10-21**]
1:00
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2137-9-19**] 3:45
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1114**], M.D. Phone:[**Telephone/Fax (1) 2010**]
Date/Time:[**2137-9-17**] 12:20
Please schedule a follow up appointment in [**1-28**] weeks in the
orthopaedic hand clinic with Dr. [**First Name (STitle) 1022**] his office number is
[**Telephone/Fax (1) 3009**]
|
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
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[
[
[]
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11398, 11495
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6945, 9788
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289, 522
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11696, 11696
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3552, 6922
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14392, 14990
|
1983, 2020
|
10537, 11375
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11516, 11675
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9814, 10514
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11872, 13243
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1280, 1853
|
2035, 2035
|
3281, 3533
|
228, 251
|
13255, 14369
|
550, 917
|
2050, 3267
|
11711, 11848
|
939, 1257
|
1869, 1967
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,472
| 123,892
|
8792
|
Discharge summary
|
report
|
Admission Date: [**2124-5-20**] Discharge Date: [**2124-7-6**]
Date of Birth: [**2066-4-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
productive cough, shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 58 yo man with PMH significant for CML s/p allo SCT
approximately 2 1/2 years ago and chronic GVHD on
Cellcept/Prednisone, chronic RUQ pain, pseudomonas in sputum, PE
on Lovenox, multiple vertebral fractures, and chronic lower
extremity edema with intermittent episodes of cellulitis
presenting with a productive cough and shortness of breath for a
few weeks. His cough has been productive of a significant
amount of greyish-white sputum. He has noticed intermittent
wheezing and congestion. He has noticed that his shortness of
breath has worsened dramatically over the past few weeks.
Currently he can only wheel himself 20 yards without getting
short of breath, whereas he stated that he could wheel himself
for a mile or so in the past. He also has significant lower
extremity edema, although he can ambulate with a walker. His
legs are wrapped, weeping fluid, and the bandage on his right
leg is soaked through with blood. He denies any fevers, sweats,
chills, loss of appetite, nausea, vomiting, or change in bowel
habits. He has a history of a recent pneumonia for which he was
treated with azithromycin. He also has had a course of
linezolid for VRE bacteremia which he contracted during a
hospitalization
for cellulitis.
Past Medical History:
# CML see below
# chronic GVH on immunosuppressants
# Chronic RUQ pain since [**2113**]
- work up unrevealing
- on narcotics
# h/o pseudomonas and stenotrophomonas in sputum
# GERD w/ Barrett's esophagus
# Hypertension
# h/o pulmonary embolism in [**3-24**]
Social History:
Lives with his sister. Previously worked as a manufacturing
manager, is now on disability
Tob: quit x12yrs; 1ppd 10yrs pack-year history
EtoH: none
Illicits: remote MJ use
Family History:
Father with diabetes mellitus, BPH, alive at 85yrs
Mother with h/o breast cancer; d. TIAs and CVD at 75yrs
Sister with h/o breast cancer in her 50s, atrial fibrillation
Two brothers with h/o melanoma
Physical Exam:
Admission Exam:
VS: T 97.3 BP 110/70 HR 92 R 20 O2 sat 94% 2L
Gen: visibly short of breath, but in NAD
HEENT: NCAT, anicteric, PERRLA, EOMI, OP clear, no thrush, MM
dry
Neck- supple, no LAD
Cor-tachy but regular, no murmurs
Lungs- coarse rhonchi throughout, expiratory wheezing throughout
Abd- +bs, distended, non-tender, no rebound or guarding
Extrem- 2+ pitting edema to knees b/l, bleeding wound on right
anterior shin, toes on right foot are dusky and cool, left foot
is warm, no palpable pulses
Neuro- grossly intact
Discharge exam:
Gen: NAD
HEENT: NCAT, anicteric, PERRLA, EOMI, OP clear, no thrush, MMM
Neck- supple, no LAD
Cor-regular rate and rhythm, no m/r/g
Lungs- mild crackles throughout
Abd- +bs, distended, non-tender, no rebound or guarding
Extrem- 1+ edema to knees b/l, wound on right anterior shin not
bleeding, toes on right foot are dusky and cool, left foot is
warm, no palpable pulses
Neuro- grossly intact
Pertinent Results:
GRAM STAIN (Final [**2124-5-21**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2124-5-25**]):
OROPHARYNGEAL FLORA ABSENT.
ESCHERICHIA COLI. HEAVY GROWTH.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species. Ertapenem = SENSITIVE.
Ertapenem sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
ESCHERICHIA COLI. MODERATE GROWTH.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species. Ertapenem = SENSITIVE.
Ertapenem sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>32 R =>32 R
AMPICILLIN/SULBACTAM-- 16 I 4 S
CEFAZOLIN------------- =>64 R =>64 R
CEFEPIME-------------- R R
CEFTAZIDIME----------- R R
CEFTRIAXONE----------- =>64 R R
CEFUROXIME------------ =>64 R =>64 R
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN---------- =>128 R R
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R =>16 R
[**2124-7-6**] 12:00AM BLOOD WBC-3.6* RBC-2.93* Hgb-9.4* Hct-29.8*
MCV-102* MCH-32.0 MCHC-31.5 RDW-19.3* Plt Ct-157
[**2124-7-4**] 12:19AM BLOOD Neuts-77.7* Lymphs-9.8* Monos-12.1*
Eos-0.4 Baso-0.1
[**2124-7-5**] 12:00AM BLOOD PT-10.2* PTT-27.4 INR(PT)-0.8*
[**2124-7-6**] 12:00AM BLOOD Glucose-97 UreaN-20 Creat-0.5 Na-140
K-4.0 Cl-100 HCO3-34* AnGap-10
[**2124-7-6**] 12:00AM BLOOD ALT-69* AST-62* LD(LDH)-292* AlkPhos-419*
TotBili-0.2
[**2124-7-6**] 12:00AM BLOOD Calcium-8.6 Phos-2.5* Mg-2.0
[**2124-6-30**] 03:21PM BLOOD Type-ART Temp-37 pO2-42* pCO2-57* pH-7.38
calTCO2-35* Base XS-6 Intubat-NOT INTUBA Comment-RECEIVED O
[**2124-6-8**] 10:31 am BRONCHOALVEOLAR LAVAGE Site: UPPER LOBE
BRONCHIAL LAVAGE, RT UPPER LOBE.
GRAM STAIN (Final [**2124-6-8**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): COLUMNAR EPITHELIAL CELLS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ (1-5 per 1000X FIELD): BUDDING YEAST.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
RESPIRATORY CULTURE (Final [**2124-6-13**]):
10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA.
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
SECOND MORPHOLOGY.
YEAST. QUANTITATION NOT AVAILABLE.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- 16 I 8 S
CEFTAZIDIME----------- 16 I 8 S
CIPROFLOXACIN--------- 1 S 2 I
GENTAMICIN------------ 8 I 4 S
MEROPENEM------------- =>16 R =>16 R
PIPERACILLIN---------- 32 S 32 S
PIPERACILLIN/TAZO----- 64 S 16 S
TOBRAMYCIN------------ <=1 S <=1 S
LEGIONELLA CULTURE (Final [**2124-6-15**]): NO LEGIONELLA
ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2124-6-8**]):
NO FUNGAL ELEMENTS SEEN.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2124-6-8**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Final [**2124-6-22**]):
YEAST.
ACID FAST SMEAR (Final [**2124-6-9**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
Brief Hospital Course:
This is a 58 yo man with PMH significant for CML s/p allo SCT
approximately 2 1/2 years ago and chronic GVHD on
Cellcept/Prednisone, chronic RUQ pain,
pseudomonas/stenotrophomonas in sputum, PE on Lovenox, multiple
vertebral fractures, and chronic lower extremity edema with
intermittent episodes of cellulitis presenting with a multilobar
pneumonia and new sternal/vertebral fractures.
.
#Pneumonia: Pulmonary and ID were consulted to assist with a
potential bronchoscopy and antibiotic management. A good sputum
sample was obtained on admission and it was felt that it would
be best to avoid a bronchoscopy given his poor respiratory
status and the quality sample. He was initially treated with
Levaquin and ceftazidime until his initial sputum culture was
positive for ESBL E. coli. His antibiotics were then switched
to meropenem. He also received IVIG. He got an aggressive
pulmonary toilet with an acapella valve and in/exsufflator.
.
Patient was found to be B glucan positive on [**5-30**] and [**6-2**].
Given this, he was bronched on [**6-8**] to evaluate for possible
fungal etiology of his persistent RUL infiltrate.
.
Bronchoscopy revealed unmarkable right and left mainstem
bronchi, BAL performed on LLL and RUL segments. Secretions
noted to be thick and profuse. 240 cc NS instilled with 60 cc
returned. Post bronchoscopy pt desaturated to 80% requiring NRB
with suctioning and nebs up to 96%. SBP noted to be in the 200s
given lopressor 5 mg IV x 1 and hydral 10 mg IV x 1 with SBP
subsequently in the 140s. Also given lasix 20 mg with ~ 1L
urine output. He was then transferred to the ICU.
.
On arrival to the ICU, pt was on non-rebreather with O2 sat 80%.
Cx-ray with new opacities in RUL and LLL. Pt was started on
NVPPV which was followed by SBP to 70s. He was given 500 cc
fluids without improvement and was started on levophed 0.04
given concern regarding his fluid/respiratory status with
further hydration. Left subclavian line placed. Right arterial
line also placed with subsequent SBP to 100s (higher than cuff
pressures in the 90s).
.
Pt had a multifocal pneumonia, thought to be caused by ESBL E.
Coli that grew on a [**5-25**] tracheal aspirate, prior to being
admitted to the [**Hospital Unit Name 153**]. He was being treated w/ Meropenem and
Voriconazole at that time. After his (+) B-glucan and since his
clinical picture was worsening he underwent BAL to assess for
fungal PNA which resulted in his respiratory failure on [**6-8**].
His antibiotic regimen was broadened at that time and included
Vancomycin, Meropenem, Voriconazole and Tobramycin. BAL
cultures subsequently grew 2 strains of resistant pseudomonas,
sensitive to Tobramycin and Zosyn, antibiotics were changed
accordingly. The patient's clinical picture continued to
improve dramatically but CXR continued to show diffuse patchy
alveolar opacities in the right upper zone, right infrahilar
region, and in the left upper> mid zones as well as worsening of
existing left lower lobe collapse and/or consolidation. He was
given treated w/ IVIG on [**6-16**] as recommended by ID. On [**6-19**] the
patient was transferred to the floor on Tobramycin/Zosyn and
completed his full course of antibiotics on [**6-24**]. On the floor,
pulmonary continued to follow him, and CXR's showed continued
radiographic resolution of his pneumonia that corellated with an
improving clinical picture. He however continued to require
2L/min O2 by nasal canulla. This was thought to be due to
chronic GVHD of the lung and ensuing bronchiectasis. It was
recommended that he follow up with pulmonary as an outpatient
for prophylactic inhaled tobramycin.
.
His functional status continued to improve with PT so that by
the date of his discharge, he was able to walk >100 feet with a
walker and clamshell torso support for his fractures.
.
# Respiratory Failure - Pt's repiratoty failure was felt to be
secondary to components of bronchospasm, fluid overload in
setting of procedure and hypertension. Also on differential was
progression of multifocal pneumonia and acute CHF exacerbation.
He tolerated non-invasives on the night of [**6-8**] but had to be
intubated to AC on [**6-9**] because of respiratory failure with
difficulty ventilating, increased work of breathing and rising
PCO2. Patient continued to be on AC and [**6-11**] a trial of PSV
15/PEEP 5 was done which patient tolerated well for several
hours. On [**6-12**] a SBT trial was done which the patient failed.
The reason for failure was thought to be a combination of his
COPD (needing PEEP), moderate to large amount of secretions
because of his ongoing PNA and persistent pulmonary edema. He
was aggresively diuresed and PSV was decreased to PSV 5/PEEP 10
over [**Date range (1) 30711**]. On [**6-14**] he was succesfully extubated to
non-invasives which he tolerated well. On [**6-15**] he was taken of
non-invasives and continued to tolerate high flow O2 during the
day, requiring BiPAP 11/5 only at night because of prolonged
work of breathing causing him to tire and hypercapnia secondary
to this. PFTs performed on [**7-3**] showed
.
When he left the ICU on [**6-19**], he was discontinued on his BiPAP.
He initially did well, however on [**6-23**] he was apneic in the
morning with a depressed mental status. Blood gases showed that
he was retaining CO2. He was re-started on his BiPAP at night
[**10-21**] which he did well on. His respiratory failure remained
well controlled throughout the rest of his hospital stay.
.
#Pain control: A CT scan performed on admission showed a new
sternum fracture and several compression fractures from chronic
steroid use. He pain was controlled with fentanyl 300mcg q48 and
morphine IR 45 mg q2 PRN. The chronic pain service was
consulted, and he was slowly titrated up on methadone tid to a
final dose of 10 mg [**Hospital1 **] and 7.5 mg at noon. His lyrica was also
increased to 150mg QID. His prn dosing of morphine IR was
changed to 60mg q4h prn.
.
#Cellulitis: He completed his previous course of linezolid for
cellulitis during this hospitalization.
.
#Anti-coagulation: The patient has a history of PE's and
bilateral DVTs that have been present since [**Month (only) 956**]. His
Lovenox was held initially on admission due to profuse bleeding
from his right leg ulcer. The bleeding was controlled, although
he did have one other episode of bleeding from the right leg
after he was transferred from the ICU to the floor. Repeat
lower extremity ultrasounds showed no change in his DVTs since
[**Month (only) **]. He was continued on lovenox for the remainder of his
admission, but at a dose of 40mg [**Hospital1 **] which is lower than the
normal treatment dose for DVTs due to his propensity
.
# CML/Chronic GVHD: We continued his home prednisone 10mg daily
and Cellcept 500mg twice daily. Pt has was on multiple
prophylactic medications including acyclovir, bactrim and
voriconazole. These were held in the setting of the patient
being NPO. They were re-started when the patient was again able
to take PO. Stress dose steroid were weaned to pt's regular
dose of prednisone. Cellcept was continued and budesonide
re-started when patient was able to take PO. His prophylaxis
was continued throughout the remainder of his admission. On
[**6-28**], it was felt that his continued O2 requirement may have
been due to GVHD of the lung, and he was pulsed with 40mg of
prednisone for 2 days with a taper. This however did not change
his respiratory status, and he was discharged on his regular
10mg of prednisone.
.
#Hematuria - The patient had hematuria that resolved
spontaneously after he came to the floor from the ICU. He was
found to have urine that was positive for BK virus. Infectious
disease was consulted, and they did not recommend that this be
treated given that his symptoms had resolved spontaneously.
.
#Urinary retention - upon discontinuation of the foley, the
patient had some urinary retention and was unable to void. This
however had mostly resolved by discharge, however, he should
continue to have q12h bladder scans with straight
catheterization if he does not void spontaneously while at
rehab.
.
#Endocrine - the patient was seen by endocrine and will require
reclast 5mg injection as an outpatient. He has a follow-up
appointment with them.
.
ICU course:
.
#Hypotension: On arrival to the [**Hospital Unit Name 153**] the patient was
hypotensive, on levophed drip, in the setting of
antihypertensives and diuresis following bronchoscopy.
Worsening infection, post-procedure increased inflammatory
response and relative adrenal insufficiency (on chronic
steroids, not started on stress dose pre-procedure) may have all
contributed in the acute setting. He was started on
hydrocortisone 50mg IV q6h for stress presumed adrenal
insuficiency. He was succesfully weaned of the levo drip on
[**6-10**].
.
#Hypertension: The patient carries a diagnosis of hypertension
but in the setting of hypotension his anti-hypertensives were
held. After hypotension resolved and pt was weaned off pressors
his BP started to rise steadily. On [**6-13**] SBP was consistently
in the 130-180s and metoprolol 25mg TID was started ([**11-19**] pt's
reg dose), BP remained high and on [**6-14**] metoprolol was increased
to 50mg TID. BP has remained stable since.
.
# Anemia: While patient was in the [**Hospital Unit Name 153**] he had 2 episodes in
which his Hct dropped acutely. The first on [**2040-6-8**] it went
from 27.1-->21.0, he was transfused 1 unit PRBC's at that time
(Hct-23.8 after transfusion). No source of bleeding was found
and hemolysis labs were negative. His Hct continued to increase
steadily w/o intervention. The second episode was on [**7-17**]
Hct dropped from 29.2-->25.1. Again no source of bleed was
found, hemolysis labs negative. Hct recovered w/o intervention
Hct 27.0 on [**6-18**].
.
#RLE rash: Pt developed RLE rash, on [**6-15**], that was
erythematous and warm. Thought to be a new cellulitis as pt is
prone to skin infections because of his GVHD. He remained
afebrile w/ stable WBC and was started on Vancomycin for empiric
treatment of MRSA cellulitis as recommended by ID. Rash
improved and on [**6-17**] it was about half the size (per leg
tracing). Pt is to finish a 7 day course (max) of Vanc. as
recommended by ID.
.
# Transaminitis: Patient had AST, ALT, AP and LDH that were
mildly elevated from previous measurements. This was thought to
be due to GVHD. MRI liver negative for acute process. LFTs
trended down and were close to baseline on [**6-18**].
Medications on Admission:
acyclovir 400 mg [**Hospital1 **]
Lyrica 150 mg tid
budenoside 3 mg tid
fentanyl 300 mcg q48 hours
combivent prn
lidocaine patch
lorazepam 1 mg qhs
metoprolol 50 mg [**Hospital1 **]
cellcept [**Pager number **] mg [**Hospital1 **]
morphine 45 mg q4 prn
protonix 40 mg qd
polyethylene glycol qd
prednisone 15 mg qd
bactrim [**11-19**] DS tab qd
voriconazole 200 mg [**Hospital1 **]
coumadin 2 mg qd
Vitamin D3 400 IU qd
colace 100 mg [**Hospital1 **]
Discharge Medications:
1. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
2. Budesonide 3 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO Q 8H (Every 8 Hours).
3. Polyethylene Glycol 3350 100 % Powder Sig: Seventeen (17)
grams PO DAILY (Daily) as needed for constipation.
4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
7. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-19**]
Drops Ophthalmic Q6H (every 6 hours) as needed for dry
eye/irritation.
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID (3 times a day).
9. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
Two (2) Adhesive Patch, Medicated Topical DAILY (Daily): Apply
to back 12 hours on, 12 hours off.
12. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
13. Fentanyl 100 mcg/hr Patch 72 hr Sig: Three (3) Patch 72 hr
Transdermal Q72H (every 72 hours).
14. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for agitation, insomnia.
15. Pregabalin 75 mg Capsule Sig: Two (2) Capsule PO QID (4
times a day).
16. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
17. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
18. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Ipratropium Bromide 0.02 % Solution Sig: One (1) Neb
Inhalation Q6H (every 6 hours).
20. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Neb Inhalation Q6H (every 6 hours).
21. Morphine 30 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
22. Methadone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
23. Methadone 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
24. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H
(every 6 hours) as needed for constipation.
25. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
26. Outpatient Physical Therapy
Patient should use accapella valve and incentive spirometer.
Patient should receive pulmonary toilet as well as get out of
bed as much as possible to work with physical therapy for
conditioning while at [**Hospital1 **].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Primary:
Pneumonia secondary to pseudomonas
Secondary:
Graft vs. host disease
Stem cell transplant
Discharge Condition:
Good, stable. Able to ambulate with assistance and walker.
Discharge Instructions:
You were admitted to [**Hospital1 18**] with a cough and shortness of breath
and found to have a pneumonia. This pneumonia was an extremely
severe one caused by E. Coli and pseudomonas aeruginosa, and you
had to be intubated in the intensive care unit for this. You
received the appropriate antibiotics for this infection, and
were doing well when you were discharged from the hospital.
However, you continued to require bipap at night and oxygen
during the day at 2L a minute. This will be provided for you at
[**Hospital6 13314**]. While at [**Hospital1 **], you will have to
continue to work hard at your pulmonary rehabilitation,
including using the acappella valve and incentive spirometry,
and getting up and moving about as much as you can.
.
During your stay, you also had some bleeding from your urinary
tract. This resolved spontaneously. You also were having some
trouble urinating, requiring straight catherization to relieve
the urine. You may continue to need this for some time, but it
should improve and you should begin being able to void
spontaneously.
.
Your pain was also an issue while you were here. While here,
your pain regimen was changed in that your lyrica was changed to
4 times a day and you were started on methadone 10mg twice a day
and 7.5mg at noon. You were also given morphine instant release
60mg every 4 hours as needed.
.
You were also diagnosed with a new sternal fracture in addition
to your compression fractures. You will need to use your
clamshell support brace while walking.
.
The endocrinologists also saw you while you were here, and you
have a follow-up appointment arranged with them. At that time
you should arrange to have your reclast injection, which is a
once yearly injection.
Followup Instructions:
You have the following follow-up appointments:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2124-7-10**] 1:30
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
HEMATOLOGY/ONCOLOGY-SC
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2124-7-13**] 9:15
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
BONE & MINERAL-CC7 (SB)
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 1112**]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2124-7-27**] 3:00
[**Hospital6 29**], [**Location (un) **]
PULMONARY UNIT-CC7 (SB)
Completed by:[**2124-7-6**]
|
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"V58.61",
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"788.29",
"E878.8",
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"518.4",
"682.6",
"789.01",
"285.29",
"790.4",
"996.85",
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"780.97",
"494.1",
"530.85",
"482.1",
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6",
"99.14",
"38.91",
"96.04",
"33.24",
"00.14",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
21797, 21871
|
8070, 18646
|
352, 358
|
22014, 22076
|
3297, 7982
|
23867, 23890
|
2126, 2328
|
19146, 21774
|
21892, 21993
|
18672, 19123
|
22100, 23844
|
2343, 2868
|
8018, 8047
|
2885, 3278
|
23915, 24668
|
275, 314
|
386, 1638
|
1660, 1920
|
1936, 2110
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,426
| 174,238
|
7516
|
Discharge summary
|
report
|
Admission Date: [**2163-5-3**] Discharge Date: [**2163-5-4**]
Date of Birth: [**2105-10-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Lightheadedness.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Patient is a 57F with DM2, hyperlipidemia, HTN who after getting
out of the shower, felt lightheaded, sat down, felt her heart
slow down. This feeling lasted for approximately 5 minutes and
resolved when she sat down. She then felt completely normal. She
denies any associated chest pain, shortness of breath,
palpitations, nausea, vomiting, seizure activity, bowel/bladder
incontinence. Patient was brought to the ED and was found to
have a HR of 40's, was given Atropine, transient Dopamine gtt,
and then placed on a Glucagon gtt.
Patient reports that she takes medication for HTN (listed as
lisinopril & norvasc) and thyroid disease, although reports
taking them diligently. She reports having these symptoms in the
past, but not as intense as this.
Of note, she reports that finger sticks usually run between
107-149, without episodes of symptomatic hypoglycemia.
She denies any PND or orthopnea.
Past Medical History:
1. Diabetes mellitus, type II
2. Dyslipidemia
3. Hypertension
4. Hypothyroidism
Social History:
Significant for the absence of current tobacco use. There is no
history of alcohol abuse. There is no family history of
premature coronary artery disease or sudden death.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS - T:97.9 HR:66 BP:126/82 RR:17 O2sat:100% 3L NC
Gen: WDWN middle aged 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 3 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
ADMIT LABS: [**2163-5-3**]
CBC:
WBC-14.0*# RBC-4.61 Hgb-11.9* Hct-36.4 MCV-79* MCH-25.9*
MCHC-32.7 RDW-16.0* Plt Ct-332
Neuts-48.0* Lymphs-44.2* Monos-4.9 Eos-1.2 Baso-1.8
COAGS:
PT-12.1 PTT-23.6 INR(PT)-1.0
CHEMISTRIES:
Glucose-163* UreaN-14 Creat-0.9 Na-134 K-4.5 Cl-100 HCO3-22
AnGap-17
Calcium-9.1 Mg-2.0
CARDIAC ENZYMES:
[**2163-5-3**] 11:55AM BLOOD CK(CPK)-58 cTropnT-<0.01
[**2163-5-3**] 05:00PM BLOOD CK(CPK)-46 cTropnT-<0.01
MISC:
%HbA1c-7.7*
HDL-49 CHOL/HD-3.0 LDLmeas-84
TSH-1.5
Free T4-1.2
Digoxin-<0.2*
TOX:
ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
CXR ([**2163-5-4**]):
No active disease.
Brief Hospital Course:
1. Presyncope:
The etiology of this was unclear. The differential included
vaso-vagal syncope, sick-sinus syndrome with symptomatic
bradycardia. EP evaluated the patient and felt that the former
was more likely. Her EKG showed a rate in the 40s with a
possible junctional rhythm. She was given atropine, transient
dopamine gtt and was then placed on a glucagon gtt. She was
admitted and monitored in the CCU. She remained asymptomatic.
She was monitored on telemetry and an ECHO was obtained showing
a normal EF and Grade I (mild) LV diastolic dysfunction. In
addition, she was ruled out for MI.
At the time of discharge, the patient was feeling well and was
without any lightheadedness. Plan was for follow-up with a new
cardiogist (Dr. [**Last Name (STitle) 171**].
2. Hyperlipidemia:
Lipid panel showed and LDL of 84 with an HDL of 49. Her
atorvastatin was continued at her home dose.
3. Diabetes mellitus:
A1c checked and 7.7. She presented on metformin, which was held
during her stay with use of a HISS.
4. Hypothyroidism:
TSH and fT4 were within normal lipids; Levothyroxine 50 mcg was
continued.
5. Anemia:
Microcytic (MCV 78). Previously had a normal hct and MCV,
although has been intermittantly anemic in the past with one
period of low MCV in [**2156**]. Iron studies were obtained and
showed an iron and ferritin at the lower limits of normal (34
and 14 respectively) with a normal TIBC.
Medications on Admission:
Atenolol 100 qd
ACETAMINOPHEN 500MG tid
ATORVASTATIN 20MG qd
FLEXERIL 10 mg qhs prn
GLUCOPHAGE 1000MG [**Hospital1 **]
LEVOTHYROXINE SODIUM 50MCG qd
Citalopram 20 qd
PERCOCET 5-325 mg--[**1-25**] tablet(s) prn
Discharge Medications:
1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO once a
day.
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO three
times a day.
9. Flexeril 10 mg Tablet Sig: One (1) Tablet PO QHS PRN.
10. Glucophage 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
11. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Vaso-vagal syncope
Secondary:
1. Diabetes mellitus, type II
2. Hyperlipidemia
3. Hypertension
4. Hypothyroidism
Discharge Condition:
Hemodynamically stable. Ambulatory.
Discharge Instructions:
You were admitted after feeling lightheaded. We have made
changes to your medication regimen, which will be outlined
below. If you experience any repeat of your symptoms, have
chest pains, shortness of breath or have any other
question/concerns, please be sure to call your primary care
doctor or go to an emergency room.
You should hear from your new cardiologist (Dr. [**Last Name (STitle) 171**]
regarding a new patient appointment.
In addition, you should be sure to follow-up with your primary
care physician.
You should obstain from driving for the ONE MONTH.
Please note the following medication changes
DOSE CHANGE:
1. ATENOLOL - This medication dose was decreased from 100mg
daily to 25mg daily.
STOPPED:
1. NORVASC (amlodipine) - This medication has been STOPPED.
STARTED:
1. HCTZ (hydrochlorothiazide) - This medication has been
STARTED. It should be taken once a day and is for blood
pressure control.
2. LISINOPRIL - This medication has been STARTED. It is also
for blood pressure control and is to be taken once a day.
3. ASPIRIN - You should take one baby [**Name (NI) 27471**] (81mg) daily.
This can be purchased over the counter.
Followup Instructions:
1. Dr. [**Last Name (STitle) 171**] (Cardiology) - You will be contact[**Name (NI) **] by Dr. [**Name (NI) 27472**] office to schedule a new patient appointment.
2. Dr. [**Last Name (STitle) 4569**] (Primary Care) - [**2163-5-10**] at 6:15pm
Phone:[**Telephone/Fax (1) 7538**]
3. [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 5500**], M.D. Phone:[**Telephone/Fax (1) 1228**] - [**2163-7-13**] 2:55
|
[
"780.2",
"250.00",
"427.81",
"427.89",
"401.9",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5684, 5690
|
3216, 4636
|
330, 338
|
5859, 5898
|
2553, 2866
|
7107, 7529
|
1580, 1663
|
4897, 5661
|
5711, 5838
|
4662, 4874
|
5922, 7084
|
1678, 2534
|
2883, 3193
|
274, 292
|
366, 1271
|
1293, 1375
|
1391, 1563
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,083
| 110,408
|
11597
|
Discharge summary
|
report
|
Admission Date: [**2126-9-22**] Discharge Date: [**2126-10-7**]
Date of Birth: [**2062-8-29**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Cephalosporins / Tetracycline Analogues / Keflex /
Propofol Analogues / Vancomycin / Nuts / Pepper / Eggs / Coconut
/ Bleach / Aztreonam / Carbapenem / Erythromycin Base
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Mechanical Fall w vertebral fracture
Major Surgical or Invasive Procedure:
orthopedic surgery fixation of thoracic spine
intubation
mecanical ventilation
[**First Name3 (LF) **] transfusion
History of Present Illness:
This is a 64 yo F with PMHx of OSA on CPAP, DMII, CKD baseline
2.5, HTN, dCHF (LVEF >55%), peripheral neuropathy, morbid
obesity, asthma, hypothyroidism and anxiety who was transferred
to [**Hospital1 18**] s/p mechanical fall from OSH ED ([**Hospital 36837**] Healthcare.
The patient fell down 10 stairs at her son's house. Per report
there was possible LOC and head strike, CT head in OSH ED
negative for ICH or fracture, but positive for subgaleal
hematoma at the vertex. CT spine showed T10 vertebral body fx,
T8-10 spinous process fx and R tranvsverse fx of T11-12. She was
briefly hypotensive in the ED, SBP nadir 80s with improvement to
133 after 1L NS and was transferred to [**Hospital1 18**] for further
management. At OSH ED she also got Zofran, Tylenol, Lidoderm
patch.
In the [**Hospital1 18**] ED, VS 109/38 64 20 98% 2L. Admission labs notable
for K 6.2 (not hemolyzed), Cr 3.3 (baseline 2.0-2.5), HCT 29
(baseline 32-35), INR 1.0, CK 2056. There were no EKG changes
and she received 10U Regular Insulin, 1 amp D50 and Kayexalate
x1, with improvement in her K to 5.8, but worsening renal
failure (Cr 4.2) and rising CK (3045). She was seen by ACS and
Ortho Spine and was neuro intact, no urinary retention or
incontinence of bowel or bladder. She is being transferred to
medicine for [**Last Name (un) **] and hyperkalemia, plan for OR tonight with
Ortho-Spine for stabilization of transverse T11-12 fractures.
Consulting services are ACS, Ortho-Spine and Neurosurgery.
Documented UOP 300cc in past 12 hours. She was seen by ACS and
Ortho Spine and was neuro intact, no urinary retention or
incontinence of bowel or bladder.
ROS: The patient says she has had increased muscle/joint aches
recently which she attributes to OA. She has felt increasingly
disoriented and dizzy recently. She says her vision has seemed
cloudier recently.
Past Medical History:
- OSA on CPAP
- DMII, peripheral neuropathy
- CKD baseline 2-2.5
- HTN
- dCHF (LVEF >55%)
- morbid obesity
- asthma
- hypothyroidism
- anxiety
Social History:
Lives with her husband, [**Name (NI) 9102**], in [**Name (NI) 5871**]. She
has a son who lives in [**Name (NI) 36838**].
Former smoker, denies alcohol or illicit drug use.
Family History:
Mother- MVP, hypothyroid. Father- lung CA, smoker, mets to
brain. Brother- healthy, lives in [**Name (NI) 4565**], 3 sons, all
healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS - 99.1 120-145/41-60 70-82 20 96% 2L NC
GENERAL - well-appearing woman in NAD, comfortable, appropriate,
lying flat on her back.
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - obese, no elevation in JVP appreciated.
LUNGS - CTA anteriorly, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use. Uncomfortable lying all the
way flat, more comfortable with head of the bed raised 10
degrees.
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)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-18**] in LEs, sensation grossly intact throughout.
DISCHARGE PHYSICAL EXAM
VS - 98.2 Tmax 100.3 136/82 72 20 99%RA
GENERAL - well-appearing woman in NAD, comfortable, appropriate,
lying flat on her back.
HEENT - + mild TTP over frontal and maxillary sinuses, improved
from prior, NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP
clear
NECK - obese, no elevation in JVP appreciated.
LUNGS - CTABL, no r/rh/wh, good air movement anteriorly, resp
unlabored, no accessory muscle use. Breath sounds distant [**2-14**]
obesity
HEART - PMI non-displaced, RRR, + 3/6 systolic murmur heard best
at LUSB, 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)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3
Pertinent Results:
ADMISSION LABS
[**2126-9-22**] 08:23PM URINE HOURS-RANDOM UREA N-425 CREAT-209
SODIUM-13 POTASSIUM-85 CHLORIDE-12
[**2126-9-22**] 08:23PM URINE OSMOLAL-383
[**2126-9-22**] 07:30PM GLUCOSE-217* UREA N-73* CREAT-4.3*
SODIUM-131* POTASSIUM-5.5* CHLORIDE-98 TOTAL CO2-24 ANION GAP-15
[**2126-9-22**] 07:30PM CALCIUM-8.9 PHOSPHATE-4.7* MAGNESIUM-2.0
[**2126-9-22**] 06:00PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.014
[**2126-9-22**] 06:00PM URINE [**Month/Day/Year 3143**]-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.0 LEUK-SM
[**2126-9-22**] 06:00PM URINE RBC-32* WBC-9* BACTERIA-NONE YEAST-NONE
EPI-0
[**2126-9-22**] 06:00PM URINE MUCOUS-RARE
[**2126-9-22**] 06:00PM URINE EOS-NEGATIVE
[**2126-9-22**] 01:00PM GLUCOSE-257* UREA N-68* CREAT-4.2* SODIUM-133
POTASSIUM-5.8* CHLORIDE-97 TOTAL CO2-25 ANION GAP-17
[**2126-9-22**] 01:00PM CK(CPK)-3045*
[**2126-9-22**] 01:00PM cTropnT-0.04*
[**2126-9-22**] 01:00PM CALCIUM-8.6 PHOSPHATE-4.7* MAGNESIUM-1.9
[**2126-9-22**] 06:20AM GLUCOSE-223* UREA N-62* CREAT-3.5* SODIUM-133
POTASSIUM-6.2* CHLORIDE-98 TOTAL CO2-22 ANION GAP-19
[**2126-9-22**] 06:20AM CALCIUM-8.6 PHOSPHATE-4.2 MAGNESIUM-1.9
[**2126-9-22**] 01:20AM GLUCOSE-234* UREA N-62* CREAT-3.3*
SODIUM-131* POTASSIUM-6.2* CHLORIDE-98 TOTAL CO2-23 ANION GAP-16
[**2126-9-22**] 01:20AM estGFR-Using this
[**2126-9-22**] 01:20AM CK(CPK)-2056*
[**2126-9-22**] 01:20AM COMMENTS-GREEN TOP
[**2126-9-22**] 01:20AM K+-5.9*
[**2126-9-22**] 01:20AM WBC-7.2 RBC-3.14* HGB-9.5* HCT-29.0* MCV-92
MCH-30.1 MCHC-32.6 RDW-13.0
[**2126-9-22**] 01:20AM NEUTS-84.7* LYMPHS-10.5* MONOS-4.3 EOS-0.3
BASOS-0.2
[**2126-9-22**] 01:20AM PLT COUNT-218
[**2126-9-22**] 01:20AM PT-11.0 PTT-30.1 INR(PT)-1.0
K 6.2-->5.8-->5.3-->5.3
Cr 3.3-->3.5-->4.2-->4.3-->4.1-->3.9-->4.1
MICROBIOLOGY
BCx [**9-25**] x2: No Growth
BCx [**10-2**]: pending
URINE CULTURE (Final [**2126-9-25**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
[**2126-9-25**] 4:43 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2126-9-29**]**
GRAM STAIN (Final [**2126-9-25**]):
[**11-7**] PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2126-9-29**]):
MODERATE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. MODERATE GROWTH.
Sensitivity testing performed by Sensititre.
[**2126-10-4**] 9:24 am SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2126-10-4**]):
[**11-7**] PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Preliminary):
SPARSE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. SPARSE GROWTH.
[**2126-10-2**] 10:20 am [**Month/Day/Year 3143**] CULTURE
**FINAL REPORT [**2126-10-5**]**
[**Month/Day/Year **] Culture, Routine (Final [**2126-10-5**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>2 R
ERYTHROMYCIN---------- =>4 R
GENTAMICIN------------ 2 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- 2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
IMAGING
OSH IMAGING
CT Abd Pelvis w/o contrast:
- Rt 11th posterior rib fracture, appears acute
- T10 Vertebral body fracture (s7:52), t8, 9, 10 spinous process
fractures. Rt trv process fracture pf T11, T12
- Right buttock and low back hematoma
- 12 x 19 x 12 cm mass in pelvis - peripheral calcification,
central areas of fat and soft tissue - likely represents a large
dermoid.
- gallstones. atrophic kidneys.
CT Head w/o contrast: subglaleal hematoma at the vertex
CT C-spine: Congenital unfused anterior and posterior arch of
C1. Congentital fusion of C2 and C3 vertebral bodies. No
fracture. Degenerative disease C5-7.
L hip and AP pelvix 3 views: No acute fracture or dislocation
L spine, 2 views: Degenerative changes in the lumbar spine, no
acute fracture
Thoracic spine, 2 views: Diffuse degenerative changes with
overhanging osyeophyte formation. Possible ankylosing
spondylitis.
[**Hospital1 18**] IMAGING
MRI Entire spine [**2126-9-22**]
1. There are 11 thoracic vertbral bodies. This results in a
discrepancy
between the CT and MRI vertebral level labeling. Utilizing 11
vertebral bodies with this report's numbering system, the T9
vertebral body is fractured. T9 vertebral body fracture without
retropulsion or compromise of the spinal canal. The anterior
longitudinal ligament is disrupted at this level. If there is to
be surgical intervention, consider correlation at time of
surgery with plain radiographs.
2. Increased fluid signal in the L4-L5 and L5-S1 intervertebral
discs may reflect disc injury or alternatively may reflect
normal signal which appears higher than expected due to
degenerative loss of normal high signal in the adjacent
intervertebral discs.
3. Spinous process and transverse process fractures in the lower
thoracic
spine are better appreciated on the prior CT.
DISCHARGE LABS
[**2126-10-7**] 07:20AM [**Month/Day/Year 3143**] WBC-5.3 RBC-2.57* Hgb-7.8* Hct-24.4*
MCV-95 MCH-30.2 MCHC-31.7 RDW-14.3 Plt Ct-486*
[**2126-10-7**] 07:20AM [**Month/Day/Year 3143**] Glucose-80 UreaN-63* Creat-2.5* Na-142
K-4.0 Cl-108 HCO3-24 AnGap-14
[**2126-10-7**] 07:20AM [**Month/Day/Year 3143**] ALT-56* AST-48* AlkPhos-104 TotBili-1.7*
Brief Hospital Course:
This is a 64 yo F with PMHx of OSA on CPAP, DMII, CKD baseline
2.5, HTN, dCHF (LVEF >55%), peripheral neuropathy, morbid
obesity, asthma, hypothyroidism and anxiety who was transferred
to [**Hospital1 18**] s/p fall down stairs, found to have thoracic vertebral
fractures.
# Traumatic thoracic spine vertebral body fractures: S/P fall
down 10 stairs. No signs and symptoms of cord impingement,
rectal tone intact. The patient was planned for urgent
orthopedic fixation procedure but CPK and Cr found to be rising
with decreasing urine output, so transfered to medicine for
stabilization before surgery (see below). Patient was optimized
medication and underwent open reduction of T
fracture/dislocation, and T8-T12 posterior fusion and
instrumentation on [**9-24**], with estimated [**Month/Year (2) **] loss of 1300 mL.
PT saw patient and recommended rehab. Post surgical pain well
controlled with medication at time of DC.
# Respiratory Failure/Shortness of breath: Post operatively,
extubation was difficult [**2-14**] increased fluid balance. Patient
was optimized and was subsequently extubated after diuresis. Of
note, in the ICU Sputum Cx were sent emperically and grew MSSA.
When the patient was extubated she was afebrile without cough or
prominent pulmonary sx, so the decision was made not to treat.
Patient has paroxsyms of breathlessness without hypoxia. CXR and
CT torso was otherwise unremarkable.
- Patient will need to continue CPAP while at rehab and would
benefit from outpatient pulmonary follow-up.
# Acute on chronic renal failure: The patient was oliguric at
presentation, urine output improved with gentle fluids (fluid
recussitation limited by h/o CHF and limitation that patient
must lie flat). All meds renally dosed, and nephrotoxic meds
held until Cr improved. [**Last Name (un) **] thought likely [**2-14**] pre-renal. After
IVF, PRBC, and diuresis in the ICU, the patient's Cr normalized
to baseline (2.0-2.5).
# S/P Fall: Unclear history of loss of consciousness leading to
fall with Thoracic fractures, and the patient endorses several
months of feeling dizzy. CPK ~3000 at peak, thought to represent
mild rhabdo. The patient was thought to be volume depleted on
presentation, given elevated Cr, low UOP, and good response to
IVF and PRBC. Fall could have been [**2-14**] orthostasis, so HCTZ was
Discontinued. Alternatively, fall may have been [**2-14**] dizziness
and confusion from medication effect, as she was on Topamax 100
HS at the time of the fall. Topamax was DCed. TSH was within
normal limites, tele showed no events, felt unlikely to be
cardiac in origin. The patient no longer felt dizzy at
discharge, but had mobilized very little given post surgical
pain.
# Anemia: During admission the patient had several episodes of
anemia requireing multiple PRBC transfusions. It was felt that
[**Last Name (un) **] had led to transient low EPO state. The patient was not felt
to be actively bleeding either at her trama/sugical sites or
elsewhere. Hct bumped appropriately after PRBC given, and [**Last Name (un) **]
improved by time of DC.
- recheck Hct in 4 days after admitted to rehab to make sure Hb
remains stable.
# Sinus infection: The patient complained of sinus pressure and
nasal discharge after being extubated, which improved without
specific therapy. Thought to be related to a viral etiology.
# Diarrhea: The patient was initially constipated having some
gassy abdominal pain, so a bowel regimin was started. After that
she began having loose stools. Since she had been exposed to
Cipro and Levofloxacin, C diff was sent, though suspicion was
not high b/c BMx were 1/day and soft not profusely wattery.
- C diff pending at time of discharge
# LFTs elevated: LFTs were found to be mildly elevated, unclear
etiology, not related to acute presentation.
- F/U w outpatient PCP to monitor for resolution or pursue
futher work up
# Blurry vision: The patient says that her R eye had blurry
vision since the fall, and improved during admisison. Denies
floaters or flashes of light or other worrisome signs of retinal
detachment. No other neurological signs. She says she has blurry
vision at baseline, and since this acute worsening the vision in
her R eye has been getting better since she has been in the
hospital. Possible etiologies include dry eyes (has a h/o this),
acute hyperglycemic episode (glucose had been 200s-300s), or
worsening of known cataracts.
# UTI: E. coli grew in urine in the setting of normal UA but
[**Last Name (un) **]. UTI may have contributed to [**Last Name (un) **] presentation, so warrents
treatment for complicated UTI given DMII.
- continue Cipro for a total of 14 day course, last day of
therapy is [**2126-10-8**]
# MSSA in sputum: The patient had difficulty with extubation
after procedure, so sputum cultures were sent and grew MSSA. The
patient says she continues to have some SOB, no cough. Has had
several low grade temps but has never spiked. Repeat Sputum
culture grew the same organism, may represent colonization.
- continue to monitor fever curve, if spikes consider treating
with linezolid (the patient is Vanc allergic)
# Coag negative staph in [**Month/Day/Year **] Cx: No growth from other
cultures. Likely contaminent.
# DM: The patien was placed on ISS. Dose was decreased for NPO
for procedure and while intubated in the ICU. When the patient
started eating again she was transiently hyperglycemic with FS
200s-300s, her insulin was titrated back to her home dose and FS
improved to well controlled.
# Asthma
- albuterol prn
# OSA
- CPAP at night
- monitor on continuous O2 monitoring
# HTN, HLD, CV risk factors, dCHF: Fluid recussitation was
gentle given dCHF. Cont home meds except HCTZ was discontinued.
# Hypothyroidism
- cont Levothyroxine Sodium 50 mcg PO/NG DAILY
# Anxiety
- cont Bupropion, hold Topamax because of side effect of
dizziness
# Pelvic mass: incidentally found on CT abd. Likely dermoid, 12
cm in size. Unlikely to be related to current presentation. The
mass was discussed w the patient, and F/U w gynecology was
obtained.
# L renal cystic lesions: Also incidentally found on CT abd.
Unlear if it is a cyst, may need US follow up per PCP.
# PPX: pneumoboots and heparin sq (held for surgery, then
restarted several days after per ortho recs)
TRANSITIONAL ISSUES
- Large pelvic mass seen on CT scan, likely dermoid. F/U with
PCP and Gyn to further eval and possibly remove mass
- L renal cystic lesions, may need US F/U per PCP
[**Name Initial (PRE) **] [**Name10 (NameIs) **] cultures pending at discharge, will communicate with
rehab if positive cultures
- Recheck Hct 4 days after admission to rehab to check that Hct
is stable.
- F/U w outpatient PCP to monitor for resolution of LFT
elevations or pursue futher work up
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. BuPROPion 150 mg PO DAILY
2. Gabapentin 100 mg PO HS
3. Lisinopril 2.5 mg PO DAILY
4. Calcitriol 0.25 mcg PO EVERY OTHER DAY
5. Topiramate (Topamax) 100 mg PO HS
6. Simvastatin 10 mg PO DAILY
7. Hydrochlorothiazide 25 mg PO BID
8. Glargine 44 Units Breakfast
Glargine 44 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
9. Levothyroxine Sodium 50 mcg PO DAILY
10. Albuterol Inhaler [**1-14**] PUFF IH Q4H:PRN wheezing
11. Symbicort *NF* (budesonide-formoterol) unknown units
Inhalation unknown
12. Carvedilol 25 mg PO BID
13. Artificial Tears 1-2 DROP BOTH EYES PRN dry eyes
14. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]
Discharge Diagnosis:
Fall
thoracic spinal fractures
acute on chronic renal failure
Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure caring for you at [**Hospital1 827**]. You were admitted after a fall where you
sustained spinal fractures, and you were found to have worsening
kidney function. You underwent orthopedic surgery for your
spinal fractures, and required care in the intensive care unit
as well as several transfusions of [**Hospital1 **]. After several days the
breathing tube was removing and transfered to the floor. Your
kidney function improved with IV fluids. You were discharged to
rehab to regain your strength.
It is important that you keep all follow up appointments, and
take all medications as prescribed. Your CT scan showed a pelvic
mass, which you should follow up with your primary doctor [**First Name (Titles) **] [**Last Name (Titles) 36839**]t for further evaluation.
You will also need follow up with a lung doctor after you leave
a rehab.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,320
| 169,808
|
38715
|
Discharge summary
|
report
|
Admission Date: [**2141-1-29**] Discharge Date: [**2141-2-6**]
Date of Birth: [**2087-3-2**] Sex: F
Service: MEDICINE
Allergies:
Penicillin G / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 5810**]
Chief Complaint:
Unresponsive
Major Surgical or Invasive Procedure:
Central venous line placement
Femoral arterial line placment
History of Present Illness:
This is a 54 year old female with a history of depression who
was found to be obtunded with evidence of seizure activity on
[**2141-1-29**]. The patient had been feeling poorly for the past few
weeks with gastrointestinal symptoms of nausea and vomiting
prior to this episode. She reports that she took increased
doses of her typical medications in an attempt to make herself
feel better. She takes trazodone 100 mg, hydroxyzine 50 mg,
clonidine 0.1 mg, citalopram 60 mg and simvastatin. She also
may have taken some of her husband's pain medications. She
denies that she took extra medications in an attempt to harm
herself. She noted to her husband that she felt lightheaded
while in bed watching television and then appeared to have a
seizure and lost consciousness. EMS was called and she was
brought to the hospital.
She was initially taken to [**Hospital6 **] where she wsa
noted to have a wide complex tachycardia to the 170s thought to
be ventricular tachycardia. She received ativan for her
potential seizure activity and was intubated for airway
protection. She was shocked four times for her wide complex
tachycardia. She was hypotensive to the 60s systolic and
received IV fluids and was started on levophed. She was started
on a bicarbonate drip. She also received 2 mg magnesium,
activated charcoal, lidocaine 100 mg, diprovan 20 mcg bolus,
ativan 4 mg IV, fentanyl 250 mg IV, pancuronium 8 mg IV and was
started on an amiodarone drip. She had a negative CT head. She
was transferred to this hospital for further management.
On arrival to this hospital her initial vitals were HR: 113 BP:
124/95 RR: 14 O2: 100% on ventilator. EKG showed sinus
tachycardia. Toxicology was consulted who recommended serial
EKGs every 30 minutes. She had a left IJ placed for access.
She was started on vancomycin and zosyn for possible sepsis
given hypotension and received an additional 2 L IVF. She had a
CXR without focal infiltrate. She was admitted to the MICU.
While in the MICU she was noted to have widening of her QRS with
wide complex tachycardia which was responsive to bicarbonate and
she required bicarbonate drip. She received additional
activated charcoal. Her antibiotics were changed to vancomycin
and meropenem for ventilator associated pneumonia given
penicillin allergy and concern that fluoroquinolones would widen
QT interval. Given persistent wide complex tachycardia there
was concern for pharmacobezoar and she had an upper endoscopy
which was within normal limits. She was extubated on [**2141-2-1**]
without difficulty. Immediately prior to transfer she was noted
to have a black tarry stool which was guaiac positive.
Subsequent stools have been dark but guaiac negative.
On exam she denies pain. She denies taking medications to try
to harm herself. No fevers, chills, chest pain, difficulty
breathing, nausea, vomiting, abdominal pain, diarrhea,
constipation, dysuria, hematuria, leg pain or swelling. All
other review of systems negative in detail.
Past Medical History:
-Depression, with past history of cutting her wrists about 5 yrs
ago, sees a psychiatrist - Dr. [**Last Name (STitle) 47238**] at [**Location (un) 5503**]
-Anxiety
-Panic Attacks
-Asthma
-History of ethanol abuse, went through detox 5 months ago
-Vasovagal syncope
-Hip arthitis, s/p 2 replacments
-Hysterectomy
-History of multiple falls with head injuries in past, last hit
head in bathroom about 5 months ago
Social History:
Former heavy alcohol use, went through detoxification five
months ago. Previously drank 1 pint per day. Smokes 1 pack per
day for many years. Previous history of narcotics abuse. She
lives with her second husband and two daughters from a previous
marriage. She is on disability.
Family History:
Father has "heart problems."
Physical Exam:
Admission Physical Exam:
VS: T: 98.3 HR: 86 BP: 77/57 RR: 15 O2: 100%RA
GEN: intubated, sedated, able to follow simple commands
HEENT: ET tube in place, conjuctiva clear, MMM
NECK: supple, no LAD
CHEST: CTA B
CV: RRR, no M, 1+ pulses
ABD: soft, NT, ND, +BS
EXT: no c/c/e
NEURO: pupils reactive, some horizontal nystagmus, no rigidity,
reflexes hard to elicit in LEs, able to move fingers and toes to
command on both sides, but very weak, sticks out tongue and
blinks to command, tracks finger with eyes
Discharge Physical Exam:
Vitals: T: 98.9 BP: 125/79 P: 92 R: 18 O2: 97% on RA
General: Alert, oriented, intermittently animated and then flat
affect
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Hematology:
[**2141-1-29**] 09:04PM WBC-12.5* RBC-4.53 HGB-11.5* HCT-35.1*
MCV-78* MCH-25.4* MCHC-32.8 RDW-14.3
[**2141-1-29**] 09:04PM NEUTS-70.1* LYMPHS-24.9 MONOS-4.1 EOS-0.6
BASOS-0.3
[**2141-1-29**] 09:04PM PLT COUNT-276
[**2141-1-29**] 09:04PM PT-12.5 PTT-29.7 INR(PT)-1.1
[**2141-2-5**] 06:55AM BLOOD WBC-6.9 RBC-4.15* Hgb-11.1* Hct-33.5*
MCV-81* MCH-26.7* MCHC-33.1 RDW-15.8* Plt Ct-308
[**2141-1-29**] 09:04PM BLOOD Neuts-70.1* Lymphs-24.9 Monos-4.1 Eos-0.6
Baso-0.3
[**2141-2-5**] 06:55AM BLOOD Plt Ct-308
[**2141-2-2**] 12:36AM BLOOD PT-12.3 PTT-37.5* INR(PT)-1.0
Chemistries:
[**2141-1-29**] 09:04PM BLOOD Glucose-129* UreaN-7 Creat-0.8 Na-142
K-3.9 Cl-110* HCO3-21* AnGap-15
[**2141-1-29**] 02:37PM BLOOD ALT-12 AST-16 AlkPhos-53 TotBili-0.7
[**2141-1-29**] 02:37PM BLOOD Lipase-42
[**2141-1-30**] 10:22AM BLOOD CK-MB-3 cTropnT-0.04*
[**2141-1-31**] 01:04AM BLOOD CK-MB-2 cTropnT-0.05*
[**2141-1-31**] 08:34AM BLOOD CK-MB-3 cTropnT-0.04*
[**2141-1-29**] 09:04PM BLOOD Calcium-9.1 Phos-3.5 Mg-2.0
[**2141-2-5**] 06:55AM BLOOD calTIBC-218* Ferritn-189* TRF-168*
[**2141-2-5**] 06:55AM BLOOD Glucose-96 UreaN-2* Creat-0.6 Na-143
K-3.4 Cl-106 HCO3-26 AnGap-14
[**2141-1-31**] 03:37AM BLOOD ALT-9 AST-12 LD(LDH)-175 AlkPhos-52
TotBili-0.5
[**2141-2-5**] 06:55AM BLOOD Calcium-8.8 Phos-4.4 Mg-1.8 Iron-81
Toxicology:
[**2141-1-29**] 02:37PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-7.5*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Hydroxyzine: pending
Microbiology:
Sputum culture [**2141-1-30**]: respiratory flora
Urine culture [**2141-1-30**]: negative
Blood cultures [**2141-1-29**] and [**2141-1-30**]: negative
Stool for C. diff [**2141-2-1**]: negative
Imaging:
CXR [**2141-1-29**]: The endotracheal tube tip terminates approximately
2.8 cm from the carina. A nasogastric tube tip terminates within
the stomach, however, the side port is superior to the
gastroesophageal junction and should be advanced. The cardiac
silhouette is normal in size. Patchy airspace opacities in both
lung bases likely reflect atelectasis. The
pulmonary vascularity is within normal limits. There is no large
pleural
effusion or sizable pneumothorax. Pulmonary vascularity is
within normal
limits.
[**2141-2-2**]: Normal sinus rhythm, normal axis, normal intervals, no
acute ST segment changes
Brief Hospital Course:
54 year old female with a history of depression and prior
suicide attempts who presented with altered mental status and
hypotension felt to be secondary to medication overdose now
transferred to the MICU in stable condition.
Altered Mental Status/Seizures/Hypotension: Likely related to
medication overdose. Likely medications taken include clonidine,
citalopram, hydroxizine, trazodone and vicodin. Tylenol and
salicylate levels were negative. She received activated
charcoal on two occasions. MICU course was complicated by wide
complex tachycardia which was responsive to bicarbonate drip.
Her QRS interval has now been stable off bicarbonate for nearly
96 hours. The time course of her widened QT interval was felt
to be longer than expected raising concern for pharmacobezoar
but she underwent upper endoscopy which was normal. Her
electrolytes are within normal limits. Her altered mental
status has resolved. Infectious workup has been negative with
the exception of a possible ventilator associated pneumonia.
She has been followed by toxicology who recommend no further
workup. She has also been seen by psychiatry who recommend
inpatient psychiatric admission once clinically stable. At the
time of discharge a hydroxyzine level was pending. The majority
of her psychiatric medications were held during this
hospitalization given overdose but she was restarted on
Risperdal 1 mg QHS which she tolerated well.
Ventilator Associated Pneumonia: On presentation patient had
fevers and leukocytosis although this was in the setting of
medication overdose. She also had concern for right sided
infiltrate. She was started on vancomycin and meropenem for
coverage of ventilator associated pneumonia. She completed a 7
day course of antibiotics.
Wide Complex Tachycardia: In association with overdose. She
transiently required bicarbonate drip for control. She received
four electric shocks prior to transfer to [**Hospital1 18**] but did not
require further electric cardioversion at this hospital. She
was monitored on telemetry throughout her stay and was
arrhythmia free for 96 hours prior to psychiatry transfer.
Depression/Anxiety: As above, patient presented with medication
overdose. She denies suicidal ideations but endorsed taking
these medications to "feel better." Her home medications were
not resumed. She was seen by psychiatry who recommended
initiation of Risperdal 1 mg QHS. She tolerated this well. She
is being transferred to inpatient psychiatry for further
management.
Anemia: Patient was noted to have a mild microcytic anemia on
presentation. This was exacerbated by fluid resuscitation. She
was guaiac negative once in the MICU but was subsequently guaiac
negative. Iron studies were negative for iron deficiency. This
should be rechecked by her primary care physician when she is
discharged from psychiatry. She should also be referred for
routine screening colonoscopy.
Asthma: Stable. She did not require any inhalers during this
admission.
Prophylaxis: She received SC heparin for DVT prophylaxis
Code Status: Full Code
Disposition: To inpatient psychiatry
Medications on Admission:
Trazadone 200mg HS
Clonidine 0.1mg [**Hospital1 **]
Hydroxyzine 100mg Q6H
Citalopram 60mg qAM
Simvastatin 40mg HS
Busperone 10mg TID
Discharge Medications:
1. Risperidone 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary:
Overdose
Wide complex tachycardia
Altered mental status
Ventilator associated pneumonia
Anemia
Depression
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were seen and evaluted for your altered mental status. This
was felt to be related to medication overdose. You were
diagnosed with pneumonia during your stay and treated with
antibiotics. You were seen by the psychiatry consult service
who recommended transfer to inpatient psychiatry for further
management.
Please take all your medications as prescribed. The following
changes were made to your medication regimen.
1. Please take risperidal 1 mg PO at night
2. Please stop your trazodone, clonidine, hydroxyzine,
citalopram and busperone
Please keep all your follow up appointments as scheduled.
Followup Instructions:
Please followup with your primary care physician [**Name Initial (PRE) 176**] [**12-17**]
weeks of discharge from psychiatry. If you do not have a
primary care physician you can arrange to have one at [**Hospital1 **] by calling [**Telephone/Fax (1) 250**].
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28,424
| 127,337
|
43131
|
Discharge summary
|
report
|
Admission Date: [**2146-5-4**] Discharge Date: [**2146-5-20**]
Date of Birth: [**2066-12-19**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
[**2146-5-4**] Exploratory Laparotomy, lysis of adhesions, left
colectomy, Hartmann procedure, Colostomy.
[**2146-5-4**] Therapeutic bronchoscopy and aspiration of mucous
plugs under sedation.
History of Present Illness:
79F w h/o colon polypse with high grade dysplasia s/p R
colectomy [**10-21**] at [**Hospital1 18**] presents now with abdominal pain. Pain
started seven hours prior to presentation to ED and she
describes the pain as pressure and bloating type sensation in
the midabdomen followed by 5-6 episodes of nonbloody but bilious
emesis. She then had a well formed non bloody bowel movement.
Some subjective chills but denies fevers
Past Medical History:
Paroxysmal A. fib
h/o embolus to L arm
s/p cardiac ablation
s/p pacemaker placement [**1-15**] sick sinus syndrome
HTN
CRI
diastolic insufficiency modest edema
sleep apnea refuses to use CPAP
Hypothyroidism
COPD
PSH:
s/p hysterectomy
Left lower lobe resection for lung nodule. [**1-21**]
Laparoscopic R colectomy [**10-21**] for adenoma c high grade
dysplasia
Social History:
Lives alone. Supportive daughter. Denies use of ETOH, tobacco,
and illicit drugs. Former smoker who quit about 6 years ago.
Family History:
Non contributory
No history of cardiac disease
No diabetes
Physical Exam:
On admission:
97.9, 87, 160/73, 18, 93RA
NAD
Slightly uncomfortable
No LAD or masses
RRR
CTAB somewhat poor inspiratory effort
Slight distention, slightly hypoactive bowel sounds. Just to
left of midline there is a likely port site hernia that is
mildly tender. Her abdomen is tender even away from the hernia.
Rectal is guaiac negative with brown stool
1+ peripheral edema
On discharge:
97.0, 89, 116/56, 18, 97 RA
NAD
A&Ox3
Irregularly irregular rhythm, regular rate
Lungs clear but with decreased breath sounds in the bases
Abdomen obese non distended. VAC dressing functioning well in
15x4 cm wound. No apparent leaks and no wound erythema. +
bowel sounds.
1+ - 2+ peripheral edema.
No rashes
Pertinent Results:
CBC
[**2146-5-3**] 10:00PM BLOOD WBC-13.2*# RBC-4.35 Hgb-10.2* Hct-33.6*
MCV-77* MCH-23.3*# MCHC-30.3* RDW-15.7* Plt Ct-323
[**2146-5-5**] 12:48AM BLOOD WBC-12.0* RBC-3.84* Hgb-9.1* Hct-30.4*
MCV-79* MCH-23.6* MCHC-29.8* RDW-16.1* Plt Ct-286
[**2146-5-6**] 02:27AM BLOOD WBC-6.3 RBC-3.11* Hgb-7.4* Hct-24.9*
MCV-80* MCH-23.9* MCHC-29.8* RDW-16.2* Plt Ct-220
[**2146-5-7**] 02:25AM BLOOD WBC-10.9# RBC-3.49* Hgb-8.4* Hct-28.2*
MCV-81* MCH-24.2* MCHC-29.9* RDW-16.5* Plt Ct-330
[**2146-5-13**] 02:17AM BLOOD WBC-17.5* RBC-3.86* Hgb-9.5* Hct-30.4*
MCV-79* MCH-24.7* MCHC-31.4 RDW-18.5* Plt Ct-429
[**2146-5-19**] 05:30AM BLOOD WBC-12.6* RBC-3.33* Hgb-8.1* Hct-26.0*
MCV-78* MCH-24.2* MCHC-31.0 RDW-17.8* Plt Ct-517*
Coags
[**2146-5-3**] 10:00PM BLOOD PT-23.7* PTT-27.9 INR(PT)-2.3*
[**2146-5-15**] 02:00AM BLOOD PT-48.7* PTT-50.6* INR(PT)-5.5*
[**2146-5-20**] 05:40AM BLOOD PT-19.0* INR(PT)-1.8*
Chemistries
[**2146-5-3**] 10:00PM BLOOD Glucose-182* UreaN-21* Creat-1.0 Na-139
K-3.9 Cl-101 HCO3-24 AnGap-18
[**2146-5-7**] 02:25AM BLOOD Glucose-92 UreaN-30* Creat-1.7* Na-140
K-3.6 Cl-102 HCO3-27 AnGap-15
[**2146-5-19**] 05:30AM BLOOD Glucose-101 UreaN-13 Creat-1.0 Na-134
K-3.7 Cl-99
[**2146-5-4**] 07:44AM BLOOD Albumin-3.8 Calcium-8.2* Phos-4.2 Mg-2.2
Iron-80
[**2146-5-14**] 05:54AM BLOOD Calcium-8.1* Phos-3.4 Mg-2.4
[**2146-5-19**] 05:30AM BLOOD Calcium-7.7* Phos-3.0 Mg-2.0
LFTs
HCO3-27 AnGap-12
[**2146-5-3**] 10:00PM BLOOD ALT-14 AST-14 CK(CPK)-30 AlkPhos-70
TotBili-1.0
Lactate
[**2146-5-3**] 10:09PM BLOOD Lactate-1.9
[**2146-5-4**] 05:46AM BLOOD Lactate-2.9*
[**2146-5-7**] 01:41PM BLOOD Lactate-0.9
[**2146-5-4**] CT scan abdomen/pelvis
IMPRESSION:
1. Free intraperitoneal air seen under the right hemidiaphragm,
in the right paracolic gutter, as well as in the pelvis.
Multiple sigmoid diverticuli are seen, with mild diverticulitis.
2. Unchanged ventral fat-containing hernias.
3. Gallbladder sludge/stones.
Findings discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] following completion
of the study.
[**2146-5-4**] Sigmoid pathology
- Segment of colon with diverticulitis and evidence of
perforation with acute serositis.
- Margins are unremarkable.
[**2146-5-4**] EKG
Atrial flutter with 2:1 block. The morphology is atypical
counterclockwise
however, the cycle length is long. Intraventricular conduction
delay. ST-T wave abnormalities. Since the previous tracing of
[**2146-3-16**] the rate is somewhat slower but probably the same blocked
interval.
[**2146-5-5**] CXR
IMPRESSION:
1. There is mild volume overload.
2. Unchanged chronic right middle lobe consolidation and
post-surgical changes in the left lower lobe.
3. Improved left lower lobe aeration with persistent moderate
retrocardiac atelectasis.
[**2146-5-7**] CXR
Still present right middle lobe atelectasis has decreased in the
short-term interval. There is no significant change in left
lower lobe areas of plate-like atelectasis. Small bilateral
pleural effusion is unchanged. The cardiomediastinal silhouette
is stable.
The right internal jugular line tip terminates at cavoatrial
junction. The pacemaker leads terminate in the right atrium and
right ventricle. There is no evidence of congestive heart
failure.
[**2146-5-12**] CT abd/pelvis
IMPRESSION:
1. Fluid is seen within the peritoneal cavity as detailed above.
No specific evidence of an organized abscess is seen.
2. Small pleural fluid is seen bilaterally.
3. Prominence of the endometrial stripe as noted above for which
an ultrasound is recommended for further evaluation given the
patient's age. This finding was placed on the notification of
critical radiology findings dashboard at the time of dictation.
[**2146-5-12**] EKG
Atrial fibrillation. Incomplete left bundle-branch block.
Inferior and
lateral ST-T wave changes are non-specific. Low QRS voltage in
the limb leads. Compared to the previous tracing of [**2146-5-11**]
there is no significant change.
[**2146-5-13**] KUB
IMPRESSION: Distended and dilated loops of bowel most consistent
with ileus.
[**2146-5-16**] CXR
IMPRESSION: Mild bibasilar atelectasis, without evidence of
acute volume overload.
Microbiology
[**5-4**] Operating room fluid cx: providencia, enterococci, E.coli,
bacteroides
[**5-4**] BAL: 10-100K oropharyngeal flora
[**5-8**] Wcx: providencia stuartii, morganella, MRSE
[**5-12**] Wcx: E.coli, morganella ([**Last Name (un) 36**] to CTX) (E.coli resistant to
amp, unasyn, cipro, gent)
[**5-13**] c.diff: neg
[**5-13**] Ucx: neg
Brief Hospital Course:
Patient was seen in the ED by surgery and cardiology and taken
emergently to the OR for perforated diverticulum. A left
colectomy, colostomy, and [**Last Name (un) 85571**] pouch was done. She was
transferred to the PACU. Written for She was on perioperative
kefzol and flagyl for 48 hours. She was reintubated emergently
in the PACU for acute respiratory distress. CXR showed a right
middle lobe collapse. She had a bronchoscopy done with removal
of her mucous plug and respiratory status was stabilized.
Troponins were negative and EKG done at time of acute
respiratory distress showed no ST changes. Cx from mucous plug
was negative for pathologic organisms. She was extubated and
her O2 sat was 98% on 2L nasal cannula. She was put on
amiodarone drip for persistent atrial fibrillation and was on
low dose neo temporarily to maintain MAP >60. Albumin was
started to maintain her blood pressure and she was restarted on
her Coumadin.
On POD 2 her amio gtt was stopped and she was back on her home
amio dose. She had a slight bump in her creatinine to 1.7 and
so her lasix was held. On POD 3 she had afib/aflutter and was
given lopressor x 3 as well as restarted on the amio gtt. NGT
was placed and had a 1300cc return. She was transitioned to
amiodarone twice daily and was stabilized. Her NGT was clamped
and was removed. Her ostomy opened up with some stool on POD 6
and the lower portion of her wound was opened for drainage and
mild cellulitis. On POD 7 she was transferred to the floor but
had afib with rapid ventricular response and was transferred
back to the ICU. Her EKG and enzymes were negative for
ischemia. She also became supertherapeutic on her coumadin and
her coumadin was held. Amio drip was restarted. On POD 8 her
wound was opened entirely and cultures were sent. She was
started on vancomycin. She was stabilized on amio gtt and
eventually transitioned back to po amio. Her antibiotic regimen
was taylored to ceftriaxone and flagyl to treat e.coli and
moraxella. She was transferred to the floor and did very well.
Her blood pressure and heart rate were within normal limits, she
was tolerating a regular diet, out of bed walking with physical
therapy and afebrile at discharge.
Medications on Admission:
amio 200', warfarin 3', lipitor 20', levoxyl 75', toprol 75',
protonix 40', tylenol prn, lasix 20'
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day) as needed.
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 1 days: Should be completed [**5-21**] (start once a day
dosing [**5-22**]).
8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): To be started [**5-22**] (begin once [**Hospital1 **] dosing completed).
9. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 1 days. To be stopped [**2146-5-22**]
11. Warfarin 1 mg Tablet Sig: One (1) Tablet PO ONCE (Once).
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
13. Ceftriaxone-Dextrose (Iso-osm) 2 gram/50 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours) for 1 days. To be
stopped [**2146-5-22**].
14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 2 days.
15. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). To start on [**2146-5-23**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Perforated Diverticulitis
Right middle lobe collapse secondary to mucous plugs
Atrial Fibrillation
Wound Infection
Discharge Condition:
Good
Discharge Instructions:
Call or come back if you have any fevers, chills, nausea,
vomiting, increasing redness around your wound, chest pain,
shortness of breath, or any other concerns.
You should take pain medications only as needed. Take stool
softeners to prevent constipation. Take medications as
prescribed. Please continue on low dose coumadin until you can
be evaluated by Dr. [**First Name (STitle) **].
Continue antibiotics for one more day and then they should be
stopped [**2146-5-21**].
Your VAC dressing should be changed on [**2146-5-23**] and thereafter
every 3 days. It should always be to suction.
You should get OOB and walk multiple times every day.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Followup Instructions:
Please follow up in 1 week with Dr. [**Last Name (STitle) **]. Please call ([**Telephone/Fax (1) 32046**] to set up an appointment.
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 2934**]
Date/Time:[**2146-6-8**] 3:40
Please see Dr. [**First Name (STitle) **] in one week to follow up your afib and
reestablish care after this hospitalization. Call [**Telephone/Fax (1) 3393**]
to set up an appointment.
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2323, 6834
|
11878, 12344
|
1523, 1583
|
9240, 10816
|
10930, 11047
|
9115, 9215
|
11099, 11855
|
1598, 1598
|
1990, 2304
|
274, 290
|
552, 980
|
1612, 1976
|
1002, 1364
|
1380, 1507
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,244
| 103,980
|
44699
|
Discharge summary
|
report
|
Admission Date: [**2168-2-2**] Discharge Date: [**2168-2-4**]
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Arterial line
History of Present Illness:
[**Age over 90 **]F with COPD, CAD, CHF sent in from [**Hospital **] rehab, russian
speaking only. History from daughter and [**Hospital 100**] rehab notes.
Per the daughter she was called by [**Hospital 100**] rehab with concerns
about her mother. [**Name (NI) **] mother's urine output had decreased she
had a new oxygen requirement, low blood pressures and poor oral
intake. The note from [**Hospital 100**] rehab is confusing as to what
exactly was going on in terms of blood pressure however it does
state that her lisinopril was stopped and she was started on
IVF. A CXR was checked which revealed a new right sided pleural
effusion. Labs at [**Hospital 100**] rehab were notable for a potassium of
6 without peaked T-waves, an increase in her creatinine from 2.2
on [**1-27**] to 4.0 on [**2-2**] with an associated drop in her bicarb
to 18. She received a kayexalate enema for her hyperkalemia.
.
She was also started on imipenem for a presumed ESBL UTI. The
patients daughter initially wanted to keep her out of the
hospital, however she asked the patient
.
In the ED, initial vs were 96.6 58 97/67 16 94% 4L. She
received vancomycin, levaquin and flagyl for initial presumption
of sepsis NOS. She received 2L of NS with no improvement in her
lactate. She was intermittently hypotensive to the 80's and
responded to a second 2L of NS. An EKG revealed AFIB without
significant changes. She had a non-contrast adbdominal CT to
look for a source of infection which was unrevealing. CXR
revealed the aformentioned new right pleural effusion. Of note
her UE BPs were unreliable in the ED, and the ED resident
attempted to check them via doppler, he was unable to find them
and bedside ultrasound revealed no radial pulses despite warm
well perfused hands. Several attempts were made at placing a
right femoral a-line which failed and finally a left femoral
a-line was placed. Two 18 gauge peripherals were placed as the
patients daughter was refusing central line. Peripheral
levophed was started prior to leaving the ED.
.
On the floor, she remained unresponsive to a 250cc NS bolus with
MAPs in the low 60's.
.
Past Medical History:
Recurrent ESBL UTIs
Dementia with hallucinations,
delerium with delusions
Hypertension
Chronic renal insufficiency
Osteoarthritis
Back Pain
Clavicle Fracture
Peripheral Artery Disease
History of an aneurysmal neck vein
A. Fib
Social History:
Lives at [**Hospital 100**] Rehab, HCP is daughter [**Name (NI) 2951**].
Family History:
Non-contributory
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,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
On admission:
[**2168-2-2**] 06:00PM BLOOD WBC-16.8*# RBC-4.25# Hgb-13.6# Hct-42.3#
MCV-99* MCH-32.0 MCHC-32.2 RDW-18.0* Plt Ct-97*#
[**2168-2-2**] 09:05PM BLOOD PT-17.5* PTT-38.3* INR(PT)-1.6*
[**2168-2-2**] 06:00PM BLOOD Glucose-116* UreaN-87* Creat-4.0*# Na-139
K-5.8* Cl-103 HCO3-20* AnGap-22*
[**2168-2-2**] 06:00PM BLOOD ALT-15 AST-48* CK(CPK)-98 AlkPhos-94
[**2168-2-2**] 06:00PM BLOOD CK-MB-8 cTropnT-0.12*
[**2168-2-3**] 02:42AM BLOOD Calcium-8.1* Phos-6.0*# Mg-2.2
[**2168-2-2**] 11:05PM BLOOD Type-ART Temp-37.3 FiO2-92 O2 Flow-15
pO2-204* pCO2-38 pH-7.22* calTCO2-16* Base XS--11 AADO2-431 REQ
O2-73 Intubat-NOT INTUBA Vent-SPONTANEOU
[**2168-2-2**] 06:22PM BLOOD Lactate-3.3*
.
IMPRESSION:
1. Partially imaged moderate right and small left pleural
effusions with
overlying atelectasis. Cardiomegaly, in conjunction with diffuse
subcutaneous
edema and mesenteric haziness suggests volume overload. Small
amount of
perihepatic fluid. Presacral edema.
2. 2 to 3 small fluid density rounded structures along the
inferior medial
border of the right lobe of the liver, of unclear etiology.
Recommend
clinical correlation with history of malignancy, superinfection
cannot be
excluded.
3. Extensive colonic diverticulosis, without evidence of acute
diverticulitis.
4. Cholelithiasis.
.
[**2-2**] CXR:
IMPRESSION:
1. Interval development of moderate-to-large right pleural
effusion with
overlying atelectasis, underlying consolidation cannot be
excluded.
2. Persistent cardiomegaly. No overt pulmonary edema.
Brief Hospital Course:
In brief, this is a [**Age over 90 **] year old female who was transferred from
[**Hospital 100**] Rehab to the MICU at [**Hospital1 18**] for further evaluation of
hypotension, hypoxia, and acute on chronic kidney injury
secondary to urosepsis. She was admitted to the MICU and
despite pressor support, fluid resuscitation, and appropriate
antibiotics, it soon became clear that the patient's clinical
status would not recover as evidenced by increasing lactate and
worsening acidemia. The patient's daughter, [**Name (NI) 2951**], was
informed of the patient's worsening clinical status and given
her poor prognosis, it was decided to change her code status
from DNR/DNI to CMO. The patient passed away shortly after
institution of a morphine drip and withdrawal of pressors. The
patient's daughter, [**Name (NI) 2951**], was present at bedside and refused
autopsy. Time of death was 4:45AM. The following summarizes
her hospital course:
.
#. Urosepsis: The patient presented with a floridly positive U/A
in the setting of gross pyuria, hypotension, hypothermia,
leukocytosis, and increased respiratory rate all c/w infectious
etiology. UTI with sepsis is the most likely source. Lactate
was initially 3.3 and the patient was fluid resuscitated. Blood
and urine cultures were drawn and pending at time of death. CT
scan was unremarkable. She was started on pressors.
Meropenem/Vancomycin were started out of concern for ESBL UTI
given history of same. Levophed was changed to phenylephrine out
of concern for tachycardia. CVP was 20 in setting of 4+ TR. On
HD #2, lactate began trending up and phenylephrine was again
changed to Levophed in addition to vasopressin. She was
administered additional fluid boluses, but her lactate trended
up to 7.5 and she was acidemic with a pH of 7.05. Her daughter,
[**Name (NI) 2951**], was informed of her worsening clinical prognosis and it
was decided to change to patient's code status to CMO.
.
#. Acute on Chronic Renal Faillure: Cr was initially 4, up from
baseline of 1. Thought to be [**3-10**] ischemic ATN in the setting of
septic shock. On HD #2, Cr improved to 3.5 with IVFs.
.
#. Lactic acidosis: 3.3 on transfer to ICU. Likely [**3-10**] to septic
shock. Initially, lactate improved with IVF but on HD#2 it
began rising and peaked at 7.5. Pressors were administered as
described above.
Medications on Admission:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO HS (at bedtime).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
4. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day: Do
not take if your systolic blood pressure is less than 105.
6. Ipratropium Bromide 0.03 % Spray, Non-Aerosol Sig: Two (2)
sprays Nasal twice a day: in each nostril.
7. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation twice a day as needed for
SOB.
9. Glyburide 5 mg Tablet Sig: 0.5 Tablet PO twice a day.
10. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
12. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Fluocinonide 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Disp:*qs * Refills:*2*
Discharge Medications:
Patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient expired
Discharge Condition:
Patient expired
Discharge Instructions:
Patient expired
Followup Instructions:
Patient expired
|
[
"496",
"995.92",
"403.90",
"584.5",
"038.9",
"518.81",
"585.9",
"250.00",
"785.52",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8468, 8477
|
4835, 5763
|
247, 262
|
8536, 8553
|
3297, 3297
|
8617, 8635
|
2779, 2797
|
8428, 8445
|
8498, 8515
|
7210, 8405
|
5780, 7184
|
8577, 8594
|
2812, 3278
|
196, 209
|
290, 2424
|
3311, 4812
|
2446, 2673
|
2689, 2763
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,018
| 100,988
|
32944
|
Discharge summary
|
report
|
Admission Date: [**2123-1-1**] Discharge Date: [**2123-1-8**]
Date of Birth: [**2089-6-9**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
33M s/p 15' fall, unwitnessed, c ?SDH, small scattered bifrontal
SAH, T8-T9 fx
Major Surgical or Invasive Procedure:
Open reduction of T8-9 dislocation, instrumented spinal fusion
for T8 fracture.
History of Present Illness:
Pt sp unwitnessed [**2089**]5' from deck. GCS on arrival to [**Hospital **]
Hospital 13-14. Intubated [**2-6**] pt unable to follow commands.
Report of no LE movement but intact UE movement.
Past Medical History:
denies
Social History:
ETOH
Tobacco
Marijuana
Family History:
non contributory
Physical Exam:
pt arrived from outside hospital medically sedated and intubated
chest clear
heart regular
neck supple, no deformity
abdomen soft
spine: palpable stepoff mid thoracic area
neuro: sedated and intubated
vascular intact
Pertinent Results:
[**2123-1-1**] 08:12PM GLUCOSE-133* UREA N-8 CREAT-0.9 SODIUM-136
POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-22 ANION GAP-14
[**2123-1-1**] 08:12PM WBC-10.5 RBC-3.11* HGB-9.6* HCT-28.2* MCV-91
MCH-31.0 MCHC-34.2 RDW-13.2
[**2123-1-1**] 08:12PM PT-12.1 PTT-25.9 INR(PT)-1.0
[**2123-1-1**] 06:24PM TYPE-ART PO2-112* PCO2-44 PH-7.35 TOTAL
CO2-25 BASE XS--1 INTUBATED-INTUBATED
[**2123-1-5**] 07:30AM BLOOD WBC-6.5 RBC-3.01* Hgb-9.1* Hct-26.6*
MCV-88 MCH-30.2 MCHC-34.3 RDW-12.9 Plt Ct-308
[**2123-1-5**] 07:30AM BLOOD PT-11.6 PTT-22.0 INR(PT)-1.0
[**2123-1-5**] 07:30AM BLOOD Glucose-125* UreaN-12 Creat-0.8 Na-134
K-4.0 Cl-97 HCO3-28 AnGap-13
[**2123-1-5**] 07:30AM BLOOD Calcium-8.8 Phos-2.0* Mg-2.3
Brief Hospital Course:
[**2123-1-1**]
CT HEAD: 1. Small SAH and a 6-mm IPH/SAH within the left
parietal lobe. No mass effect or midline shift. The findings
are roughly stable compared to outside hospital CT taken one
hour prior.
.
CT TORSO: T8 3 colulmn injury with inevitable ligamentous
injury. T8 fx include: anterior superior corner, through
vertbral body, through left posterior costo-vertebral joint,
with perched facets (T8 on T9) bilaterally, anterolisthesis of
T8 on T9, T8 spinous process fx. Bony fragments abut left side
of thecal sac at T8, with likely small epidural hematoma and no
obvious cord compression- to be evaluated by MRI. T9 fractures
include anterior superior corner --> through vertebral body -->
Left T9 transverse process.
Pt to OR with Ortho Spine for open redution and instrumented
fusion with no complication.
He tolerated the procedure well and returned to the ICU. On POD
2, he was transferred to the spine service and the regular
hospital floor.
A TLSO brace was obtained for use with ambulation.
He remained medically stable with no complications of the
hospital stay.
A ambulated safely and was cleared by physical and occupational
therapy.
He was discharged to home in stable condition.
Medications on Admission:
none
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
Disp:*10 Suppository(s)* Refills:*0*
3. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
4. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q8H (every 8 hours).
Disp:*90 Tablet Sustained Release 12 hr(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
HomeHealth VNA
Discharge Diagnosis:
Thoracic spine fracture T8
Discharge Condition:
Good
Discharge Instructions:
Keep the incision dry. You may shower as long as you cover the
incisions with Band-aids. Do not take a bath or submerge the
incision under water. You need to wear the brace whenever you
are out of bed. You do not need the brace when you are in bed.
Do not lift anything heavier than a gallon of milk. do not bend
or twist from the lower back.
Do not smoke.
call the office if you have a fever over 101F or if you have an
increase in pain or discharge from the incisions.
Physical Therapy:
Activity: Out of bed to chair [**Hospital1 **]
Thoracic lumbar spine: when ambulating
pt may be OOB to chair without brace.
Treatment Frequency:
Please continue to change the dressings daily with dry sterile
gauze.
Followup Instructions:
Dr. [**Last Name (STitle) 363**] in 2 weeks, call the office for an appointment: [**Telephone/Fax (1) 18552**]
|
[
"805.2",
"852.21",
"285.1",
"E884.9",
"852.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.05",
"03.90",
"81.64",
"03.53"
] |
icd9pcs
|
[
[
[]
]
] |
3605, 3650
|
1781, 1797
|
395, 476
|
3720, 3726
|
1056, 1758
|
4494, 4608
|
784, 802
|
3052, 3582
|
3671, 3699
|
3023, 3029
|
3750, 4232
|
817, 1037
|
4250, 4379
|
277, 357
|
504, 698
|
1806, 2997
|
4400, 4471
|
720, 728
|
744, 768
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,660
| 126,390
|
41745+41746+58472
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2152-11-15**] Discharge Date: [**2152-11-24**]
Date of Birth: [**2090-3-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
ProAir HFA
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
lethargy- known pericardial effusion
Major Surgical or Invasive Procedure:
[**2152-11-17**] Left VATS - Pleural effusion evac/ Pericardial window
[**2152-11-15**] PROCEDURE:
Pericardiocentesis: was performed via the left 4th intercostal
space,
mid-axillary line under direct ultrasound guidance using an
micropuncture needle followed by placement of a 4F Terumo
sheath.
History of Present Illness:
62yoM s/p 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.
[**2152-10-4**]. Post-op course c/b acute renal injury with creatinine
that returned to baseline prior to discharge. Discharged home on
[**9-30**].
Over past 1-2 weeks has been noticing increasing dyspnea
w/exertion to the point that this weekend could not make it to
the bathroom w/o shortness of breath. Recovers w/rest.
Of note patient states his INR was subtherapeudic and he was put
on Lovenox [**Hospital1 **] 2 weeks ago by PCP.
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: 100 Resp: 16 O2 sat: 98% RA
B/P Right: 126/87 Left: 132/86
Height: 5'[**51**]" Weight: 89.6kg
General: NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] sharp click
Abdomen: Soft [x] non-distended [x] non-tender [x] +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**]: Left:
Radial Right: 2+ Left:2+
Carotid Bruit Right: none Left: none
Pertinent Results:
Admission labs:
[**2152-11-15**] 11:06AM PT-30.1* PTT-42.5* INR(PT)-2.9*
[**2152-11-15**] 11:06AM PLT COUNT-481*
[**2152-11-15**] 11:06AM WBC-7.8 RBC-3.67* HGB-9.6* HCT-30.7* MCV-84
MCH-26.3*# MCHC-31.4 RDW-15.7*
[**2152-11-15**] 11:06AM CALCIUM-9.3 PHOSPHATE-3.4 MAGNESIUM-2.1
[**2152-11-15**] 11:06AM ALT(SGPT)-39 AST(SGOT)-36 ALK PHOS-127 TOT
BILI-0.5
[**2152-11-15**] 11:06AM ALT(SGPT)-39 AST(SGOT)-36 ALK PHOS-127 TOT
BILI-0.5
[**2152-11-15**] 11:06AM GLUCOSE-96 UREA N-19 CREAT-0.9 SODIUM-134
POTASSIUM-4.5 CHLORIDE-100 TOTAL CO2-25 ANION GAP-14
Discharge labs:
[**2152-11-22**] 06:20AM BLOOD WBC-5.3 RBC-3.28* Hgb-7.9* Hct-26.4*
MCV-81* MCH-24.0* MCHC-29.8* RDW-15.4 Plt Ct-475*
[**2152-11-24**] 06:20AM BLOOD PT-24.2* PTT-62.7* INR(PT)-2.3*
[**2152-11-23**] 12:20PM BLOOD PT-20.8* PTT-64.7* INR(PT)-1.9*
[**2152-11-24**] 06:20AM BLOOD Glucose-85 UreaN-19 Creat-0.9 Na-133
K-4.4 Cl-98 HCO3-27 AnGap-12
STUDIES:
CXR [**2152-11-15**]: Left pleural effusion is small. Cardiomegaly is
stable accentuated by projection. There is minimal atelectasis
in
the left lower lobe. There is no pneumothorax.
Chest CT scan Date:[**2152-11-14**] [x] outside film ([**Hospital1 3793**])
Impression: large pericardial effusion measuring 4.2cm at apex.
Fluid tracking about pericardium and up into anterior superior
mediastinal space. Small left pleural effusion
Echocardiogram [**2152-11-16**]: LVEF 50%, there is a large pericardial
effusion, primarily anterior and apical in location. The
effusion
appears loculated. No signs of cardiac tamponade seen. Preserved
contractile function and no septal or free wall rupture
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: >= 55% >= 55%
TR Gradient (+ RA = PASP): 20 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of [**2151-11-17**].
LEFT VENTRICLE: Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
Abnormal septal motion/position.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
PERICARDIUM: Moderate pericardial effusion. Effusion echo dense,
c/w blood, inflammation or other cellular elements. No
echocardiographic signs of tamponade.
Conclusions
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There is abnormal septal motion/position. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There is a moderate sized pericardial effusion. The
effusion is echo dense, consistent with blood, inflammation or
other cellular elements. There are no echocardiographic signs of
tamponade.
Compared with the prior study (images reviewed) of [**2151-11-17**],
the findings are similar. There is a large, echodense
pericardial effusion over the anterior surface and near the apex
of the heart. The distal lateral wall and apex appear fixed in
position likely due to pericardial adhesions. There is a more
prominent septal bounce, raising concern for possible
constriction. However the wide QRS could also explain this
septal bounce.
Electronically signed by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2152-11-23**] 22:30
Radiology Report CHEST (PA & LAT) Study Date of [**2152-11-19**] 8:57 AM
Comparison to [**2152-11-18**] at 14:27.
IMPRESSION:
Interval removal of the left chest tube. No evidence of a
pneumothorax.
Residual subcutaneous emphysema is seen involving the lateral
left soft
tissues. There is patchy opacity at the left base, which likely
reflects a
combination of atelectasis and fluid in this patient status post
median
sternotomy with valvular replacement. Overall, cardiac and
mediastinal
contours remain stable but enlarged in this postoperative
patient.
Right lung is grossly clear, though there may be a trace pleural
effusion as the costophrenic angle is slightly blunted. No
evidence of pulmonary edema.
Brief Hospital Course:
The patient was admitted for evaluation of pericardial effusion
after Bentall/AVR [**2152-10-2**]. He was referred for drainage of large
pericardial effusion with tamponade
physiology on echocardiogram after presenting with increasing
dyspnea on
exertion and exercise intolerance.
He initially had effusion drained in cardiac catheterization lab
and was then brought to the operating room on [**11-17**] for:
Left video-assisted thoracic surgery, drainage of pleural
effusion and exploration of pericardial space.
The patient tolerated the procedure well and post-operatively
was transferred to the CVICU in stable condition.
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. He was
anticoagulated for previous mechanical valve with Heparin and
Coumadin.
The patient was transferred to the telemetry floor for further
recovery. Chest tubes were discontinued without complication
per cardiac surgery protocol.
The patient was evaluated by the physical therapy service for
assistance with strength and mobility.
By the time of discharge on POD7 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged home with VNA in good
condition with appropriate follow up instructions.
The INR and coumadin dosing will be followed by Dr
[**Last Name (STitle) 11006**],[**First Name3 (LF) 640**] W [**Telephone/Fax (1) 23874**].
Medications on Admission:
Azopt 1% 1 drop each eye [**Hospital1 **], Latanoprost 0.005% 1 drop each eye
hs, Toprol 25mg daily, asa 81mg daily, MVI daily, coumadin
Discharge Medications:
1. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. multivitamin Tablet Sig: 1-2 Tablets PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. brinzolamide 1 % Drops, Suspension Sig: One (1) Ophthalmic
[**Hospital1 **] (2 times a day).
5. 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*
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
8. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
9. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
10. warfarin 2.5 mg Tablet Sig: as directed Tablet PO once a
day: take 5mg on [**11-24**]
take 2.5 mg on [**11-25**] and [**11-26**] then as directed by
Dr [**Last Name (STitle) 11006**],[**First Name3 (LF) 640**] W [**Telephone/Fax (1) 23874**].
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Pericardial effusion s/p drainage/pericardial window
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with tramadol
left thoracotomy incision - healing well, no erythema or
drainage
Edema: 1 to 2+ bilat
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 while taking narcotics, drivng will be discussed at
follow up appointment with surgeon.
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:
Follow up with your Cardiologist: 2-3 weeks
-tried to schedule appt- office closed for holiday
patient will need to call for follow-up appt.
Name: [**Last Name (LF) 5686**], [**Name8 (MD) **] MD
Phone: [**Telephone/Fax (1) 11554**]
Fax: [**Telephone/Fax (1) 11555**]
Department: Thoracic Surgery
When: TUESDAY [**2152-12-5**] at 9:30 AM
With: [**Known firstname **] [**Last Name (NamePattern4) 3000**], MD [**0-0-**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please report 30 minutes prior to your appointment to the [**Location (un) **] Radiology Department in the [**Hospital Ward Name 23**] Clinical Center for a
chest xray.
Department: CARDIAC SURGERY
When: WEDNESDAY [**2152-12-13**] at 2:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD [**Telephone/Fax (1) 170**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Labs: PT/INR for Coumadin ?????? indication mechanical aortic valve
Goal INR 2.5-3.0
First draw [**11-27**]
Results to phone Dr [**Last Name (STitle) 11006**],[**First Name3 (LF) 640**] W [**Telephone/Fax (1) 23874**]
Completed by:[**2152-11-24**] Admission Date: [**2152-11-29**] Discharge Date: [**2152-11-30**]
Date of Birth: [**2090-3-11**] Sex: M
Service: MEDICINE
Allergies:
ProAir HFA
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Shortness of Breath/possible syncopal event
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
62 y/o male with HTN, HLD, AR and ascending aortic aneurysm s/p
resection and AVR (St. [**Male First Name (un) 923**]) on [**2152-10-2**] with course c/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] with
recent admission from [**Date range (3) 90691**] for pericardial effusion
with tamponade physiology s/p pericardiocentesis followed by
pericardial window, believed to be post-surgical, also s/p chest
tube for pleural effusion who presented to [**Hospital3 1443**]
today for INR check and developed shortness of breath with
subsequent syncopal event. He reports that he was walking into
the ED and "lost breath" and was breathing heavy. + LOC for
5-10 seconds; denies any urinary/stool incontinence, no shaking,
no tongue biting. Pt unsure if he felt flushed prior to the
episode; just remembers feeling very short of breath. A TTE was
performed that by report revealed a medium-sized effusion with
RV collapse. He was subsequently transferred to [**Hospital1 18**] for
further evaluation.
.
The patient states that he has had increasing DOE over the last
1-2 weeks to the point that he cannot walk to the bathroom
without developing SOB. His SOB does resolve with rest. He was
recently started on Lovenox for a subtherapeutic INR. Since his
surgery, the patient reports having intermittent episodes of
shortness of breath. Denies any associated chest pain,
palpitations, chest tightness. Just reports some chest
tightness, pleuritic chest pain. Denies any PND, has not
noticed any increasing LE edema. Reports using two pillows to
sleep at night, but is able to lay flat without getting short of
breath.
.
Denies any headaches, changes in vision, no chest pain, no
palpitations, no n/v/d. Reports constipation for three days,
abdominal pain which he attributes to lovenox injections, no
recent fevers/chills.
.
On transfer to the CCU, the patient reports feeling well. Chest
pain free, breathing comfortably on room air. Bedside echo
showed small pericardial effusion without clear e/o RA/RV
collapse though visualization of the RA and RV was difficult
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- PERCUTANEOUS CORONARY INTERVENTIONS: [**2152-8-18**], [**2152-11-15**] (see
below)
- PACING/ICD: none
- Aortic regurgitation s/p AVR
- Ascending aortic aneurysm
3. OTHER PAST MEDICAL AND SURGICAL HISTORY:
- h/o hyponatremia
- Cataract
- Glaucoma
- Depression
- Anxiety
- Vitamin D deficiency
- s/p skin tag removal
- Mild varicose veins
- Left patellar fracture ([**2147**])
- Left foot crush injury ([**2147**])
- s/p left knee surgery [**2147**] with titanium wires in place
- Tonsillectomy
Social History:
Lives alone. Reports high stress after being laid off in [**12-23**]
from job at [**Location (un) 6692**] in cargo. Smoked 1 ppd x 40+ years but quit
[**2152-9-19**]. Former heavy drinker who drank [**4-18**] 12 oz beers on most
days but stopped on [**2152-9-19**]. Used to smoke occasional marijuana.
Family History:
Premature coronary artery disease - none
Reports cardiac issues in his family, but unsure of what.
Physical Exam:
Admission PE:
VS: 97.1 97 123/80 19 98% on 1.5L
GENERAL: NAD. Oriented x3. pleasant elderly gentleman, laying
comfortably in bed
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, JVP to earlobe
CHEST: + well healed vertical scar extending from midsternum
down to xiphoid, three horizontal 2 cm scars near xiphoid, all
well healed
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4, + mechanical valve click
LUNGS: clear to auscultation b/l, good air movement,
respirations unlabored, no crackles/wheezes/rhonchi
ABDOMEN: soft, nontender, nondistened, +BS
EXTREMITIES: 1+ LE edema, warm, well perfused
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Neuro: strength and sensation normal throughout
.
Discharge PE:
Tmax: 37.1 ??????C (98.7 ??????F) Tcurrent: 36.9 ??????C (98.4 ??????F)
HR: 104 (88 - 104) bpm
BP: 120/79(88) {97/64(74) - 127/80(90)} mmHg
RR: 18 (12 - 19) insp/min
SpO2: 96%
Heart rhythm: SR (Sinus Rhythm)
GENERAL: NAD. Oriented x3. pleasant elderly gentleman, laying
comfortably in bed
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, JVP to earlobe
CHEST: + well healed vertical scar extending from midsternum
down to xiphoid, three horizontal 2 cm scars near xiphoid, all
well healed
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4, + mechanical valve click
LUNGS: clear to auscultation b/l, good air movement,
respirations unlabored, no crackles/wheezes/rhonchi
ABDOMEN: soft, nontender, nondistened, +BS
EXTREMITIES: 1+ LE edema, warm, well perfused
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Neuro: strength and sensation normal throughout
Pertinent Results:
ADMISSION LABS:
.
[**2152-11-29**] 10:13PM BLOOD WBC-6.6 RBC-3.87* Hgb-9.1* Hct-29.7*
MCV-77* MCH-23.4* MCHC-30.5* RDW-15.7* Plt Ct-534*
[**2152-11-29**] 10:13PM BLOOD PT-23.9* PTT-37.9* INR(PT)-2.2*
[**2152-11-29**] 10:13PM BLOOD Glucose-213* UreaN-18 Creat-1.0 Na-134
K-4.3 Cl-101 HCO3-26 AnGap-11
[**2152-11-29**] 10:13PM BLOOD Calcium-8.5 Phos-3.4 Mg-2.2
.
PERTINENT LABS:
.
[**2152-11-30**] 07:53AM BLOOD CK-MB-2 cTropnT-<0.01
[**2152-11-29**] 10:13PM BLOOD ALT-35 AST-26 AlkPhos-130 TotBili-0.4
.
Discharge labs:
.
[**2152-11-30**] 07:53AM BLOOD WBC-7.0 RBC-3.74* Hgb-9.0* Hct-29.0*
MCV-78* MCH-24.1* MCHC-31.1 RDW-15.7* Plt Ct-588*
[**2152-11-30**] 07:53AM BLOOD PT-29.6* INR(PT)-2.9*
[**2152-11-30**] 07:53AM BLOOD Glucose-82 UreaN-15 Creat-0.8 Na-134
K-4.1 Cl-101 HCO3-25 AnGap-12
[**2152-11-30**] 07:53AM BLOOD CK(CPK)-32*
[**2152-11-30**] 07:53AM BLOOD CK-MB-2 cTropnT-<0.01
[**2152-11-30**] 07:53AM BLOOD Mg-2.1
.
MICRO/PATH:
.
MRSA SCREEN (Final [**2152-12-2**]): No MRSA isolated.
.
IMAGING/STUDIES:
.
ECHO [**11-29**]:
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
A mechanical aortic valve prosthesis is present. There is
borderline pulmonary artery systolic hypertension. There is a
small to moderate sized pericardial effusion with preferential
fluid deposition along the anterolateral aspect of the left
ventricle measuring up to 1.3 centimeters in greatest dimension.
The effusion is echo dense, consistent with blood, inflammation
or other cellular elements. There are no echocardiographic signs
of tamponade. No right atrial or right ventricular diastolic
collapse is seen.
IMPRESSION: Small to moderate sized, echo dense pericardial
effusion without echcardiographic evidence of pericardial
tamponade. Borderline pulmonary artery systolic hypertension.
.
CXR PA/LAT [**11-29**]:
FINDINGS: As compared to the previous radiograph, the
retrocardiac lung areas are better ventilated. The right lung
also shows improved ventilation. Small bilateral pleural
effusions persist. Mild areas of atelectasis at the left lung
bases. Status post CABG. The gas collection in the left lateral
soft tissues has decreased in the interval.
.
TTE [**11-30**]:
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
A mechanical aortic valve prosthesis is present. There is
borderline pulmonary artery systolic hypertension. There is a
small to moderate sized pericardial effusion with preferential
fluid deposition along the anterolateral aspect of the left
ventricle measuring up to 1.3 centimeters in greatest dimension.
The effusion is echo dense, consistent with blood, inflammation
or other cellular elements. There are no echocardiographic signs
of tamponade. No right atrial or right ventricular diastolic
collapse is seen.
IMPRESSION: Small to moderate sized, echo dense pericardial
effusion without echcardiographic evidence of pericardial
tamponade. Borderline pulmonary artery systolic hypertension.
Brief Hospital Course:
62 y/o male with HTN, HLD, h/o AR and ascending aortic aneurysm
s/p AVR c/b pericardial effusion s/p pericardiocentesis and
pericardial window who presents with recurrent pericardial
effusion without echocardiographic findings of tamponade
physiology.
.
ACTIVE DIAGNOSES:
.
# Syncope/Recurrent Pericardial Effusion: Mr. [**Known lastname 90690**] was
transferred from OSH for concern of pericardial tamponade after
he experienced a syncopal event with an echo showing pericardial
fluid. He was found to be clinically stable on arrival without
clinical evidence of tamponade. He had an echo which
demonstrated a significant amount of pericardial fluid but
without echocardiographic evidence of tamponade. He also did not
have any arrythmias on telemetry but was found to have
borderline blood pressures with mild orthostatic symptoms. Other
labs and imaging were unrevealing for a cause of his syncopal
event and repeat TTE did not show significant interval
progression of his effusion. It was determined that his
pericardial effusion was not the cause of his syncopal event or
intermittent shortness of breath and no further management of
this issue was undertaken at this time. His home lasix was
discontinued as it was beleived that he was likely hypovolemic
and that his event may have been caused by orthostatic
hypotension. He was arranged with outpatient follow-up.
.
CHRONIC DIAGNOSES:
.
#. Asending Aortic Aneurysm and AR s/p AVR (St. [**Male First Name (un) 923**]): His
admission INR of 2.9 (goal of 2.5-3.5). He was briefly taken off
his coumadin and managed on heparin drip for his [**Hospital3 9642**] valve
but his coumadin was resumed when it was determined he would not
require a procedure.
.
#. Hypertension: He had somewhat borderline blood pressures
during this admission but without tamponade. He was continued on
his home metoprolol but his home lasix was discontinued.
.
# BPH: Stable. His tamsulosin was initially held for concern of
tamponade but was later continued. He was instructed to take
this medication at night given our concern for possible
orthostatic hypotension. He stated his continued need for it in
order for him to get a good night's sleep.
.
#. Glaucoma: Stable. He was continued on his home latanoprost
and brinzolamide eye drops.
.
TRANSITIONAL ISSUES:
-He will need continued close outpatient monitoring of his
symptoms as he may develop tamponade in the future if his
pericardial window malfunctions.
-Should he continue to have pre-syncopal or syncopal events, he
will need another syncopal workup.
Medications on Admission:
1. Latanoprost 0.005% 1 drop OU QHS (need to confirm if OU)
2. Aspirin EC 81 mg PO daily
3. Multivitamin 1-2 tablets PO daily
4. Brinzolamide 1% 1 drop OU [**Hospital1 **] (need to confirm if OU)
5. Tamsulosin ER 0.4 mg PO QHS
6. Docusate sodium 100 mg PO BID
7. Metoprolol tartrate 100 mg PO BID
8. Tramadol 50 mg PO Q4H PRN pain (usually only takes dose
before bed)
9. Furosemide 40 mg PO daily for 2 weeks (at d/c [**11-24**] so likely
still on)
10. Warfarin 2.5-5 mg PO daily
Discharge Medications:
1. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
2. brinzolamide 1 % Drops, Suspension Sig: One (1) Ophthalmic
[**Hospital1 **] ().
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO at bedtime.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. tramadol 50 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
9. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis:
status post pericardial window for pericardial effusion
aortic valve replacement
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 90690**],
It was a pleasure taking care of you while you were hospitalized
at [**Hospital1 18**]. You were admitted to the hospital because you had an
episode of shortness of breath and then fell at an outside
hospital. While you were there, they did an echocardiogram of
your heart and thought that they saw fluid around your heart.
You were transferred to [**Hospital1 18**] for further management.
When you got here, we also did an echocardiogram, and on our
study, we did not think that you had a significant amount of
fluid around your heart that would account for your shortness of
breath. We did NOT think that any intervention was indicated at
this time.
We do not think that you need to continue your water pill
anymore. The following changes were made to your medications:
STOP Lasix 40 mg daily
DECREASE metoprolol to 100 mg daily
Please continue to take the rest of your medications as
directed.
.
Please call [**Telephone/Fax (1) 23874**] tomorrow to schedule an appointment
with your PCP. [**Name10 (NameIs) **] will also have to get your INR checked
tomorrow, and send the results to your PCP.
Followup Instructions:
Name: [**Last Name (LF) 5686**], [**Name8 (MD) **] MD
Location: [**Hospital3 1443**] Hospital
Department: [**Location (un) **] Cardiology
Address: [**Street Address(2) 54015**] [**Location (un) 1468**], [**Numeric Identifier 11562**]
Phone: [**Telephone/Fax (1) 11554**]
Appointment: Monday [**2152-12-4**] 2:30pm
.
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2152-12-5**] at 9:30 AM
With: [**Known firstname **] [**Last Name (NamePattern4) 3000**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SURGERY
When: WEDNESDAY [**2152-12-13**] at 2:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD [**Telephone/Fax (1) 170**]
Building: LM [**Hospital Unit Name **] [**Location (un) 551**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Name: [**Last Name (LF) 11006**],[**First Name3 (LF) 640**] W
Location: [**Hospital1 **] HEALTH MEDICAL ASSOCIATES
Address: [**Location (un) 24577**] [**Apartment Address(1) 6850**], [**Location (un) **],[**Numeric Identifier 6086**]
Phone: [**Telephone/Fax (1) 23874**]
Appointment: Tuesday [**2153-1-9**] 4:45pm
*The office is going to call you at home with the next available
cancellation appointment.
.
Completed by:[**2152-12-10**] Name: [**Known lastname 14310**],[**Known firstname **] Unit No: [**Numeric Identifier 14311**]
Admission Date: [**2152-11-15**] Discharge Date: [**2152-11-24**]
Date of Birth: [**2090-3-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
ProAir HFA
Attending:[**First Name3 (LF) 741**]
Addendum:
Chief Complaint: shortness of breath/lethargy
History of Present Illness: 62yoM s/p Resection of the ascending
aortic aneurysm and aortic valve replacement with a Bentall
procedure with a [**Street Address(2) 14316**]. [**Hospital 744**] Medical mechanical valve
conduit.
[**2152-10-4**]. Post-op course c/b acute renal injury with creatinine
that returned to baseline prior to discharge. Discharged home on
[**9-30**].
Over past 1-2 weeks has been noticing increasing dyspnea
w/exertion to the point that this weekend could not make it to
the bathroom w/o shortness of breath. Recovers w/rest.
Of note patient states his INR was subtherapeudic and he was put
on Lovenox [**Hospital1 **] 2 weeks ago by PCP.
Impression: 62yo man s/p Bental/mech AVR anticoagulated
w/Coumadin and more recently Lovenox now w/large pericardial
effusion and signs of tamponade by echo.
Impression should reflect that the patient is admitted with
large pericardial effusion after Bental procedure which is
likely a complication of the surgery associated with
anticoagulation.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 136**] Homecare
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2152-12-12**]
|
[
"365.9",
"366.9",
"423.9",
"V58.61",
"423.3",
"782.3",
"268.9",
"401.9",
"272.0",
"305.1",
"511.89",
"276.52",
"785.0",
"600.00",
"V85.23",
"V43.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.12",
"34.06",
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
28959, 29141
|
20806, 21060
|
12569, 12577
|
24878, 24878
|
17705, 17705
|
26198, 27878
|
15630, 15731
|
23882, 24705
|
24755, 24755
|
23378, 23859
|
25029, 26175
|
18224, 20783
|
15746, 16629
|
14799, 15295
|
23102, 23352
|
16643, 17686
|
27895, 27924
|
2017, 2077
|
27952, 28936
|
17721, 18066
|
24774, 24857
|
24893, 25005
|
18082, 18208
|
21078, 23081
|
14713, 14779
|
15311, 15614
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,770
| 146,448
|
41863
|
Discharge summary
|
report
|
Admission Date: [**2190-12-13**] Discharge Date: [**2190-12-17**]
Date of Birth: [**2128-11-23**] Sex: M
Service: MEDICINE
Allergies:
Zosyn
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
rash
Major Surgical or Invasive Procedure:
Skin biopsy
History of Present Illness:
62M history of obesity, depression hypertension that presents
with chief compliant of rash. He was in his usual state of
health. He noticed over the past day the rapid evolution of a
red and itchy rash on his left hand that was worsening and
spreading to the left neck and ear associated with swelling down
the neck. There was also a necrotic area on the left hand with
streaking up the arm. It was also noted that the right index
finger had "purpura". He had noted gradual onset of left facial
swelling that extends to the lateral neck. He has also noted
purulent drainage to the left ear, which is swollen, red, and
flaking. Initial VS on [**2190-12-12**] were T 99.8, HR 90, BP 121/81,
RR 18, pOx 100 RA with Tm 100.6.
OSH labs were reassuring. His temperature on transfer was around
100. CT Neck did not show any free air, and he was
hemodynamically stable. He was given Vancomycin 2 gm IV, Zosyn
4.5 gm IV, acetaminophen 325 mg PO qD, hydromorphone 1 mg IV x
1, and ondansetron 4 mg IV. He was transferred for presumed
necrotizing fasciitis. Per EMS, the aforementioned area has
been extending with worsening blisters since leaving [**Location (un) 8641**].
He denies trauma, insect bites, or any other exposures such as
seafood.
In the [**Hospital1 18**] ED, initial vs were: 7 98.6 84 101/63 97 %.
Labs were significant for lactate 1.6. CBC showed a WBC 8.3, Hgb
13 (unknown baseline), and platelets 252 with differential of 73
% neutrophils. Blood culture was sent.
Chemistry panel was within normal limits with a Cr 0.9 (unknown
baseline), BUN 13, glucose 119. Coags were significant for PTT
20.7 and INR 1.2.
Past Medical History:
- Obesity
- Hypertension
- depression
Social History:
Retired former welder -- not working due to disability
Lives in [**Location (un) 3844**]
Non smoker, denies illicit drug use
Family History:
Unknown as patient was adopted
Physical Exam:
Admission:
VS: T 98.4, P: 84, BP: 102/41, rr: 22, 96% on RA
General Appearance: No acute distress, Overweight / Obese
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present, Obese
Extremities: Right lower extremity edema: 1+, Left lower
extremity edema: 1+
Skin: Warm, Rash: Ecchymosis to left palm with blister.
Moderate swelling that extends up left forearm. There are areas
of erythema and mild swelling up from the left arm to the left
neck. Right index finger with purpura. The left side of neck has
mild swelling with impetigo-like changed. Some urticaria noted.
+ intertriginous [**Female First Name (un) **] in groin
Neurologic: Attentive, Responds to: Not assessed, Movement: Not
assessed, Tone: Not assessed, non-focal. Patient denies sensory
or motor to left hand
Discharge:
VS: 97.3 129/72 66 18 96% RA
GEN: well-appearing gentleman in no apparent distress
HEENT: full beard with improved edema over L face, there is a
recently sutured biopsy site with no oozing, sclera not icteric,
no conjunctival pallor
NECK: no anterior cervical LAD
CV: RRR, no m/r/g, normal S1, S2
EXT: there is urticaria/erythema of the LUE with swelling of the
entire extremitity, there is a red discoloration of the L palm,
the purple discoloration has almost completely resolved - this
is improved from yesterday; edema likewise is improving with
increased dexterity in his L hand; similar discoloration and
swelling is present on the R third digit, also improving. There
is 1+ edema to both lower extremities, DP pulses are 2+,
however. There is a sutured biopsy incision on the L hand.
Pertinent Results:
Admission labs:
[**2190-12-13**] 02:00AM BLOOD WBC-8.3 RBC-4.11* Hgb-13.0* Hct-36.1*
MCV-88 MCH-31.5 MCHC-35.9* RDW-13.2 Plt Ct-252
[**2190-12-13**] 02:00AM BLOOD Neuts-73.0* Lymphs-22.6 Monos-3.0 Eos-1.3
Baso-0.2
[**2190-12-13**] 02:00AM BLOOD PT-13.9* PTT-20.7* INR(PT)-1.2*
[**2190-12-13**] 02:00AM BLOOD Glucose-119* UreaN-13 Creat-0.9 Na-139
K-3.3 Cl-105 HCO3-23 AnGap-14
[**2190-12-13**] 05:40AM BLOOD Calcium-7.3* Phos-2.7 Mg-1.8
[**2190-12-13**] 02:11AM BLOOD Lactate-1.6
Discharge Labs:
[**2190-12-16**] 06:05AM BLOOD WBC-5.3 RBC-3.50* Hgb-11.0* Hct-31.5*
MCV-90 MCH-31.4 MCHC-34.8 RDW-13.8 Plt Ct-268
[**2190-12-16**] 06:05AM BLOOD Neuts-58.9 Lymphs-33.5 Monos-2.7 Eos-4.6*
Baso-0.3
[**2190-12-16**] 06:05AM BLOOD Plt Ct-268
[**2190-12-16**] 06:05AM BLOOD Glucose-97 UreaN-15 Creat-0.8 Na-143
K-3.4 Cl-108 HCO3-28 AnGap-10
[**2190-12-16**] 06:05AM BLOOD Vanco-9.1*
Notable studies
CT Left Upper extremity [**2190-12-14**]:
IMPRESSION:
1. Skin nodularity in the distal forearm and hand is compatible
with the
clinical history of bullous disease.
2. Soft tissue defect at the radial aspect of the wrist
associated with a few locules of subcutaneous air may relate to
recent biopsy, or extension of air through a ruptured bulla.
Underlying infection is not excluded. Clinical correlation is
required.
3. Extensive cellulitis of the forearm and hand with no
drainable fluid
collection.
4. Two incidental small foreign bodies in the hand.
Skin Biopsy:
. Skin, left arm, punch biopsy (A):
Marked dyskeratosis/patchy epidermal necrosis, intraepidermal
vesicles, and pandermal mixed inflammatory cell infiltrate, see
note.
2. Skin, left neck, punch biopsy (B):
Marked dyskeratosis/patchy epidermal necrosis, intraepidermal
vesicles, and pandermal mixed inflammatory cell infiltrate, see
note.
Note: Sections show orthokeratosis with marked dyskeratosis and
areas of full epidermal necrosis. Intraepidermal vesicles
containing red blood cells, neutrophils, eosinophils, and
Langerhans cells are noted. Marked superficial and papillary
dermal edema is appreciated. The dermis is involved by
exuberant inflammatory infiltrate composed of neutrophils,
lymphocytes, and eosinophils. No vasculitis seen, but marked
karyorrhexis is present. The inflammation extends to deep
aspects of the dermis and superficial panniculus. The tissue
Gram, PAS, HSV [**1-17**], and VZV stains are negative for bacterial,
fungal, and viral micro-organisms, respectively. Overall, the
findings are compatible with an extensive hypersensitivity-type
reaction (such as to drugs, among other etiologies). The
differential diagnosis includes Sweet's syndrome, however,
presence of marked dyskeratosis and intraepidermal vesiculation
is unusual for this differential. Other possibilities include
infections (such as erysipelas, etc.). Given the negative
results of special stains, this possibility is unlikely.
Assessment with more sensitive assays - like tissue culture - is
recommended. Multiple levels have been examined. The findings
in two specimens are very similar, but the second biopsy (from
the left neck) shows a somewhat milder reaction. The findings
were discussed with Dr. [**Last Name (STitle) **]. Cukras on [**2190-12-15**].
Brief Hospital Course:
62 year old male with obesity and hypertension admitted with
progressive rash.
#Bullous dermatitis:
Patient was found to have rapidly progressing erythematous
edematous rashes with bullae over his hands and arms extending
up the arm and including his neck, back, and torso with
associated swelling. He was initially admitted to the Intensive
Care Unit for concern for a systemic infectious process such as
necrotizing fasciitis or toxic shock syndrome. Infectious
Disease, Dermatology, and Allergy were consulted. The patient
was treated with broad spectrum antibiotics initially, but the
antibiotics were eventually discontinued when the biopsy was
most suggestive of an allergic/hypersensitivity process. Over
the course of the hospitalization the rash improved and the
patient felt well and was at no time hemodynamically unstable.
He did not require systemic steroids, but was treated with
topical steroid and antihistamines. He was discharged to follow
up with Allergy, Dermatology, and infectious disease.
# Hypertension: Patient was not hypertensive off Benicar, and
therefore this was held on discharge.
# Intertriginous [**Female First Name (un) **]: Patient was treated wtih miconazole
Medications on Admission:
- Cymbalta 60 mg PO qD
- Benicar HCT 40 mg/12.5 mg PO qD
Discharge Medications:
1. duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for intertringinous [**Female First Name (un) **].
Disp:*1 container* Refills:*0*
3. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
4. triamcinolone acetonide 0.1 % Cream Sig: One (1) application
Topical 2-3 times per day for 14 days: apply a thin layer to
areas of redness/firmness.
Disp:*1 tube* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1) Hypersensitivity Reaction
2) Interiginous Candidasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr [**Known lastname 90907**]:
It was a pleasure taking care of you during your stay in the
hospital. A comprehensive multidisciplinary team including
infectious disease, allergy/immunology, plastic surgery, and
dermatology worked along with your primary medical care team for
your skin lesions and rash.
Ultimately it was felt that your rash developed as a
hypersensitivity (allergic) reaction to an as yet unknown
stimulus. You will need additional evaluations from several
clinics as an outpatient to further determine the cause and
possible treatments.
Additionally, you will need to have your sutures removed - this
can be done at your primary care appointment on [**12-22**].
The following medication changes were made during your hospital
stay:
1) START fexofenadine 60mg, twice a day
2) START triamcinalone 0.1% cream to red/firm areas 2-3 times
per day for 7-14 days
3) START Miconazole Powder 2% 1 Appl four times a day
intertriginous [**Female First Name (un) **] (where skin is touching)
4) STOP Benicar (your blood pressure has been normal)
You will need to have further evaluation from your primary care
physician as to whether you should restart your blood pressure
medication.
You should continue taking all of your other medications as
prescribed.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 29702**] Care
Address: 80 ROUTE 125, [**Location (un) **],[**Numeric Identifier 66525**]
Phone: [**Telephone/Fax (1) 90908**]
Appt: [**12-22**] at 12:15pm
Department: DIV OF ALLERGY AND INFLAM
When: MONDAY [**2190-12-27**] at 2:30 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 9316**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) 895**]
Campus: OFF CAMPUS Best Parking: Parking on Site
Department: Dermatology
Phone: [**Telephone/Fax (1) 1971**]
***The offic is working on a follow up appt for you in the next
week and will call you at home with an appt. If you dont hear
from them by Friday afternoon, please call directly to book.
Department: INFECTIOUS DISEASE-OPAT
When: THURSDAY [**2190-12-30**] at 3:30 PM
With: [**Doctor First Name 1412**] [**Name Initial (MD) **] [**Name8 (MD) 1413**], M.D. [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
***Please make sure you keep your appointment in [**Hospital 4898**] clinic
with the Infectious Diseases [**Hospital **]. [**First Name (Titles) **] [**Last Name (Titles) 21334**] are
[**Name5 (PTitle) 7941**] your progress on your antibiotics as well as watching
you for any significant side effects.
Department: INFECTIOUS DISEASE
When: FRIDAY [**2191-1-21**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13125**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2191-1-28**]
|
[
"692.9",
"401.9",
"278.00",
"311",
"112.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.11"
] |
icd9pcs
|
[
[
[]
]
] |
9309, 9315
|
7412, 8613
|
273, 286
|
9424, 9424
|
4155, 4155
|
10877, 12782
|
2163, 2195
|
8721, 9286
|
9336, 9403
|
8639, 8698
|
9575, 10854
|
4651, 7389
|
2210, 4136
|
229, 235
|
314, 1942
|
4171, 4635
|
9439, 9551
|
1964, 2004
|
2020, 2147
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,537
| 197,321
|
38205
|
Discharge summary
|
report
|
Admission Date: [**2122-7-26**] Discharge Date: [**2122-7-29**]
Date of Birth: [**2057-3-25**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Nitroglycerin / Iodine
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
Unresponsive
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
65 F w/ h/o Ileocolectomy/Ileostomy/Mucous fistula on [**6-28**] found
unresponsive at nursing home. Pt had recently been takien to the
OR for delayed resection after small bowel obstruction (delayed
[**2-17**] patient refusal) with resection of proximal right colon,
distal [**1-18**] of small bowel. At that time the cecum and distal [**1-18**]
of the small bowel were seen to be infarcted and necrotic, but
no perforation was identified. The patient was intubated on
scene by EMS and taken to [**Hospital 15405**] where a head CT was obtained.
Initial labs were significant for: WBC=34.7, K=7.0 Lactate 19.3,
AST 932, ALT 263. Patient recieved total of 6mg of versed 1mg of
ativan for potential seizure activity and 50mcg of fentanyl.
Prior to discharge from her previous hospitalization, the
patient had been alert and oriented, had refused PEG placement
and remained full code. By report, the patient was found
unresponsive at her nursing facility and was intubated and taken
to [**Hospital 15405**] where she was observed to be in multisystem organ
failure and transferred to [**Hospital1 18**] for further managment.
At [**Hospital1 **] initial vitals were BP 50/30 on levophed in ED. Was
pulseless for less than a minute while bag was being changed and
no CPR was done. Ileostomy had gross blood, colostomy had guaiac
pos stool. Foley had purulent fluid. She did withdraw to pain in
the ED. Ab CT without acute process. ECG: NSR, LAD, qtc 444, ST
dep II, IV V4-V6. [**Doctor First Name **] consulted and said not surgical candiate.
Pt vommited around OG tube, tube was clogged and replaced.
On the floor, patient intubated and withdraws to pain only.
[**Name (NI) **] son who is coming into [**Hospital1 **].
Past Medical History:
DMII
CAD
CHF
A-fib
CKI
Blind
Seizure disorder
Glaucoma
Psychosis
Renal stones
Stroke
Pneumonia
CABG
PPM
ORIF right hip with subsequent removal of R hip prosthesis
Laproscopic lysis of adhesions
mesenteric ischemia s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 85184**], [**First Name3 (LF) **] ileostomy and
creation of mucous fistula
Social History:
No tob
No EtOH
Family History:
NC
Physical Exam:
Admission:
General: Intubated, withdraws to pain only.
HEENT: MMM
Neck: supple, JVP not elevated
Lungs: B/l rhales, decreased BS on left v. right.
CV: Tachy, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: Midline incision with sutures that are have eroded
surroinding skin, areas of incision left open. Iliostomy bag and
colostomy bag in place.
GU: +foley
Ext: cold extremities, LE contracted.
Discharge:
Extuabted, responding appropriatly
Mid line placed on left IJ pulled
Otherwise exam unchanged.
Pertinent Results:
LABS:
[**2122-7-26**] 08:00PM BLOOD WBC-29.1* RBC-4.53 Hgb-12.7 Hct-38.5
MCV-85 MCH-28.0 MCHC-32.9 RDW-18.7* Plt Ct-264
[**2122-7-29**] 03:48AM BLOOD WBC-11.7* RBC-3.25* Hgb-9.4* Hct-27.7*
MCV-85 MCH-29.0 MCHC-34.1 RDW-19.4* Plt Ct-153
[**2122-7-26**] 08:00PM BLOOD PT-37.1* PTT-37.8* INR(PT)-3.8*
[**2122-7-29**] 03:48AM BLOOD PT-18.9* PTT-33.3 INR(PT)-1.7*
[**2122-7-28**] 04:58PM BLOOD FDP-10-40*
[**2122-7-26**] 08:00PM BLOOD Glucose-234* UreaN-53* Creat-5.2* Na-142
K-5.2* Cl-107 HCO3-18* AnGap-22
[**2122-7-29**] 03:48AM BLOOD Glucose-88 UreaN-28* Creat-0.8 Na-143
K-3.6 Cl-119* HCO3-19* AnGap-9
[**2122-7-27**] 01:31AM BLOOD ALT-972* AST-4810* LD(LDH)-4030*
CK(CPK)-528* AlkPhos-109* TotBili-0.4
[**2122-7-27**] 02:33PM BLOOD ALT-557* AST-929* LD(LDH)-496* AlkPhos-82
TotBili-0.3
[**2122-7-26**] 08:00PM BLOOD cTropnT-0.08*
[**2122-7-27**] 02:33PM BLOOD CK-MB-5 cTropnT-0.10*
[**2122-7-27**] 01:31AM BLOOD Albumin-2.3* Calcium-7.9* Phos-4.9*
Mg-1.4*
[**2122-7-29**] 03:48AM BLOOD Calcium-7.0* Phos-2.4* Mg-2.2
[**2122-7-27**] 02:33PM BLOOD Hapto-201*
[**2122-7-27**] 05:37AM BLOOD HAV Ab-POSITIVE IgM HAV-NEGATIVE
[**2122-7-28**] 06:30AM BLOOD Vanco-15.8
[**2122-7-28**] 06:35AM BLOOD Lactate-1.6
IMAGING:
Echo:
The left atrium and right atrium are normal in cavity size. 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 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. No mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. Pulmonary
artery systolic hypertension. Aortic valve sclerosis
LENI's:
Portable duplex son[**Name (NI) 867**] of the lower extremities was
performed. The deep vein demonstrates patent flow with normal
compressibility and normal response to augmentation. There is no
evidence of deep venous thrombosis.
IMPRESSION:
No evidence of deep venous thrombosis in either lower extremity
CT A/P:
1. Limited evaluation due to lack of IV and oral contrast.
However, no
evidence of obstruction, abscess or other acute intra-abdominal
process in
this patient status post ileocolectomy.
2. Extensive calcification of the abdominal and pelvic arterial
vasculature.
Brief Hospital Course:
65 year old female with a history of DM, CAD, CHF, recent
mesenteric ischemia s/p partical large and small bowel resection
who was found down at nursing home for an indeterminate amount
of time, intubated on the scene and eventually transferred to [**Hospital1 **]
for multi-organ failure. Patient was in multiorgan failure
which resolved with broad spectrum antibiotics and aggressive
fluid resuscitation. She was ultimately extubated successfully.
She was discharge to hospice at her nursing home.
# Septic Shock: Treated with broad spectrum abx and aggressive
fluid resusciation (~12 L). The source was unclear though her
urinanalysis was positive so treated for urine source. Also
suspected possible abdominal source given recent surgery and had
multiple pressure ulcers upon arrival which could be a potential
source. Treated initially with vanc/zosyn, changed to
vanc/cefepime/cipro/flagyl and then narrowed to
cefepime/cipro/flagyl.
# Respiratory Failure: Patient was intubated in the setting of
unresponsiveness. She was quickly weaned to pressure support
and extubated without difficulty. There was no evidence of COPD
or pneumonia on her imaging.
# Coagulopathy: Patient was in low grade DIC which improved
with treatment as above. There was likely a nutritional
component of this as well as her albumin was 2.3 on admission
and she was reversed with vitamin K 10mg iv - po not given as
concern for poor absorption.
# Acute on Chronic Renal Failure: Creatinine initially elevated
to 5 likely from hypovolemia which resolved with IVF as above.
Returned to baseline of....
# Electrolyte Abnormalities: Was hyperkalemic and hypernatremic
which was likely related to renal failure. Abnormalities
resolved.
# Elevated LFTs: Likely shock liver, trended down.
# NSTEMI: Likely related to poor perfusion in setting of shock.
Was not a candidate for cath as was probably microvascular
hypoperfusion.
# Code: Discussed with son - DNR/[**Name2 (NI) 835**]
Communication: Son [**Name (NI) **]: c[**0-0-**]
Medications on Admission:
Per recent D/C sum:
ASA 91mg daily
humalog SS
Synthroid 100mcg daily
lisinopril 10mg daily
Imodium 4mg po BID
Calmoseptine oint to coccyx TID
Lopressor 25mg [**Hospital1 **]
zyprexa 5mg daily
omeprazole 20mg daily
Zocor 40mg daily
timolol eye gtt to right eye
Percocet 1-2 tabs q6 orn pain
ativan 0.5 mg q4 orn ativan
Discharge Medications:
1. Cefepime 1 gram Recon Soln Sig: One (1) gram Injection Q24H
(every 24 hours) for 2 weeks: last dose [**2122-8-10**].
Disp:*14 gram* Refills:*0*
2. Morphine Concentrate 20 mg/mL Solution Sig: 1-10 mg PO q1h as
needed for SOB, pain.
Disp:*60 mL* Refills:*0*
3. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) patch
Transdermal every seventy-two (72) hours as needed for
secretions.
Disp:*12 patches* Refills:*3*
4. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours
as needed for anxiety, SOB: can give sublingual in place of
oral.
Disp:*30 Tablet(s)* Refills:*0*
5. Acetaminophen 650 mg Suppository Sig: One (1) tab Rectal
every six (6) hours as needed for pain, fever.
Disp:*90 tabs* Refills:*3*
6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*3*
7. normal saline
100 cc/hr on going to keep up with ostomy output. Can
increase/decrease based on ostomy output.
8. Oxygen
Please titrate to patient comfort at 2-6L by nasal cannula,
shovel mask or non-rebreather.
9. Foley catheter
Care per protocol.
10. Atmosphere mattress
11. Admit to general in-patient level of care hospice.
Discharge Disposition:
Extended Care
Facility:
Catholic [**Hospital1 107**] Home - [**Location (un) 8973**]
Discharge Diagnosis:
Urinary tract sepsis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted to the hospital with a urinary tract infection
and sepsis. You were treated with antibiotics and fluids. You
initially had a breathing tube wich was pulled. We had many
discussions with you and your family about your code status and
you were made DNR/DNI.
Followup Instructions:
[**Hospital 3390**]
Hospice care
|
[
"570",
"369.00",
"276.7",
"995.92",
"410.71",
"286.6",
"V58.67",
"584.8",
"041.4",
"250.00",
"345.90",
"298.9",
"518.81",
"780.97",
"427.31",
"038.9",
"V44.2",
"276.0",
"365.9",
"707.03",
"428.0",
"V45.01",
"785.52",
"599.0",
"V12.54",
"585.9",
"707.22",
"414.00",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9279, 9366
|
5712, 7741
|
305, 330
|
9430, 9430
|
3048, 5689
|
9869, 9904
|
2503, 2507
|
8110, 9256
|
9387, 9409
|
7767, 8087
|
9568, 9846
|
2522, 3029
|
253, 267
|
358, 2080
|
9445, 9544
|
2102, 2454
|
2470, 2487
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,807
| 129,144
|
18599+56973
|
Discharge summary
|
report+addendum
|
Admission Date: [**2119-7-24**] Discharge Date: [**2119-7-27**]
Date of Birth: [**2069-8-4**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Patient presented on [**2119-7-24**] for elective stent-assisted coiling
of her 2 right middle cerebral aneurysms. Patient had
previously suffered from sub-arachnoid hemorrhages in [**4-/2119**] and
6/[**2119**].
Major Surgical or Invasive Procedure:
[**7-24**] Right middle cerebral [**Last Name (un) **] aneurysm with sent-assisted
coiling
History of Present Illness:
49 y/o female presented for elective right middle cerebral
artery stent assissted coiling. Patient has a history of
sub-arachnoid hemorrhage x2 in [**2119-4-23**] and [**2119-6-23**]. During
her latest hospitalization, she underwent coiling of right MCA
without stent. As such, patient was recommended to undergo
elective repeat aniogram for stent placement.
Past Medical History:
HIV (diagnosed 22 years ago, not on HAART, last CD4 303 and VL
[**Numeric Identifier **] on [**2119-7-19**])
Hepatitis C (last VL 14.6 million on [**2118-9-16**])
Emphysema
Sarcoidosis
HTN
Abnormal pap smears
Social History:
Lives in [**Location 669**], works as medical tech at Community Health
Center
- Tobacco: 30 years x 1ppd, "in process of quitting"
- EtOH: social
- Illicits: denies current, + in past
Family History:
Her father had a history of lung cancer, and her mother had a
history of throat cancer.
Physical Exam:
Admission Physical Examination: non-focal
Discharge Physical Examination: unchanged from admission
Pertinent Results:
[**2119-7-24**] Angiogram: [**Known firstname 1894**] [**Known lastname 51078**] underwent cerebral
angiography and recoiling of
distal right middle cerebral aneurysm with Enterprise stent,
Micrus and Target
coils.
Brief Hospital Course:
Ms. [**Name13 (STitle) **] is a 49 yo F with h/o SAHx2 and two right MCA
aneurysms s/p coiling x2 who was admitted for elective
stent-assisted repeat coiling of right MCA.
.
# RIGHT MCA ANEURYSM STENT AND COILING: On [**7-24**], patient
presented for elective stent-assisted emobilization of her 2
right middle cerebral artery aneurysms. Pre-operatively, she
was loaded with plavix. Intra-operatively, a clot was identified
in the parent vessel. Integrillin was adminitered, and a heparin
drip initiated. The Post-procedure,the patient was tranfered
in stable condition to the ICU for monitoring. Her neurological
examination post-operatively was non-focal. On HD#2 (POD #1),
patient resumed her diet. The heparin drip was discontinued.
Three hours later, her sheath was pulled with some bleeding (HCT
dropped 29->25 then remained stable), otherwise no issues.
Patient remained on bedrest for __ hours and was later
transferred to the floor where she remained neurologically
stable. She will need to continue Plavix 75mg daily for one
month and ASA 325mg daily for ___.
.
# FEVER: patient tachycardic to 130s and febrile to 103
overnight post-operatively on HD#1, complained of bitemporal
dull HA and left ear pain the following morning. Of note has h/o
HIV not on HAART, CD4 303 and VL [**Numeric Identifier **] on [**2119-7-19**] (recently
dropped, PCP considering starting [**Name9 (PRE) 2775**] therapy soon per pt).
Blood/urine cultures, CXR and head CT were obtained which showed
no evidence of hemorrhage or infarct.
Now dod, patient is afebrile and vitals sigs are stable. She is
set for d/c home in stable condition.
Medications on Admission:
1. nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours) for 13 days.
Disp:*156 Capsule(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. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
5. 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*
6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
Start on [**2119-7-25**]. Dose of 300 mg was already given.
RX *clopidogrel 75 mg 1 Tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Nicotine Patch 21 mg TD DAILY
RX *nicotine 21 mg/[**Street Address(2) **] 1 patch daily Disp #*30 Each
Refills:*0
4. Acetaminophen-Caff-Butalbital 1 TAB PO Q4H:PRN headache, pain
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg 1 Tablet(s)
by mouth every four (4) hours Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right middle cerebral artery aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with Embolization and/or Stent placement
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily indefinately.
?????? Take Plavix (Clopidogrel) 75mg once daily for one month.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
Followup Instructions:
??????Please call [**Telephone/Fax (1) 1669**] for a follow-up appointment. You
should return to Dr. [**Last Name (STitle) **] office in 6 months.
??????You will need a Brain MRA [**Doctor Last Name **] coiling protocol for your
visit. This will be scheduled with your appointment.
- please follow-up with your PCP
Completed by:[**2119-7-27**] Name: [**Known lastname 9512**],[**Known firstname **] Unit No: [**Numeric Identifier 9513**]
Admission Date: [**2119-7-24**] Discharge Date: [**2119-7-27**]
Date of Birth: [**2069-8-4**] Sex: F
Service: NEUROSURGERY
Allergies:
acyclovir / vancomycin / ceftazidime
Attending:[**First Name3 (LF) 40**]
Addendum:
added bactrim for UTI.
Discharge Disposition:
Home
[**Name6 (MD) **] [**Last Name (NamePattern4) 43**] MD [**MD Number(2) 44**]
Completed by:[**2119-7-27**]
|
[
"285.29",
"E878.1",
"492.8",
"434.00",
"305.1",
"135",
"041.49",
"437.3",
"785.0",
"V12.54",
"599.0",
"996.74",
"V08",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.72",
"88.41",
"99.20"
] |
icd9pcs
|
[
[
[]
]
] |
6985, 7126
|
1921, 3556
|
519, 612
|
4892, 4892
|
1680, 1898
|
6223, 6962
|
1455, 1544
|
4279, 4781
|
4831, 4871
|
3582, 4256
|
5043, 6200
|
1559, 1569
|
1635, 1661
|
266, 481
|
640, 1004
|
4907, 5019
|
1026, 1237
|
1253, 1439
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,548
| 142,905
|
31728+57761
|
Discharge summary
|
report+addendum
|
Admission Date: [**2192-9-26**] Discharge Date: [**2192-10-4**]
Date of Birth: [**2130-8-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2192-9-28**] Four Vessel Coronary Artery Bypass Grafting(LIMA to LAD,
SVG to Diagonal, SVG to Ramus, SVG to RCA)
History of Present Illness:
Mr. [**Known lastname 74521**] is a 62 year old male who was transferred from
[**Hospital1 **] after cardiac catheterization revealed severe three
vessel coronary artery disease and normal left ventricular
function. He was admitted to [**Hospital1 **] with chest pain and ruled
out for myocardial infarction. Chest pain improved with
intravenous therapy. He remained pain free on transfer with
plans for surgical revascularization.
Past Medical History:
Coronary Artery Diseae
Hypertension
Elevated Cholesterol
History of gout
Benign Prostatic Hypertrophy
Prior Vasectomy, Tonsillectomy
Social History:
Denies tobacco history. Admits to only occasional ETOH. Married,
employed as an engineer.
Family History:
Brother diagnosed with CAD in his 40's.
Physical Exam:
Vitals: 99.8, 170/88, 81, 18, 97% RA
General: WDWN male in no acute distress
HEENT: Oropharynx benign, EOMI
Neck: Supple, no JVD, no carotid bruits noted
Lungs: CTA bilaterally
Heart: Regular rate and rhythm, normal s1s2, no murmur or rub
Abdomen: Soft, nontender with normoactive bowel sounds
Ext: Warm, no edema
Pulses: 2+ distally
Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal
deficits noted
Pertinent Results:
[**2192-10-4**] 07:15AM BLOOD WBC-6.7 RBC-2.87* Hgb-8.9* Hct-26.5*
MCV-93 MCH-31.0 MCHC-33.6 RDW-14.5 Plt Ct-397
[**2192-10-3**] 10:35AM BLOOD PT-13.1 INR(PT)-1.1
[**2192-10-2**] 06:55AM BLOOD Glucose-110* UreaN-16 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-26 AnGap-12
RADIOLOGY Final Report
CHEST (PA & LAT) [**2192-10-3**] 2:11 PM
CHEST (PA & LAT)
Reason: evaluate left effusion - please do in the afternoon
[**10-3**]
[**Hospital 93**] MEDICAL CONDITION:
62 year old man with s/p CABG
REASON FOR THIS EXAMINATION:
evaluate left effusion - please do in the afternoon [**10-3**]
CHEST PA AND LATERAL:
COMPARISON: Chest portable AP [**2192-9-30**].
HISTORY: 60-year-old male with left pleural effusion.
FINDINGS: There has been interval decrease in the amount of left
pleural effusion. There are no focal consolidations identified.
On lateral view, there is a small right pleural effusion as
well. There is no evidence of pneumothorax. The
cardiomediastinal silhouette is unremarkable. The hilar contours
are normal. The sternotomy wires are unchanged.
IMPRESSION: Interval decrease in left pleural effusion. Small
right pleural effusion seen on lateral view.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 8648**] [**Name (STitle) 8649**]
DR. [**First Name8 (NamePattern2) 4075**] [**Last Name (NamePattern1) 5999**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 74522**] (Complete)
Done [**2192-9-28**] at 5:22:27 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2130-8-28**]
Age (years): 62 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Abnormal ECG. Chest pain. Hypertension.
ICD-9 Codes: 402.90, 786.51, 440.0
Test Information
Date/Time: [**2192-9-28**] at 17:22 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1510**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW1-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.6 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Aorta - Ascending: 3.1 cm <= 3.4 cm
Aortic Valve - Peak Gradient: 8 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 3 mm Hg
Findings
LEFT ATRIUM: Normal LA size. No spontaneous echo contrast in the
body of the LA. No spontaneous echo contrast is seen in the LAA.
Good (>20 cm/s) LAA ejection velocity. No thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA and extending into the RV. No ASD
by 2D or color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness. Normal LV
cavity size. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no atherosclerotic plaque. Normal aortic diameter at
the sinus level. Simple atheroma in ascending aorta. Simple
atheroma in aortic arch. Complex (>4mm) atheroma in the
descending thoracic aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets. No masses or vegetations on aortic valve.
No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The patient received antibiotic prophylaxis. The
TEE probe was passed with assistance from the anesthesioology
staff using a laryngoscope. No TEE related complications.
Conclusions
PRE-CPB:1. The left atrium is normal in size. No spontaneous
echo contrast is seen in the body of the left atrium. No
spontaneous echo contrast is seen in the left atrial appendage.
No thrombus is seen in the left atrial appendage. No atrial
septal defect is seen by 2D or color Doppler.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. The ascending, transverse and descending thoracic aorta are
normal in diameter. There are simple atheroma in the ascending
aorta. There are simple atheroma in the aortic arch. There are
complex (>4mm) atheroma in the descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. No masses or vegetations are seen
on the aortic valve. There is no aortic valve stenosis. No
aortic regurgitation is seen.
6. The mitral valve appears structurally normal with trivial
mitral regurgitation.
POST-CPB: On infusion of phenylephrine, levo, vasopressin.
Preserved LV systolic function post CPB. LVEF= 55%. Trace MR.
Normal aortic contour post decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting
physician
Brief Hospital Course:
Mr. [**Known lastname 74521**] was admitted under cardiac surgery and underwent
routine preoperative evaluation. Workup was unremarkable and he
was cleared for surgery. On [**9-28**], Dr. [**First Name (STitle) **] performed
coronary artery bypass grafting surgery. For surgical details,
please see seperate 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. He developed atrial fibrillation on
postoperative day two which was initially treated with
Amiodarone and beta blockade. His CVICU course was otherwise
uneventful and he transferred to the SDU on postoperative day
three. Given persistent atrial fibrillation, he was eventually
started on Wafarin anticoagulation. He continued on beta
blockers and amiodarone which he converted to sinus rhythm POD 5
and remained in SR. He was ready for discharge home with
swervices POD 6.
Medications on Admission:
Diovan 320 qd, HCTZ 25 qd, Lopressor 100 [**Hospital1 **], Lipitor 10 qd,
Hytrin 4 qd, Plavix 75 qd, Aspirin 81 qd, Avodart 0.5 qd, Flomax
0.4 qd, Allopurinol 300 qd, Sodium Bicarb, Potassium
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. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 5 days: Take 400 mg twice a day for 5 days, then
decrease to once a day for 7 days after this dose completed,
then take 200 mg PO daily after this dose completed and follow
up with Dr [**Last Name (STitle) 20222**].
Disp:*80 Tablet(s)* Refills:*0*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*0*
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
8. Avodart 0.5 mg Capsule Sig: One (1) Capsule PO daily ().
Disp:*30 Capsule(s)* Refills:*0*
9. Valsartan 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
10. Outpatient [**Name (NI) **] Work
PT/INR for coumadin dosing
Draws Monday-Wednesday-Friday with goal INR 2-2.5 indication
atrial fibrillation
results to [**Hospital1 **] heart center coumadin clinic ([**Telephone/Fax (1) 20259**]
11. Terazosin 2 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*0*
12. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
13. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*0*
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
15. Coumadin 5 mg Tablet Sig: goal inr 2-2.5 Tablets PO goal inr
2-2.5: dose based on INR results .
Disp:*30 Tablet(s)* Refills:*0*
16. Coumadin 2 mg Tablet Sig: goal inr 2-2.5 Tablets PO once a
day: dose based on INR results .
Disp:*60 Tablet(s)* Refills:*0*
17. medications
Coumadin you have been give prescription for 5mg and 2mg tablets
- your dose will be adjusted based on your PT/INR results
First draw [**10-5**] with results to MWHC
If questions or concerns please call [**Telephone/Fax (1) 170**]
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Coronary Artery Disease - s/p CABG
Hypertension
Hypercholesterolemia
Postoperative Atrial Fibrillation
Discharge Condition:
Good
Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call cardiac surgeon if there is concern for wound infection.
[**Telephone/Fax (1) 170**]
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
5)No driving for at least one month.
Followup Instructions:
Dr. [**First Name (STitle) **] in [**3-29**] weeks, call for appt [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 20222**] in [**1-28**] weeks, call for appt [**Telephone/Fax (1) 6256**]
Dr. [**Last Name (STitle) 59121**] in [**1-28**] weeks, call for appt [**Telephone/Fax (1) 74523**]
Wound check [**Hospital1 **] heart center [**10-11**] thrusday at 930 am with
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 20259**]
PT/INR for coumadin dosing Monday-Wednesday-Friday with goal INR
2-2.5 indication atrial fibrillation
results to [**Hospital1 **] heart center coumadin clinic ([**Telephone/Fax (1) 20259**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2192-10-4**] Name: [**Known lastname 12284**],[**Known firstname **] R Unit No: [**Numeric Identifier 12285**]
Admission Date: [**2192-9-26**] Discharge Date: [**2192-10-4**]
Date of Birth: [**2130-8-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 265**]
Addendum:
Correction to previous summary. Mr. [**Known lastname **] did rule in for a
NSTEMI at [**Hospital6 **] prior to transferring to
[**Hospital1 8**] for his CABG.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 437**] VNA
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2192-11-12**]
|
[
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"414.01",
"600.00",
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"272.0",
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"V17.3",
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"427.31",
"511.9",
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icd9cm
|
[
[
[]
]
] |
[
"36.13",
"36.15",
"88.72",
"39.61"
] |
icd9pcs
|
[
[
[]
]
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13145, 13324
|
7553, 8524
|
331, 449
|
11416, 11423
|
1675, 2095
|
11787, 13122
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1189, 1230
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2132, 2162
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11291, 11395
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1245, 1656
|
281, 293
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2191, 7530
|
477, 910
|
932, 1066
|
1082, 1173
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,226
| 171,749
|
9907
|
Discharge summary
|
report
|
Admission Date: [**2179-9-16**] Discharge Date: [**2179-9-26**]
Service: MED
Allergies:
Neosporin
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Nausea, vomiting
Major Surgical or Invasive Procedure:
Ultrasound-guided paracentesis, diagnostic
History of Present Illness:
Pt. is an 81 year old female with likely autoimmune hepatitis
with h/o new-onset jaundice, ascites since mid-[**Month (only) **] who
presents with nausea and vomiting x 2 weeks. Evaluated at
[**Hospital 1474**] Hospital s/p liver biopsy which showed inflammatory
changes with positive anti-smooth antibody, [**Doctor First Name **] with HbSurface
Ab, negative HBCoreIgM. Patient states she's gained weight
recently and noticed increasing abdominal girth.
Past Medical History:
Autoimmune hepatitis
Social History:
From nursing home. Denies alcohol, IV drug use.
Family History:
Father with jaundice at age 70, ?liver cancer
Physical Exam:
Tc= 97 P=71 BP=110/66 RR=18 96% RA I/O=250/450
Gen - NAD, AOx3 but cannot recall number of grandchildren,
names, jaundiced
HEENT - scleral icterus, PERLA, EOMI, dry MM, no LAD, neck
supple, no carotid bruits bilaterally
Heart - RRR, Grade II/VI systolic murmur
Lungs - CTAB
Abd - No organomegaly, slightly distended with +2 pitting edema
to mid-upper abdomen, + BS, NT
Ext - +2 p. edema bilaterally, tender calves bilaterally, warm
and erythematous bilaterally, with +1 d. pedis bilaterally
Pertinent Results:
RUQ U/S [**2179-9-15**]: Liver coarse, nodular with 3.7x3.2x3.9
echogeneic lesion in right lobe of liver, small sludge in
gallbladder, free fluid in abdomen with small right pleural
effusion
.
[**2179-9-15**] 04:10PM PT-16.4* PTT-39.3* INR(PT)-1.7
[**2179-9-15**] 04:10PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-OCCASIONAL MACROCYT-3+ MICROCYT-NORMAL
POLYCHROM-NORMAL TARGET-OCCASIONAL SCHISTOCY-OCCASIONAL
[**2179-9-15**] 04:10PM ALT(SGPT)-165* AST(SGOT)-206* ALK PHOS-342*
AMYLASE-192* TOT BILI-17.9* DIR BILI-8.9* INDIR BIL-9.0
Brief Hospital Course:
Pt. is an 81 yo female with newly diagnosed autoimmune hepatitis
who presented with nausea/vomiting with an elevated WBC pt was
found to be in liver failure and treatment with prednisone was
initiated. Over the course of the next few days she became
lethargic, with change in mental status and was transfered to
ICU. In ICU she continued to deteriorate, complained of pain
thought to be associated with massive anasarca, and was also
hypotensive. She did not respond to the steroids or albumin
infusions. Her breathing became more labored and she continued
to show signs of pain. Her family made the decision to treat
her pain to make her comfortable, and the steroids were
withdrawn. Pt continued to deteriorate with hypotension
resistant to fliuds and family did not want to use pressors. Pt
became asystolic and died at 1:05 am with family by bedside.
Medications on Admission:
KCl 10 meq QD
Lactulose 50 cc TID
Amoxicillin
Colace
Lasix
Discharge Medications:
N/A
Discharge Disposition:
Home
Discharge Diagnosis:
N/A
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2179-9-27**]
|
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58,526
| 148,559
|
42103
|
Discharge summary
|
report
|
Admission Date: [**2118-7-7**] Discharge Date: [**2118-7-12**]
Date of Birth: [**2082-3-21**] Sex: F
Service: MEDICINE
Allergies:
Levaquin
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
Diabetic Ketoacidosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
36F with type 1 diabetes with nearly monthly admissions for DKA
over the past year presents with nausea, vomiting, chills and
elevated blood sugar at home x1 day. Sugar was "critical high"
when she tested today. She states it is similar to her previous
episodes of DKA. Also feels short of breath. Denies fevers,
abdominal pain, dysuria, chest pain. She has a chronic cough
which is unchanged. Patient did not change her insulin dosing,
and did not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**]. Of note, patient just finished her
period, which has precipitated DKA in 7 of the last 9 months.
She has been seen at [**Hospital3 417**] in the past few months, and
was seen here in [**2117-9-2**]. She was on OCPs, but stopped
it recently, with no changes in her DKA episodes.
Patient initially seen in OSH where FSBS > 600, Bicarb of 12-
received Reg insulin 10u , ativan and metoprolol 5mg IV x2 and
possibly 2L NS by report.
In the ED, initial VS were: 04:02 0 98.2 104 191/114 14 100%
- EKG: sinus at 98, no peaked T's, narrow QRS. Patient was
started on an insulin drip 7U/h, unclear if bolus given, and 2L
NS with 40meq of K at 250/hr. She was also given Promethazine
6.25mg IV x2 and 2mg morphine sulfate IV x1 and 2mg IV
lorazepam.
Vitals on transfer HR 110 sinus tachy, 100% RA, 104/49, RR 18.
temp 98.7
22 and 20 gauge in place.
On arrival to the MICU, patient is sleepy but in no acute
distress. She is appropriate. Her finger sticks are still
above detection range. She was given an additional 14 units of
insulin.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
Type 1 diabetes mellitis w/ neuropathy, nephropathy, and
retinopathy - multiple past episodes of DKA
HTN - 5 years
gastroparesis - 2.5 years
CKD - stage III, baseline Cr 2.4-2.5, proteinuria
L1 vertebral fracture - [**2117-7-17**]
Systolic ejection murmur
Social History:
Patient lives at home in [**Location (un) **] with her almost 10 y/o daughter
and
boyfriend. She has no history of EtOH, tobacco, or illicit drug
use. She is currently unemployed and seeking disability.
Family History:
Both parents have HTN and T2DM. Grandfather had an MI in his
40s.
Physical Exam:
Vitals: T: 98.7 BP: 147/75 P: 113 R: 18 O2: 100%
General: Alert, oriented but sleepy, no acute distress
HEENT: Sclera anicteric, dry mucus membranes, oropharynx clear,
EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Tachycardic rate and regular rhythm, normal S1 + S2, [**2-7**]
flow murmur, no rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Discharge Exam:
Gen: NAD, resting comfortably
HEENT: MMD, PERRL, EOMI
CV: RRR, nl S1/S2
Pulm: CTAB
Abd: NT, ND, BS decreased but present
Ext: WWP, no cyanosis, clubbing, or edema.
Neuro: alert and oriented x3, [**Last Name (un) 17610**]
Pertinent Results:
Admission Labs:
[**2118-7-8**] 03:44AM BLOOD WBC-17.2* RBC-3.60* Hgb-9.4* Hct-29.1*
MCV-81* MCH-26.0* MCHC-32.2 RDW-15.6* Plt Ct-326
[**2118-7-7**] 04:30AM BLOOD WBC-12.7*# RBC-4.46 Hgb-11.7* Hct-36.7
MCV-82 MCH-26.2* MCHC-31.8 RDW-15.2 Plt Ct-387
[**2118-7-7**] 10:02AM BLOOD PT-10.0 PTT-34.1 INR(PT)-0.9
[**2118-7-8**] 03:44AM BLOOD Glucose-103* UreaN-67* Creat-4.5* Na-141
K-4.0 Cl-112* HCO3-20* AnGap-13
[**2118-7-7**] 03:23PM BLOOD Glucose-151* UreaN-73* Creat-4.7* Na-144
K-4.5 Cl-115* HCO3-19* AnGap-15
[**2118-7-7**] 04:30AM BLOOD Glucose-488* UreaN-78* Creat-4.8*# Na-141
K-4.5 Cl-105 HCO3-10* AnGap-31*
[**2118-7-7**] 04:30AM BLOOD ALT-10 AST-15 AlkPhos-108* TotBili-0.4
[**2118-7-8**] 03:44AM BLOOD Calcium-8.4 Phos-4.3 Mg-1.7
[**2118-7-7**] 04:30AM BLOOD Albumin-4.0 Calcium-9.2 Phos-5.0* Mg-2.1
[**2118-7-7**] 03:54PM BLOOD Type-[**Last Name (un) **] pO2-43* pCO2-33* pH-7.33*
calTCO2-18* Base XS--7
[**2118-7-7**] 12:42PM BLOOD Type-[**Last Name (un) **] pO2-47* pCO2-33* pH-7.32*
calTCO2-18* Base XS--8
[**2118-7-7**] 10:44AM BLOOD Type-[**Last Name (un) **] pO2-204* pCO2-26* pH-7.28*
calTCO2-13* Base XS--12 Comment-GREEN TOP
[**2118-7-7**] 04:37AM BLOOD Type-[**Last Name (un) **] pO2-140* pCO2-16* pH-7.41
calTCO2-10* Base XS--11 Comment-GREEN TOP
[**2118-7-7**] 03:54PM BLOOD Lactate-1.5
[**2118-7-7**] 04:37AM BLOOD Glucose-447* K-5.2*
Discharge Labs:
[**2118-7-12**] 02:00AM BLOOD WBC-8.1 RBC-3.69* Hgb-9.6* Hct-29.6*
MCV-80* MCH-26.0* MCHC-32.4 RDW-15.8* Plt Ct-281
[**2118-7-12**] 02:00AM BLOOD Plt Ct-281
[**2118-7-12**] 02:00AM BLOOD Glucose-107* UreaN-30* Creat-3.6* Na-137
K-3.9 Cl-110* HCO3-20* AnGap-11
[**2118-7-12**] 02:00AM BLOOD Calcium-8.0* Phos-4.0 Mg-2.1
Micro:
MRSA SCREEN (Final [**2118-7-11**]): No MRSA isolated.
URINE CULTURE (Final [**2118-7-8**]): NO GROWTH.
Blood Culture, Routine (Final [**2118-7-13**]): NO GROWTH.
CXR [**7-7**]: FINDINGS: The replaced left PICC now terminates within
the right atrium,
approximately 1 cm beyond the cavoatrial junction. The
remainder of the study is unchanged and normal.
IMPRESSION:
New left PICC terminates approximately 1 cm beyond the
cavoatrial junction
within the right atrium.
NOTE: Findings were communicated to [**Doctor First Name **], the IV nurse by Dr.
[**Last Name (STitle) **] via
telephone on [**2118-7-7**] at 1:05 p.m.
The study and the report were reviewed by the staff radiologist.
CXR [**7-7**]: FRONTAL AND LATERAL CHEST RADIOGRAPHS: The lungs are
clear. No confluent opacities are identified. There is no
pulmonary edema or pleural effusions. Cardiomediastinal and
hilar contours are within normal limits. No pneumothorax is
evident.
IMPRESSION: No acute cardiopulmonary process.
EKG: Sinus rhythm. Possible left ventricular hypertrophy with
repolarization
changes. Compared to the previous tracing of [**2117-8-16**] the heart
rate is
increased, repolarization changes in leads V4-V6 are more
prominent.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
98 146 84 378/444 71 49 -150
Brief Hospital Course:
36F with type 1 diabetes with nearly monthly admissions for DKA
over the past year who presented with DKA, again in the setting
of her menstrual period, which resolved on an insulin gtt and
aggressive fluid resuscitation using a picc that was placed and
then removed at the end of hospitalization. Her hospital course
was extended given her nausea/vomiting secondary to
gastroparesis which could not be treated as well as she does at
home b/c her home domperidone is not FDA approved. She was
managed with ativan and phenergan because compezine and zofran
did not help her. Her actively managed problems are discussed
below:
#)"Menstrual" DKA with anion gap acidosis/ DM1:
[**First Name8 (NamePattern2) **] [**Last Name (un) **] notes: her HbA1c baseline 9.9% ([**2118-3-11**]). On home,
patient on Levemir 22 Units Breakfast, Levemir 12 Units Bedtime,
Insulin SC Sliding Scale using HUM Insulin. She only takes FSGs
a couple times per week. She has very labile sugars ranging from
100-400 at meals. She has known diabetic foot neuropathy w/ hx
ulcer, diabetic retinopathy (proliferative retinopathy + macular
edema), and diabetic nephropathy (baseline Cr 2.3). This episode
was similar to previous episodes.
She presented w/ glucose 447(above 600 when she read at home),
K+ 5.2, and blood gas pH 7.41/pCO2 16/base excess -11 which
worsened to ph 7.28/pCO2 26/ base excess -12, and Cr 4.8 (above
baseline 2.3). There was no clear infectious precipitant (CXR
clear, no growth in BCx or UCx). However, it was associated with
being in the setting of her menstrual period (1-2 days after it
ends), as past admissions for DKA in the past year have been as
well. She was using OCPs (Enpresse) recently to control this,
although she stopped since this seemed to be unhelpful for her.
Gastroparesis causing n/v also complicates her ability to
control her glucose, as she holds her home Humalog and reduces
levemir in the setting of n/v, resulting in spikes in her
glucose.
She developed pulmonary crackles and brief hypoxia to O2 sat in
the mid-80s the first night of admission, but this quickly
resolved w/ her sitting up and being more alert as well as by
reducing her IVF to 120cc/hr. Notably, she has no cardiac
history.
She remained on the insulin gtt the 2nd-4th days of admission
despite glucose in the 100s mostly and a closed anion gap given
that she was unable to eat (her baseline gastroparesis makes
taking in good PO difficult, especially in this setting). An
endocrinology consult was called, which noted that DKA is not
uncommon in patients w/ uncontrolled DM1 in the setting of their
menstrual period. Since the patient also decreases levemir in
setting of poor PO intake due to gastroparesis, this can also be
precipitating DKA as well. They recommended a repeat HbA1c 8.5
dwon from 9.9 in [**2118-3-3**], switching to lantus to be taken
at night for basal control and using a regular ISS to be
administered 10-15 min before a meal if not vomiting. Also, they
recommended a long-acting birth control preparation vs. IUD to
minimize menstruation as a precipitating factor for DKA. She has
a gynecology appt [**7-13**] for recommendation about birth control
methods to help prevent future episodes of DKA. Notably, she is
amenable to a Mirena IUD.
#)Gastroparesis:
She vomits regularly at baseline independent of DKA. She
controls this with domperidone which she gets from [**Country 6607**]. Since
this is not an approved medication in the U.S., her nausea was
controlled w/ promethazine Q6hr PRN, ativan Q6hr PRN, and
standing Zofran. However, this regimen did not provide good
relief. Standing Zofran was discontinued and compazine was
tried, but this did not provide good relief either. Eventually,
she was able to take PO while on phenergan and ativan on HOD4
([**7-11**]).
#)HTN:
She has a known hx of orthostatic hypotension + supine
hypertension. Blood pressure initially was SBP 130-180s since
arrival in MICU. She was managed initially w/ IV metoprolol 5 mg
which did not help. IV labetalol 10 mg reduced her BPs from the
180s to the 140s. Since she began tolerating PO, she started
home metoprolol, at 25 mg TID, and was also started on PO
hydralazine 25 mg PO PRN to control her BPs along w/ labetalol
10 mg IV PRN for SBP >140. She was also started on amlodipine 5
mg PO QD to give her better baseline BP control. She was
transitioned to IV hydralazine for breakthrough hypertension in
lieu of labetalol.
#)Acute on Chronic Kidney Disease:
CKD is known to be from diabetic nephropathy. Her previous
baseline was known to be 2.3 as of 3/[**2118**]. She presented w/ Cr
4.8 which rose to 5.1, likely from prerenal azotemia from volume
depletion in the setting of DKA and inability to take in good PO
from gastroparesis. ATN was another possibility, but no muddy
brown casts were seen on U/A on admission [**7-7**] or on repeat U/A
[**7-10**]. She also may have had some progression of intrarenal
diabetic nephropathy. Her Cr did trend down to 3.6 on discharge.
#)Leukocytosis:
She presented w/ WBC 12.3, which increased to WBC 17.2 on [**7-8**]
labs. Infectious work-up remained negative during
hospitalization. This was likely a stress response from DKA
which resolved back to normal by HOD4.
#)Anemia:
She was hemoconcentrated on admission, and her Hct fell back to
baseline (29-32) w/ fluid resuscitation. Her anemia was stable
throughout her admission.
#)LE Edema:
She has no known cardiac history. Her home furosemide was held
in the setting of volume depletion from DKA, as well as due to
her resolving ARF.
#)History of depression:
She was continued on duloxetine and citalopram during her
hospitalization.
#)Hypothyroidism:
She is not on medication for this. Since acute illness can
complicate TFT interpretation, endocrinology consult recommended
testing in [**6-10**] weeks.
#)History of edema in setting of CKD and LVH by EKG:
-held Furosemide 20 mg PO PRN edema during the hospitalization
Transitonal Issues:
Appointment with Gyn on [**7-13**]
Appointment at [**Hospital **] Clinic
Htn along with orthostatic hypotension
Full code
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient also taking domperidone
10mg TID, which is not available OMR, Humalog sliding scale not
avilable..
1. Furosemide 20 mg PO PRN edema
2. Metoprolol Succinate XL 75 mg PO HS
3. Promethazine 25 mg PO Q6H:PRN nausea
4. Midodrine 7.5 mg PO Q4H:PRN Hypotension
5. Duloxetine 30 mg PO DAILY
6. Levemir 22 Units Breakfast
Levemir 12 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Citalopram 20 mg PO DAILY
8. Domperidone 10mg TID
Discharge Medications:
1. Citalopram 20 mg PO DAILY
2. Duloxetine 30 mg PO DAILY
3. Furosemide 20 mg PO PRN edema
4. Metoprolol Succinate XL 75 mg PO HS
5. Promethazine 25 mg PO Q6H:PRN nausea
6. Glargine 25 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
RX *Lantus 100 unit/mL 25 Units before bedtime at bedtime Disp
#*1 Bottle Refills:*0
7. Amlodipine 10 mg PO DAILY
hold for SBP <100
RX *amlodipine 10 mg 1 Tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
8. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using REG Insulin
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetes mellitus type 1
hypertension
diabetic ketoacidosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the ICU for diabetic ketoacidosis; we think
this occurred because of your menstrual period as well as your
gastroparesis. It is important that you go to your gynecology
appointments in order to discuss potential treatments to prevent
this from occuring.
Changes to your medications:
CHANGE insulin Lantus to 25 units at bedtime, start this
TOMORROW [**2118-7-13**]
TONIGHT please take insulin Lantus 14 units only (since you had
11 units this morning, to add to total 25 units today)
CHANGE regular insulin sliding scale to dosing according to
attached sheet
STOP taking midodrine since blood pressure was high during this
admission
START taking amlodipine 10 mg daily for high blood pressure.
Please discuss this with your primary care doctor as you may
need other medications to control your blood pressure.
Followup Instructions:
Please follow up with your gynecology appointment tomorrow. You
should also schedule an appointment with your primary care
doctor within 1 week of discharge, this is very important since
your blood pressure has been high.
Other appointments:
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
Appt: [**7-14**] at 10:30am
|
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"250.43",
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
|
[
[
[]
]
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14141, 14147
|
6927, 13007
|
289, 295
|
14251, 14251
|
3899, 3899
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15262, 15839
|
2863, 2930
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13589, 14118
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14168, 14230
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13033, 13566
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1900, 2348
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228, 251
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323, 1881
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3915, 5257
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14266, 14378
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2370, 2627
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2643, 2847
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,110
| 129,043
|
7218+7219+7253
|
Discharge summary
|
report+report+report
|
Admission Date: [**2162-6-13**] Discharge Date: [**2162-6-30**]
Service: MEDICINE
ADMISSION DIAGNOSIS:
Mental status.
DISCHARGE DIAGNOSES:
1. Mental status change.
2. Urosepsis.
3. Myocardial infarction.
4. Gastrointestinal bleed.
5. Renal failure.
HISTORY OF PRESENT ILLNESS: The patient is an 87 year-old
man with a history of dementia, diabetes, and hypertension, who
was in his usual state of health until two days ago when he was
noted by the family to have decreased po intake. The day prior
to admission the patient also decreased verbal output. Finger
sticks taken at home were greater then 500 and the patient
was sent to [**Hospital1 69**] for
admission. In the Emergency Room he was obtunded,
tachycardic with an electrocardiogram question of flutter in
the 130s and anterior ST segment depressions that persisted
when the rate slowed. Laboratories demonstrated him to have
HONK, renal failure and myocardial infarction. There was
purulent output from his Foley. He was treated for sepsis
with Vancomycin, Levofloxacin and Flagyl, provided
intravenous fluids of 6 liters of lactated Ringers, normal
saline and D5. Cultures were sent with the urinalysis
demonstrating greater then 50 white blood cells and 3 to 5
epithelial cells. There was a nitrite, moderate leukocyte,
negative esterase. His chest x-ray was initially clear and
then on repeat chest x-ray showed left lower lobe small
effusion, retrocardiac infiltrate. The patient spiked to 101
in the Emergency Department and then 102 on his arrival to
the [**Hospital Unit Name 153**]. His blood pressure also dropped to 80/palp in the
Emergency Department briefly to which he responded to
intravenous fluids. The patient was seen by cardiology and a
beta blocker and aspirin for demand ischemia were initiated.
However, given the recent gastrointestinal bleed, the patient
was not provided with heparin. This was discussed with the
family. The patient was given lactated Ringers for renal
failure and was initiated for an insulin drip. The patient's
creatinine improved and he continued to have urine output.
Renal ultrasound was ordered. The patient's repeat
hematocrit was 24 and therefore 2 units of blood were
ordered.
PAST MEDICAL HISTORY:
1. [**Last Name (un) 309**] body dementia followed by Dr. [**Last Name (STitle) **].
2. Hypertension with goal blood pressure of 140 to 160
3. h/o Gastrointestinal bleed secondary to gastric Dieulafoy
lesion, AVM.
4. History of colonic adenomas.
5. Diverticular disease.
6. B-12 deficiency.
7. Type 2 diabetes.
8. Proteinuria.
9. Elevated lipids, CRI baseline is 1.3 to 1.9.
10. Peripheral vascular disease.
11. Peripheral neuropathy.
12. He is status post a prostatectomy and inguinal hernia
repair.
ALLERGIES: No known drug allergies.
MEDICATIONS AT HOME:
1. Aricept.
2. Celexa.
3. Atenolol.
4. Lisinopril.
5. Glipizide.
6. Seroquel.
7. Protonix.
SOCIAL HISTORY: The patient has a health care proxy [**Name (NI) 8369**]
[**Name (NI) **] daughter, [**Telephone/Fax (1) 26747**]. Son-in-law is [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD,
PhD research at [**Hospital6 **]. Full time care giver is
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 26748**]. The patient's MP is in his building [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 3805**] and he is a former professor [**First Name8 (NamePattern2) **] [**Last Name (Titles) 26749**] languages.
PHYSICAL EXAMINATION: The patient is an elderly man
responding to painful stimuli and nonverbal. Temperature was
102. Pulse 80. Blood pressure 110/60. Sats 97% on 4
liters. Respiratory rate 27. HEENT pupils are equal, round
and reactive to light. He resists eye opening with eye
movements roving back and forth with occasional forward
fixation. JVP at approximately 8 cm, resting tremor.
Increased muscle tone throughout with some cogwheeling.
Extremities warm. Cardiovascular examination is tachycardic
with 2 out of 6, difficulty here over upper airway
rhoncherous breath sounds bilaterally with no crackles.
Abdomen positive bowel sounds, nontender, nondistended. No
palpable liver edge, but normal span on percussion. Rectal
the vault was empty. He is guaiac positive. Lower extremity
no edema. 2+ pulses.
LABORATORY: White blood cell count of [**6-13**] of 18.3,
hematocrit 24.5, MCV 92. The differential on [**6-13**] was
neutrophils 92, lymphocytes 5, monocytes 3, platelets 149.
Urinalysis showed blood moderate, nitrite negative, protein
trace, glucose 1000, ketone negative, bilirubin negative,
urobili negative. Electrolyte panel with glucose 93, BUN 67,
creatinine 2.5, sodium 157, K 4.7, chloride 129, bicarb 15.
CK in order was 499, 482, 523. ALT was 25, AST 47, alkaline
phosphatase 133, T bili .4, lipase 50. Again the troponin
was greater then 20, greater then 20 and 48 respectively. MB
index was 2, 2.5, 2.5. CKMB was 10, 12, 13. [**6-13**] calcium
7.5, mag 2.1, HBA1C was 5.7, PHR 7.43, PCO2 24, PO2 104.
[**First Name11 (Name Pattern1) 4283**] [**Last Name (NamePattern4) 4284**], M.D. [**MD Number(1) 7551**]
Dictated By:[**Last Name (NamePattern1) 201**]
MEDQUIST36
D: [**2162-6-29**] 11:03
T: [**2162-6-29**] 11:25
JOB#: [**Job Number 26750**]
Admission Date: [**2162-6-13**] Discharge Date: [**2162-7-2**]
Service:
ADDENDUM TO HOSPITAL COURSE: 1. Infectious disease: The
patient was admitted to the medical intensive care unit with
decreased mental status and the urine growing greater than
100,000 E. coli was discerned. The patient was initiated on
Xigris with an APACHE score of greater than 38. The
patient's Xigris was held on [**2162-6-16**] due to a drop in his
hematocrit from 30 to 27 but restarted on [**2162-6-17**]. The
Xigris was finished on [**2162-6-19**] at 8 PM. The patient
received a full course of antibiotics for his evidence of
urosepsis. The patient remained afebrile throughout the
subsequent hospital course however the patient continued to
have low-grade temperatures in the 99 to 100 range. The
patient had several repeat urine and blood cultures which
were negative.
2. Pneumonia: Chest x-ray was indicative of possible
aspiration pneumonia and the patient was initiated on
levofloxacin and Flagyl and received a full course. The patient
had a fever of note of 101.6 on [**2162-6-19**]. The patient's
subsequent x-rays were clear.
3. Endocrine: The patient had a history of diabetes.
Initial electrolytes demonstrated likely HONK. The patient
was initially placed on an insulin drip and he was changed to
sliding coverage on [**2162-6-16**] and NPH Insulin was started on
[**2162-6-20**]. Of note, a baseline cortisol was 51.
4. Renal: The patient initially presented with metabolic
acidosis, initially a combination of nongap and gap
component. The patient was also initially hypernatremic and
corrected with six liters of free water. The patient's acute
renal failure resolved throughout the course of his
hospitalization. It was likely prerenal in nature.
5. Cardiology: The patient ruled in for myocardial
infarction in house with CK peak in the 700s and a troponin
greater than 50. He had no history of coronary artery
disease in the past. The patient was placed on aspirin noted
beta blocker. No anticoagulation as the patient was on
Xigris and a history of GI bleed. An echocardiogram on
[**2162-6-18**] showed an ejection fraction of 70% and diastolic
dysfunction with no focal wall motion abnormalities. This
compares to an echocardiogram of [**10/2161**] that showed a left
ventricular ejection fraction of 55%. The patient's aspirin
was discontinued on [**2162-6-30**] after evidence of a possible
continued GI bleed.
6. Pulmonary: The patient was placed on aspiration
precautions, initially treated for a pneumonia. The
patient's O2 saturations remained stable throughout the
course of the hospitalization.
7. Neurological: The patient was obtunded with a history of
dementia and a history of sepsis. The patient's mental
status improved slightly. He was able to mouth one word,
open his eyes spontaneously, however this was decreased from
his baseline where he was able to say a few words, feed
himself and per report ambulate. The patient will be
discharged to rehabilitation for further work-up. MRI was
performed which showed no acute changes, as was a TSH at 12,
all normal.
8. Gastrointestinal: The patient had a history of GI bleed,
Dieulafoy lesion discerned in [**10/2161**] and diverticular
disease. The patient's stools were chronically positive.
The patient had a GI work-up on [**2161-7-1**] to evaluate the
stomach. At that time a PEG tube was placed for tube
feeding. The patient's hematocrit remained stable. The
patient required six units of blood in the medical intensive
care unit for continued blood loss. Once the patient was
transferred to the floor his hematocrit remained stable for
three days however then again required three units. The
patient's hematocrit subsequently remained stable.
9. Hematology: The patient had a history of anemia. The
patient had a DIC work-up which initially was positive but
resolved throughout the course of his hospitalization.
10. Nutrition: The patient was fed by nasogastric tube
through the majority of his hospitalization, switched to a
PEG tube on [**2162-7-2**]. EGD performed at the time of PEG
placement showed no culprid lesions for the GIB, suggesting a
small bowel source. Further evaluation of this was deferred as
hct remained stable off aspirin.
DISCHARGE STATUS: Discharged to rehabilitation.
CONDITION ON DISCHARGE: Fair.
DISCHARGE MEDICATIONS:
1. Lisinopril 10 mg p.o. q.d.
2. Metoprolol 75 mg p.o. t.i.d.
3. Bisacodyl 10 mg p.r. h.s. p.r.n.
4. Heparin 5,000 units subcutaneous q. 12.
5. Lansoprazole 30 mg NG b.i.d.
6. Docusate sodium 100 mg p.o. b.i.d.
7. Tylenol p.r.n.
8. Quetiapine fumarate 25 mg p.o. q.d.
9. Ipratropium bromide nebulizers 1 neb i.h. q. 6.
10. Albuterol nebulizers 1 neb i.h. q. 6 p.r.n.
11. Insulin sliding scale per nursing worksheets.
12. Tube feeding per nursing worksheets.
DISCHARGE RECOMMENDATIONS:
1. Follow up with primary care physician within [**Name Initial (PRE) **] month.
2. Physical rehabilitation, occupational rehabilitation.
3. Follow up with tube feeds, insulin care, decubiti care.
DISCHARGE DIAGNOSES:
1. Urosepsis.
2. Mental status change.
3. Myocardial infarction.
4. Gastrointestinal bleed.
5. PEG tube placement.
6. Pneumonia.
[**First Name11 (Name Pattern1) 4283**] [**Last Name (NamePattern4) 4284**], M.D. [**MD Number(1) 7551**]
Dictated By:[**Last Name (NamePattern1) 201**]
MEDQUIST36
D: [**2162-7-2**] 09:01
T: [**2162-7-2**] 09:31
JOB#: [**Job Number 26751**]
Admission Date: [**2162-6-13**] Discharge Date: [**2162-7-6**]
Service:
ADDENDUM: Please see the previous dictation for full
hospital course.
1. GI bleed: Status post PEG tube placement the patient's
hematocrit remained stable. The patient was initiated on
tube feeds without complications.
2. Diabetes mellitus: The patient has insulin dependent
diabetes mellitus. He will be discharged on insulin sliding
scale of 5 units NPH Insulin in the AM and 3 units NPH
Insulin in the PM. The patient's NPH Insulin should be
monitored as an outpatient for control.
3. Hypertension: The patient's lisinopril dose was increased
secondary to high blood pressure. The patient's creatinine
remained stable.
DISCHARGE MEDICATIONS:
1. Albuterol one dose q. 6 p.r.n.
2. Ipratropium bromide one dose inhalation q. 6 hours.
3. Quetiapine fumarate 25 mg one tablet p.o. q.d.
4. Docusate sodium 150 mg one dose oral b.i.d.
5. Lansoprazole 30 mg one p.o. q.d.
6. Heparin subcutaneous 5,000 units b.i.d.
7. Bisacodyl 10 mg suppository rectal 1 h.s. as needed.
8. Metoprolol 50 mg tablet, 1.5 tablets t.i.d.
9. Lisinopril 5 mg tablet, 6 tablets oral q.d.
10. NPH Insulin 5 in the AM, 3 in the PM.
11. Sliding scale insulin.
DISCHARGE INSTRUCTIONS:
1. Subcutaneous heparin b.i.d.
2. Tube feedings per nursing orders.
3. Physical therapy and occupational therapy.
4. Check hematocrit and BUN and creatinine q. week.
5. Decubiti care.
6. Insulin services.
[**First Name11 (Name Pattern1) 4283**] [**Last Name (NamePattern4) 4284**], M.D. [**MD Number(1) 7551**]
Dictated By:[**Last Name (NamePattern1) 201**]
MEDQUIST36
D: [**2162-7-6**] 08:53
T: [**2162-7-6**] 09:23
JOB#: [**Job Number 26824**]
|
[
"038.9",
"584.9",
"276.0",
"707.0",
"410.71",
"276.2",
"599.0",
"286.6",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"00.11",
"45.13",
"38.93",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
10401, 11530
|
11553, 12038
|
5426, 9641
|
12062, 12549
|
2821, 2920
|
3505, 5408
|
115, 131
|
297, 2226
|
2248, 2800
|
2937, 3482
|
9666, 9673
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,631
| 113,043
|
20714
|
Discharge summary
|
report
|
Admission Date: [**2197-12-1**] Discharge Date: [**2197-12-13**]
Date of Birth: [**2121-12-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2197-12-1**] coronary artery bypass grafts x4,aortic valve
replacement(25 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] tissue)
History of Present Illness:
75 year old male with history of hyperlipidemia and aortic
stenosis. He reports being able to walk about 30 minutes on flat
ground without symptoms. He does reports shortness of breath
after climbing stairs or walking up inclines
relieved with rest. He also reports that symptoms have improved
over the past several months, however, he has limited his
activity. His most recent ECHO is from [**2197-8-8**] revealing a
normal LV wall thickness, cavity size and regional/global
systolic function with an LVEF of 55%, severely thickened and
deformed aortic valve leaflets with critical aortic valve
stenosis noting a valve area of <0.8 cm2, mild to moderate [**1-29**]+
aortic regurgitation as well as trivial mitral regurgitation. He
was referred for right and left heart catheterization. He is now
being referred to cardiac surgery for an aortic valve
replacement and revascularization.
Past Medical History:
Critical aortic stenosis
Mild to moderate aortic insufficiency
Hyperlipidemia
Hypertension
[**2191**] Atrial tachycardia s/p ablation
[**2190**] Colon cancer s/p chemo/XRT and surgery now with colostomy
Glaucoma
Past Cardiac Procedures: none
PSH:
LAR [**7-31**]
Ileostomy takedown [**12-1**]
Social History:
Race:Caucasian
Last Dental Exam:5 months ago, will call dentist and have dental
clearance faxed to office
Lives with:Wife
Contact: [**Name (NI) **] (wife) Phone #[**Telephone/Fax (1) 55293**].
Occupation:retired teacher
Cigarettes: Smoked no [x] yes []
Other Tobacco use:
ETOH: < 1 drink/week [x] [**3-6**] drinks/week [] >8 drinks/week []
Illicit drug use
Family History:
Family History:Premature coronary artery disease- Father died of
MI at age 76
Physical Exam:
Physical Exam
Pulse:53 Resp:13 O2 sat:97/RA
B/P Right:138/60 Left:140/62
Height:5'[**97**]" Weight:205 lbs
General: Dry awake alert oriented
Skin: [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] harsh 5/6 systolic ejection Murmur; with
radiation to R carotid
Abdomen: Soft [x] non-distended [x] non-tender [x]
+ bowel sounds
Extremities: Warm [x], well-perfused [x] no Edema [] no
Varicosities
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: harsh murmur Left: + bruit
Pertinent Results:
Abd/Pelvis CT [**2197-12-7**]
1. Stable bilateral pleural effusions and atelectasis.
2. Small pericardial effusion.
3. Diminished volume of intraperitoneal free air likely related
to recent
surgery.
4. No bowel obstruction.
[**2197-12-1**]
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are focal calcifications in the aortic arch. There are
simple atheroma in the descending thoracic aorta. There are
three aortic valve leaflets. The aortic valve leaflets are
moderately thickened. There is critical aortic valve stenosis
(valve area <0.8cm2). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened.
Trivial mitral regurgitation is seen.
There is no pericardial effusion.
Dr. [**First Name (STitle) **] was notified in person of the results before surgical
incision.
POST-BYPASS:
Normal RV systolic function.
LVEF 55%.
The aortic bioprosthesis is intact, functioning well with a
residual mean gradient of 5 mm of Hg. Intact thoracic aorta.
Minimal MR.
[**2197-12-11**] 04:21AM BLOOD WBC-6.5 RBC-2.94* Hgb-9.1* Hct-27.6*
MCV-94 MCH-30.8 MCHC-32.8 RDW-14.8 Plt Ct-239
[**2197-12-10**] 05:29AM BLOOD WBC-5.7 RBC-2.93* Hgb-9.2* Hct-27.5*
MCV-94 MCH-31.3 MCHC-33.4 RDW-14.8 Plt Ct-213
[**2197-12-12**] 05:44AM BLOOD PT-15.6* INR(PT)-1.4*
[**2197-12-11**] 04:21AM BLOOD Plt Ct-239
[**2197-12-10**] 05:29AM BLOOD PT-18.9* INR(PT)-1.7*
[**2197-12-12**] 05:44AM BLOOD UreaN-16 Creat-0.9 Na-139 K-4.3 Cl-106
[**2197-12-11**] 04:21AM BLOOD Glucose-103* UreaN-11 Creat-0.8 Na-137
K-4.2 Cl-106 HCO3-24 AnGap-11
[**2197-12-10**] 05:29AM BLOOD Glucose-94 UreaN-9 Creat-0.7 Na-140 K-3.9
Cl-107 HCO3-24 AnGap-13
Brief Hospital Course:
The patient was brought to the operating room on [**12-1**] where the
patient underwent
Aortic valve replacement with size 25-mm St. [**Male First Name (un) 923**] Epic tissue
valve and coronary artery bypass graft x4: Left internal
mammary artery to left anterior descending artery and saphenous
vein grafts to distal left anterior descending artery,
obtuse marginal and posterior descending arteries. See
operative note for full details. Overall the patient tolerated
the procedure well and post-operatively was transferred to the
CVICU in stable condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight.
Pt did have minimal bowel sounds with nausea and vomiting with a
history of a post operative ileus. A KUB revealed an ileus. Pt
was made NPO. A Nasogastric tube was placed and general surgery
was consulted when the patient had a prolonged ileus. An
abdominal CT was performed and revealed no bowel obstruction.
The patient's diet was slowly advanced with good tolerance and
NG tube was removed. He regained his bowel sounds and his diet
was advanced to regular. On discharge he was tolerating a
regular oral diet well and his stoma was putting out stool.
Pt also went into a rapid atrial fibrillation, he was given a
bolus of amiodarone and given a drip for 24 hours and Lopressor
was titrated up for better rate control. When the patients bowel
sounds returned, he was started on PO amiodarone. He went into
paroxysmal atrial fibrillation (rapid at times to 130's) but he
was in rate controlled sinus rhythm at the time of discharge.
Due to his repeated atrial fibrillation, he was started on
Coumadin. INR goal 2.0-2.5 - Coumadin follow up was arranged
with PCP.
[**Name10 (NameIs) **] 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 #12 the patient was ambulating with
assistance, the wound was healing well and pain was controlled
with oral analgesics. He was discharged home with VNA and PT
services. All appropriate follow up instructions and
appointments were given.
Medications on Admission:
BRIMONIDINE 0.2 % Drops one drop right eye [**Hospital1 **], DORZOLAMIDE 2 %
Drops one drop right eye [**Hospital1 **], METOPROLOL TARTRATE 25 mg [**Hospital1 **],
SIMVASTATIN 20 mg daily, TIMOLOL 0.5 % Drops one drop right eye
[**Hospital1 **], ASPIRIN 81 mg daily
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): please tape, 200 [**Hospital1 **] x 7 days, then 200 mg po qd untill
f/u with PCP.
[**Name Initial (NameIs) **]:*44 Tablet(s)* Refills:*2*
5. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
7. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
8. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
[**Hospital1 **]:*30 Tablet, Chewable(s)* Refills:*2*
10. Insulin
Sliding Scale & Fixed Dose
Fingerstick QACHS
Insulin SC Fixed Dose Orders
Breakfast
Glargine 25 Units
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog
Glucose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol
71-119 mg/dL 0 Units 0 Units 0 Units 0 Units
120-159 mg/dL 2 Units 2 Units 2 Units 0 Units
160-199 mg/dL 4 Units 4 Units 4 Units 2 Units
200-239 mg/dL 6 Units 6 Units 6 Units 4 Units
240-280 mg/dL 8 Units 8 Units 8 Units 6 Units
> 280 mg/dL Notify M.D.
11. Outpatient Lab Work
Coumadin for AFib
Goal INR 2-2.5
First draw [**2197-12-14**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr. [**Last Name (STitle) 3142**]
Results to phone [**Telephone/Fax (1) 19980**] (fax [**Telephone/Fax (1) 19981**])
12. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
[**Telephone/Fax (1) **]:*90 Tablet(s)* Refills:*2*
13. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Telephone/Fax (1) **]:*30 Tablet(s)* Refills:*2*
14. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): [**1-29**] home dose while on amiodarone.
[**Month/Day (2) **]:*30 Tablet(s)* Refills:*2*
15. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO DAILY (Daily) for 7 days.
[**Month/Day (2) **]:*14 Tablet Extended Release(s)* Refills:*0*
16. warfarin 1 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily): dose
based on INR for afib
Goal 2.0-2.5.
[**Month/Day (2) **]:*80 Tablet(s)* Refills:*2*
17. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
[**Month/Day (2) **]:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Critical aortic stenosis
Mild to moderate aortic insufficiency
Hyperlipidemia
Hypertension
Atrial tachycardia- s/p ablation,
[**2190**] Colon cancer (s/p chemo/XRT and surgery now with colostomy)
Glaucoma
Discharge Condition:
Alert and oriented x3 ,nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema 1+ to knees bilaterally
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 170**]on [**2198-1-9**] at 1:15pm in the
[**Hospital **] Medical Office Building [**Last Name (NamePattern1) **] [**Hospital Unit Name **].
Wound Check:WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2197-12-20**] 10:45 in the [**Hospital **] Medical Office Building
[**Last Name (NamePattern1) **] [**Hospital Unit Name **].
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3142**] ([**Telephone/Fax (1) 19980**]) on [**2198-1-11**] at
1:20pm
**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
Coumadin for AFib
Goal INR 2-2.5
First draw [**2197-12-14**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr. [**Last Name (STitle) 3142**]
Results to phone [**Telephone/Fax (1) 19980**] (fax [**Telephone/Fax (1) 19981**])
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2197-12-13**]
|
[
"272.4",
"458.29",
"424.1",
"511.9",
"V10.05",
"560.1",
"427.31",
"276.2",
"V44.3",
"V58.61",
"997.1",
"414.01",
"997.49",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.13",
"35.21",
"36.15",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
10571, 10630
|
5036, 7533
|
332, 484
|
10879, 11110
|
2942, 5013
|
11951, 13129
|
2124, 2189
|
7849, 10548
|
10651, 10858
|
7559, 7826
|
11134, 11928
|
2204, 2923
|
272, 294
|
512, 1400
|
1422, 1715
|
1731, 2093
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,895
| 130,600
|
47030
|
Discharge summary
|
report
|
Admission Date: [**2112-2-15**] Discharge Date: [**2112-2-20**]
Date of Birth: [**2054-2-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
respiratory distress, s/p suicide attempt
Major Surgical or Invasive Procedure:
none
History of Present Illness:
CC:
HPI: 57M h/o HTN, HCV, heroin and alcohol abuse, admitted w/
SOB, rhabdomyolysis, and renal failure. Pt was in USOH until
[**2112-2-13**] when drank quart of gin and took 400 mg methadone in
suicide attempt. Woke up on [**2112-2-15**] and called EMS because of ?
respiratory distress and because of desire to seek treatment
since regrets decision to commit suicide. Patient is divorced,
has lost car, daughter has moved away, and recently lost job at
end of [**Month (only) 1096**]. Feels this was the event that led him to
attempt suicide.
.
In ED T 97.8, P 111, BP 222/126, RR 24, SaO2 96% RA. + visual
hallucinations with visible tremors, sweats. Serum EtOH 27,
HCO3 16, Cr 3.2, anion gap 15, CK 6950, tox screen otherwise
negative. SBP increased to 270. Pt received lorazepam 2 mg IV
x 3, 2 L NS, banana bag, and was eventually started on lorazepam
per CIWA scale and D5W HCO3 @ 150 cc/hr. SBP decreased to 200s
with lorazepam. HCO3 improved to 25. Given metoprolol 5 mg IV
prior to transfer to floor.
.
MICU course: In the MICU, patient was monitored on a CIWA scale.
He developed some hypoxia on hospital day 2 and a V/Q span
showed low likelihood for a PE. CT chest on [**2-15**] had shown
bibasilar opacities that could represent atelectasis or
consolidations and he was started on zosyn for coverage of
pneumonia with aspiration as a possibility. His creatinine
steadily trended down with hydration. He was followed by psych
and addiction services. He was given metoprolol to treat
hypertension, which was thought likely secondary to withdrawal
.
ROS: + depressed mood, decreased appetite, poor concentration,
guilt, poor sleep; + numbness/weakness in L hand, new since
suicide attempt; denies fevers, CP, palpitations, SOB, cough,
abd pain, N/V, hematemesis, diarrhea, constipation, bloody
stool, melena, auditory/visual hallucinations, prior suicidal
ideation
Past Medical History:
1. HTN
2. HCV
3. heroin abuse
.
Social History:
SH: Lives alone in [**Location (un) **]. Divorced 10 years ago. Lost car
5 years ago. Daughter recently moved away. Lost job as
magician at local joke shop on [**2112-1-22**]. Has friends and
support in area.
- EtOH: 1 pint vodka/gin per day
- tobacco: 1 pk per day x 30 years
- IV heroin use: quit 14 months ago, initially started on 120 mg
methadone, now maintained on 60 mg; shared needles > 30 years
ago, but not after HIV epidemic.
- Sexually active with prostitute recently. Used condoms.
Family History:
FH: No h/o psychiatric disease or alcoholism. Father with CHF
and renal failure.
Physical Exam:
VS: 97.7, 89, 180/89, 23, 96% RA
GEN: WD/WN man in NAD, lying comfortably in bed w/o agitation,
somnolent but conversant and appropriate, + tremor
SKIN: 14 x 8 cm erythematous area over L scapula w/
desquamation, no telangectasias or jaundice
HEENT: NC/AT, PERRL, EOMI w/o nystagmus, sclera anicteric, MM
dry, OP clear
NECK: supple without C-spine tenderness
PULM: faint crackles at bases improving w/ cough, otherwise CTA
b/l
CV: RRR, nl S1 and S2, no mrgs, no heave
ABD: umbilical hernia, +BS, mild distention, nontender, liver
edge palpable 4 cm below costal margin, splenomegaly appreciated
GU: no CVAT
EXT: 2+ distal pulses, 1+ LE edema
MSK: L wrist w/ erythema and edema, no point tenderness; limited
abduction (~ 70 degrees) of L shoulder [**2-26**] to pain and weakness
NEURO: MS: AOx3, CN: II-XII intact, strength: [**5-28**] throughout
except 4/5 L handgrip, shoulder abduction; sensation: nl
throughout except decreased light touch in all L hand/fingers
Pertinent Results:
[**2112-2-15**] 09:25AM GLUCOSE-233* UREA N-60* CREAT-3.2* SODIUM-135
POTASSIUM-4.6 CHLORIDE-94* TOTAL CO2-16* ANION GAP-30*
[**2112-2-15**] 02:40PM CALCIUM-8.5 PHOSPHATE-3.2 MAGNESIUM-3.0*
[**2112-2-15**] 09:25AM WBC-15.2* RBC-4.73 HGB-14.9 HCT-44.2 MCV-94
MCH-31.4 MCHC-33.6 RDW-15.2
[**2112-2-15**] 09:25AM PLT COUNT-277
[**2112-2-15**] 09:25AM NEUTS-92.9* LYMPHS-2.4* MONOS-4.1 EOS-0.2
BASOS-0.3
[**2112-2-15**] 09:25AM ALT(SGPT)-107* AST(SGOT)-170* LD(LDH)-524*
CK(CPK)-6950* ALK PHOS-125* AMYLASE-165* TOT BILI-0.4
[**2112-2-15**] 09:25AM LIPASE-78*
[**2112-2-15**] 09:25AM cTropnT-0.04*
[**2112-2-15**] 09:25AM CK-MB-66* MB INDX-0.9
[**2112-2-15**] 09:25AM ASA-NEG ETHANOL-27* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2112-2-15**] 10:46AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-POS
[**2112-2-15**] 10:46AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-250 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2112-2-15**] 10:46AM URINE RBC-0 WBC-0-2 BACTERIA-0 YEAST-NONE
EPI-0
Brief Hospital Course:
57M h/o HTN, HCV, heroin and alcohol abuse, p/w EtOH withdrawal,
rhabdomyolysis, ARF s/p suicide attempt with EtOH and methadone.
.
1. Long QTc: Mr. [**Known lastname **] was initially admitted to the ICU for
close monitoring of his prolonged QTc (446 on arrival in the
ED). This was likely due to methadone overdose and resolved
during his ICU course. His methadone was restarted on [**2-19**] after
EKG showed QTc normal.
.
2. EtOH withdrawal: Mr. [**Known lastname **] symptoms of withdrawl were
treated with lorazepam/diazepam prn per CIWA scale. His
hypertension and tachycardia were managed with a beta-blocker
given his risk of end-organ damage. He was treated with
nutritional supplements with thiamine, folate, and Vitamin B12.
.
3. HTN: Patient was intially hypertensive with systolic bp's
from 180-200. This was likely the manifestation chronic HTN
compounded by adrenergic surge in setting of w/d. In addition
to treating underlying withdrawal, HTN was treated directly with
beta blockade and hydralizine given concern for hypertensive
stroke and other end organ damage. Until he was able to take
oral medications, he was treated with IV metoprolol and IV
hydralazine. Once able to take PO medications, he was
transitioned to oral metoprolol and hydralizine. Norvasc was
added for blood pressure control. He was on low dose lisinopril
and his lopressor was converted to atenolol to be started on
transfer to [**Hospital1 **] 4.
.
4. ARF: Likely [**2-26**] to rhabdomyolysis in setting of LOC following
overdose, burn, or possible preadmission seizure. Baseline
creatinine is unknown although may be elevated in setting of
chronic HTN. His renal failure improved with aggressive
hydration with resolution of his metabolic acidosis and
improvement of his creatinine from 3.2 at admission to 1.3 at
the time of transfer to psych [**Hospital1 **] which we suspect is his
baseline. CK was followed serially with progressive decline
throughout his course.
.
5. L arm pain/swelling/unilateral weakness: Likely tramautic [**2-26**]
to fall at time of LOC. Patient had a negative workup for
c-spine trauma or cortical etiology of unilateral weakness. He
was seen by neuro who felt his weakness to be consistent with
peripheral neuropathy from compression and less likely a
radiculopathy. Plain films of the wrist and humerus were
negative. There was no evidence of compartment syndrome.
.
6. Suicidal ideation: Patient expresses regret about suicide
attempt and desires counseling and psychiatric support.
Psychiatry has followed the patient throughout his course and
will accept the patient on their service when he is medically
stable.
.
7. Opiate addiction: Methadone maintenance dose confirmed with
clinic as 57.5 mg qd. Methadone was held while in ICU per psych
recs and restarted when the patient was medically stable.
.
8. Hepatitis: Likely [**2-26**] EtOH, although patient has HCV. There
was no evidence of hepatic failure or cirrhosis. LFTs were
followed serially with progressive improvement. The patient had
a RUQ U/S which demonstrated fatty liver and renal cysts. This
can be followed up as an outpatient. His hepatitis serologies
are pending at the time of transfer. Please follow up and
vaccinate for hep A and hep B as appropriate. Feel free to
consult med consult to assist with this if necessary. He reports
2 negative HIV tests in the past 5 years and reports solely
protected sexual intercourse since then. Denies other high risk
behaviors and thus declined an HIV test.
.
9. Pancreatitis: Likely [**2-26**] EtOH. Amylase and lipase initially
improved but were trending up at the time of transfer. However,
the patient had no clinical signs or symptoms of pancreatitis.
.
10. L back burn: Unclear etiology. Topical silver sulfadiazine
was applied with good effect and the patient was followed for
the possibilty of evolving cellulitis. On the day of discharge
his wound were clean with good red granulation tissue without
signs of cellulitis.
Medications on Admission:
1. atenolol 100 mg qd (stopped 1 year ago due to poor access to
[**Hospital1 2177**] pharmacy)
2. ASA 81 mg qd
3. methadone 57.5 mg qd (receives treatment at Addiction
Treatment Center in [**Location (un) 583**])
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary:
Methadone intoxication
Suicide Attempt
Alcohol Intoxication
Secondary
1. HTN
2. HCV:
3. heroin abuse
Discharge Condition:
Good, ambulating independently
Discharge Instructions:
You were admitted with alcohol intoxication and methadone
overdose. You were transferred to the ICU for closer monitoring.
You started to withdraw from alchol and were treated with high
doses of valium. Your withdrawal improved. You had low oxygen
levels but you were not found to have a pulmonary embolus. Your
low oxygen levels improved without antibiotics making pneumonia
unlikely. You were transferred to the floor where your ECG was
monitored, your respiratory status improved and you did not have
any CIWA scale requirements.
Please stop drinking alcohol
Followup Instructions:
Please follow up with your PCP in one week. If you do not have
one feel free to call [**Telephone/Fax (1) 1247**] to make a new appointment
with a PCP at [**Hospital1 18**]
|
[
"584.9",
"401.9",
"728.88",
"304.00",
"305.90",
"729.5",
"070.70",
"507.0",
"303.90",
"E980.9",
"980.9",
"965.02",
"577.0",
"E950.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9292, 9307
|
5039, 9029
|
357, 363
|
9461, 9494
|
3948, 5016
|
10104, 10280
|
2866, 2948
|
9328, 9440
|
9055, 9269
|
9518, 10081
|
2963, 3929
|
276, 319
|
391, 2277
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2299, 2332
|
2348, 2850
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,568
| 186,588
|
21863
|
Discharge summary
|
report
|
Admission Date: [**2190-11-24**] Discharge Date: [**2190-12-4**]
Date of Birth: [**2145-3-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3266**]
Chief Complaint:
bloody diarrhea, jaundice, malaise
Major Surgical or Invasive Procedure:
EGD
Paracentesis
History of Present Illness:
Mr. [**Known lastname **] is a 45 year old man with a history of hepatitis C,
past heavy alcohol consumption, splenectomy, and upper GI bleed
s/p esophageal and gastric banding who presented to an OSH on
[**11-23**] with grossly bloody diarrhea, jaundice, and malaise. He
recently returned from a trip to [**Country 27440**] ([**Date range (3) 57358**])
and felt well up until approximately [**11-6**]. He started having
large volume, loose brown (not dark) stools without blood or
mucus that morning. The bowel movements were accompanied by
sharp pain mostly in his right flank. He did not have any
fevers, chills, nausea, or vomiting, but he did have symptoms of
rectal urgency and some constipation/straining with bowel
movements. His diarrhea persisted following his return to the US
and increased in frequency, up to 5-6 episodes per day. In
addition, his right flank pain became constant and sometimes
radiated across his back. Mr. [**Known lastname **] went to see his PCP [**Last Name (NamePattern4) **].
[**Last Name (STitle) 27187**] on [**11-19**] after he began experiencing shortness of
breath, chest pain, tachycardia, and lightheadedness (with
standing after having a BM). He was started on levofloxacin and
metronidazole but developed bloody diarrhea (bright red blood
mixed with stool) the following day. In addition, he experienced
increased malaise and noticed that he appeared jaundiced. He
presented to [**Hospital **] Hospital on [**11-23**] due to concerns
regarding the bloody diarrhea and jaundice.
At OSH, Mr. [**Known lastname **] had a hematocrit of 21.8. EGD showed
engorged grade [**3-25**] varices and streak-like gastritis in his
stomach. Abdominal CT showed liver cirrhosis, ascites, varices,
a distended GB with stones, but not CBD dilation. He was
transfused with a total of 8U PRBCs then transferred to [**Hospital1 18**].
Past Medical History:
(1) Hepatitis C Diagnosed [**2177**], treated with IFN [**2178**]-[**2180**]
inducing remission
(2) "Broken back" [**2171**] following fall from ladder
(3) L knee reconstructive surgery [**2178**]
(4) Splenectomy [**2158**], following fight with cousin. Received
transfusions
(5) GI bleeds Esophageal and gastric varices banded 3.04, 8.04,
11.04
(6) Colon polyps Colonoscopy 6.05 revealed polyps in sigmoid
colon
(7) Internal hemorrhoids
(8) Long-standing h/o tremor
Social History:
Mr. [**Known lastname **] is divorced, lives with his brother and aunt in
[**Name (NI) 5289**]. He works in construction (painting, roofing, and other
jobs). He has an approximately 20 pack year history of smoking.
Used cocaine and injected heroin in early 80's, denies alcohol
in last two years or current substance use.
Family History:
No liver disease or diarrhea in family. Mother died of lung
cancer, father had brain tumor. Multiple family members with
diabetes, MI, other cancers.
Physical Exam:
Temp 98.0 BP 145/55 HR 90 RR 16 99% RA
Gen: sitting in bed comfortable, NAD
Derm: Numerous telangiectasias, no caput medusa or palmar
erythema appreciated. Dry scaly skin on shins.
HEENT: NC/AT, PERRL, EOMI, + scleral and soft palate icterus,
mmm, wears half set dentures, oropharynx without lesions.
Neck: Trachea midline, no goiter or masses. JVP 5 cm above CM,
supple
CV: RRR nl S1 S2, 3/6 SEM @ ULSB. 2+ pedal pulses.
Chest: CTA b/l no r/r/t + gynecomastia
Abd: NT markedly distended, mild fluid wave, + BS. Tender to
palpation RUQ and flank. Midline scar from laparotomy. Liver
span difficult to appreciate due to habitus.
Ext: Warm and well perfused, no c/c. 1 + pitting edema half way
up calves
Neuro: A&O x 3. dozing off occasionally. CN 2-12 intact. Resting
tremor persists with movement. No significant muscle atrophy.
Motor strength 5/5 UE and LE. [**Doctor First Name **] intact, on FTN sometimes
missed examiners finger. Reflexes biceps, patellar 2+
bilaterally. Ankle 1+ bilaterally. Babinski: toes downgoing. No
pronator drift, Romberg negative, normal gait, no asterixis.
Pertinent Results:
[**2190-12-1**] 05:40AM BLOOD Albumin-2.6* Calcium-8.0* Phos-2.7
Mg-1.4*
[**2190-12-1**] 10:00AM ASCITES WBC-350* RBC-180* Polys-20* Lymphs-9*
Monos-69* Mesothe-2*
[**2190-12-1**] 10:00AM ASCITES TotPro-0.6 Glucose-120 LD(LDH)-51
Amylase-9 Albumin-<1.0
Time Taken Not Noted Log-In Date/Time: [**2190-12-1**] 2:25 pm
PERITONEAL FLUID
GRAM STAIN (Final [**2190-12-1**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
[**2190-11-27**] 05:20AM BLOOD HIV Ab-NEGATIVE
[**2190-11-27**] 05:20AM BLOOD CEA-11* PSA-1.6 AFP-6.0
[**2190-11-26**] 02:58AM BLOOD HBsAb-NEGATIVE
[**2190-11-25**] 04:30PM BLOOD IgM HAV-NEGATIVE
[**2190-11-24**] 06:37PM BLOOD HBsAg-NEGATIVE HBcAb-POSITIVE HAV
Ab-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2190-11-29**] 7:45 pm IMMUNOLOGY
**FINAL REPORT [**2190-12-1**]**
HCV VIRAL LOAD (Final [**2190-12-1**]):
HCV-RNA NOT DETECTED.
Performed by RT-PCR.
Detection range: 600 - 700,000 IU/ml.
FOR RESEARCH USE ONLY. NOT FOR USE IN DIAGNOSTIC
PROCEDURES.
This test has been validated by the Microbiology
laboratory at [**Hospital1 18**].
[**2190-11-24**] 11:44 pm STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT [**2190-11-27**]**
FECAL CULTURE (Final [**2190-11-27**]):
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final [**2190-11-27**]): NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final [**2190-11-25**]):
NO OVA AND PARASITES SEEN.
.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FECAL CULTURE - R/O YERSINIA (Final [**2190-11-27**]): NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2190-11-27**]):
NO E.COLI 0157:H7 FOUND.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2190-11-25**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
Brief Hospital Course:
45 yo male w/ PMHx significant for Hep C cirrhosis, esophageal
varices s/p multiple banding procedures, w recent travel to far
East admitted for diarrhea and GI bleed from presumed
gastroenteritis and esophageal varices.
(1) Liver disease
A. GI bleed
-s/p variceal banding on [**11-23**] at OSH
-No melena or hematochezia while on floor. Guiac positive
stools x2 on [**12-2**].
-Beta blocker held due to concern of hypotension
developing with GI bleed.
-Sucralfate and pantoprazole to promote mucosal healing
given varices
B. Cirrhosis
-Ultrasound and CT abdomen consistent with cirrhosis
-Portal vein thrombosis [**11-27**] CT, unchanged on [**12-1**] CT
abdomen
-Transplant team consulted, pre-transplant evaluation
began. Had PFTs, TTE.
Negative for HIV, RPR, CMV, Toxo, EBV.
-Will continue evaluation for liver transplant as
outpatient
-Not grossly encephalopathic, maintained on lactulose
C. Ascites
-SAAG > 1.6 consistent with portal hypertension as
etiology of ascites
-Patient developed low grade fever, abdominal pain.
Concerned for SBP even
though patient had been on cipro 500 mg [**Hospital1 **] for
prophalaxis. Ceftriaxone and
metronidazole started on [**11-30**]. Switched to PO
metronidazole, discontinued
ceftriaxone, started cephalexin on [**12-3**] per hepatology.
To complete 5 more days of course of cephalexin and
metronidazole. Will continue ciprofloxacin 250 mg PO ongoing
after cephalexin/metronidazole course finishes.
daily for SBP prophalaxis
-Abdominal pain managed with oxycontin and oxycodone
-Ultrasound-guided paracentesis on [**12-1**] yielded 2.6 L
fluid. Gram stain
negative, culture pending. Total leukocyte count 350, 20%
polys. No laboratory
evidence for SBP.
-Diuresed with sprionolactone and furosemide. Low Na diet,
water restriction
(3) Diarrhea - Levofloxacin and metronidazole discontinued on
[**11-27**]. Diarrhea resolved, strong suspicion for infectious
etiology in light of recent travel history.
However, cultures for Salmonella, Shigella, Campylobacter,
Yersinia, C. difficile toxin negative. Etiology remains unclear
at this time.
(4) ARF - Likely due to volume depletion secondary to diarrhea.
Renal failure resolved, has continued to put out small volumes
of dark urine.
(5) Hyponatremia - Managed with 1.5L/day fluid restriction.
Continue spironolactone and furosemide.
(5) FEN - Low sodium diet
(6) PPX - pneumoboots for dvt prophalaxis, pantoprazole and
sucralfate as above.
Medications on Admission:
At admission to outside hospital:
?????? Pantoprazole 40 mg PO daily
?????? Propanolol 20 mg PO twice daily
From [**Hospital1 18**] MICU
?????? Octreotide Acetate 50 mcg/hr IV DRIP INFUSION
?????? Zolpidem Tartrate 10 mg PO HS:PRN
?????? Artificial Tears 1-2 DROP OU PRN eye lubrication
?????? Sucralfate 1 gm PO QID
?????? Pantoprazole 40 mg PO Q12H
?????? Levofloxacin 250 mg PO Q24H
Discharge Medications:
1. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
2. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for eye lubrication.
Disp:*1 * Refills:*1*
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
4. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
6. Oxycodone HCl 20 mg Tablet Sustained Release 12HR Sig: One
(1) Tablet Sustained Release 12HR PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*0*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 5 days.
Disp:*20 Capsule(s)* Refills:*0*
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
11. Cipro 250 mg Tablet Sig: One (1) Tablet PO once a day: Only
start after you have finished with the 5 day treatment of Keflex
and Flagyl.
Disp:*30 Tablet(s)* Refills:*2*
12. Lotrimin 1 % Cream Sig: One (1) application Topical twice a
day for 10 days.
Disp:*1 tube* Refills:*0*
13. Propranolol HCl 20 mg Tablet Sig: One (1) Tablet PO twice a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
cirrhosis; decompensated liver failure
esophageal varices
Discharge Condition:
Fair
Discharge Instructions:
Please call you primary care physician if you experience bloody
stool, shortness of breath, lightheadedness, markedly increased
leg swelling, abdominal pain, chest pain, fevers, heart
palpitations.
Please make an appointment with your primary care
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 5628**]
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2190-12-6**] 9:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name12 (NameIs) 1046**] Where: TRANSPLANT SOCIAL WORK
Date/Time:[**2190-12-6**] 11:00
|
[
"585",
"572.8",
"456.21",
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"571.5",
"572.3",
"276.1",
"558.9",
"535.50",
"452",
"456.8",
"574.20",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
11333, 11339
|
6667, 9251
|
350, 369
|
11441, 11447
|
4388, 4849
|
11744, 12073
|
3105, 3256
|
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3271, 4369
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276, 312
|
397, 2260
|
4932, 6644
|
2282, 2750
|
2766, 3089
|
4881, 4896
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,447
| 116,595
|
4665
|
Discharge summary
|
report
|
Admission Date: [**2200-4-8**] Discharge Date: [**2200-4-14**]
Date of Birth: [**2158-11-18**] Sex: F
Service: [**Location (un) **]
CHIEF COMPLAINT:
1. Melanotic stools.
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 19730**] is a 41 year-old
female with past medical history significant for type I
diabetes, end stage renal disease on hemodialysis,
hypertension, hyperprolactinemia, history of a GI bleed who
presents to the Emergency Department with shortness of
breath, abdominal pain and nausea. The patient states that
she has had epigastric pain for the past three or four days
and that her mother had noted dark / bloody stools which
subsequently lead her to bring her daughter to the Emergency
Department.
The patient states she has been taking two Motrin a day for
the past month for chronic leg pain. The patient has a
history of upper GI bleed several years ago. She denies any
hematemesis, vomiting. She states she has not eaten since the
night before admission.
In the Emergency Department the patient's blood pressure was
79/44. Her O2 saturation was 100% on room air with a heart
rate of 60%, access was obtained in view of a femoral triple
lumen catheter. Her blood pressure increased without bolus of
fluid or transfusion. Her blood pressure on arrival to the
MICU was 100/70 and G tube was placed. Bright red blood was
retained which did not clear after 750 cc of flushing with
normal saline. The patient continued to remained
hemodynamically stable. Her laboratory values were
significant for hypokalemia with peaked T waves seen on her
EKG.
The patient was given sliding scale insulin IV to enhance
sodium bicarb along with 2 grams of calcium gluconate. The
renal fellow on call was notified and emergent hemodialysis
was arranged upon arriving in the medical ICU.
REVIEW OF SYSTEMS: Negative for fevers or chills. She has
decreased po intake lately secondary to nausea, pain. She
does not complain of any shortness of breath or cough. She
denies any chest pain. No history of syncope. The patient is
completely anuric. She has a left lower extremity foot ulcer
which has been improving over the past four weeks.
PAST MEDICAL HISTORY:
1. Type I diabetes since the age of 23 years old. She has
had several episodes of DKA.
2. End stage renal disease on hemodialysis Tuesday, Thursday
and Saturday secondary to diabetes.
3. Diabetes.
4. Hyperprolactinemia.
5. History of upper GI bleed
6. Foot ulcer for which she has had for one month.
ALLERGIES: Azithromycin leads to gastric upset.
MEDICATIONS AT HOME:
1. Lorazepam 2 milligrams po given at hemodialysis.
2. Protonix 40 milligrams po q day.
3. Nortriptyline 75 milligrams q HS.
4. Metoprolol 50 milligrams po bid.
5. Reglan 10 milligrams po q AC / q HS.
6. Norvasc.
7. PhosLo.
8. Nephrocaps one po q day.
9. Atlantis 10 units subcutaneous q HS.
10. Humalog sliding scale.
SOCIAL HISTORY: She lives with her mother. She is a
nonsmoker. She occasionally uses alcohol. She has VNA for
foot ulcer care.
PHYSICAL EXAMINATION: Temperature 95 F orally in the
Emergency Department. Heart rate 60. Blood pressure 100/60.
O2 saturation is 100% on two liters. General she appears
slightly anxious female sitting upright. HEENT - pale
conjunctivae. Mucous membranes are moist. Her lungs are clear
to auscultation bilaterally. She had decreased breath sounds
at the right base. She has no wheezing and no crackles heard
on auscultation. Her heart was regular rate and rhythm with
an S3 heard. There are no murmurs appreciated. Abdomen has
decreased bowel sounds, soft and nontender on examination.
Rectal - there is evidence of gross hematochezia. Extremities
were slightly cool. She has a left lower extremity plantar
ulcer 1 cm in diameter with hepatorrheic edges without warmth
or erythema. Pulses were not palpable. Neurologically she
was alert and oriented times three. There is no facial droop.
Her tongue was midline. She was moving all four extremities.
LABORATORY DATA: White count 9.2, hematocrit 24.7, platelet
count 320,000. Sodium 134, potassium 7.4, chloride 96, bicarb
21, BUN 149, creatinine 7, glucose 312. Anion gap 13, INR
1.5, PTT 28.2, PT 14.5. CK 44, Troponin less than 0.3.
EKG revealed that she was in sinus rhythm with beats of 64
beats per minute. She had left axis deviation with evidence
of left ventricular hypertrophy. She had poor R wave
progression, precordium with peaked T waves. She had QRS
interval of 144 compared with 88 from previous EKG. She had T
wave depressions on lateral leads. She had an HG done
in[**2200-2-5**] which revealed a mild reversal of septal defect.
HOSPITAL COURSE:
1. Upper Gastrointestinal Bleed - The patient was started on
IV proton inhibitor and transfused a total of 40 units of
packed red blood cells during this admission. An EGD was
performed which revealed blood in the entire stomach. There
was erythema and congestion in the pre-pyloric region
compatible with gastritis. Her EGD was otherwise normal to
the third part of the duodenum.
The cause of her GI bleed was thought to be end stage induced
gastritis. Her hematocrit remained stable throughout the rest
of her hospital course. She was discharged on proton pump
inhibitor to be dosed twice a day and to follow up with her
gastroenterologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 19731**].
2. Diabetes - The patient was started on an insulin drip for
mild DKA after hospital day three her anion gap had closed
and the patient was started on her outpatient dose of Lantus
with fair control of her blood sugars.
3. Renal failure - The patient had emergency hemodialysis
for hyperkalemia with EKG changes which subsequently resolved
after one course of hemodialysis. During this admission the
patient continued to have multiple courses of hemodialysis
every other day which she tolerated well. The patient was
given Vancomycin at dialysis for a question of SBP given
return of .................... fluid from a new peritoneal
dialysis catheter placed two weeks ago. Her peritoneal fluid
was sampled on the day prior to discharge which fit criteria
for SBP.
Her abdominal exam was nontender throughout her hospital
stay. She will resume the use of her peritoneal dialysis
catheter in the near future as dictated by her nephrologist.
During this admission her PhosLo does was increased from two
tablets with meals to four tablets with meals due to
persistent hyperphosphatemia. She was discharged from the
hospital to continue her usual regimen of hemodialysis three
times a week.
4. Cardiovascular - During this admission the patient's
Troponin levels were found to be elevated with no CK leak.
Despite these findings and significant anemia, the patient
remained chest pain free throughout her hospital course.
Given her known history of mild reversible septal defect on a
recent Persantine MIBI the patient should be evaluated for a
cardiac catheterization in the near future. Her Troponin leak
is most likely from a combination of anemia and
..................... She was not started on aspirin
secondary to her ANSAID induced GI bleed and was continued on
her beta-blocker and on an Ace inhibitor. She was set to
follow up with Dr. [**Last Name (STitle) **] of the cardiology division for
evaluation of a possible cardiac catheterization.
5. Dizziness - The patient developed persistent dizziness
two days prior to being discharged. After being restarted on
Florinef her symptoms of dizziness resolved completely.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: Discharged to home.
DISCHARGE MEDICATIONS:
1. Florinef 0.2 milligrams po q day.
2. Lantus 10 units subcutaneous q HS.
3. Neurontin 100 milligrams po tid.
4. PhosLo four caps po with meals.
5. Nephrocaps one po q day.
6. Nortriptyline 75 milligrams po q HS.
7. Protonix 40 milligrams po bid.
8. Lopressor 50 milligrams po bid.
9. Ativan 1 to 2 milligrams po q six to eight hours prn
anxiety.
10. Lisinopril 10 milligrams po q day.
DISCHARGE INSTRUCTIONS: Return to the Emergency Department
if you develop chest pain, shortness of breath, or persistent
dark or bloody stools. Follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 19512**]
of [**Company 191**] within one week to review the results of this
admission. Please follow up with Gastroenterologist, Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 19731**] on [**2200-5-30**] at 10:40 A.M. Follow up with
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] on [**2200-5-6**] at 3 P.M. at [**Last Name (NamePattern1) 19732**] for further cardiac work up.
DISCHARGE DIAGNOSIS:
1. ANSAID induced gastritis.
2. Positive cardiac pharmacologic stress test.
3. End stage renal disease on hemodialysis.
4. Type I diabetes.
5. Hypertension.
6. Hyperprolactinemia.
7. Left lower extremity foot ulcer.
[**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D. [**MD Number(1) 7855**]
Dictated By:[**Last Name (NamePattern1) 7690**]
MEDQUIST36
D: [**2200-4-18**] 20:44
T: [**2200-4-21**] 09:47
JOB#: [**Job Number 19733**]
cc: [**Doctor First Name 475**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 474**], M.D. Division of Cardiology
[**First Name11 (Name Pattern1) 20**] [**Last Name (NamePattern4) 19734**], M.D. Division of Gastroenterology
and Hepatology
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**Company 191**] West
|
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62,035
| 100,202
|
47017
|
Discharge summary
|
report
|
Admission Date: [**2196-7-26**] Discharge Date: [**2196-7-29**]
Date of Birth: [**2120-2-8**] Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin / Augmentin
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
coffee ground emesis
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
Patient is severely demented at baseline and history was
obtained via [**Hospital1 1501**] records.
.
This is a 76 y/o F with history of CHF, Afib on coumadin, HTN,
dementia who prsented from her living facility after vomiting
coffee grounds earlier today. Per records, patient was suffering
from constipation. Bowel regimen was aggressively uptitrated and
on day prior to admission, patient was given magnesium citrate.
Patient began vomiting coffee grounds on several occasions.
Unclear if patient had fevers or chills, or abdominal
discomfort.
.
In ED patient's initially VS were 99.7 140 167/110 22 99%4LNC.
Patient triggered for HR. Exam was unrevealing. Initial EKG
demonostrated SVT. Patient was given a total of 12mg of
adenosine which revealed atrial flutter. Patient was given a
total of 40mg IV diltiazem and 1LNS. NGL was completed which
showed 1L coffee grounds with clots. This apparently cleared
with an additional 500cc NS. GI was consulted and planed to
scope patient in AM. Patient was started protonix gtt. Lab
findings were significant for a WBC of 18, Hct of 44.5 (both
which were thought to be hemoconcentrated) and a Na of 129 with
Cr of 1.2. INR was noted to be 3.3. Patient received a total of
10mg of vitamin K and 1 unit of FFP. Lastly pt spiked to 101;
blood cultures were taken and pt was given ceftriaxone for ?UTI.
Prior to transfer, vital signs were 125/62 144 (still in
flutter) 98% RA.
.
In the MICU, patient was resting comfortable complaining of
thirst.
Past Medical History:
s/p CVA
HTN
DM
A flutter
Neurogenic bladder
Obesity
Social History:
Lives at [**Hospital3 2558**]. Per the patient, her son visits her
frequently.
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM:
Vitals: 124/88 144 94% RA
General: alert, not oriented
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
DISCHARGE EXAM:
Vitals: 98.8 126/62 80 18 98% RA
GEN: Alert and oriented to person, place, time but not to living
situation
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Irregular 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: Incontinent
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: coalesced diffuse erythematous blanching patch on upper
back crossing midline. Scaly. Two 2 cm scaly plaques on
bilateral knees. Excoriations on right lower leg. itchy
coalesced diffusely erythematous blanching patch on L buttocks
Neuro: Facial droop on right, 0/5 strength of LUE with atrophied
left hand, and 3/5 strength of L gastroc and anterior tibial,
all consistent with her baseline [**1-27**] distant MCA stroke.
.
Pertinent Results:
Admission Labs:
[**2196-7-26**] WBC-18.0*# RBC-5.70*# Hgb-14.9# Hct-44.5# MCV-78*
MCH-26.1*# MCHC-33.5 RDW-17.0* Plt Ct-451*
[**2196-7-26**] Neuts-84.9* Lymphs-10.2* Monos-4.3 Eos-0.4 Baso-0.3
[**2196-7-26**] PT-33.1* PTT-29.4 INR(PT)-3.3*
[**2196-7-26**] Glucose-283* UreaN-25* Creat-1.2* Na-129* K-3.5 Cl-83*
HCO3-30 AnGap-20
[**2196-7-27**] ALT-8 AST-11 LD(LDH)-147 AlkPhos-76 TotBili-0.6
[**2196-7-26**] Calcium-10.3 Phos-2.3* Mg-2.8*
.
DISHCARGE LABS:
[**2196-7-29**] WBC-8.4 RBC-4.35 Hgb-11.6* Hct-35.2* MCV-81* MCH-26.7*
MCHC-33.0 RDW-17.6* Plt Ct-254
[**2196-7-29**] Glucose-152* UreaN-10 Creat-0.8 Na-136 K-3.4 Cl-102
HCO3-21* AnGap-16
[**2196-7-29**] Calcium-8.8 Phos-1.2* Mg-2.0
.
Micro:
[**2196-7-27**] 1:44 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2196-7-28**]**
MRSA SCREEN (Final [**2196-7-28**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
.
Imaging:
EGD:
Esophagus:
Mucosa: Grade D esophagitis with stigmata of recent bleeding
was seen starting at 15 cm from the incisors to the GE junction,
compatible with severe erosive esophagitis most likely from
GERD.
Stomach:
Excavated Lesions Multiple superficial non-bleeding ulcers
ranging in size from 1 cm to 1 cm were found in the fundus,
stomach body, and antrum .
Duodenum:
Mucosa: Normal mucosa was noted.
Impression: Grade D esophagitis in the From 15cm to the GE
junction compatible with severe erosive esophagitis most likely
from GERD
Ulcers in the fundus, stomach body, and antrum
Normal mucosa in the duodenum
Otherwise normal EGD to third part of the duodenum
Recommendations: Follow up in Dr.[**Name (NI) 84029**] clinic in 4 weeks
[**Telephone/Fax (1) 9891**]
Start high dose ppi (protonix 40mg [**Hospital1 **] or equivalent) for 6
weeks
Avoid Nsaids
Continue management per inpatient GI consult team
.
.
CT ABD/PELVIS ([**7-26**]):
CT ABDOMEN WITH IV CONTRAST: There is dependent subsegmental
atelectasis at the lung bases. The heart is enlarged without
pericardial effusion. There is coronary artery and thoracic
aortic atherosclerotic calcification.
The liver, spleen, and bilateral adrenal glands are normal. The
gallbladder is surgically absent. A poorly evaluated 13-mm
hypodensity arising from the posterior aspect of the pancreatic
body may be new from the prior study. There is fatty atrophy of
the pancreas. The non-opacified stomach and intra-abdominal
loops of small bowel are normal without evidence of obstruction.
A nasogastric tube terminates in the gastric fundus. There is
colonic diverticulosis without evidence of acute diverticulitis.
There is mild bilateral hydronephrosis and hydroureter. Within
the right
kidney, there is a fat-fluid level in an anterior interpolar
calyx (2A:35). In addition, a fat-fluid level is noted within
the mid right ureter (2A:66). Multiple hypodensities in the
bilateral kidneys are mostly new compared to [**2189**] and are too
small to further characterize, but may represent cysts. There
has been interval atrophy of both kidneys. In addition, cortical
thinning in the upper pole of the right kidney suggests prior
infection or ischemia.
There is no free air or fluid in the abdomen. There are no
mesenteric lymph nodes meeting CT criteria for pathologic
enlargement. A left para-aortic lymph node measuring 16 mm is
similar to the prior study (2A:42). There is atherosclerotic
calcification of the abdominal aorta which is of normal caliber
throughout. Vascular calcifications are also noted in the branch
vessels.
CT PELVIS WITH IV CONTRAST: There is a tiny fat-fluid level
within the
anterior portion of the bladder (2A:82). The distal ureters are
dilated
bilaterally, and scattered areas of mild urothelial enhancement
are seen
bilaterally. The urinary bladder is distended with irregular and
lobulated
appearance of the wall, with diverticula. Heterogeneity is noted
in the
region of the endometrium, possibly due to an underlying polyp
or fibroid.
Adnexa and sigmoid colon are normal. There is a large amount of
stool within the rectum. There is no free fluid in the pelvis.
No pelvic or inguinal lymphadenopathy meeting CT criteria for
pathologic enlargement is noted.
BONE WINDOWS: No suspicious lytic or sclerotic osseous lesion is
identified. There is multilevel degenerative change of the
thoracolumbar spine.
IMPRESSION:
1. No evidence of bowel obstruction.
2. Irregular lobulated appearance of the bladder wall with
diverticula
suggests neurogenic bladder and clinical correlation is
recommended.
Mild bilateral hydroureteronephrosis may be due to bladder
distention. Mild urothelial enhancement could be seen with
infection and correlation with urinalysis and urine culture
recommended.
3. Chyluria, of unclear etiology. Correlation with urine studies
and history of instrumentation or prior urologic procedures is
recommended.
4. Renal scarring in the right kidney suggests sequela of prior
infection or infarction.
5. 13-mm pancreatic body hypodensity for which MRI could be
obtained for
further evaluation as clinically indicated.
6. Heterogeneous endometrium, possibly due to polyp or a
submucosal fibroid. Correlation with non-emergent pelvic
ultrasound recommended if not previously performed.
The study and the report were reviewed by the staff radiologist.
.
ECHO ([**2196-7-27**]):
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is unusually small. Left ventricular systolic
function is hyperdynamic (EF>75%). Doppler parameters are
indeterminate for left ventricular diastolic function. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets are mildly thickened (?#).
There is no aortic valve stenosis. Mild to moderate ([**12-27**]+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Physiologic
mitral regurgitation is seen (within normal limits). The
tricuspid valve leaflets are mildly thickened. The estimated
pulmonary artery systolic pressure is normal.
IMPRESSION: Small LV cavity size with hyperdynamic LV systolic
function. An abnormal LVOT flow contour is seen but an LVOT
gradient is not present. Mild to moderate aortic regurgitation.
.
.
CXR (PA/LAT): ([**7-27**]):
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Lung volumes and moderate cardiomegaly with retrocardiac
atelectasis, but no evidence of pulmonary edema or pneumonia.
The presence of minimal pleural effusion on the left cannot be
excluded. On the right, there is no pleural effusion.
Brief Hospital Course:
76 y/o F with CHF, dementia, Afib on coumadin presenting with
coffee ground emesis found be in aflutter with RVR.
# GI Bleed: Patient was admitted to the MICU with coffee ground
emesis that was confirmed with nasogastric lavage. Patient was
tachycardic (see below), however BP was stable. Hct initially
was 44. With hydration, her hct fell to 35 but then remained
stable. Patient received 1 unit of FFP and vitamin K for
supratherapeutic INR however did not receive any packed RBCs.
EGD revealed multiple superficial non-bleeding ulcers in the
fundus, stomach body, and antrum as well as severe esophagitis.
She was started on pantoprazole 40mg [**Hospital1 **]. Patient remained
hemodynamically stable and was subsequently transferred to the
general medicine floors. Her hct remained stable around 35 with
no further episodes of vomiting. She was able to tolerate PO
intake. She was discharged to continue high dose PPI and to have
follow up EGD in [**6-1**] weeks.
.
# Tachycardia: Patient initially presented in SVT and received
12mg of adenosine which revealed underlying afib/aflutter with
RVR. HRs remained fluid unresponsive, however were treated with
IV beta blockade. Upon restarted home dual nodal blockade, HRs
became appropriate. However, pt displayed evidence of
tachy-brady syndrome, with heart rates up to 150s and down to
60s, so her diltiazem was decreased to 60mg TID She remained
hemodynamically stable. Her coumadin was initially held in the
setting of an acute bleed. However, GI felt that her risk of
stroke was greater than her risk of rebleeding, so her coumadin
was resumed on discharge, to be bridged with lovenox.
.
# SIRS: Patient met SIRS criteria by heart rate and WBC count.
She received empiric treatment with ceftriaxone x1 in the ED.
However, since no clear source of infection was identified,
antibiotics were discontinued. Her WBC decreased to 8.4 at time
of discharge and pt was afebrile. Her UA was significant for
large leukocytes, 101 WBC, few bacteria, however as she was
asymptomatic and her urine culture showed only mixed bacterial
flora, she was not treated.
.
# [**Last Name (un) **]: Patient presented with elevated creatinine and
hyponatremia, both which improved with gentle fluid
resuscitation.
.
CHRONIC ISSUES:
.
CHF: Pt was dehydrated on presentation. She received gentle
hydration and remained euvolemic during her hospital course.
.
DM: Metformin was held during hospitalization. Her BG was
managed with sliding scale insulin. She was resumed on
metformin upon discharge.
.
Pain management: Pt was managed on lidocaine patch only during
hospitalization. She had no complaints of lower back pain. She
may be able to dc percocet and continue only on lidocaine patch
to decrease her constipation.
.
TRANSITIONAL ISSUES:
Pt is DNR/DNI. She has a follow up EGD and GI appointment
scheduled for 4 weeks from discharge. She also had several
findings on CT that may deserve follow-up as an outpatient as
described in her CT findings. As constipation seems to be an
issue for her, she may benefit from pain control with lidocaine
patch only, as she reported her pain was well controlled on that
regimen while she was hospitalized. She was restarted on
coumadin given that the benefit of stroke reduction seemed to
outweight the risk of re-bleeding, per GI. She is being bridged
with lovenox. We were unable to contact the son during her
hospitalization, however the final decision to continue
anticoagulation should be addressed with him.
Medications on Admission:
- Ventolin HFA 90mcg 2 puffs IN q6h prn
- Ipratropium/Albuterol 3cc via Neb QID prn wheezing
- Acetaminophen 1000mg PO Q4h prn
- Magnesium Citrate 1 bottle PO
- Diltiazem 90mg PO TID
- Bisacodyl 5mg PO QHS
- Milk of Magnesia 400mg/5mL PO 30cc QHS
- Lidoderm patch
- Percocet 5/325mg 1 tab PO TID
- Coumadin
- Bupropion XL 150mg Daily
- Metformin 500mg Daily
- Docusate 100mg [**Hospital1 **]
- Metoprolol tartrate 50mg [**Hospital1 **]
Discharge Medications:
1. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Adhesive Patch, Medicated(s)
2. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO QAM (once a day (in the morning)).
3. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
6. warfarin 4 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
7. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
8. enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) mg
Subcutaneous [**Hospital1 **] (2 times a day): Can be stopped once INR
theraputic for 24-48 hours.
9. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
10. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO twice
a day as needed for constipation.
11. diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary diagnosis:
Upper GI bleed
Secondary diagnosis:
atrial flutter
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms [**Known lastname 4318**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital because you
had bloody vomit. You had an upper endoscopy that showed that
you have severe acid reflux with ulcers in your esophagus and
stomach. Because of this, you were started on a new medication
to control your stomach acid. You should take this medicine
twice a day indefinitely. You will also need to follow up with
the Gastrointestinal doctors because they [**Name5 (PTitle) 9004**] to repeat an
endoscopy in [**3-30**] weeks.
Your heart rate was also very fast when you came to the
hospital. We gave you medication to slow your heart rate down,
and then restarted your home dose of metoprolol and diltiazem.
Please make the following changes to your medications:
1. start taking pantoprazole 40 mg by mouth twice a day
2. your back pain was well controlled with a lidocaine patch
while you were in the hospital. Since this worked for you here,
you may want to consider stopping percocet (it can make
constipation worse) and using a lidocaine patch instead.
3. take lovenox
Followup Instructions:
Department: WEST PROCEDURAL CENTER
When: THURSDAY [**2196-8-25**] at 8:00 AM
With: WPC ROOM THREE [**Telephone/Fax (1) 5072**]
Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: GI-WEST PROCEDURAL CENTER
When: THURSDAY [**2196-8-25**] at 8:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6953**], MD [**Telephone/Fax (1) 463**]
Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2196-8-31**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6953**], 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
Please call patient registration at ([**Telephone/Fax (1) 99686**] prior to
appointment.
Completed by:[**2196-7-30**]
|
[
"E934.2",
"531.90",
"530.19",
"790.01",
"428.0",
"438.83",
"564.00",
"401.9",
"438.89",
"427.32",
"V49.86",
"530.81",
"584.9",
"530.82",
"294.8",
"278.00",
"729.89",
"276.1",
"427.31",
"E935.9",
"427.81",
"V02.54",
"250.00",
"428.32",
"596.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
15336, 15406
|
10215, 12471
|
306, 312
|
15521, 15521
|
3547, 3547
|
16843, 17995
|
2019, 2037
|
14206, 15313
|
15427, 15427
|
13746, 14183
|
15699, 16480
|
2052, 2546
|
2562, 3528
|
13001, 13720
|
16509, 16820
|
245, 268
|
340, 1831
|
15483, 15500
|
3564, 10192
|
15446, 15462
|
15536, 15675
|
12487, 12980
|
1853, 1907
|
1923, 2003
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,673
| 111,858
|
6499
|
Discharge summary
|
report
|
Admission Date: [**2200-10-17**] Discharge Date: [**2200-10-23**]
Date of Birth: [**2134-2-12**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 66 year-old
woman with progressive numbness and weakness to both arms and
legs left greater then right times two years. She was noted
to have difficulty with gait and balance. In the past six
months also has increase in bowel and urinary incontinence.
She wears a neck brace and uses a cane for ambulation and
safety. C spine films show positive atlantoaxial instability
with flexion. CT shows cystic lesion of the odontoid and C1
lateral mass. The patient underwent transoral excision of
the mass and occipital cervical fixation and fusion.
PAST MEDICAL HISTORY: Gastric ulcers, hiatal hernia,
Raynaud's disease.
PAST SURGICAL HISTORY: Appendectomy, cholecystectomy,
hysterectomy, bladder suspension and partial gastrectomy
secondary to ulcers.
ALLERGIES: Morphine.
PHYSICAL EXAMINATION: Vital signs, blood pressure 102/65.
Pulse 65. The patient is a pleasant woman in no obvious
pain. Ambulation unsteady without assistance. HEENT
anicteric. No lymphadenopathy. Neck severely limited motion
secondary to pain. Chest clear to auscultation. Cardiac S1
and S2, regular rate and rhythm. Abdomen soft diffusely
tender to palpation secondary to back pain. Extremities,
palpable radial pulses. Unable to palpate dorsalis pedis
pulse or posterior tibial pulses in the lower extremities.
Lower extremities are very sensitive to touch. Palms
erythematous.
HOSPITAL COURSE: The patient underwent transoral excision of
cystic lesion with occipital to cervical C2 fusion. There
were no intraoperative complications. Postoperatively, the
patient remained intubated and sedated in the Surgical
Intensive Care Unit. She was arousable and moving all
extremities. Postop day one she continued to be intubated
and sedated. Pupils were 4 down to 3 mm. She was following
commands. No clonus. Toes down going bilaterally. Dressing
was clean, dry and intact. The patient was extubated on
[**2200-10-19**]. She was awake, alert and oriented times three.
Her motor strength, she was 5- out of 5 in the right deltoid,
5- out of 5 at the right triceps, IP were 5 out of 5, AT 5
out of 5 on the right side. On the left side she was 4+ in
the deltoids and triceps and 5 out of 5 in the IP and AT.
She had no clonus. Her drain was discontinued. Dressing was
changed. The patient was transferred to the regular floor
with C collar in place. She had a feeding tube in place and
was started on tube feedings. She is NPO for ten days
postop. She was out of bed ambulating with physical therapy
and occupational therapy and found to require rehab prior to
discharge to home.
Her vital signs remained stable. She was afebrile. Her
speech, dysarthria was improving. Her pain control was
improved. Extraocular muscles are intact. Mouth symmetric.
Wrist, hand grasps were 5 out of 5 bilaterally. She had
improved motor strength in the lower extremities. As of
[**2200-10-23**] she is still five days to remain NPO for an
additional five days. She has a feeding tube in place. She
will follow up with Dr. [**Last Name (STitle) 1327**] in ten days postop for staple
removal and also follow up in ten to fourteen days with Dr.
[**Last Name (STitle) 24956**] at [**Hospital 4415**]. Her vital signs have
remained stable.
MEDICATIONS ON DISCHARGE: Zantac 150 mg per G tube b.i.d.,
Dilaudid 2 to 4 mg per G tube q 3 to 4 hours prn, Colace 100
mg per G tube b.i.d., Tylenol 650 po pr q 4 hours prn. She
is on Impact with fiber at 60 cc an hour, which is her goal.
Her vital signs have remained stable. She has been afebrile.
Neurologically improving. She is stable at the time of
discharge.
[**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2200-10-23**] 08:43
T: [**2200-10-23**] 09:14
JOB#: [**Job Number 24957**]
|
[
"715.90",
"553.3",
"443.0",
"721.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.4",
"81.03"
] |
icd9pcs
|
[
[
[]
]
] |
3441, 4055
|
1569, 3414
|
825, 958
|
981, 1551
|
162, 727
|
750, 801
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,919
| 155,386
|
47197
|
Discharge summary
|
report
|
Admission Date: [**2185-6-12**] Discharge Date: [**2185-6-15**]
Date of Birth: [**2145-10-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
respiratory distress in setting of trach tube dislodgement
Major Surgical or Invasive Procedure:
PROCEDURE:
1. Flexible bronchoscopy.
2. Serial dilation of tracheostomy tract with Hegar
dilators.
3. Placement of 7.0 long flexible [**Last Name (un) 295**] tracheostomy tube.
4. Placement left femoral arterial line
History of Present Illness:
39 y/o male with hx of Prader-Willi syndrome, DM type II, morbid
obesity, CRI, OSA, hypothyroidism admitted for failed trach tube
change (attempt to change to down-sized trach tube) at rehab.
Pt recently in the [**Hospital Ward Name 332**] MICU for 3 weeks and developed
unspecified hypercarbic respiratory failure, required intubation
and was then never able to extubate so tracheotomy tube was
placed. At rehab on POD #9 s/p trach placement trach tube
change attempted, dislodged, went into respitory distress with
high PIPs (in the 60s) on the vent. Patient had CXR that was
reported to have no PNA but that new tube likely too small. At
[**Hospital 882**] hospital patient was bag masked for 1.5 hours and if
trach moved difficult to bag mask, sent to [**Hospital1 18**] was unable to
be intubated in ED. He was sent to OR were he was intubated
through his nose by thoracic surgery.
Past Medical History:
Prader Willi Syndrome
Morbid Obesity
DM II
CRI w/ baseline creatinine 1.8-2
OSA on home cpap
Mental retardation
Hypothyroidism
Social History:
Patient lived in group home, came from rehab this time. Patient
denies any smoking, ethanol or drug use. Intermittently
sexually active with a female partner.
Family History:
Positive family history for diabetes.
Physical Exam:
On admission:
PE: T 96 HR 75 BP 146/89 RR 20 AC 400/20 PEEP 5 FiO2 100% O2sat
1005
Gen: Intubated sedated, morbidly obese
Heent: PERRL. anicteric sclera Nasotracheal tube,
Neck: Trach in place
Lungs: CTA B/L ant and Lat
Cardiac: RRR S1/S2 no murmurs
Abdomen: obese, +BS, PEG in place
Ext: warm, 1+ pitting edema upto shin, L brachial PICC
Neuro: sedated able to move extremities before sedation
Pertinent Results:
CXR ([**6-13**])
FINDINGS: A tracheostomy overlies the trachea 5 cm above the
carina at the level of the clavicles. No pneumothoraces are
present. Otherwise the study is unchanged with significant
bilateral airspace opacities. Spine hardware is also present.
Left subclavian central line is unchanged in position.
IMPRESSION: Successful tracheostomy.
[**2185-6-12**] 03:43PM GLUCOSE-115* UREA N-45* CREAT-1.3* SODIUM-142
POTASSIUM-5.7* CHLORIDE-100 TOTAL CO2-37* ANION GAP-11
[**2185-6-12**] 03:43PM CK(CPK)-25*
[**2185-6-12**] 03:43PM CALCIUM-8.4 PHOSPHATE-3.1 MAGNESIUM-2.0
[**2185-6-12**] 03:43PM URINE HOURS-RANDOM CREAT-40.0 SODIUM-63
POTASSIUM-22
[**2185-6-12**] 03:43PM WBC-12.3* RBC-3.75* HGB-8.9* HCT-31.3* MCV-84
MCH-23.8* MCHC-28.5* RDW-18.8*
[**2185-6-12**] 03:57AM TYPE-[**Last Name (un) **] PO2-54* PCO2-84* PH-7.30* TOTAL
CO2-43* BASE XS-11
[**2185-6-12**] 03:57AM TYPE-[**Last Name (un) **] PO2-54* PCO2-84* PH-7.30* TOTAL
CO2-43* BASE XS-11
[**2185-6-12**] 02:45AM URINE COLOR-Yellow APPEAR-SlHazy SP [**Last Name (un) 155**]-1.012
[**2185-6-12**] 02:45AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM
[**2185-6-12**] 02:45AM URINE RBC-[**4-3**]* WBC-0-2 BACTERIA-NONE
YEAST-RARE EPI-<1
[**2185-6-12**] 02:34AM WBC-14.3* RBC-3.56* HGB-8.4* HCT-29.8* MCV-84
MCH-23.5* MCHC-28.1* RDW-19.4*
[**2185-6-12**] 02:34AM PLT COUNT-255
[**2185-6-11**] 10:30PM PLT SMR-NORMAL PLT COUNT-273
[**2185-6-11**] 10:30PM PT-14.5* PTT-26.1 INR(PT)-1.3*
[**2185-6-15**] 03:31AM BLOOD WBC-10.8 RBC-3.30* Hgb-7.8* Hct-26.3*
MCV-80* MCH-23.6* MCHC-29.6* RDW-19.3* Plt Ct-289
[**2185-6-11**] 10:30PM BLOOD Neuts-72* Bands-1 Lymphs-9* Monos-13*
Eos-2 Baso-1 Atyps-0 Metas-2* Myelos-0
[**2185-6-15**] 03:31AM BLOOD Plt Ct-289
[**2185-6-15**] 03:31AM BLOOD Glucose-166* UreaN-39* Creat-1.4* Na-145
K-4.9 Cl-104 HCO3-37* AnGap-9
[**2185-6-12**] 03:43PM BLOOD CK(CPK)-25*
[**2185-6-15**] 03:31AM BLOOD Calcium-7.8* Phos-3.7 Mg-1.9
Brief Hospital Course:
A/P: 39 y/o M with hx of Prader-Willi syndrome, DM2, CRI, OSA,
who presented in respiratory failure after trach changed at
rehab.
.
## Respiratory failure in setting of trach tube dislodgement.
His respiratoty status was stable with nasotracheal intubation.
Pt was taken to OR on Monday [**6-10**] for definitive change of
trach.
Pt taken to OR - Please see operative note:
"Flexible bronchoscopy was then done through the tracheostomy
tube and it was apparent that the tracheostomy was placed
into the mediastinum anterior to the trachea. When I pulled
the tracheostomy tube back, I was able to see the anterior
opening into the trachea that we had done at the original
operation. We performed flexible bronchoscopy via the
nasotracheal tube as well for toilet and additionally to give
us some guidance. We serially dilated the tract using Hegar
dilators up to 14 size. I then took a 7.0 tracheostomy tube
over the top of the bronchoscope and then had the
anesthesiologist withdraw the nasotracheal tube with a
flexible bronchoscope within that as well. I was not able to
easily slide the 7.0 [**Last Name (un) 295**] trach tube into the lumen over
the bronchoscope. Therefore, I replaced the bronchoscope
with an obturator and attempted again with the obturator in
place. At this point, it slide very easily into the tracheal
lumen. Confirmed placement with chest rising, end-tidal CO2,
as well as bronchoscopically. We then performed a toilet
bronchoscopy to the segmental level bilaterally."
.
## ARF: Stably elevated at 1.4, baseline 0.9. FeNa<1 which
suggests prerenal, although not improving with hydation. Cr
should continue to be monitored.
.
## Hyperkalemia:
Patient K+ noted to be elevated at OSH. Received dosed of
kayexelate early in course, as remained stable at slightly
elevated levels with stable renal function and no EKG changes,
tolerated borderline high levels of K w/u treatment on last few
days.
.
## Diabetes - Insulin drip early in course, transitioned to home
standing regimen
.
## Anemia - Patient previous anemia showed AOCD. Patient Hct
currently at baseline.
.
## Hypothyroidisim - stable on levothyroxine
.
## HTN - Was continued on metoprolol 25mg tid, no difficulty
with hypertension
Medications on Admission:
Heparin (Porcine) 5,000 TID
Senna 8.6 mg PO BID
Docusate Sodium 150 mg/15 mL PO BID
Nystatin 100,000 unit/mL Suspension (5) ML PO BID
Miconazole Nitrate 2 % Powder prn
Lactulose 10 g/15 mL Thirty (30) ML PO Q6H
Nexium
Tramadol 50 q12
Levothyroxine 125 mcg PO DAILY
Metoprolol Tartrate 25 mg PO TID
Acetaminophen 325 mg prn
Insulin Glargine 15U am and RISS
Vit C [**Hospital1 **]
MVI
Zinc Sulfate
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q4H (every 4 hours) as needed.
2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4)
Puff Inhalation Q6H (every 6 hours).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
4. Lantus 100 unit/mL Solution Sig: Fifteen (15) units
Subcutaneous once a day: give in am.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
7. Esomeprazole Magnesium 40 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day.
8. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
11. Ascorbic Acid 90 mg/mL Drops Sig: Five Hundred (500) mg PO
BID (2 times a day).
12. Therapeutic Multivitamin Liquid Sig: Five (5) ml PO
DAILY (Daily). ml
13. Regular Insulin
14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 3 days.
15. Keflex 250 mg Capsule Sig: One (1) Capsule PO every six (6)
hours for 3 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
tracheostomy tube dislodgement
Prader Willi Syndrome
Morbid Obesity
DM II
CRI w/ baseline creatinine 1.8-2
OSA on home cpap
Mental retardation
Hypothyroidism
Discharge Condition:
stable
Discharge Instructions:
Pt had a 7 french bovina trach tube placed. This may not be
removed until after [**7-14**]. Continue Levofloxacin and Flagyl
until [**6-17**] for prophylaxis of mediastinitis s/p new trach
tube placement.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8386**], M.D. Date/Time:[**2185-7-5**] 4:30
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"250.00",
"518.81",
"584.9",
"278.01",
"519.02",
"403.91",
"759.81",
"E878.3",
"585.9",
"780.57",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.21",
"96.71",
"97.23",
"96.04",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
8300, 8373
|
4361, 6593
|
375, 602
|
8575, 8584
|
2335, 4338
|
8838, 9085
|
1865, 1904
|
7040, 8277
|
8394, 8554
|
6619, 7017
|
8608, 8815
|
1919, 1919
|
277, 337
|
630, 1519
|
1933, 2316
|
1541, 1670
|
1686, 1849
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,971
| 123,389
|
12187+56337
|
Discharge summary
|
report+addendum
|
Admission Date: [**2102-2-22**] Discharge Date: [**2102-3-1**]
Date of Birth: [**2031-2-23**] Sex: F
Service: CARDIOTHOR
HISTORY OF THE PRESENT ILLNESS: This is a 70-year-old female
with exertional and rest chest tightness. She first noticed
exertional dyspnea in [**2099**]. The patient denied symptoms of
paroxysmal nocturnal dyspnea, orthopnea, light headedness,
pedal edema. The patient had a Myoview done
[**1-12**], [**2101**], where she exercised for eight minutes to
91% of maximal predicted heart rate. She experienced chest
tightness and the EKG revealed 1-mm ST depression from V3 to
V6.
PAST MEDICAL HISTORY: History revealed type 2 diabetes
mellitus, elevated lipids, question claudication.
PAST SURGICAL HISTORY: None.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Aspirin 81 mg q.d.
2. Pravachol 40 mg q.d.
3. Actos 45 mg q.d.
4. Atenolol 25 mg q.d.
5. Zantac 150 mg b.i.d.
6. Cholestyramine packets one b.i.d.
CATHETERIZATION: Please see report for full details. In
summary, the ejection fraction was 60%, distal LAD 80%, OM1
60%, RCA 80%. DLMCA 50%.
It was decided that the patient be brought to the operating
room and this was done on [**2102-2-23**]. A coronary
artery bypass graft times three was performed with the LIMA
to the LAD, and saphenous vein graft to the OM, distal right
CEA. Bypass time was 74 minutes and cross-clamp time was 41
minutes. The patient was brought to the ICU on a
Neosynephrine drip. She was rapidly extubated in the ICU.
The Neosynephrine was appropriately weaned on postoperative
day #1. On postoperative day #2, the patient was A paced and
stable for transfer to the floor. On postoperative day #3,
the chest tubes were removed due to minimal output and no air
leak. The chest x-ray revealed no pneumothorax and no
consolidations or effusions.
On postoperative day #4, the patient had an episode of rapid
atrial fibrillation, which lasted for approximately three
hours. The patient was rate controlled with IV Lopressor and
orally loaded with Amiodarone.
On postoperative day #5, the patient's wires were
discontinued. By postoperative day #6, the patient was
ambulating at a level 5 status and tolerating a regular diet
well.
CONDITION ON DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
1. Lopressor 25 mg p.o. b.i.d.
2. Lasix 20 mg p.o. b.i.d. times 7 days.
3. Potassium chloride 20 mEq p.o.b.i.d. times 7 days.
4. Aspirin 325 mg q.d.
5. Actos 45 mg p.o.q.d.
6. Percocet 1-2 tablets p.o.q.4-6h.p.r.n.
7. Colace 100 mg p.o.b.i.d.
8. Amiodarone 400 mg t.i.d. times four days; then 400 mg
b.i.d. times 7 days; then 400 mg q.d. times 14 days.
DISCHARGE STATUS: Home. The patient will followup with the
Primary care physician and cardiologist in three weeks and
Dr. [**Last Name (STitle) 1290**] in four weeks.
DIAGNOSIS: Status post coronary artery bypass graft times
four.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 1308**]
MEDQUIST36
D: [**2102-3-1**] 10:13
T: [**2102-3-1**] 10:15
JOB#: [**Job Number **]
Name: [**Known lastname 3654**], [**Known firstname **] Unit No: [**Numeric Identifier 6883**]
Admission Date: [**2102-2-22**] Discharge Date:
Date of Birth: [**2031-2-23**] Sex: F
Service:
Patient's physical exam upon discharge: Her cor was regular,
rate, and rhythm. Lungs are clear to auscultation
bilaterally. Sternum stable with no drainage. Extremities:
No edema.
DISCHARGE LABORATORIES:
White count 5.1, hematocrit 30.7, platelets 244,000. Sodium
138, potassium 4.1, chloride 100, bicarb 32, BUN 10,
creatinine 0.6, glucose 109.
DR [**Last Name (STitle) **] [**Last Name (STitle) **] [**Name (STitle) **] 02.351
Dictated By:[**Name8 (MD) 1561**]
MEDQUIST36
D: [**2102-3-1**] 10:17
T: [**2102-3-1**] 10:27
JOB#: [**Job Number 6884**]
|
[
"427.31",
"414.01",
"272.0",
"413.9",
"440.21",
"250.00",
"429.9",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"88.53",
"39.61",
"36.12",
"37.22",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
2296, 3375
|
757, 2239
|
3406, 3959
|
649, 733
|
2264, 2273
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,613
| 199,140
|
31650
|
Discharge summary
|
report
|
Admission Date: [**2111-2-12**] Discharge Date: [**2111-2-17**]
Date of Birth: [**2035-8-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
raspy voice, difficulty swallowing
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 9464**] is a 75 yo M w/ metastatic papillary thyroid cancer
awaiting palliative XRT. Patient spoke on the phone with his
endocrinologist yesterday and was noted to have a "raspy and
breathless" voice, and was asked to come to the emergency room
for evaluation. A recent MRI shows progression of his thyroid
cancer with metastatic disease.
He reports that since [**2-9**] he has had hoarseness of his voice and
increased swelling in his neck. He reports some "hard swallows"
but denies odynophagia. He has no dyspnea. In addition, he has
had a dry cough x 1 week accompanied by fatigue, malaise,
anorexia, fever to 101F at home, chills, and sweats. Has had
occ. headaches denies facial plethora.
.
In the ED, his vitals were T98.7 P104 Bp 141/85 RR 18 O2 94% RA.
He was seen by surgery in the ED who recommended further imaging
of the neck mass via ultrasound or CT as there was a question of
whether it was cystic in nature. Ultrasound showed no drainable
fluid collection. He had a CXR which showed some evidence of
tracheal deviation (known issue). He received ceftriaxone and IV
steroids and admitted to the [**Hospital Unit Name 153**] for close monitoring of
respiratory status given planned neck irradiation and potential
for airway compromise due to edema.
Past Medical History:
Papillary thyroid cancer dx [**2111**] right neck mass
--s/p neck mass resection [**7-13**]; unable to perform thyroidectomy
[**2-7**] high bleed risk, proximity to trachea and recurrent
laryngeal nerve and large tumor size
--s/p XRT to neck [**11-13**]
--s/p RAI ablation
--Metastatic to lymph nodes and adrenal glands
* s/p hernia repair
* s/p tonsillectomy
Social History:
Lives with wife.
Family History:
NC
Physical Exam:
VS: T: 97 BP: 116/70 P: 64 RR: 20 O2 sat: 95% on RA
Gen: Thin elderly man in no acute distress
HEENT: Mild facial plethora, + injection, EOMI, OP clear, MMM,
neck supple, nontender anterior mass surrounding scar from
previous thyroidectomy with overlying erythema, no fluctuance
CV: Regular rate S1 S2 no m/r/g
Lungs: Clear bilaterally no wheezing, rales, rhonchi. Breathing
comfortably on room air, speaking full sentences without
accessory muscle use.
Abd: Soft, nontender, ND, + bowel sounds
Ext: Warm, well perfused, + 2 DP pulses BL
Neuro: Alert, interactive, sensory exam intact, strength 5/5 in
upper and lower extremities BL
Brief Hospital Course:
#Tumor with obstruction: Started on steroids and radiation with
good effect. Swallowing and voice improved. Discharged to
continue radiation as outpatient, as well as steroids.
#Hypothyroid: Started Levoxyl at dose suggested by endocrine
consult team.
Discharge Medications:
1. Prednisone 10 mg Tablet Sig: 1-5 Tablets PO once a day: 5
tabs/day for 3 days, then 4/day for 3 days, then 3/day for 3
days, then 2/day for 3 days, then 1/day for 3 days .
Disp:*45 Tablet(s)* Refills:*0*
2. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day for 3 weeks.
Disp:*21 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Levoxyl 100 mcg Tablet Sig: One (1) Tablet PO once a day: NO
SUBSTITUTIONS.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
thyroid cancer
Discharge Condition:
stable
Discharge Instructions:
Please follow up with your endocrinologist. Take the prednisone
steroid and continue radiation. You will slowly decrease the
dose of steroids (prednisone). You will also take prilosec
(omeprazole) to protect your stomach while on prednisone.
Please start new medication levoxyl for your thyroid.
Followup Instructions:
Continue radiation as according to the schedule given by
radiation oncology.
Follow up with endocrinologist as planned.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
Completed by:[**2111-2-24**]
|
[
"198.89",
"193",
"519.8",
"197.3",
"198.7",
"197.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"92.29"
] |
icd9pcs
|
[
[
[]
]
] |
3586, 3635
|
2784, 3040
|
350, 357
|
3694, 3703
|
4051, 4325
|
2107, 2111
|
3063, 3563
|
3656, 3673
|
3727, 4028
|
2126, 2761
|
276, 312
|
385, 1673
|
1695, 2057
|
2073, 2091
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,860
| 122,841
|
14415
|
Discharge summary
|
report
|
Admission Date: [**2197-6-10**] Discharge Date: [**2197-6-18**]
Date of Birth: [**2125-3-15**] Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 4616**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Mr. [**Known lastname **] is a 72 yo M with COPD and stage 1 Lung Ca who
presented to [**Hospital1 18**] with cough and dyspnea at rest. BIPAP was
attempted but failed, he desaturated, showed signs of fatigue,
was intubated and transfered to the ICU. He had a new LBBB on
EKG but cardiac enzymes were negative and so cardiology thought
LBBB was [**1-11**] COPD exacerbation and PNA. He was initially treated
with Ceftriaxone and Levofloxacin for PNA. He received a BAL
which revelaed to organisms but was significant for blood. ABx
regimen changed to include Vancomycin because of concern for
necrotizing PNA caused by kleb or staph. PEEP was lowered and
his LBBB resolved, cardiac markers continued to be negative.
While in ICU his Hct dropped from 35->27, guiac was negative. He
received 20mg Lasix yesterday and was negative 1L, overall
during ICU admission he was positive 2L. He has been in and out
of A.Fib with RVR into 120s which responded to IV lopressor. EKG
revealed t-wave inversions in III and aVF, but again cardiac
enzymes continued to be negative. Vancomycin course completed
but he will be on Ceftriaxone for 2 more days. Of note, patient
was extubated [**2197-6-13**], has been saturating in low 90s on RA, at
times requiring 2L NC and/or face mask. He is also being viral
screened and is on droplet precautions.
Past Medical History:
1. CNS lymphoma - followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**]
-Dx'd by biopsy on [**2188-6-4**] - B-cell CD20+ CNS lymphoma
-Tx'd w/methotrexate high dose IV and intrathecal
-Relapse [**8-11**] tx'd w/induction Rituxan and temozolomide
immunotherapy
-Completed 12 cycles of maintenance temozolomide chemotherapy
[**8-13**]
2. Polymyalgia rheumatica
3. Stage I seminoma in the right testicle treated with
orchiectomy and
irradiation in [**2159**]
4. Waldenstrom's macroglobulinemia - per notes stable. His serum
IgM
from [**2191-2-17**] was 432 (range 20-230). + hypogammaglobulinemia
5. Squamous Cell Carcinoma of the Skin: followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**]
s/p electron-beam irradiation for squamous cell carcinoma to
his right neck and mid-back from [**2190-12-28**] to [**2191-1-27**].
6. Bronchiectasis and Granulomatous Lung Mass: [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 217**], M.D.
7. Neurocognitive Dysfunction: Stable on Ritalin LA and Namenda.
8. Low Testosterone on adrogel
9. S/p DVT, IVC placement on lovenox therapy
10. Bovine atrial valve replacement 3 yrs ago at [**Hospital1 112**]
Social History:
Patient lives with his wife and son. [**Name (NI) **] manages auto dealership.
He has >60 pkyr smoking history, quit 20 yrs ago. He ~30yrs ago
he previously was a heavy drinker but now drinks one to two
alcoholic drinks a month. He denies illicit drug use. His only
exposure history is that related to radiation that he had for
his squamous cell and seminoma.
Family History:
Father died of colon cancer at the age of 80. Mother died of CVA
at the age of 94. No family history of lung cancer.
Physical Exam:
General: Alert, oriented, no acute distress, using accessory
muscles to breath
HEENT: Sclera anicteric, PERRL, MMdry, oropharynx clear
Neck: supple, JVD flat, no LAD
Lungs: Diffuse rhonchi throughout R>L, crackles and wheezes at
the left base
CV: RRR, loud S1, nl S2, no murmurs, rubs, gallops
Abdomen: +BS, soft, non-tender, distended, no rebound tenderness
or guarding, no organomegaly
GU: + foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, CN 2-12 intact
Discharge PE: ******
VS*******
GEN: Well nourished male, laying in bed, pleasant and in good
humor. He is AOx3, comfortable but appears to be in some
respiratory distress.
HEENT: Scar and noticeable deformity over R parietal bone where
Omaya reservoir placed. PERRL. MMM. no LAD. no JVD. neck supple.
No cervical, supraclavicular, or axillary LAD.
Cards: heart sounds difficult to appreciate because of diffuse.
Heart sounds RR S1, S2 clear and of good quality. no
murmurs/gallops/rubs appreciated
Pulm: On 1L NS saturating in mid 90s. On auscultation he has
diffuse inspiratory stridor, coarse rhonchi throughout R>L and
end expiratory wheezes R>L. Crackles not appreciated on exam.
Using accessory muscles. There is a large radiation scar over R
upper back.
Abd: BS+, soft, NT, ND, no rebound/guarding, no HSM, no [**Doctor Last Name 515**]
sign
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: There are many ecchymoses throughout
Neuro: CNs II-XII intact. 5/5 strength in U/L extremities. DTRs
2+ BL. sensation intact to LT, gait deferred.
Pertinent Results:
Admission Labs:
[**2197-6-10**] 09:30PM WBC-8.3 RBC-4.83 HGB-13.9* HCT-42.1 MCV-87
MCH-28.7 MCHC-32.9 RDW-15.8*
[**2197-6-10**] 09:30PM NEUTS-87.2* LYMPHS-8.7* MONOS-1.9* EOS-1.7
BASOS-0.5
[**2197-6-10**] 09:30PM GLUCOSE-177* UREA N-34* CREAT-1.2 SODIUM-140
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-26 ANION GAP-16
[**2197-6-10**] 09:36PM LACTATE-2.1*
[**2197-6-10**] 09:36PM PO2-45* PCO2-54* PH-7.30* TOTAL CO2-28 BASE
XS-0 COMMENTS-GREEN TOP
[**2197-6-10**] 10:20PM TYPE-ART O2-50 PO2-89 PCO2-38 PH-7.40 TOTAL
CO2-24 BASE XS-0 INTUBATED-NOT INTUBA
[**2197-6-10**] 10:45PM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
[**2197-6-10**] 10:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2197-6-10**] 10:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
CE Trend:
[**2197-6-10**] 09:30PM BLOOD cTropnT-<0.01
[**2197-6-11**] 03:15AM BLOOD CK-MB-3 cTropnT-<0.01
[**2197-6-11**] 04:22PM BLOOD CK-MB-4 cTropnT-<0.01
[**2197-6-11**] 11:36PM BLOOD CK-MB-4 cTropnT-<0.01
[**2197-6-14**] 01:01AM BLOOD CK-MB-3 cTropnT-<0.01
Discharge Labs: **************
Results:
[**6-17**] CXR: Bilateral pleural effusions, right greater than left
are probably unchanged allowing the difference in positioning of
the patient. Cardiomediastinal contours are unchanged. Patient
is status post right upper lobectomy. There is no evident
pneumothorax. Left lower lobe opacities consistent with
pneumonia are unchanged. Opacities in the left mid lung are
worsening likely due to another focus of infection. Right lower
lobe opacity has worsened, most likely due to worsening large
area of atelectasis. Sternal wires are aligned. Patient is
status post aortic valve replacement.
Brief Hospital Course:
Mr. [**Known lastname **] is a 72 yo M with COPD and stage 1 Lung Ca who
presented to [**Hospital1 18**] with cough and dyspnea at rest. BIPAP was
attempted but failed, he desaturated, showed signs of fatigue,
was intubated and transfered to the ICU. He had a new LBBB on
EKG but cardiac enzymes were negative and so cardiology thought
LBBB was [**1-11**] COPD exacerbation and PNA. He was initially treated
with Ceftriaxone and Levofloxacin for PNA. He received a BAL
which revelaed no organisms but was significant for blood. ABx
regimen changed to include Vancomycin because of concern for
necrotizing PNA caused by kleb or staph. PEEP was lowered and
his LBBB resolved, cardiac markers continued to be negative.
While in ICU his Hct dropped from 35->27, guiac was negative. He
was in and out of A.Fib with RVR into 120s which responded to IV
lopressor in ICU. EKG revealed t-wave inversions in III and aVF,
but again cardiac enzymes continued to be negative.
Vancomycin/Ceftriaxone/Levofloxacin course completed
(3day/5d/5d). He was extubated [**2197-6-13**]. On the floor he was
weaned off oxygen and continuous O2 monitoring until he was mid
90s on 1L with only occasional desat with exertion.
# Respiratory failure/Hypoxia: Came to the floor S/P intubation
for increasing respiratory distress and fatigue while on Bipap.
Respiratory failure was likely [**1-11**] CAP given left shift,
infiltrate seen on CXR and increasing respiratory distress.
Necrotizing PNA caused by kleb or staph could not be r/o in
light of bloody BAL. Pseudomonas less likely without
bronchiectasis and no prior history of resistant organisms or
recent hospitalizations. Nasopharyngeal viral studies were
negative, Blood cultures were negative and sputum cultures
unremarkable. He completed a course of Prednisone and IV
Vanc/Ceftriaxone/Levoflox. A/A nebs for COPD with relief of
wheezes. He was afebrile during admission, without a
leukocytosis and without s/s of PNA. Day before discharge he had
worsening wheezes and occasional desats. ALthough CXR showed ?
new opacities in mid lung, he was afebrile, there was no change
in cough character and recently completed abx -- therefore,
repeat abx course deferred. He was weaned down to 1L NC with
only occasional desats. The patient was able to ambulate around
the floor multiple times a day and stated that he felt
significantly improved. Patient knows to call with any pulmonary
changes
#Episode of Afib: associated w/ TWI in III and AVF and a RBBB.
Pt has h/o Aflutter and RBBB is seen on EKG from [**2197-5-15**].
Asymptomatic. Trops and CK-MBs have been negative x5. He was
kept on full dose aspirin (325) as he was treated as an
outpatient per family coumadin was not started in past because
?bleeding while on it in past. Restarted on Dilt in addition to
metoprolol per outpatient regimen. He converted into A. Flutter
but had some hypotensin and bradycardia. Dilt reduced to 120mg
instead of 360mg and he tolerated that better.Ritalin was also
decreased on discharge. Discussed plan with cardiology, who
agreed.
#Anemia: HCT from 42 on admission to 35 and then to 29. there
was no clear source of bleeding, guaic negative, but he was
having some bloody secretions previously (BAL)and a slow
pulmonary bleed might be contributing. He was hemodynamically
stable for duration of admission except for duol nodal blocker
effect and his H/H remained stable.
# Acute kidney injury: Seems to be resolved in ICU, likely
pre-renal in setting of infection. [**Last Name (un) **] resolved with IVF
boluses. Will continue to monitor
#COPD: We continued home regimen A/A nebs (see above. He was
discharged on Symbicort, and Spiriva with as needed albuterol.
#HTN: Well controlled, we continued home meds Metoprolol and
Dilt but went down on Dilt as above.
#History of DVT: Legs appeared symmetric without pain. DVT
filter in place. Aspirin and pneumoboots continued. Heparin was
not started because of dropping H/H and history of bloody
secretions.
Transitional Issues:
- ?Opacity in left mid lung on CXR after abx course without
clinical signs of infection:If he does show new signs of PNA or
clinical status changes he should be covered with Vanc/Cefepime
for HAP/pseudomonas.
- Pt asked to follow up with cardiology for ass titrating his
BP/nodal blocking meds
- Pt to f/u with Dr. [**Last Name (STitle) 724**] r.e decreasing Ritalin to 40 from 55
and history of mental status changes when off of Ritalin.
Consider using Provigil instead for less cardiac irritation.
-Reassess need for home oxygen and titration of COPD medications
as tolerated.
Medications on Admission:
albuterol sulfate 90 mcg HFA Aerosol Inhaler 2 puffs inh q6h prn
sob
alendronate 35 mg Tablet one Tablet(s) by mouth one tab weekly
budesonide-formoterol 160 mcg-4.5 mcg 2 puffs inh [**Hospital1 **]
citalopram 40 mg Tablet daily
diltiazem HCl 360 mg Capsule, ER daily
fluticasone 50 mcg Spray, 2 spray(s) each nostril daily
gabapentin 300 mg Capsule 1 Capsule(s) by mouth evening
levothyroxine 25 mcg Tablet once a day
Namenda 10 mg Tablet by mouth twice a day
nr methylphenidate 20 mg Tablet ER 2 Tablet(s) by mouth daily
nr methylphenidate [Ritalin] 5 mg Tablet 2 Tablet(s) by mouth
[**Hospital1 **] metoprolol tartrate 50 mg Tablet by mouth twice daily
pantoprazole 40 mg Tablet, Delayed Release by mouth daily
rivastigmine 1.5 mg Capsule 3 Capsule(s) by mouth qAM, 2 caps
qPM
rosuvastatin 40 mg Tablet by mouth daily
nr testosterone 50 mg/5 gram (1 %) Gel 25 mg transdermally DAILY
tiotropium bromide 18 mcg Capsule inh once a day
aspirin 325 mg Tablet by mouth daily
cholecalciferol (vitamin D3) 2,000 unit Capsule 2 capsules daily
nr multivitamin [Multiple Vitamin]
.
Allergies: Bactrim
Discharge Medications:
1. Home Oxygen
Please provide home Oxygen at 2-3L continuous
2. citalopram 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).
3. gabapentin 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO HS (at
bedtime).
4. levothyroxine 25 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
5. memantine 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
6. metoprolol tartrate 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID
(2 times a day).
7. rivastigmine 1.5 mg Capsule [**Hospital1 **]: Three (3) Capsule PO qAM ().
8. rivastigmine 3 mg Capsule [**Hospital1 **]: One (1) Capsule PO qPM ().
9. rosuvastatin 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
10. aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
11. cholecalciferol (vitamin D3) 1,000 unit Tablet [**Hospital1 **]: Four (4)
Tablet PO DAILY (Daily).
12. multivitamin Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
13. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
14. senna 8.6 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
15. docusate sodium 100 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO BID
(2 times a day).
16. bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
17. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
18. magnesium hydroxide 400 mg/5 mL Suspension [**Last Name (STitle) **]: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
19. methylphenidate 20 mg Tablet Extended Release [**Last Name (STitle) **]: Two (2)
Tablet Extended Release PO DAILYAM ().
Disp:*30 Tablet Extended Release(s)* Refills:*0*
20. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing, sob.
21. diltiazem HCl 120 mg Capsule, Extended Release [**Last Name (STitle) **]: One (1)
Capsule, Extended Release PO DAILY (Daily).
Disp:*15 Capsule, Extended Release(s)* Refills:*0*
22. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler [**Last Name (STitle) **]: Two
(2) puffs Inhalation twice a day.
23. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
[**Last Name (STitle) **]: One (1) capsule Inhalation once a day.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
COPD exacerbation secondary to pneumonia
Atrial Fibrillation / Atrial Flutter
Stage 1 lung cancer
CNS Lymphoma
DVTs
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a great pleasure treating you during your
hospitalization. You were admitted to [**Hospital1 18**] for respiratory
distress. You were treated for a COPD exacerbation secondary to
pneumonia. You did not do well with non-invasive respiratory
therapy initially and had to be intubated. After a stay in the
ICU where you were treated with steroids and antibiotics you
were transfered to the OMED team after extubation for treatment
of penumonia. You were treated with Vancomycin, Ceftriaxone and
Levofloxacin. Your breathing improved but you still required
supplemental oxygen.
The following changes to your medications were made:
- Diltiazem reduced to 120mg PO Daily
- Ritalin reduced to 40mg PO Daily
- No other changes were made to your home medications, please
continue to take your home medications as prescribed.
- Please see your outpatient cardiologist to titrate your
Diltiazem
Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2197-6-21**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2003**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**State **]When: WEDNESDAY [**2197-6-28**] at 2:40 PM
With: [**First Name11 (Name Pattern1) 312**] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 2205**]
Building: [**State **] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
Department: PULMONARY FUNCTION LAB
When: MONDAY [**2197-10-23**] at 10:40 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"V46.2",
"518.81",
"276.2",
"491.21",
"486",
"427.31",
"V10.47",
"273.3",
"V10.11",
"584.9",
"202.80",
"725"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"96.04",
"96.71",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
15108, 15157
|
6805, 10788
|
288, 301
|
15317, 15317
|
5025, 5025
|
16448, 17323
|
3330, 3448
|
12536, 15085
|
15178, 15296
|
11416, 12513
|
15500, 16425
|
6160, 6782
|
3463, 3961
|
10809, 11390
|
3975, 5006
|
229, 250
|
329, 1662
|
5041, 6144
|
15332, 15476
|
1684, 2934
|
2950, 3314
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,389
| 176,340
|
53723
|
Discharge summary
|
report
|
Admission Date: [**2111-5-14**] Discharge Date: [**2111-5-28**]
Date of Birth: [**2047-3-13**] Sex: M
Service: NEUROLOGY
Allergies:
Plavix / Dofetilide
Attending:[**First Name3 (LF) 21193**]
Chief Complaint:
CC:[**CC Contact Info 110287**]
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI:asked to eval this 64 year old white male with extensive PMH
on coumadin for SDH. Pt states he hit his head on a low ceiling
2
days ago. Denies LOC at that time or since. Denies N/V,
seizure, visula changes. Today he noted that his speech was
slurred so he drove himself to his PCP's office. Was brought in
by ambulance from PCP [**Name Initial (PRE) 3726**]. CT scan shows right sided SDH with
interhemispheric component.
Past Medical History:
1. CAD: s/p CABG in [**2098**] (LIMA to LAD, SVG to OM1, SVG to PDA)
-[**2109**] echo: EF 20%, MR [**First Name (Titles) **] [**Last Name (Titles) **]
-[**12-11**] stress: negative, though stopped [**1-9**] fatigue
-[**12/2102**] cath: stenting of the proximal SVG-RCA lesion, angio-jet
thrombectomy of the thrombotic occlusion SVG-OM graft, stenting
of the mid-graft and ostial graft SVG-OM lesions
-[**10/2102**] cath: done for recurrent angina showed severe native
vessel disease, a patent LIMA with a 40% stenosis in the LAD
distal to the touchdown, a proximal 50% stenosis in the SVG to
RCA, and a mid 50% stenosis in the SVG to the OM branch.
-[**2098**]: Coronary artery bypass graft x 3,including one arterial
and two saphenous vein anastomoses, left internal mammary artery
to the left anterior descending coronary artery, saphenous vein
graft to first obtuse marginal, saphenous vein graft to
posterior descending coronary artery.
2. type II diabetes mellitus.
3. Hypertension.
4. Hypercholesterolemia
5. CRI
6. BiV [**Year (4 digits) 3941**] placed in [**12-11**] for low EF, generator changed (DDD
45-120) on [**2110-2-7**]
7. Enterococcal bacteremia- admitted [**4-12**]
8. Afib- started on Coumadin [**2-11**].
Social History:
Denies smoking and drinking. He works as a cab driver. Lives
alone. There is no history of alcohol abuse.
Family History:
Father died at 59 years with diabetic complications. Mother
died at 77 years. She had a coronary artery bypass graft in her
mid 50s. Brother had a coronary artery bypass graft at the age
of 53.
Physical Exam:
PHYSICAL EXAM:
O: T:afebrile BP:116 / 68 HR: 74 R 18 O2Sats95%
Gen: WD/WN, comfortable, NAD.
HEENT: NCAT Pupils: ERRL EOMI
Extrem: venous stasis changes to lower extremeties.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech slurred with good comprehension and repetition.
Naming intact.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: right facial noted (slight), sensation intact and
symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius difficult to assess/ (pt
s/p sz at present and attempting to participate.
XII: Tongue slight left deviation
Motor: Normal bulk and tone bilaterally. Strength full power
[**3-12**]
throughout (?participartion). ? left pronator drift
Toes downgoing bilaterally
no clonus
Pertinent Results:
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2111-5-14**] 10:22 PM
CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN
Reason: S/P 2 SEIZURES, KNOWN SDH. ? EXPANSION.
[**Hospital 93**] MEDICAL CONDITION:
64 year old man with SDH, now s/p 2 seizures
REASON FOR THIS EXAMINATION:
eval for expansion
CONTRAINDICATIONS for IV CONTRAST: None.
STUDY: CT head without contrast.
INDICATION: 64-year-old male with subdural hematoma status post
two seizures, evaluate for expansion.
COMPARISON: [**5-14**], two hours prior.
TECHNIQUE: CT head without IV contrast.
FINDINGS: Again noted is a hyperattenuating collection along the
right cerebral convexity and layering adjacent to the right side
of the falx cerebri and tentorium cerebelli, consistent with an
acute subdural hematoma. There has been no appreciable increase
in mass effect from this collection. The major intracranial
cisterns are preserved and there is no evidence of
transtentorial or uncal herniation. There is no hydrocephalus or
evidence of intraventricular extension of blood products. Again
noted is opacification of the right maxillary sinus. There is
some hyperdensity of the central components in this sinus-
inspissated secretions or hemorrhage could both be considered.
IMPRESSION: No significant increase in acute subdural hematoma
or mass effect.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**Doctor Last Name 4391**]
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9987**]
Approved: FRI [**2111-5-15**] 9:26 AM
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2111-5-19**] 10:14 AM
CT HEAD W/O CONTRAST
Reason: change in mental status, decreased L sided movement
[**Hospital 93**] MEDICAL CONDITION:
64 year old man with
REASON FOR THIS EXAMINATION:
change in mental status, decreased L sided movement
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 64-year-old man with change in mental status and
decreased left-sided movement.
TECHNIQUE: Non-contrast head CT scan.
COMPARISON STUDY: Numerous prior head CT scans, the last having
been obtained on [**5-17**].
FINDINGS: There is continued demonstration of the longitudinally
extensive acute subdural hemorrhage covering the right cerebral
convexity surface, with a subtentorial component as well as a
parafalcine component. Overall, there seems little progression
in extent of the subdural hemorrhage. There is minor compression
of the right lateral ventricular body, not overtly changed
compared to the prior examination. There is no definite
subfalcine or uncal herniation noted at this time. There is
continued near complete opacification of the right maxillary
sinus. No other new extracranial abnormality discerned.
CONCLUSION: Stable but very extensive right cerebral hemispheric
acute subdural hemorrhage as noted above.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9987**]
Approved: TUE [**2111-5-19**] 4:32 PM
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2111-5-18**] 12:52 PM
CHEST (PORTABLE AP)
Reason: s/p change of ETT. confirm placement
[**Hospital 93**] MEDICAL CONDITION:
64 year old man with SDH, intubated for decreased mental status.
NGT replaced
REASON FOR THIS EXAMINATION:
s/p change of ETT. confirm placement
INDICATION: Endotracheal tube placement for decreased mental
status.
CHEST, ONE VIEW: Comparison with [**2111-5-16**], among multiple
previous other studies. Endotracheal tube, nasogastric tube,
triple-lead biventricular defibrillator, and nasogastric tube
are unchanged in position. Heart shadow is enlarged but
unchanged. Midline sternotomy wires, clips, and stent along the
left heart border are unchanged. Bilateral perihilar fullness,
bilateral small pleural effusions, and left lower lobe
atelectasis are similar to the last examination. Osseous
structures are also unchanged.
IMPRESSION: Similar appearance of mild pulmonary edema,
bilateral small pleural effusions, and left lower lobe
atelectasis.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: TUE [**2111-5-19**] 6:43 AM
RADIOLOGY Final Report
UNILAT UP EXT VEINS US LEFT PORT [**2111-5-17**] 1:35 PM
UNILAT UP EXT VEINS US LEFT PO
Reason: SWELLING ASSESS FOR CLOT
[**Hospital 93**] MEDICAL CONDITION:
64 year old man with subdural hematoma. left arm swelling
REASON FOR THIS EXAMINATION:
Assess for clot
INDICATION: 64-year-old male with subdural hematoma and left arm
swelling. Please assess for clot.
FINDINGS: [**Doctor Last Name **] scale, color and pulse wave Doppler son[**Name (NI) 1417**]
were performed of the left internal jugular, subclavian,
axillary, brachial, and basilic veins. Normal flow,
compressibility, waveforms, and augmentation is demonstrated. No
intraluminal thrombus is identified.
IMPRESSION: No evidence of DVT in the left upper extremity.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5718**]
DR. [**First Name (STitle) 3934**] [**Name (STitle) 3935**]
Approved: MON [**2111-5-18**] 10:50 AM
Brief Hospital Course:
Neurology: Patient was admitted to Neurosurgery service for
acute SDH after presentation to PCP for slurred speech. His INR
on admission was 3.9 with nml platelets. This was actively
reversed with Profiline 9, Vit K and FFP. He was admitted to the
ICU / neurosurgical service for observation. While in ED, the
patient had 3 generalized tonic clonic seizures and patient was
given a Dilantin load. He had one seizure after this with in the
24 hour period (no Dilantin post load level checked) and Keppra
was started. The LP was neg for infection with CSF cx NGTD.
Patient was noted to be very somulent and was intubated on HOD 2
for airway protection. He was noted to be more alert on the
following days and EEG done on [**2111-5-19**] showed showed global
encephalopathy without active or subclinical sz. Patient was
monitored closely in Neuro ICU because of noted right cerebral
edema though minimal midline shift noted. No neurosurgical
intervention recommended. Neurology was consulted and
recommended Glycerol and Mannitol which was started. The patient
became slightly more alert in the ICU and was able to be
extubated by HOD #7. He was then transferred to the Neurology
Service Step down unit where he was noted to have a wax and
[**Doctor Last Name 688**] alertness. His Mannitol was weaned off slowly. All
sedating medications were discontinued and metabolic work-up
revealed increased pulmonary edema. The patient's mental status
gradually improved but follow-up head CT on [**5-24**] showed evidence
of increased right cerebral edema with new 8 mm midline shift.
Neurosurgery was notified and again no surgical intervention
recommended. His neurological exam has been followed closely and
it was felt patient was staying alert, awake, oriented, and
interactive. No change in motor or sensory exam. He was seen
with PT/OT which recommended acute rehab needs. He will also
benefit from speech therapy as well.
Patient had repeat EEG on [**2111-5-28**] which showed generalized
slowing consistent with encephalopathy. The patient's Keppra was
decreased to 1250 mg po BID and Dilantin should continue at 100
mg po tid
CV: Patient has known EF 15-20% and biventricular [**Date Range 3941**] in place.
Baseline SBP per PCP is [**Name Initial (PRE) **] 80s to low 100s. He had some
evidence of worsening pulmonary edema on CXRs and was treated
with Lasix and Bumex standing medications. Last CXR was [**2111-5-25**]
which showed increased pulmonary edema and Bumex was increased 2
mg po qday. On [**2111-5-28**], patient respiratory exam was stable and
he was being titrated down for 35% face mask to room air.
FEN/GI: Patient had multiple failed swallow studies for
somulence. During this time patient was on NG tube feeds of
Nutrin pulmonary at goal 60cc hour with free water flushes. On
[**2111-5-26**], patient was finally alert enough to have a video
swallow which revealed that though patient was impulsive, he
could tolerate purees and thin liquids with crushed meds. One to
one supervision with his diet is recommended. With
encouragement, the patient is taking good oral intake.
ID: Patient had UCX on [**5-26**]/o7 which grew coag negative staph.
No treatment initiated.
Endo: Patient was on NPH 10 units in the AM and 10 units qhs and
insulin sliding scale. On [**2111-5-28**] early AM, he had one low fs of
50 and NPH dose was decreased by half. It may be prudent to
decrease NPH dosing to half doses in rehab while patient working
on oral feeds and following fingersticks closely.
Social: Health Care proxy is daughter [**Name (NI) **].
Medications on Admission:
Medications prior to admission:
coumadin 3mg / 3 tabs qd
coreg 3.125 mg [**Hospital1 **]
lipitor 20 daily
ASA 325 daily
amioderone 200 qd
bumex 2mg [**Hospital1 **]
ativan .5 qd-[**Hospital1 **] prn
lantus 22units at bedtime
zantac 150 i tab daily
humulin R [**5-15**] [**Hospital1 **]
Potassium Chloride 10 Meq, 3 tabs QD
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Acetaminophen 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain.
3. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
4. Amiodarone 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
5. Carvedilol 3.125 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day).
6. Senna 8.6 mg Capsule [**Hospital1 **]: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
7. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: [**12-9**] PO BID (2 times a
day) as needed for constipation.
8. Phenytoin 100 mg/4 mL Suspension [**Month/Day (2) **]: One (1) PO TID (3
times a day).
9. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Month/Day (2) **]: One (1)
Inhalation Q4-6H (every 4 to 6 hours) as needed for wheezing.
10. Ipratropium Bromide 0.02 % Solution [**Month/Day (2) **]: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
12. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection TID (3 times a day).
13. Furosemide 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
14. Bumetanide 2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
15. Levetiracetam 500 mg Tablet [**Last Name (STitle) **]: 2.5 Tablets PO BID (2 times
a day).
16. Insulin Regular Human 100 unit/mL Cartridge [**Last Name (STitle) **]: sliding
scale Injection qac and qhs: sliding scale per your
institution.
17. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Cartridge
[**Last Name (STitle) **]: Ten (10) units Subcutaneous twice a day: Would use 1/2 dose
if patient not taking good po or NPO.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
right subdural hematoma
Discharge Condition:
neurologically patient has left arm hemiparesis with proximal
0/5 delt, [**1-12**] triceps, [**1-12**] biceps, 0/5 WE, [**1-12**] WF and 5-/5 grip.
He has [**1-12**] hip flexion and [**1-12**] quads, triple flexes with stim on
left.
Discharge Instructions:
Weigh yourself every morning, call PMD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
You have a seizure disorder after your brain injury. No bathing,
swimming alone. Avoid heights. By Massachusettes Law, you cannot
drive 6 months after last seizure activity.
Followup Instructions:
1. call Dr. [**Last Name (STitle) 548**] for an appointment to be seen in 4 weeks with
a CT scan of your brain. [**Telephone/Fax (1) **]
2. Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 902**]
Date/Time:[**2111-6-4**] 2:40
Provider: [**Name10 (NameIs) 3941**] CALL TRANSMISSIONS Phone:[**Telephone/Fax (1) 59**]
Date/Time:[**2111-7-27**] 11:30
3. Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**]
Date/Time:[**2111-9-28**] 3:00 pm
4. [**Hospital 878**] Clinic Provider: [**Name Initial (NameIs) 540**]/[**Doctor Last Name **]
Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2111-7-8**] 4:30 pm
[**Name6 (MD) 3523**] [**Name8 (MD) 3524**] MD [**MD Number(2) 21196**]
|
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45,277
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31250
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Discharge summary
|
report
|
Admission Date: [**2191-2-9**] Discharge Date: [**2191-2-16**]
Date of Birth: [**2143-2-4**] Sex: M
Service: MEDICINE
Allergies:
Ibuprofen / Codeine
Attending:[**First Name3 (LF) 2290**]
Chief Complaint:
CC: nausea, vomiting, DKA
Reason for MICU transfer: acute kidney injury with recent kidney
transplant
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Mr. [**Known lastname 9449**] is a 48 yo male with history of Type I DM,
hypertension, and ESRD s/p living unrelated transplant [**8-31**] who
presented to [**Hospital3 36606**] Hospital on [**2-7**] with DKA. He was
initially found by his mother at his home nauseous, vomiting,
and unable to maintain adequate po intake. On arrival to the
OSH his BS was 500's. He was admitted to the ICU for treatment
of DKA on an insulin gtt as well as sepsis. He received a dose
of vanc in the ED and was started on zosyn.
.
He was lethargic on presentation which worsened in the setting
of receiving his home pain and antianxiety medications, so on
[**2-8**] he was intubated for airway protection. On [**2-8**] his pH
dropped to 6.9 and bicarb was 15 so he was started on a bicarb
gtt with improvement in his pH. His hospital course was also
complicated by acute kidney injury with his most recent BUN/Cr
of 77/4.6 (baseline Cr 1.7-2.0). Prograf level was noted to be
elevated. Renal was consulted and he underwent a transplant
ultrasound which was normal. He was briefly off the insulin gtt
on [**2-8**], however his sugars climbed back up and he was placed
back on the insulin gtt. He was also noted to have a trop bump
to 0.28 with EKG showing no acute ischmic changes. TTE was
performed which showed EF of 60-65%, but did show a focal wall
abnormality. Cardiology was consulted who recommended treating
him emprically for CAD once DKA resolved. He was tachycardic in
the 100's so he was started on IV lopressor. Additionally he
has a leukocytosis to 19.6 and CXR showing a LLL PNA so he is
being treated for HAP with zosyn and vanc. He was on PS 5/5
prior to transfer and his main barrier to extubation was mental
status (per report he gets agitated and does not follow commands
so hasn't been able to be extubated).
.
On arrival to the MICU he was intubated and sedated. He no
longer had the insulin gtt running, but did have a bicarbonate
gtt.
.
Unable to obtain a ROS as the patient is intubated.
Past Medical History:
1. End-stage renal disease secondary to diabetes s/p living
unrelated transplant in [**8-31**]
2. Type 1 diabetes since the age of 18.
3. Hypercholesterolemia.
4. Hypertension for at least ten years.
5. Hepatitis C which he knew about in [**2187-4-22**]. It is most
likely acquired by IV drug abuse in his early 20s.
6. Anemia
7. Retinopathy
8. s/p appendectomy
9. s/p nerve reconstruction of his right fifth finger.
10. Arthroscopic surgery on his left knee after a major trauma.
11. Osteoporosis
12. Testosterone deficiency
13. Anxiety
Social History:
(per medical records)
He lives with his mother. [**Name (NI) **] works as a mechanical engineer.
He is a former smoker. No drug use, social alcohol use.
Family History:
(per MEDICAL RECORDS) Negative for kidney disease, kidney
stones, and CAD. His mother has COPD and developed diabetes late
in her life.
Physical Exam:
GEN: intubated, doesn't follow commands.
HEENT: PERRL, anicteric, ETT in place
RESP: Coarse breath sounds present bilaterally anteriorly.
CV: RRR, no MRG
ABD:+BS, soft, NTND, well-healed scar present in the lower
abdomen.
EXT: no c/c/e, 2+DP
SKIN: no rashes/no jaundice/no splinters
NEURO: sedated. moves all extremities spontaneously.
Pertinent Results:
[**2191-2-9**] 11:12PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2191-2-9**] 11:12PM URINE BLOOD-LG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2191-2-9**] 11:12PM URINE RBC-[**3-26**]* WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2191-2-9**] 09:27PM GLUCOSE-127* UREA N-72* CREAT-4.3*#
SODIUM-148* POTASSIUM-3.8 CHLORIDE-114* TOTAL CO2-20* ANION
GAP-18
[**2191-2-9**] 09:27PM ALT(SGPT)-70* AST(SGOT)-58* LD(LDH)-221
CK(CPK)-99 ALK PHOS-140* TOT BILI-0.7
[**2191-2-9**] 09:27PM ALBUMIN-3.6 CALCIUM-9.3 PHOSPHATE-4.7*#
MAGNESIUM-2.0
[**2191-2-9**] 09:27PM VANCO-9.9*
[**2191-2-9**] 09:27PM URINE HOURS-RANDOM CREAT-62 SODIUM-61
POTASSIUM-31 CHLORIDE-59
[**2191-2-9**] 09:27PM URINE OSMOLAL-400
[**2191-2-9**] 09:27PM WBC-12.1*# RBC-3.96* HGB-11.9* HCT-35.9*
MCV-91 MCH-30.0 MCHC-33.2 RDW-14.1
[**2191-2-9**] 09:27PM NEUTS-94.5* LYMPHS-2.7* MONOS-2.5 EOS-0.1
BASOS-0.1
[**2191-2-9**] 09:27PM PLT COUNT-101*
[**2191-2-9**] 09:27PM PT-14.2* PTT-33.5 INR(PT)-1.2*
[**2191-2-9**] 09:27PM URINE EOS-NEGATIVE
Labs at OSH:
tacro level [**2-7**] - 38.5
[**2-8**]
Na 142 K 2.9 Cl 110 Bicarb 14 BUN 73 Cr 4.0
Alb 3.8 Tprot 6.6 Tbili 0.5 AST 85 ALT 84 Alk phos 160
CK 333 Trop 0.382
[**2-9**]
Na 149 K 3.3 Cl 115 Bicarb 20 BUN 71 Cr 4.5
Ca 9.4 Mg 2.2 Phos 4.0
CBC 19.6 Hct 28.5 Plt 166
EKG: normal sinus rhythm, nl axis, nl intervals, poor R wave
progression. No STE or STD. Unchanged from previous EKG.
.
Micro:
OSH
UA [**2-8**] 4 WBC, 20 RBC, 3 granular casts, neg nitrites, pos leuk
esterase, 1+ ketones
BCx [**2-7**] - NGTD
Sputum cx [**2-8**] - yeast
.
Imaging:
OSH:
TTE [**2-8**]:
EF 60-65%, normal biventricular systolic function with
inferobasilar wall motion abnormality. Unremarkable cardiac
valves. Dilated IVC.
.
Renal US [**2-8**]:
Unremarkable transplant renal ultrasound with normal arterial
waveforms. Renal artery and vein are patent.
.
CXR [**2-7**]:
Mild interstital pulmonary edema
.
Head CT [**2-7**]:
No evidence of acute infarction, hemorrhage, or mass lesion.
.
CXR [**2-9**] ([**Hospital1 18**]):
left basilar [**Doctor Last Name **], ETT needs to be advanced 2-3 cm. NG tube in
place.
.
[**2-10**] Transplant ultrasound:
1. No hydronephrosis and no perinephric fluid collection seen at
the site of the transplant kidney. Small simple renal cyst.
2. Patent renal transplant vasculature with appropriate
waveforms.
Brief Hospital Course:
Mr [**Known lastname 9449**] is a 48 yoM with PMH ESRD s/p renal transplant
[**8-/2190**], IDDM, HCV, chronic pain, who was admitted to the ICU at
[**Hospital1 18**] after transfer from saints hospital for managment of
diabetic ketoacidosis.
# Diabetic ketoacidosis/Insulin dependent diabetes: Patient
initially presented to [**Hospital **] hospital with DKA after 1-2 days
of nausea and vomiting and inability to tolerate PO intake. At
saints hospital, he was treated with an insulin drip, and the
anion gap closed and he had been transitioned to basal and
parandial insulin at the time of transfer. Following transfer,
he re-developed hyperglycemia with anion gap and the insulin
drip was resumed until the anion gap closed. [**Last Name (un) **] was
consulted who assisted in management of insulin regimen while in
hospital. After transfer to the medical floor, patient reported
food and fluid restriction prior to admission with a targed
finger stick glucose of 70 (which had been set by the patient).
He was seen by nutrition and counseled on diabetic diet and
appropirate glucose targets. He was normalized on a
basal/prandial insulin regimen and discharged with close follow
up with his PCP. [**Name10 (NameIs) **] was reluctant to return to the [**Last Name (un) 387**] as an
outpatient but agreed to take their phone number and make an
appointment if he changed his mind.
.
# Acute kidney injury/ESRD s/p living related transplant:
Baseline Cr is 1.7-2.0. Cr elevated at [**Doctor Last Name 15594**] Hospital with
creatinine here initially 4.3. Patient was reportedly oliguric
at [**Doctor Last Name 15594**] Hospital, but making urine at the time of transfer.
FeNa was calculated at 2% suggesting prerenal etiology, he was
treated with intervenous fluids and creatinine returned to
baseline. US of renal transplant was unremarkable. The renal
transplant team consulted and felt his ARF may be due to a
combination of ATN from the DKA and PNA as well as tacrolimus
toxicity. Tacrolimus level was high on admission and this was
held. According to renal recommendations tacrolimus was changed
to sirolimus which was started in the morning of [**2-13**]. He was
continued on his home cellcept and bactrim and discharged with a
plan for close follow up with Dr. [**Last Name (STitle) **], his renal
transplant physician.
.
# Respiratory status: Prior to transfer, patient was intubated
for airway protection in the setting of lethargy which is
believed to be related to impaired clearance of outpatient pain
and anti-anxiety medications in the setting of renal failure
(see below). Chest films from [**Doctor Last Name 15594**] hospital showed LLL
infiltrate and he was covered with with vanc/zosyn for
healthcare associated pneumonia, and completed an 8 day course.
His ventilator settings were gradually weaned and he was
extubated on [**2191-2-11**]. Sputum cultures grew yeast which is
believed to be a contaminant.
.
# Lethargy/decreased mental status: The patient was reported
to be lethargic upon presentation to [**Doctor Last Name 15594**] Hospital was
intubated for airway protection. Given high dose outpatient
narcotic regiment and presentation with acute on chronic renal
insufficiency, lethargy is believed to be related to impaired
clearance of outpatient narcotics and benzodiazepines. Head CT
in the [**Doctor Last Name 15594**] hospital was negative. Narcotics and
benzodiazepines were minimized. His sedation was weaned and
after extubation his mental status slowly improved. He was
re-started on benzodiazepines (which he takes at home). In
house, his narcotic requirement was lower than outpatient and he
was discharged with a lower dose of MS contin and oxycodone,
both in limited prescription. He was discharged with a plan for
close followup with his PCP to titrate pain regimen.
.
# Elevated CK/trop at [**Doctor Last Name 15594**] Hospital: Patient with a mildly
elevated trop in setting of renal failure at [**Doctor Last Name 15594**] hospital
without EKG changes, TTE showed a focal wall motion abnormality
of undetermined age cardiology consulted at [**Doctor Last Name 15594**] hospital who
did not believe that presentation was consistent with ACS and
recommended medical treatment for CAD since patient has DMI for
many years and is at risk for early CAD. ECGs remained
unchanged and cardiac enzymes remained flat. He was started on
metoprolol and asprin as well as high dose statin, however, his
lfts trended up and statin was discontinued. The addition of ACE
inhibitors was avoided in the setting of renal insufficiency. ON
discharge, it is recommended that he follow up with his PCP [**Last Name (NamePattern4) **]:
repeating his TTE versus a stress test to risk stratify him and
guide the medical management of his CAD. He was started on
metoprolol and aspirin which were continued at the time of
discharge.
.
# Widened mediastinum: Initially CXR read as widened
mediastinum, however, patient had had prior scans with
lymphadenopathy and had no clinical evidence of aortic
dissection. Serial chest xrays revealed stable mediastinal
width. It is recommended that he have a chest CT in followup.
.
# Hypernatremia: Was initially hypernatremic on admission
which resolved with intervenousfluids.
.
# Mild transaminitis: Patient had a mild transamnitis at the
[**Doctor Last Name 15594**] Hospital and has known Hepatitis C. No evidence of
synthetic dysfunction. LFTs were slightly higher on repeat check
and his atorvastatin was discontinued. At the time of discharge,
his AST/ALT remained mildly elevated at 44/30 respectively.
Atorvastatin was held at discharge, he should have his LFTs
checked again before resuming this medication.
.
# Thrombocytopenia: Plt of 100 on admission here with a
baseline aroudn 170's and trended down to nadir of 74 although
he had been on SQH there was low suspicion for HIT. Renal
consultants felt he may have tacrolimus induced thrombotic
microangiopathy, as haptoglobin was low and LDH was elevated.
However, smear was reviewed by heme service who did not see
evidence of hemolytic anemia. Tacrolimus was changed to
sirolimus and platelets increased to low 200's at the time of
discharge.
.
# Chronic anemia: Hct at baseline. No clinical evidence of
bleeding, may be related to renal disease however colonoscopy is
recommended to evalate for occult malignancy in this middle aged
male.
.
# Chronic pain: He received fetanyl gtt while intubated. Once
extubated and mental status stabilized his pain reqirement was
relatively low and he was discharged with a limited prescription
for MS contin 30mg [**Hospital1 **] and oxycodone 5mg Q4 PRN. He will follow
up with his PCP regarding titration of his pain medication.
.
# Anxiety: His citalopram was continued and ambien, trazodone,
and xanax were held while intubated. Once extubated he was kept
on IV ativan while unable to take POs and then transitioned back
to his home regimen.
.
# Testosterone deficiency: Continued androderm patch 5mg/24h
q24h
.
# Osteoporosis: Patient is on alendronate 70 mg po qweekly. He
was continued Ca/Vit
and alendronate was resumed at the time of discharge.
.
Comm: brother, [**Name (NI) **] [**Name (NI) 9449**], [**Telephone/Fax (1) 73738**]
mother, [**Name (NI) **] [**Name (NI) 9449**] [**Telephone/Fax (1) 73739**]
Code: Full code
.
Medications on Admission:
Alendronate 70 mg po every week
Alprazolam 0.5 mg po tid prn
Citalopram 30 mg po daily
Lantus 10 units qam and 4 units qpm
Humalog sliding scale
Morphine SR 100 mg po bid
Morphine IR 30mg PO bid
Mycophenolate mofetil 1000 mg po bid
Omeprazole 40 mg po bid
oxycodone 15-25 mg po q4h prn
polyethylene glycol 17g daily
Bactrim 400-80 mg po daily
tacrolimus 5 mg po bid
Androderm patch 5mg/24h q24h
trazodone 200 mg po qhs
Ambien 10 mg po qhs prn
Calcium/VitD
Discharge Medications:
1. Outpatient Lab Work
Please draw sirolimus trough (morning level prior to dose) on
Friday [**2-18**] and fax results to Dr. [**First Name (STitle) **] [**Name (STitle) **] at ([**Telephone/Fax (1) 28179**].
2. Androderm 5 mg/24 hr Patch 24 hr Sig: One (1) Transdermal
once a day.
3. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
4. duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. insulin glargine 100 unit/mL Cartridge Sig: as directed
Subcutaneous twice a day: Take 12 units every am and 6 units
every pm.
6. insulin lispro 100 unit/mL Cartridge Sig: as directed
Subcutaneous four times a day: see attached sliding scale.
7. morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*10 Tablet Sustained Release(s)* Refills:*0*
8. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*15 Tablet(s)* Refills:*0*
11. polyethylene glycol 3350 17 gram/dose Powder Sig: 17 grams
PO DAILY (Daily).
12. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. sirolimus 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily).
Disp:*120 Tablet(s)* Refills:*0*
14. calcium carbonate 400 mg (1,000 mg) Tablet, Chewable Sig:
One (1) Tablet, Chewable PO three times a day.
15. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*0*
16. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
17. alprazolam 0.5 mg Tablet Sig: One (1) Tablet PO three times
a day as needed for anxiety.
Disp:*15 Tablet(s)* Refills:*0*
18. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Diabetic ketoacidosis
Secondary: Acute on chronic renal failure, Delirium, Type 1
diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with DKA (diabetic
ketoacidosis, a consequence of poorly controlled blood sugars).
We adjusted your insulin with the help of the [**Last Name (un) **] diabetes
doctors. You kidney function initially worsened, but is now back
to your baseline.
Please take all medications as prescribed and go to all follow
up appointments. The following medication changes were made:
- Started metoprolol, a medication for your heart that helps
reduce blood pressure
- Started aspirin to protect your heart
- Changed tacrolimus to sirolimus for your kidney transplant
- Stopped your trazodone and zolpidem (Ambien) until you discuss
with your primary care doctor next week
- Increased your glargine (Lantus) insulin and provided a new
Humalog sliding scale
- Decreased your morphine and oxycodone doses as you were overly
sedated when you came in
Followup Instructions:
Please go to your local lab on Friday ([**2191-2-18**]) morning BEFORE
taking your sirolimus dose to have the sirolimus level checked.
This result will be faxed to Dr. [**Last Name (STitle) **].
Name: [**Last Name (LF) 10000**],[**First Name3 (LF) **] J.
Address: [**Location (un) 73740**], [**Apartment Address(1) 31103**], [**Location (un) **],[**Numeric Identifier 73741**]
Phone: [**Telephone/Fax (1) 53192**]
Appt: [**Last Name (LF) 766**], [**2-21**] at 1pm
Department: TRANSPLANT CENTER
When: TUESDAY [**2191-3-8**] at 2:40 PM
With: [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
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"250.13",
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icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
16032, 16038
|
6167, 9125
|
381, 393
|
16192, 16192
|
3692, 6144
|
17232, 17977
|
3183, 3320
|
14004, 16009
|
16059, 16171
|
13523, 13981
|
16343, 17209
|
3335, 3673
|
239, 343
|
421, 2432
|
16207, 16319
|
2454, 2994
|
3010, 3167
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,447
| 128,477
|
12340
|
Discharge summary
|
report
|
Admission Date: [**2136-1-20**] Discharge Date: [**2136-2-14**]
Service: Neurosurgery
CHIEF COMPLAINT: Decreased memory and difficulty finding
words.
HISTORY OF PRESENT ILLNESS: This patient is a 70-year-old
white male, Italian speaking, who presents with complaints
that he feels he cannot remember anything; he states other
than that he feels fine. He indicates he is comfortable with
his family translating at the time of initial visit due to
his Italian speaking language barrier. Family indicates that
the reason he is seen was for the wife having noticed
progressive deterioration of the patient's memory. For
example, on the day that he was seen in the outpatient clinic
he could not remember his daughters' names.
REVIEW OF SYSTEMS: Essentially unremarkable. The patient
denied any fevers, chills, headache, sore throat, ear pain,
earache, visual blurring, cough, shortness of breath, chest
pain, abdominal pain, nausea, vomiting, diarrhea or
constipation. He further denied any dysuria, focal numbness,
weakness or rash.
PAST MEDICAL HISTORY: Coronary artery bypass graft x2
approximately one year prior to admission.
ADMISSION MEDICATIONS:
1. Lisinopril
2. Metoprolol
3. Aspirin
ALLERGIES: He had no known allergies to medications.
SOCIAL HISTORY: He is married with a very supportive family.
He has a positive past history of cigarette smoking.
PHYSICAL EXAMINATION:
GENERAL: Well developed, well nourished Italian speaking
white male in no acute distress. He was alert and
appropriate at the time of his physical exam and he did
indeed exhibit memory loss both to recent and distant events.
As an example, he did not know the President's name, the
mayor of [**Location (un) **] name or his daughters' names.
VITAL SIGNS: Heart rate 66, blood pressure 166/89,
respiratory rate 16, temperature 97.1?????? and O2 saturation was
98%.
HEAD, EARS, EYES, NOSE AND THROAT: Unremarkable.
Extraocular movements were intact. Pupils were equal, round
and reactive to light and accommodation.
NECK: Supple.
HEART: Regular rate and rhythmic without murmurs, rubs or
gallops.
LUNGS: Clear to auscultation bilaterally with no evidence of
wheeze, rales, rhonchi or accessory muscle use.
ABDOMEN: Nontender, soft with no guarding, rebound or mass
appreciated.
NEUROLOGIC: Cranial nerves II through XII intact. Muscle
strength was [**4-15**] in all four extremities. The exam was
severely limited due to fairly poor patient cooperation and
compliance with instructions.
LABORATORY DATE AT THE TIME OF INITIAL ASSESSMENT AT [**Hospital6 **] ON [**1-17**]: Essentially within normal
limits and he was seen at the [**Hospital6 2561**] in
consultation by Dr. [**First Name (STitle) **] [**Name (STitle) 6910**] who made arrangements
for the patient to be transferred and admitted to the [**Hospital1 **] Hospital for a craniotomy on the [**1-20**].
The patient had undergone an MRI prior to transfer from the
[**Hospital3 **]. An MRI showed heterogeneously enhancing lesion
in the left posterior frontal parietal lobe with a smaller
satellite nodule at the left periatrial location abutting the
left lateral ventricle. There was mild mass effect with
effacement of the left lateral ventricle, but no significant
midline shift. Due to these findings and the history of
decreased memory, the patient was admitted to the [**Hospital1 **] Hospital on the morning of [**2136-1-20**] at
which time he was taken to the operating room where, under a
general endotracheal anesthetic, the patient underwent a
craniotomy and subtotal excision of the enhancing lesion.
The patient tolerated the procedure well, went to the post
anesthesia care unit in stable condition and was subsequently
transferred to the floor the morning following surgery and
did quite well on the floor for the first several days. A
repeat head CT scan on the [**1-24**] showed a small
amount of blood products in the area of the tumor bed and
cavity of the tumor with some mild residual ring enhancement.
However, there was no indication for further surgery.
A neuro-oncology consult was obtained on the [**1-25**]
and the patient exhibited a brief episode of unresponsiveness
with a deep drop in his blood pressure to systolics of 70s
while he was sitting on the bed pan for bowel movement. His
oxygen saturation at the time was 91% to 94%. He was placed
supine and quickly became more responsive with the oxygen
saturation returning to 98% to 99%. An electrocardiogram was
done which showed T-wave inversions in lead AVL. He was
placed on telemetry. He otherwise did fine from this and
there were no further electrocardiogram changes.
On the 14th, he was seen in consultation by neuro-oncology
and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] who recommended external beam radiotherapy.
On the morning of the 15th, the patient was noted to
initially be afebrile with vital signs stable. He was awake,
alert and oriented x3. He had a mild to moderate persistence
of a right hemiparesis that was first noted after surgery.
His lungs were clear, however a CTA of the chest was obtained
which did reveal a saddle embolus and therefore the
interventional radiology department was consulted and this
lead to a thrombectomy and IVC filter. The patient tolerated
this procedure quite well, was returned to the floor that
evening in stable condition.
On the morning of the 16th, he had a brief episode of
decreased responsiveness. A head CT was obtained, but showed
no change in the tumor bed or condition of the brain and the
patient became much more responsive later in the day and
remained stable. He was seen in consultation in the x-ray
therapy department on the [**1-31**] for evaluation and
initial planning and measurements for planned external beam
radiotherapy to be begun in an outpatient manner. The
patient remained hospitalized with mildly waxing and [**Doctor Last Name 688**]
responsiveness and alertness. However, on the [**2-6**], due to bouts of respiratory failure, the patient
was intubated urgently and readmitted to the neurosurgical
Intensive Care Unit in acute respiratory distress and after
discussion with the family, the patient was then heparinized
for prophylactic treatment to avoid further risk of deep
venous thrombosis or embolus. He did quite well, was weaned
from the intubation within 48 hours and was transferred to
the floor on the [**2135-2-9**].
He was maintained on heparin until the [**1-16**] with
Lovenox started on the [**1-15**] to overlap for one day
and did well throughout the remainder of his hospitalization.
The patient had been given a PEG tube for tube feedings and
nutritional support prior to discharge and on the morning of
the [**1-16**], he was noted to be awake, alert, afebrile
with vital signs stable. Pupils 3 mm, bilaterally reactive
to 2 mm. He continued to show a right dense hemiparesis, had
a slightly wet cough but with stable O2 saturations in the
mid 90s. He responded with dysarthric speech and again was
noted to speak only Italian, so level of appropriateness was
difficult to obtain without the presence of an interpreter.
The telemetry was discontinued on the 4th and the patient was
subsequently to be discharged to the [**Hospital3 7**]
Rehabilitation Center on the morning of the [**2136-2-14**]
with plans for follow up appointment with Dr. [**Last Name (STitle) 6910**] in
the clinic in approximately three to four weeks time and
instructions for the patient and/or family to call Dr.[**Name (NI) 38469**] office for scheduling of this and also plans
were made for the patient to begin his x-ray therapy as an
outpatient at the [**Hospital1 **] Hospital with plans
for the patient and family or rehabilitation staff to call
and confirm the start date for the outpatient x-ray therapy.
DISCHARGE CONDITION: Stable
DISCHARGE DIAGNOSES:
1. Glioblastoma multiforme of brain
2. Status post saddle emboli, status post embolectomy and
inferior vena cava filter placement.
DISCHARGE MEDICATIONS:
1. Lovenox 60 mg subcutaneous q 12 hours
2. Oxacillin 1 gm intravenous q 12 hours x10 days total
which was begun on the [**2136-2-9**].
3. He was also to take aspirin 81 mg po or per PEG tube qd.
4. Lopressor 50 mg per PEG tube or po bid, but hold
Lopressor if systolic blood pressure less than 110 or heart
rate less than 60.
5. Reglan 10 mg po or PEG tube tid
6. Dilantin 200 mg po or PEG tube [**Hospital1 **]
7. Zantac 150 mg po or PEG tube [**Hospital1 **]
8. Colace 150 mg po or PEG [**Hospital1 **]
9. He was also discharged on tube feedings to include ProMod
with 5 or 75 cc per hour per the PEG tube
Treatment frequencies at the rehabilitation center were to
consist of aggressive physical therapy and occupational
therapy, as well as outpatient x-ray therapy to be done at
the [**Hospital1 **] Hospital. Anticipated goals were
return to full activities of daily living and rehabilitation
potential was considered good at the time of discharge.
[**Name6 (MD) 6911**] [**Name8 (MD) **], MD [**MD Number(1) 6913**]
Dictated By:[**Name8 (MD) 5474**]
MEDQUIST36
D: [**2136-2-13**] 16:42
T: [**2136-2-13**] 18:25
JOB#: [**Job Number 18085**]
|
[
"518.81",
"191.9",
"V45.81",
"415.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59",
"38.93",
"96.71",
"38.7",
"96.04",
"96.6",
"38.91",
"44.39"
] |
icd9pcs
|
[
[
[]
]
] |
7836, 7844
|
7865, 7999
|
8022, 9219
|
1175, 1273
|
1411, 7814
|
761, 1053
|
116, 164
|
193, 741
|
1076, 1152
|
1290, 1389
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
605
| 149,601
|
3968
|
Discharge summary
|
report
|
Admission Date: [**2197-12-4**] Discharge Date: [**2197-12-14**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
blood from trach
Major Surgical or Invasive Procedure:
Bronchoscopy (bedside): small area of injury at main carina
without active bleeding. Blood seen in all segments and cleared
fully. Upon re-inspection return of blood seen and with BAL
progressive bloody return seen.
History of Present Illness:
HPI: Ms. [**Known lastname **] is an 89 yo female with PMH notable for
Alzheimer's disease, depression, paroxysmal afib on coumadin and
recent admission to [**Hospital1 18**] MICU for MRSA pneumonia, Proteus
urosepsis and stenotrophomonas VAP who presents from her rehab
facility with bright red blood from her trach. On [**12-3**] at 1400,
the patient was noted to have blood-tinged secretions. At that
time, labs were obtained and heparin was held. Lasix was also
increased to 40 mg IV BID. At 1500, nurse [**First Name (Titles) 12883**] [**Last Name (Titles) **] blood from
trach. INR noted to be 5.4 with Hct 29.1. Later in the evening
(2300), her nurse [**First Name (Titles) 8706**] [**Last Name (Titles) 17577**] [**Last Name (Titles) **] hemoptysis with hct down
to 23.8; vent settings at that time AC 12X350, peep 5, fio2 40%
with oxygen saturation 93%. CXR showed worsening bilateral
infiltrates by report; she had a CT scan of the chest which
showed At midnight, she was seen by the ICU resident that she
had been treated with 2 U FFP and 5 mg vitamin K. ABG at that
time demonstrated pH 7.46 / pCO2 59 / pO2 77. Due to [**Last Name (Titles) 17577**]
hemoptysis, the patient was transferred back to the [**Hospital1 18**] ICU
for further evaluation and treatment.
.
On arrival to the CCU, the patient has [**Hospital1 **] blood secretions
from her ET tube. She opens eyes to voice and actively opposes
eye opening but otherwise is nonverbal at present.
Past Medical History:
Alzheimer's
Depression
Hypernatremia
Paroxymal Afib
h/o Urinary tract infections
Cholelithiasis
h/o Influenza A/b
Social History:
Permanent resident of [**Hospital3 **] Manor. Chinese speaking only,
Son and daughter active in her life and visit daily.
Family History:
N/A
Physical Exam:
vitals: T 98.9, HR 108, BP 171/88, RR 37, O2 100% on AC 12X400,
PEEP 5, FiO2 60%
gen: lying still with eyes closed, trach in place, no distress
heent: actively opposes eye opening, tongue slightly dry
neck: trach in place with mild bright red ooze surrounding
insertion site
pulm: coarse breath sounds bilaterally, expiratory wheeze R>L
cv: RRR, difficult to hear due to vent noise
abd: firm, no guarding or rebound, hypoactive bowel sounds, no
specific areas of palpation which elicit grimace, PEG tube in
place in LUQ with minimal surrounding erythema
extr: extremities warm, 3+ pitting edema to thighs, bruise on
right hand, R PICC in place
neuro: trached, opens eyes to sound occasionally, actively
opposes eye opening and does not follow other commands
Pertinent Results:
[**2197-12-4**] 02:37AM BLOOD WBC-10.8# RBC-2.09* Hgb-7.2* Hct-20.9*
MCV-100* MCH-34.6* MCHC-34.6 RDW-18.2* Plt Ct-271
[**2197-12-4**] 03:54PM BLOOD Hct-25.4*
[**2197-12-5**] 04:00AM BLOOD WBC-8.9 RBC-2.49* Hgb-8.1* Hct-23.5*
MCV-94 MCH-32.3* MCHC-34.3 RDW-19.5* Plt Ct-228
[**2197-12-5**] 10:53AM BLOOD Hct-22.8*
[**2197-12-5**] 10:53AM BLOOD Hct-22.8*
[**2197-12-5**] 10:00PM BLOOD Hct-25.4*
[**2197-12-6**] 03:32AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.5* Hct-24.0*
MCV-91 MCH-32.0 MCHC-35.4* RDW-18.4* Plt Ct-207
[**2197-12-6**] 03:32AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.5* Hct-24.0*
MCV-91 MCH-32.0 MCHC-35.4* RDW-18.4* Plt Ct-207
[**2197-12-7**] 03:34AM BLOOD WBC-13.5* RBC-2.80* Hgb-9.0* Hct-26.6*
MCV-95 MCH-32.0 MCHC-33.7 RDW-18.3* Plt Ct-280
[**2197-12-8**] 03:56AM BLOOD WBC-11.6* RBC-2.28* Hgb-7.5* Hct-21.6*
MCV-95 MCH-33.1* MCHC-35.0 RDW-18.1* Plt Ct-249
[**2197-12-8**] 05:23AM BLOOD Hct-20.7*
[**2197-12-8**] 03:19PM BLOOD WBC-11.0 RBC-2.83* Hgb-9.1* Hct-25.4*
MCV-90 MCH-32.0 MCHC-35.7* RDW-18.7* Plt Ct-198
[**2197-12-10**] 03:35AM BLOOD WBC-11.8* RBC-3.38* Hgb-10.5* Hct-30.4*
MCV-90 MCH-31.0 MCHC-34.5 RDW-17.4* Plt Ct-192
[**2197-12-4**] 02:37AM BLOOD Neuts-91.5* Lymphs-2.6* Monos-4.2 Eos-1.5
Baso-0.2
[**2197-12-4**] 02:37AM BLOOD PT-23.6* PTT-41.5* INR(PT)-2.3*
[**2197-12-4**] 03:54PM BLOOD PT-16.7* INR(PT)-1.5*
[**2197-12-5**] 04:00AM BLOOD PT-16.1* PTT-34.5 INR(PT)-1.4*
[**2197-12-6**] 03:32AM BLOOD PT-20.9* PTT-35.8* INR(PT)-2.0*
[**2197-12-7**] 03:34AM BLOOD PT-25.3* PTT-32.2 INR(PT)-2.5*
[**2197-12-8**] 03:56AM BLOOD PT-16.4* PTT-28.8 INR(PT)-1.5*
[**2197-12-9**] 03:54AM BLOOD PT-15.5* PTT-30.1 INR(PT)-1.4*
[**2197-12-10**] 03:35AM BLOOD PT-16.5* PTT-28.4 INR(PT)-1.5*
[**2197-12-8**] 05:23AM BLOOD Ret Aut-2.4
[**2197-12-4**] 02:37AM BLOOD Glucose-161* UreaN-32* Creat-1.4* Na-134
K-4.6 Cl-90* HCO3-40* AnGap-9
[**2197-12-5**] 04:00AM BLOOD Glucose-76 UreaN-34* Creat-1.4* Na-136
K-4.8 Cl-91* HCO3-39* AnGap-11
[**2197-12-7**] 03:34AM BLOOD Glucose-132* UreaN-38* Creat-1.9* Na-134
K-5.0 Cl-89* HCO3-42* AnGap-8
[**2197-12-8**] 03:56AM BLOOD Glucose-71 UreaN-43* Creat-2.0* Na-134
K-4.6 Cl-90* HCO3-38* AnGap-11
[**2197-12-10**] 03:35AM BLOOD Glucose-120* UreaN-44* Creat-1.8* Na-137
K-4.0 Cl-93* HCO3-38* AnGap-10
[**2197-12-10**] 06:55PM BLOOD Glucose-133* UreaN-44* Creat-1.7* Na-140
K-4.2 Cl-97 HCO3-40* AnGap-7*
[**2197-12-4**] 02:37AM BLOOD ALT-18 AST-25 LD(LDH)-209 AlkPhos-88
TotBili-0.2
[**2197-12-4**] 02:37AM BLOOD Lipase-54
[**2197-12-4**] 02:37AM BLOOD Albumin-2.6* Calcium-8.5 Phos-4.0# Mg-2.5
[**2197-12-8**] 03:56AM BLOOD Hapto-142
[**2197-12-4**] 03:54PM BLOOD ANCA-NEGATIVE B
[**2197-12-8**] 06:29PM BLOOD Vanco-15.0
[**2197-12-7**] 06:06PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-NEG pH-5.0 Leuks-MOD
[**2197-12-7**] 06:06PM URINE RBC-21-50* WBC-[**6-13**]* Bacteri-MOD
Yeast-NONE Epi-0-2 RenalEp-1
[**2197-12-7**] 06:06PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.017
[**2197-12-7**] 06:06PM URINE CastHy-<1
[**2197-12-7**] 03:02PM URINE Eos-POSITIVE
[**2197-12-7**] 10:27AM URINE Hours-RANDOM UreaN-440 Creat-64 Na-18
Cl-LESS THAN Uric Ac-23.9
[**2197-12-7**] 10:27AM URINE Osmolal-336
.
Micro data:
[**2197-12-4**] 3:56 am BRONCHIAL WASHINGS
**FINAL REPORT [**2197-12-6**]**
GRAM STAIN (Final [**2197-12-4**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2197-12-6**]): ~[**2189**]/ML
OROPHARYNGEAL FLORA.
.
[**2197-12-5**] 9:57 pm CATHETER TIP-IV Source: R arm PICC.
**FINAL REPORT [**2197-12-8**]**
WOUND CULTURE (Final [**2197-12-8**]): No significant growth.
.
[**2197-12-7**] 2:51 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2197-12-8**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2197-12-8**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
Radiographic studies:
[**12-4**] CXR:
IMPRESSION:
1. Developing right upper lobe infiltrate.
2. Continued bilateral pleural effusions with bibasilar
atelectasis.
3. Findings concerning for mild congestive failure.
.
[**12-8**] CT:
IMPRESSION:
1. Migration of gastric tube into the rectus sheath. There is a
clear
connection, however, into the stomach and no evidence for free
air or free
fluid. Repositioning of tube is recommended.
2. No radiographic explanation for falling hematocrit.
3. Multiple incidental findings including right staghorn
calculus, porcelain gallbladder, anasarca, bilateral pleural
effusions with associated atelectasis, and severe
atherosclerotic disease.
.
[**12-9**] CXR:
Compared to the study from the prior day, there is increased
vascular
congestion and increased volume loss in both lower [**Known lastname **]s. An
underlying
infectious infiltrate cannot be excluded. Diffuse alveolar
opacities are
again seen.
.
Brief Hospital Course:
A/P: 89 yo with PMH of alzheimer's dementia, hypernatremia, UTI
presents with AMS, sepsis physiology, UTI, and impressive
hypernatremia.
.
# Blood from trach: Seems from clinical history provided by
rehab that patient's secretions initially were "blood tinged"
and progressed to frankly blood over the course of the day on
[**12-3**]. Her hematocrit in the same time period has decreased from
29-->23.8. Bronchoscopy on arrival to the ICU demonstrated
bloody secretions which did not clear but became progressively
bloodier making diffuse alveolar hemorrhage most likely
diagnosis. However, could also represent lesion near trach
insertion but this is less likely given bronch findings. Was
given 2U PRBC x1 at initial presentation. Held aspirin and
coumadin, reversed INR with FFP, Vitamin K PO, and then Vitamin
K IV for refractory elevated INR. Once INR reversed trach
oozing stoped. ANCA negative, anti-GBM negative.
.
# Anemia: Hct drop x3 since admission. Transfused 3x with 2U of
blood. Initial drop explained by DAH. Hct did not bump
appropriately, found to have melena x1 and repeatedly giauac pos
stool. Melena explained by the PEG gastric wall erosion.
Hemolysis labs negative. Enlarging hematoma in L arm, axilla,
and anterior chest, but likely source of Hct drop. CT showed
no intraperitoneal or retroperitoneal hemorrhage. Hct has been
stable as of [**12-10**].
.
# Respiratory failure: Initial decompensation likely due to
diffuse alveolar hemorrhage, although contribution of underlying
pneumonia, fluid overload, and baseline [**Known lastname **] disease (?) likely
contribute. Of note, during prior admission patient was
unsuccessfully extubated twice and could not be weaned off the
vent after several attempts due to high RISBIs and acidemia.
The patient continued to be ventilator dependent at her rehab
facility and has failed trach mask and low pressure support
ventilation during this admission b/c of very low tidal volumes
(down to 130??????s) which improved after pressure support was
increased from 10 to 20. Patient??????s air movement also did improve
after albuterol nebulizer treatment as per nursing staff. Lasix
boluses initially attempted without much improvement in UOP and
stopped because of rising Cr. Stenotrophomonis pneumonia
treatment course completed. 3+GNR in sputum stain, sputum
culture growing ceftriaxone-sensitive E.coli. Ecoli also
isolated for PEG site culture and Urine culture. Her antibiotic
regimen was adjusted. Lasix drip was again attempted later in
the hospital course with good response in urine output but not
significant improvement in respiratory status. Lasix converted
to IV 60mg TID. Cr and fluid status should continue to be
monitored.
.
# Acute renal failure: Likely related to volume depletion
secondary to blood loss and up titration of lasix at rehab and
in MICU as creatinine has trended up over the past week per
their records Higher bicarbonate level and FeUREA of 34% would
support volume depletion as well. UA w/few eos, rare hyaline
casts reported. Did have hematuria, but difficult to interpret
in setting of indwelling foley, elevated INR. On urine culture
grew ceftriaxone-sensitive E.coli and antibiotic regimen was
adjusted to cover. Last day of ceftriaxone treatment should be
[**2197-12-25**]. Could also represent component of systemic process if
DAH associated with Goodpasture's or Wegener's (however anti-GBM
negative). Staghorn R kidney stone noted on CT could be
contributing. Urine has been progressively more clear and her
urine output has improved on lasix drip. With improved urine
output, lasix drip was stopped and she was started on lasix PO
60mg tid.
.
#UTI: Ecoli with same sensitivity profile as the PEG swab
culture and sputum isolated in urine. Treatment with ceftriaxone
as above. VRE colonized in urine as well.
.
# PEG complications: Erythema/ Pus around peg likely
combination of dermatitis/skin breakdown from pressure of PEG on
skin w/some cellulitic component. Initially improved after 3
days on vanco and after padded bandage placed between PEG and
skin but has worsened over last 48 hours with increasingly
purulent exudate around the tube. Patient also with erosion of
gastric wall around PEG site. Endoscopy by IP showed that peg
balloon still in stomach, was re-positioned to decrease pressure
on wall to better allow for healing. No free intraperitoneal air
was noted on CT. [**12-11**] repeat EGD showed dobbhoff still post
pyloric. Erosion around peg greatly improved. PEG ballon in
place. No stiches needed. Cultures of discharge shown to be
E.coli, also sensitive to ceftriaxone. Vanco was continued to
treat cellulitis- last day [**12-14**] for 10 day course. As per IP
recommendations, PEG to low intermittent suction. CT confirmed
PEG placement, dobhoff placement and r/o free air (final read
pending). Per IP PEG tip is 2cm from stomach wall and should not
be moved for 3 weeks. Tube feeds were restarted via PEG and
well-tolerated.
.
# Paroxysmal afib: The patient was recently started on coumadin
at the rehab facility with INR now > 5 on coumadin 5 mg daily.
CHADs-2 score by my calculation only 1 due to age-not clear that
patient has h/o hypertension or CHF and no documented h/o stroke
or DM. Aspirin and coumadin were held. She has not been on
anti-arrhythmic medications and maintained a good heart rate.
Futher anticoagulation should be avoided
.
# Abdominal distension: NTTP. Has been intermittently present
since admission. Usually resolves with bowel movement. LFTs and
lipase normal. CT w/PEG findings discussed above and porcelain
gallbladder, but no evidence of intraperitoneal bleed or other
intraabdominal process. Further work up of porcelian gallbladder
as outpatient as this is often associated with adenocarcinoma.
.
# Recent Stenotrophomonas VAP: Treated with Bactrim 250 mg IV
q8h, stop date 12/5 per prior d/c summary.
.
# Alzheimer's: cont home meds when using PEG tube. During
admission pt mouths words but will not follow commands. Pt
non-english speaking.
.
# PPx: PPI, heparin SQ& pneumoboots, bowel regimen prn
.
# FEN: TF via PEG.
.
# Code: DNR/DNI, confirmed with son [**Name (NI) **] [**Name (NI) **] who is HCP
.
# Access: Right-sided PICC (placed at [**Hospital1 18**] during previous
admission)
.
# Communication: With patient and son [**Name (NI) **] [**Known lastname 17578**]([**Telephone/Fax (1) 17579**]
cell
.
# Dispo: ICU level care given vent requirement
Medications on Admission:
Meds:
coumadin 5 mg daily
bactrim 250 mg IV q8h (until [**12-7**])
lasix 40 mg IV Qam, 20 mg IV qnoon, 40 mg IV qpm
dulcolax 10 mg po daily
miralax 17 g daily
chlorhexidine mouth wash [**Hospital1 **]
colace 100 mg [**Hospital1 **]
ranitidine 150 mg daily
xopenex nebs q4h and q2h prn
atrovent nebs q4h & q2h prn
neutraphos 1 cap 4X/day X 3 days
K-phos 1 packet q6h X 3 days
vitamin K 5 mg PO X 1
aricept 10 mg daily
memantine 10 mg [**Hospital1 **]
vitamin E 800 U daily
hep sc tid
lactulose 15 ml po daily
ASA 325 mg po daily
miconazole powder [**Hospital1 **] prn
caltrate with vit D 600 U po bid
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
2. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
3. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Six (6)
Puff Inhalation Q6H (every 6 hours).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Two (2) PO BID (2
times a day) as needed.
6. Polyethylene Glycol 3350 100 % Powder [**Hospital1 **]: Seventeen (17) g
PO DAILY (Daily) as needed.
7. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: 2-4 Puffs Inhalation
Q4H (every 4 hours) as needed for wheezing.
8. Lactulose 10 gram/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO Q8H
(every 8 hours) as needed.
9. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed.
10. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) 5000
unit dose Injection TID (3 times a day).
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
12. Metoclopramide 5 mg IV Q6H:PRN
13. 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.
14. CeftriaXONE 1 g IV Q24H
day 1 [**12-12**]
15. 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.
16. Furosemide 60 mg IV Q8H
17. Insulin Lispro 100 unit/mL Solution [**Month/Day (4) **]: 2-10 units
Subcutaneous ASDIR (AS DIRECTED): per humalog isulin sliding
scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
diffuse aveolar hemmorrhage
acute on chronic respiratory failure
Acute renal failure
Gastric erosion secondary to PEG tube
Ecoli Pneumonia
Ecoli UTI
Abdominal cellulitis
End stage dementia
Anemia
paroxysmal Atrial fibrillation
Discharge Condition:
stable, Vent dependent.
Discharge Instructions:
You were admitted to the hospital for bleeding from your
tracheotomy tube. You were found to have diffuse [**Known lastname **] injury
termed diffuse aveolar hemmorhage. The bleeding in your [**Known lastname **]s
was stoped with reversing your coumadin. You were given blood
for your anemia. We have not been able to wean you off the
ventilator.
.
You had acute renal failure from overdiuresis and blood loss. It
has gradually improved. We are now trying to take fluid off with
diuretics.
.
You PEG tube was found to be eroding through your stomach wall.
The tube was repositioned and the erossion has improved. Tube
feeds were resumed.
.
You were found to have E. coli present in your [**Known lastname 17580**], over the
PEG, and in the urine. You are being treated with antibiotics
for the infection.
.
The following pertinent changes were made to your medications.
Coumadin was stoped.
Bactrim course was completed
You were started on Ceftriaxone
.
Please follow up with your doctor as detailed below
.
If you develop presistant fever, return of bloody secretions
from your [**Known lastname 17580**], abdominal pain or return of pus from around the
PEG site, dirrhea, please seek urgent medical attention.
Followup Instructions:
Please call your PCP for follow up within 1-2 weeks after
discharge from rehab.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2197-12-14**]
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[
[
[]
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17034, 17117
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287, 507
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17389, 17415
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3093, 8055
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2294, 2299
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15167, 17011
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17138, 17368
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14543, 15144
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17439, 18653
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2314, 3074
|
231, 249
|
535, 2000
|
2022, 2138
|
2154, 2278
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,757
| 179,091
|
36541
|
Discharge summary
|
report
|
Admission Date: [**2184-7-1**] Discharge Date: [**2184-7-2**]
Date of Birth: [**2114-11-23**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Hematochezia 200cc clots x 2
Major Surgical or Invasive Procedure:
[**7-1**] ex-lap and attempted SMA revascularization
[**7-2**] second look
History of Present Illness:
This 69M was discharged to [**Hospital **] rehab on [**6-29**] s/p AVR/CABG
with Dr. [**Last Name (STitle) 914**] on [**2184-5-31**]. His post-operative course then was
complicated by encephalopathy, ileus, sternal dehiscense, and
pericardial effusion requiring takeback and sternal plating.
This evening he had 2 episodes of
BRBPR of ~200cc each and was transferred to the ED for work up.
He has had diffuse abdominal pain today. His SPB is stable in
the 130's and his Hct is 39. A paracentesis was performed and
acitic fluid was sent for studies. A rectal revealed BRB in the
vault.
Past Medical History:
- Aortic Stenosis/Coronary Artery Disease
- Type II Diabetes Mellitus
- Hypertension
- Cirrhosis, Portal Hypertension, with Splenomegaly, Varices and
Ascites
- Psoriasis
- Cataract Surgery
- AVR and CABG x 2 on [**2184-5-31**]
Social History:
Mr. [**Known lastname 1007**] is a custodian at a retail store. He reports smoking
cigars in the past. He denies drinking alcohol. He lives with
his wife.
Family History:
Noncontributory
Physical Exam:
Admission
PE: VSS
Lungs: Clear
CV: RRR without R/G/M
Abd: soft, diffusely tender to palpation, +BS
Incisions: healing well, sternum stable. JP drain in place.
Neuro: alert, sl. confused
Pertinent Results:
[**2184-7-1**] 09:01AM BLOOD Type-[**Last Name (un) **] pH-7.36 Comment-GREEN TOP
[**2184-7-1**] 01:14PM BLOOD Type-ART pO2-244* pCO2-42 pH-7.17*
calTCO2-16* Base XS--12 Intubat-INTUBATED
[**2184-7-1**] 02:04PM BLOOD Type-ART FiO2-21 pO2-246* pCO2-44
pH-7.26* calTCO2-21 Base XS--6 Intubat-INTUBATED
[**2184-7-1**] 03:01PM BLOOD Type-ART pO2-155* pCO2-46* pH-7.15*
calTCO2-17* Base XS--12 Intubat-INTUBATED
[**2184-7-1**] 05:17PM BLOOD Type-ART pO2-86 pCO2-41 pH-7.24*
calTCO2-18* Base XS--9
[**2184-7-2**] 03:32AM BLOOD Type-ART pO2-79* pCO2-34* pH-7.41
calTCO2-22 Base XS--1
[**2184-7-2**] 08:41AM BLOOD Type-ART pO2-104 pCO2-26* pH-7.43
calTCO2-18* Base XS--4
[**2184-7-2**] 10:09AM BLOOD Type-ART pO2-112* pCO2-25* pH-7.41
calTCO2-16* Base XS--6
[**2184-7-2**] 12:34PM BLOOD Type-ART pO2-158* pCO2-28* pH-7.37
calTCO2-17* Base XS--7
[**2184-7-1**] 03:00AM BLOOD Albumin-2.0* Calcium-8.1* Phos-5.1*
Mg-2.3
[**2184-7-1**] 08:48AM BLOOD Albumin-2.1* Calcium-7.7* Phos-5.1*
Mg-2.1
[**2184-7-1**] 05:03PM BLOOD Albumin-2.1* Calcium-7.8* Phos-5.4*
Mg-1.8
[**2184-7-2**] 03:08AM BLOOD Albumin-2.1* Calcium-7.7* Phos-4.2#
Mg-1.6
[**2184-7-1**] 03:00AM BLOOD ALT-19 AST-38 CK(CPK)-43 AlkPhos-147*
TotBili-5.9*
[**2184-7-1**] 08:48AM BLOOD ALT-16 AST-30 CK(CPK)-41 AlkPhos-128*
TotBili-5.5*
[**2184-7-1**] 05:03PM BLOOD ALT-16 AST-33 AlkPhos-112 TotBili-5.4*
[**2184-7-2**] 03:08AM BLOOD ALT-18 AST-53* AlkPhos-123* TotBili-9.1*
[**2184-7-1**] 03:00AM BLOOD Glucose-129* UreaN-40* Creat-2.1* Na-150*
K-4.0 Cl-115* HCO3-20* AnGap-19
[**2184-7-1**] 05:03PM BLOOD Glucose-88 UreaN-38* Creat-2.0* Na-150*
K-3.7 Cl-117* HCO3-18* AnGap-19
[**2184-7-2**] 03:08AM BLOOD Glucose-113* UreaN-34* Creat-2.1* Na-146*
K-3.8 Cl-111* HCO3-19* AnGap-20
[**2184-7-1**] 03:01AM BLOOD PT-22.4* PTT-38.0* INR(PT)-2.1*
[**2184-7-1**] 05:03PM BLOOD PT-23.8* PTT-150* INR(PT)-2.3*
[**2184-7-1**] 10:15PM BLOOD PT-21.1* PTT-40.6* INR(PT)-2.0*
[**2184-7-2**] 03:08AM BLOOD PT-22.0* PTT-40.3* INR(PT)-2.1*
[**2184-7-1**] 03:00AM BLOOD WBC-17.1*# RBC-3.67* Hgb-11.8* Hct-36.6*
MCV-100* MCH-32.1* MCHC-32.2 RDW-18.2* Plt Ct-244
[**2184-7-2**] 03:08AM BLOOD WBC-13.5* RBC-3.79* Hgb-11.8* Hct-36.7*
MCV-97 MCH-31.1 MCHC-32.1 RDW-18.4* Plt Ct-168
[**2184-7-1**]
1. No findings to account for bright red blood per rectum.
Multiple air-
fluid levels throughout non-dilated loops of small bowel and
colon, which is nonspecific. The stomach is mildly distended and
fluid is noted within the esophagus; the patient may benefit
from an NG tube. No large abdominal mass and no secondary signs
of ischemic bowel.
2. Anasarca with increased ascites and slightly increased right
greater than left pleural effusions.
[**2184-7-1**] EGD Food in the lower third of the esophagus
Erythema and congestion in the whole stomach compatible with
mild portal hypertensive gastropathy Normal mucosa in the
duodenum
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
Admitted to West I surgical service. He received aggressive IV
hydration. Anticoagulants were held due to coagulopathy and GI
bleeding. CT scan was performed which didn't show any source
for the GI bleed. EGD was negative. Due to worsening clinical
status he was brought to the operating room for exploration.
Laparoscopy showed dusky bowel from ligament of treitz to ileum.
The abd was opened and there was no pulse in the SMA. Patient
was brought to the angiography suite and an occlusion of the sma
was visualized via angiogram of the celiac trunk. Multiple
attempts were made to access the SMA but were not successful.
He was brought back to the icu. He was taken back to the OR the
next day for a 2nd look. His bowel looked more dusky and
irrecoverable. Discussions were had with family members and he
was made [**Name (NI) 3225**]. He was disconnected from the ventilator at 6pm and
died at 8:10.
Medications on Admission:
Medications - Prescription
ADALIMUMAB [HUMIRA PEN] - (Prescribed by Other Provider) -
Dosage uncertain
CLOBETASOL - (Prescribed by Other Provider) - Dosage uncertain
GLIPIZIDE - (Prescribed by Other Provider) - 2.5 mg Tablet
Extended Rel 24 hr (2) - 1 (One) Tab(s) by mouth once a day
LISINOPRIL - (Prescribed by Other Provider) - 5 mg Tablet - 1
(One) Tablet(s) by mouth once a day
METFORMIN - (Prescribed by Other Provider) - 500 mg Tablet - 1
(One) Tablet(s) by mouth once a day
METOPROLOL TARTRATE - (Prescribed by Other Provider) - 50 mg
Tablet - 0.5 (One half) Tablet(s) by mouth once a day 25mg
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 1 (One) Capsule(s) by mouth once a day
SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1
(One) Tablet(s) by mouth once a day
Medications - OTC
ASPIRIN - (Prescribed by Other Provider; OTC) - 325 mg Tablet -
0.5 (One half) Tablet(s) by mouth once a day
CALCIUM - (Prescribed by Other Provider) - Dosage uncertain
CYANOCOBALAMIN - (Prescribed by Other Provider) - 1,000 mcg
Tablet Sustained Release - 1 (One) Tablet(s) by mouth once a day
FERROUS SULFATE - (Prescribed by Other Provider) - 325 mg (65
mg
Iron) Tablet - 1 (One) Tablet(s) by mouth once a day
MULTIVITAMIN [DAILY VITAMIN] - (Prescribed by Other Provider;
OTC) - Tablet - 1 (One) Tablet(s) by mouth once a day
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
mesenteric ischemia
Discharge Condition:
deceased
Completed by:[**2184-7-2**]
|
[
"571.5",
"250.00",
"V45.81",
"401.9",
"557.0",
"537.89",
"584.5",
"572.3",
"789.59",
"V43.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.11",
"45.13",
"54.91",
"54.12",
"45.23",
"88.42",
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
7034, 7043
|
4651, 5566
|
341, 417
|
7106, 7144
|
1717, 4628
|
1478, 1495
|
7005, 7011
|
7064, 7085
|
5592, 6982
|
1510, 1698
|
273, 303
|
445, 1036
|
1058, 1286
|
1302, 1462
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,362
| 110,667
|
27045
|
Discharge summary
|
report
|
Admission Date: [**2186-12-24**] Discharge Date: [**2187-1-14**]
Date of Birth: [**2131-10-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
VF arrest
Major Surgical or Invasive Procedure:
[**2186-12-24**] Head and Chest CT Scan
[**2186-12-24**], [**2186-12-26**] [**Month/Day/Year **]
[**2186-12-26**] Cardiac Catheterization
[**2187-1-8**] Three Vessel Coronary Artery Bypass Grafting utilizing
the left internal mammary to left anterior descending; vein
grafts to posterior descending artery and obtuse marginal.
History of Present Illness:
Mr. [**Known lastname 66460**] is a pleasant 55 year old male with hypertension,
elevated cholesterol and smoking history who was lifting a harp
into the car when he started breathing heavy and collapsed.
Wife started CPR immediately. Paramedics initial rhythm was
ventricular fibrillation. He was shocked multiple times and
intubated in the field, and transferred to [**Location (un) **]. ECG with
wide complex tachycardia at rate of ~140. He was treated with
Amiodarone and Lidocaine, and subsequently med flighted to
[**Hospital1 18**]. While in the ED, found to be in atrial flutter at 150
with 2:1 block and BP 170/110. CXR revealed CHF. He was
admitted to the CCU, intubated and sedated.
Past Medical History:
Hypertension, Hypercholesterolemia, Subclinical Hyperthyroidism,
s/p Appendectomy, s/p Testicular Surgery, s/p Deviated Septum
Social History:
Active pipe smoker for >30 years. Denies excessive ETOH. He is
married and works as a chemist. He denies IVDA and recreational
drugs.
Family History:
Mother had MI at age 72, s/p CABG. Father died of osteosarcoma.
Physical Exam:
Vitals in CCU T100.8 HR 154, BP154/114, intubated
Gen: Middle aged male intubated in bed unresponsive to commands
HEENT: PERRL, MMM, JVP not assessed as pt intubated and lying
flat.
Chest: vented breath sounds, clear anteriorly
CVR: tachycardic, regular, nl s1, s2, +s4
Abdomen: soft, obese, nontender, +bs
Ext: 2+ femoral pulses, 1+ PT pulses bilaterally.
Neuro: pt intubated, pupilary reflexes intact
Pertinent Results:
[**2187-1-7**] 04:20PM BLOOD WBC-14.0* RBC-4.81 Hgb-14.5 Hct-42.9
MCV-89 MCH-30.2 MCHC-33.9 RDW-14.4 Plt Ct-515*
[**2187-1-14**] 05:10AM BLOOD WBC-11.4* RBC-2.94* Hgb-9.1* Hct-25.5*
MCV-87 MCH-30.8 MCHC-35.6* RDW-13.9 Plt Ct-525*
[**2186-12-31**] 06:55AM BLOOD Neuts-56 Bands-7* Lymphs-23 Monos-8 Eos-4
Baso-0 Atyps-0 Metas-0 Myelos-2*
[**2187-1-14**] 05:10AM BLOOD Plt Ct-525*
[**2187-1-7**] 04:20PM BLOOD PT-11.9 INR(PT)-0.9
[**2187-1-7**] 04:20PM BLOOD Plt Ct-515*
[**2187-1-14**] 05:10AM BLOOD Glucose-97 UreaN-17 Creat-1.0 Na-136
K-4.7 Cl-102 HCO3-25 AnGap-14
[**2187-1-7**] 04:20PM BLOOD Glucose-131* UreaN-16 Creat-1.0 Na-138
K-4.9 Cl-103 HCO3-20* AnGap-20
[**2187-1-7**] 04:20PM BLOOD ALT-56* AST-21 LD(LDH)-271* AlkPhos-113
TotBili-0.2
[**2186-12-30**] 10:50AM BLOOD CK-MB-4 cTropnT-0.17*
[**2187-1-6**] 10:40AM BLOOD Albumin-3.9 Calcium-9.5 Phos-3.7 Mg-1.9
[**2186-12-26**] 02:00PM BLOOD VitB12-613
[**2187-1-7**] 04:20PM BLOOD %HbA1c-5.6 [Hgb]-DONE [A1c]-DONE
[**2186-12-26**] 02:00PM BLOOD Triglyc-187* HDL-35 CHOL/HD-3.6
LDLcalc-53
[**2186-12-24**] 06:03PM BLOOD [**Month/Day/Year **]-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
On admission to the CCU, an [**Month/Day/Year 461**] was notable for a
dilated left ventricle and severely depressed LVEF of around
20%. Chest and head CT scans were also obtained. The chest scan
revealed diffuse ground glass opacities and bilateral lower lobe
air space disease. There was no evidence of pulmonary embolism.
The head scan was remarkable for two foci of low attenuation,
one within the right subcortical temporal lobe white matter, and
one within the right medial temporal lobe. Both of these may
represent areas of lacunar infarction.
He was concomitantly noted to have a leukocytosis and spiked a
fever to 102.0. He was empirically started on broad spectrum
antibiotics. Pan cultures remained negative. He also experienced
a transient decline in renal function with creatinine peaking to
2.4. Within days, his renal function normalized and his
hypoxia/acidosis improved. He maintained stable hemodynamics and
was eventually extubated on hospital day two. No further
ventricular arrhythmias were noted on telemetry and he remained
pain free. His CK-MB and troponin peaked to 70 and 1.5
respectively.
On [**12-26**], cardiac catheterization revealed severe three
vessel coronary artery disease in a right dominant system. The
left main demonstrated mild diffuse disease. The LAD had a 70%
stenosis after the 1st Diagonal. The D1 was totally occluded and
filled via left to left collaterals. The LCX demonstrates a 40%
proximal lesion along with a totally occluded OM2 that filled
via left to left collaterals. The RCA demonstrated a 70%
proximal lesion along with a total occlusion
of the distal vessel that filled via left to right collaterals.
Repeat [**Month (only) 461**] again showed moderately to severely
depressed left ventricular systolic function of approximately
30-35%. Resting regional wall motion abnormalities included
inferior/inferolateral akinesis/hypokinesis and distal septal
and apical hypokinesis. There was only mild mitral regurgitation
and mild aortic insufficiency.
He was referred to Dr. [**Last Name (STitle) **] for CABG when he was medically
ready to go to the OR. He remained in the CCU prior to his
surgery initially and then was transferred to the floor. His
rising WBCs was an issue that prevented him from going to the OR
earlier. There was a question of an aspiration PNA and he
completed abx. Blood and urine cultures were negative. Heparin
turned off several days before surgery. He underwent CABG x3 on
[**1-8**]. He was seen on [**1-9**] by the EP service for evaluation for
possible ICD. It was determined he could see Dr. [**Last Name (STitle) **] in
one month as an outpatient. Swan and chest tubes were removed on
POD #1. He was extubated and was alert and oriented. He remained
on an amiodarone loading drip and the neo drip was weaned off on
POD #2. He was transferred to the floor in the afternoon.
On the floor he developed a rash on his RUE where the BP cuff
had been. He was given benadryl and lidex cream and had a
dermatology consult. He remained in SR and the amiodarone was
DCed. His leukocytosis was improving and he had no evidence of
active infection. Ibuprofen had been started for a pericardial
rub, but this was stopped the next day when his creatinine rose
to 1.6. This decreased to 1.0 the next day. He had a small
hematoma at the left thigh. Flomax was started for complaints of
difficulty urinating. Diuresis and beta blockade continued and
he was cleared for discharge to home with VNA on [**1-14**].
T 99.0 HR 80 SR 120/88 RR 16 sat 95% RA
Medications on Admission:
HCtz 25 qd, Lisinoprril 20 qd, Lipitor 20 [**Last Name (LF) **], [**First Name3 (LF) **] 81 qd, Viagra
prn
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 1
weeks.
Disp:*28 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. 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*
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
tba
Discharge Diagnosis:
CAD
HTN
hypercholesterolemia
s/p Vfib arrest
s/p cabg x3
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
2) Report any fever greater then 100.5.
3) Report any weight gain greater then 2 pounds in 24 hours or 5
pounds in one week.
4) Take lasix as directed with potassium and stop in one week.
5) No lifting more then 10 pounds for 10 weeks.
6) No creams, lotions or powders to wounds until they have
healed. Steristrips will fall off on there own. If have not
fallen off in 2 weeks from discharge, please remove.
7) Call with any questions or concerns.
Followup Instructions:
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2187-2-14**]
1:00
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 2934**]
Date/Time:[**2187-2-14**] 3:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Provider: [**Name10 (NameIs) 3390**] [**Name11 (NameIs) **] appointment should be in 2 weeks
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **] appointment should be in 2
weeks
Completed by:[**2187-1-25**]
|
[
"584.5",
"401.9",
"427.1",
"410.91",
"692.4",
"428.0",
"278.00",
"305.1",
"507.0",
"272.4",
"518.81",
"414.01",
"518.0",
"276.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"36.15",
"99.62",
"36.12",
"96.71",
"37.22",
"88.72",
"00.17",
"96.04",
"39.61",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
8270, 8304
|
3402, 6937
|
333, 661
|
8405, 8414
|
2216, 3379
|
9003, 9618
|
1706, 1771
|
7094, 8247
|
8325, 8384
|
6963, 7071
|
8438, 8980
|
1786, 2197
|
284, 295
|
689, 1388
|
1410, 1538
|
1554, 1690
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,059
| 131,490
|
48191
|
Discharge summary
|
report
|
Admission Date: [**2127-5-19**] Discharge Date: [**2127-5-23**]
Date of Birth: [**2065-11-22**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Clindamycin / Celery / apple / bees
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
nausea/vomiting, abdominal pain, shortness of breath
Major Surgical or Invasive Procedure:
Mechanical Ventilation
History of Present Illness:
61F hx of obesity-hypoventilation syndrome, asthma, obstructive
sleep apnea complicated by pulmonary hypertension, cor pulmonale
and s/p trach on home O2 who presents with with nausea x [**1-31**]
days. Per family patient has not been feeling over the last few
days. She c/o abdominal pain and poor po intake. No fevers or
chills, vomiting or diarrhea. Family also noted that she was
c/o increased secretions on morning of presentation and
requesting to be suctioned. Also noted to be coughing more than
normal, have increased lower extremity swelling, and the need to
sit up while sleeping. The [**Month/Day (3) 269**] evaluated the patient and felt
she should be brought to the ED.
.
She was initially admitted to [**Hospital1 18**] in [**12-9**] for hypercarbic
respiratory failure requiring intubation and tracheostomy. She
was discharged to [**Hospital1 **] and she was weaned of the vent. She was
managed at rehab with red capping during the day and passe muir
valve at night with humidified air. She was then readmitted to
[**Hospital1 18**] recently in [**3-/2127**] after routine visit to PCP where she
was found to be volume overloaded. She was initially admitted to
the MICU due to transient hypotension and then was transferred
back to the MICU after triggering for hypoxia on the floor.
During this admission she was also restarted on sildenafil for
her pulmonary hypertension. She was diuresed with IV lasix and
discharged on lasix 40 mg po daily. She was also treated for E.
Coli UTI with ceftriaxone x 7 days.
.
In the ED, initial VS were: 97.7 96 110/74 28 92% 4L Nasal
Cannula. On exam patient appeared tachypneic to the 20s with
wheezes bilaterally and 3+ bilateral lower extremity edema. She
was also noted to be tender to palpation in the LLQ without
rebound or guarding. Labs were significant for H/H of 10/36
(baseline), Cr of 1.9 (up from 1.3 on recent discharge), INR of
3 (anticoagulated), BNP of [**Numeric Identifier 961**] (up from 4000), and troponin of
0.02. She had a ECG which showed SR with RAD and TWI in III,
V1-V3 consistent with prior. CXR showed evidence of volume
overload. CT abdomen/pelvis showed no acute process. She was
given zofran for nausea, 40 mg IV lasix, solumedrol 125 IV,
azithromycin, and nebs for concern of COPD/CHF exacerbation.
After nebulizer treatments, she was persistently hypoxic to the
70s-80s on FiO2 of 100%. Patient was then started on BiPAP 12/5
FiO2 60% with improved sats to 93%. Patient then became
somnolent and desatted to 70s-80s. She was evaluated by
respiratory and placed on CMV with TV 350 PEEP 10 FiO2 60% and
sat 100%. Blood pressures also dropped to 70s-80s and considered
starting peripheral levo but did not. Patient refused central
access and ABG.
.
On arrival to the CCU, VS were 98.3 72 91/51 20 98% on vent.
Patient somnolent and arousable only to noxious stimuli.
Past Medical History:
1. Morbid obesity (s/p gastric bypass [**2113**])
2. Obstructive sleep apnea (noctural BiPAP 18/15, home O2 3-4L
via nasal cannula)
3. Obesity hypoventilation syndrome
4. Severe pulmonary artery hypertension (attributed to OSA)
5. Cor pulmonale attributed to severe pulmonary hypertension
6. Asthma
7. Osteoarthritis (bilateral knees)
8. Diastolic heart failure (2D-Echo [**1-/2124**] showing LVEF 70-80%,
PAP 64 mmHg)
9. Chronic kidney disease (stage III-IV, baseline creatinine
1.8-2.2)
10. Rosacea
11. Hypertension
12. Iron deficiency anemia
11. s/p ventral hernia repair with mesh and component separation
([**5-/2119**])
12. s/p debridement of anterior abdominal wall and complex
repair ([**6-/2119**])
Social History:
She has 2 adult children and adopted 3 so total of 5 children.
She notes no tobacco use, rare alcohol use currently but notes a
former heavy alcohol history in the distant past. She denies
recreational substance use.
Family History:
Notable for diabetes mellitus in her mother and sister,
hypertension in siblings, mother and throughout the maternal
family as well as kidney disease.
Physical Exam:
Admission Physical:
Vitals: T: 98.3 BP: 91/51 P: 72 R: 20 18 O2: 98% ventilated
General: somnolent but arousable
HEENT: Sclera anicteric, MMM, PERRL
Neck: supple, trach in place, JVP difficult to interpret given
body habitus
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: distant breath sounds, no wheezes appreciated.
Abdomen: obese, soft, non-distended, bowel sounds present
Ext: warm, well perfused, 2+ pitting edema bilaterally, pulses
difficult to palpate with edema
Neuro: somnolent, arousable to noxious stimuli, moves all
extremities, unable to follow commands
Discharge Physical Exam:
Vitals: T 98.2 Tc 97.8 BP 92/57 (90's-110's/50's-60's) P 91
(80's-90's) RR 20 95% on 3L NC
Weight: 119 kgs
General: pleasant, conversant, in no acute distress
HEENT: Sclera anicteric, MMM, PERRL
Neck: supple, trach in place, JVP difficult to interpret given
body habitus
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: distant breath sounds, no wheezes, rales or rhochi
appreciated.
Abdomen: obese, soft, non-distended, bowel sounds present
Ext: warm, well perfused, 2+ pitting edema bilaterally
Neuro: A&0 X 3, 5/5 strength in upper and lower extremities,
sensation in tact throughout
Pertinent Results:
Admission Labs:
[**2127-5-19**] 02:00PM BLOOD WBC-9.0 RBC-3.70* Hgb-10.1* Hct-36.1
MCV-98 MCH-27.4 MCHC-28.1* RDW-16.6* Plt Ct-250
[**2127-5-19**] 02:00PM BLOOD Neuts-87.4* Lymphs-7.5* Monos-2.8 Eos-2.0
Baso-0.4
[**2127-5-19**] 02:00PM BLOOD Plt Ct-250
[**2127-5-19**] 02:55PM BLOOD PT-31.1* PTT-43.6* INR(PT)-3.0*
[**2127-5-19**] 02:00PM BLOOD Glucose-136* UreaN-34* Creat-1.9* Na-144
K-5.2* Cl-98 HCO3-33* AnGap-18
[**2127-5-19**] 02:55PM BLOOD cTropnT-0.02* proBNP-[**Numeric Identifier **]*
[**2127-5-19**] 02:55PM BLOOD Lipase-27
[**2127-5-19**] 02:00PM BLOOD ALT-17 AST-29 AlkPhos-95 TotBili-0.2
[**2127-5-19**] 02:00PM BLOOD Albumin-4.0
[**2127-5-20**] 01:13AM BLOOD Type-[**Last Name (un) **] Temp-36.8 pO2-55* pCO2-42
pH-7.55* calTCO2-38* Base XS-12
[**2127-5-19**] 02:53PM BLOOD Lactate-0.8
EKG:
Cardiovascular Report ECG Study Date of [**2127-5-19**] 1:59:40 PM
Sinus rhythm. Right axis deviation. Early R wave progression.
ST-T wave
abnormalities. Since the previous tracing of [**2127-4-22**] the rate is
slower.
Otherwise, unchanged.
Imaging:
[**5-19**] AP Chest:
IMPRESSION: Cardiomegaly and vascular congestion consistent
with mild
pulmonary edema.
[**5-19**] CT Abd/Pelvis:
IMPRESSION:
1. Unremarkable postoperative appearance.
2. Cholelithiasis.
3. Multifocal opacities in the visualized lower lungs most
suggestive of
atelectasis. Mosaic attenuation is present in the partly
visualized lingula, and appearance that is most often associated
with air trapping but not completely characterized; edema could
also be considered.
Discharge labs:
[**2127-5-23**] 05:45AM BLOOD WBC-8.3 RBC-3.28* Hgb-8.8* Hct-31.9*
MCV-97 MCH-26.7* MCHC-27.5* RDW-16.7* Plt Ct-231
[**2127-5-23**] 05:45AM BLOOD PT-22.4* INR(PT)-2.1*
[**2127-5-23**] 05:45AM BLOOD Glucose-135* UreaN-41* Creat-1.6* Na-146*
K-3.8 Cl-100 HCO3-38* AnGap-12
[**2127-5-22**] 06:10AM BLOOD Calcium-8.2* Phos-4.2
Brief Hospital Course:
61 yo female with hx morbid obesity, obesity-hypoventilation
syndrome, obstructive sleep apnea complicated by pulmonary
hypertension and cor pulmonale s/p trach who presents with
abdominal pain, n/v and LE edema, found to be hypoxic with
improved respiratory status s/p mechanical ventilation and
diuresis.
Active Issues:
# Acute REspiratory failure:
Due to acute diastolic CHF exacerbation (based on LE edema,
elevated BNP and improvment with diuresis) in the setting of
poor pulmonary reserve with severe pulm hypertension, OSA, and
restrictive lung disease/obesity hypoventilation syndrome.
CXR was without evidence of consolidation and she had no fever
or leukocytosis to suggest infectious etiology. Pt's
respiratory status dramatically improved with IV lasix 80 mg x 3
in the ICU and she was able to be weaned off the ventilator
after one night. Once on the medicine floor her oxygen
saturations remained in the mid 90's on 3L NC. She was also
restarted on her home lasix dosing of 40 mg daily. She was also
continued on albuterol nebs Q4H prn, fluticasone 2 puffs [**Hospital1 **] and
sildenafil 20 mg tid for pulmonary hypertension
# Abdominal pain - Unclear etiology, possibly related to
constipation as she did report some improvement with BM's. CT
abdomen and pelvis, EGD without any acute processes. We
continued her on an agressive bowel regimen and simethicone for
gas pains. Pt should be followed as an outpt for this chronic
abdominal pain.
# CKD - baseline Cr previously noted to be 1.5-1.8 (1.3 on
recent discharge). Cr peaked at 2.7 after diuresis in the MICU,
downtrended to 1.6 on discharge.
# RUE DVT - Pt was supratheraputic to 3.4, therefore coumadin
was held for two days. She was restarted on her home dose of 7
mg of coumadin on [**5-22**]. On discharge her INR was 2.1. She will
have her INR drawn on [**5-27**] and have the results faxed to Dr.
[**Last Name (STitle) 3029**].
Inactive Issues:
# Gout - continued allopurinol (renally dose) and prednisone 5
mg daily per rheum
# type 2 diabetes - most recent A1c 7.7 in [**12-9**]. She was
placed on sliding sclae insulin.
Medications on Admission:
Medications: per discharge summary [**2127-5-1**]
1. allopurinol 300 mg Tablet [**Month/Day/Year **]: 0.5 Tablet PO once a day.
2. fluticasone 110 mcg/actuation Aerosol [**Month/Day/Year **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. furosemide 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
4. sildenafil 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a
day).
5. polyethylene glycol 3350 17 gram Powder in Packet [**Hospital1 **]: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
6. warfarin 2 mg Tablet [**Hospital1 **]: Three (3) Tablet PO Once Daily at 4
PM.
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as
needed for wheeze.
8. aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO once a day.
9. docusate sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO twice
a day as needed for constipation.
10. ferrous sulfate 325 mg (65 mg iron) Tablet [**Hospital1 **]: One (1)
Tablet PO once a day.
11. prednisone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
Discharge Medications:
1. allopurinol 100 mg Tablet [**Hospital1 **]: 1.5 Tablets PO DAILY (Daily).
2. fluticasone 110 mcg/actuation Aerosol [**Hospital1 **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. furosemide 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
4. sildenafil 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a
day).
5. polyethylene glycol 3350 17 gram/dose Powder [**Hospital1 **]: One (1) PO
once a day.
6. warfarin 1 mg Tablet [**Hospital1 **]: Seven (7) Tablet PO Once Daily at 4
PM.
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) treatment Inhalation every six (6)
hours as needed for shortness of breath.
8. aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
9. docusate sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
10. prednisone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
11. ferrous sulfate 325 mg (65 mg iron) Tablet [**Hospital1 **]: One (1)
Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] [**Location (un) 269**]
Discharge Diagnosis:
Primary:
Diastolic Heart Failure exacerbation
Secondary:
Abdominal Pain
Right arm deep venous thrombosis
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 pleasure taking care of you during your
hospitlaization at [**Hospital1 69**]. You
were admitted with shortness of breath, low oxygen levels and
leg swelling. We believe that this was caused by an
exacerbation of your heart failure. You improved with large
doses of IV lasix. At the time of discharge your breathing was
back to your baseline.
You also complained of abdominal pain, which was chronic in
nature. You had an abdominal CT scan that did not show any
cause of your pain. You should follow up with your primary
provider for further [**Name9 (PRE) 8019**] of your abdominal pain.
NO MEDICATION CHANGES WERE MADE DURING THIS HOSPITALIZATION
Followup Instructions:
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2127-5-27**] at 11:15 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3020**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: MEDICAL SPECIALTIES
When: TUESDAY [**2127-7-1**] at 10:30 AM
With: DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3172**] [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: FRIDAY [**2127-5-30**] at 11:10 AM
With: [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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49,544
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42095
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Discharge summary
|
report
|
Admission Date: [**2181-2-5**] Discharge Date: [**2181-2-9**]
Date of Birth: [**2121-2-4**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Cipro / vancomycin
Attending:[**First Name3 (LF) 10593**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
This is a 60F with a h/o IDDM, CAD s/p CABG [**2172**] (LIMA -> LAD,
SVG to [**Year (4 digits) 11641**]), s/p STEMI ([**2174**]) w/ occlusion of vein graft, s/p
stents to LAD and [**Year (4 digits) 11641**] ([**2174**]), sCHF (EF 30-35% [**8-4**]), s/p AICD,
PVD s/p R toe amputations and L BKA presenting after a period of
unresponsiveness. Per report, the patient was found to be
unresponsive and cyanotic (lips, chest) at her rehab facility
([**Hospital1 **] [**Location 1268**]). Unclear whether the patient was
pulseless, but chest compressions were not performed and the pt
was placed on a nonrebreather. When EMS arrived, the pt had a
normal HR and eventually became interactive. There was a
question of whether the patient had accidentally gotten a large
dose of oxycodone prior to the event. The patient does not
recall what happened; she says she was speaking to another
patient and then woke up to EMS.
.
On arrival in the ED, VS were 98.7 74 143/66 20 100% 12L
non-rebreather. Labs showed lactate 2.3, normal ABG on room air,
troponin 0.04 (~bl), Creat 2.2 (bl 1.8), BNP 7894. Pt was given
full-dose ASA. CT Head showed no accute intracranial process.
CXR was concerning for pulmonary edema. The patient was admitted
to the MICU.
.
On arrival to the MICU, patient noted to be lethargic but
without complaint. Her mental status gradually improved. She had
a repeat TTE which was stable w/r/t her prior (EF ~ 35%). Her O2
was weaned. Her clinical status continued to improve and today
(hospital day 2) she is transferred to the floor.
.
On arrival on the floor, the patient c/o tenderness under the
outside of her R breast. She otherwise has no complaints. Cannot
recall what happened at her rehab facility.
Past Medical History:
Cardiovascular Risk Factors:
+ HTN + HL + DM
# CAD
STEMI in [**2174**] with occlusion of vein graft
INTERVENTIONS:
CABG: [**2172**] with LIMA -> LAD and vein graft to [**Last Name (LF) 11641**], [**First Name3 (LF) **] 25 %
at the time
PERCUTANEOUS CORONARY INTERVENTIONS:
-- [**2174**] stents in left anterior descending and [**Year (4 digits) 11641**] art
# Systolic CHF - ischemic cardiomyopathy, severely reduced LV
function. ECHO in [**4-2**] with EF 25 - 30%
# PACING/ICD: Right-sided AICD in place
# IDDM, eye and renal manifestations, last HbA1c 9.3% ([**2180-4-23**])
# asthma
# PVD
# s/p left BKA [**2176**]
# s/p right 1st toe amputation [**2176**]
# h/o left intraductal breast cancer - s/p left mastectomy in
[**Month (only) 116**]/[**2173**], now question of right-sided breast cancer, which is
just being followed
# s/p cholecytectomy
Social History:
Resides in rehab currently wheelchair bound; some family is
nearby, but "they are all busy and have their own families." Not
close to anyone.
-Tobacco history: none
-ETOH: rarely
-Illicit drugs: denies, but used marijuana in the past
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
General: Sleepy but arousable and oriented x3, oriented, no
acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP hard to assess in setting of habitus, no LAD
CV: Regular rate and rhythm, normal S1 + S2, soft SEM murmurs,
rubs, gallops
Lungs: anterior fields, relatively clear with decreased bs at
bilateral bases
Abdomen: soft, non-tender, distended, bowel sounds present, no
organomegaly
Ext: warm, well perfused, 1+ pulses, left BKA, RLE with 1+
edema, R. foot wrapped in ace bandage; 4 eschars on extremity;
no clubbing, cyanosis
Neuro: following commangs, 5/5 strength upper/lower extremities,
grossly normal sensation, gait deferred
Pertinent Results:
ADMISSION LABS
[**2181-2-5**] 08:30PM BLOOD WBC-8.2 RBC-3.85* Hgb-9.8* Hct-32.0*
MCV-83 MCH-25.5* MCHC-30.6* RDW-21.8* Plt Ct-253
[**2181-2-5**] 08:30PM BLOOD Neuts-74.5* Lymphs-14.8* Monos-5.9
Eos-3.4 Baso-1.4
[**2181-2-5**] 08:30PM BLOOD PT-15.2* PTT-33.4 INR(PT)-1.4*
[**2181-2-5**] 08:30PM BLOOD Glucose-216* UreaN-94* Creat-2.2* Na-136
K-4.6 Cl-102 HCO3-25 AnGap-14
[**2181-2-6**] 03:07AM BLOOD ALT-38 AST-71* LD(LDH)-426* CK(CPK)-610*
AlkPhos-138* TotBili-0.6
[**2181-2-5**] 08:30PM BLOOD CK-MB-7 proBNP-7894*
[**2181-2-5**] 08:30PM BLOOD cTropnT-0.04*
[**2181-2-6**] 03:07AM BLOOD CK-MB-7 cTropnT-0.04*
[**2181-2-6**] 03:07AM BLOOD Albumin-2.9* Calcium-8.5 Phos-5.2* Mg-2.4
[**2181-2-5**] 08:30PM BLOOD TSH-6.9*
[**2181-2-6**] 03:07AM BLOOD Digoxin-1.0
[**2181-2-6**] 03:07AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2181-2-5**] 08:41PM BLOOD Type-ART Temp-37.1 FiO2-21 pO2-71*
pCO2-36 pH-7.42 calTCO2-24 Base XS-0 Comment-ROOM AIR
[**2181-2-5**] 08:57PM BLOOD Lactate-2.3*
[**2181-2-6**] 05:47AM BLOOD Lactate-1.4
[**2-5**] CT head: No evidence of acute intracranial process.
[**2-5**] CXR: Findings consistent with fluid overload including
pulmonary
vascular congestion, small bilateral pleural effusions and
enlarged cardiac silhouette.
[**2-6**] TTE: The left atrium is mildly 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 moderately depressed (LVEF
?35 %). Poor image quality precluded segmental wall motion
analysis. The right ventricular free wall thickness is normal.
The right ventricular cavity is dilated with depressed free wall
contractility. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Mild to moderate ([**12-25**]+) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. [Due to acoustic shadowing caused by the defibrillator
coil, the severity of tricuspid regurgitation may be
significantly UNDERestimated.] There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the findings of the prior study (images
reviewed) of [**2180-8-8**], the findings are grossly similar,
but the technically suboptimal nature of both studies precludes
definitive comparison. The tricuspid regurgitation may be
markedly underestimated on both studies due to acoustic
shadowing caused by the defibrillator coil.
[**2-7**] EEG: This is an abnormal awake and sleep EEG because of
diffuse
slowing of background indicative of moderate to severe
encephalopathy.
No epileptiform discharges or electrographic seizures are
present in the
recording.
[**2-7**] RLE arterial studies: Patent popliteal and posterior tibial
arteries with no evidence of stenosis.
Indeterminant study with falsely elevated ABI and artifact,
likely moderate right lower extremity occlusive disease.
[**2-8**] RUQ u/s: 1. Within limitations above, normal liver
echotexture. Pulsatile flow in the portal vein indicates right
heart failure and tricuspid insufficiency. In the setting of
elevated LFTs, congestive hepatopathy is a consideration.
2. Right pleural effusion.
3. Nonvisualization of the left kidney, spleen and pancreas.
Discharge labs ([**2-8**]):
BUN/creat: 87/1.5
Hct 31.0
B12 > 1000
Glucose 153
Brief Hospital Course:
BRIEF HOSPITAL COURSE
60F with a PMH of IDDM, CAD s/p CABG in [**2172**](LIMA -> LAD, SVG to
[**Year (4 digits) 11641**]), s/p STEMI ([**2174**]) with occlusion of vein graft, s/p
stents to LAD and [**Year (4 digits) 11641**] ([**2174**]), sCHF with last EF of 30-35% (TTE
in [**7-/2180**]), s/p AICD, PVD s/p right toe amputations and left BKA
presenting after a period of unresponsiveness.
.
.
ACTIVE ISSUES
.
# Unresponsiveness. Etiology unclear. Initial differential
included arrythmia (perhaps [**1-25**] ACS), medication overdose,
hypoglycemia, syncope, PE, and seizure. Unlikely ACS given EKG
w/o ischemia, troponins at baseline, no bump in lactate, etc.
TTE stable. Thromboembolism unlikely given lack of tachycardia,
tachypnea and pt's subsequent clinical improvement. Hypoglycemia
possible given pt's IDDM, but confirmed w/ [**Hospital1 **] that
patient's FS was >200 at time of event. ABG on admission wnl.
Cardiology interrogated the patient's AICD and found no record
of tachyarrhythmia; AICD was functioning normally. EEG did not
disclose focal epileptiform activity but did reveal diffuse
background slowing. Additional metabolic etiologies were ruled
out: normal T4, ammonia not elevated, no parenchymal hepatic
abnormality on RUQ U/S. At this time the most likely possibility
is that the patient became obtunded/hypoventilated from
medication effect (though the offending drug is unclear). [**Name2 (NI) **]
discussion with providers at [**Hospital1 **], patient is frequently
somnolent and difficult to arouse, so a more severe episode in
the setting of declining renal function is possible. Regarding
the patient's clinical course, she was lethargic on admission
but without focal neurologic symptoms. She was monitored
overnight in the MICU and then followed on the general medical
floor. Extensive workup (as above) was unrevealing. She was
periodically difficult to arouse, and some of her sedating
medications were held (ativan) or reduced (gabapentin). This
yielded perhaps some improvement, and by [**2-9**] she was deemed
stable enough for discharge.
.
# Acute on Chronic Kidney Failure. Patient with gradually
worsening renal failure since [**12-4**] in setting of toresimide
weaning and ultimate d/c. Possibly contributed to her episode of
unresponsiveness (per above). Urine lytes on admission c/w
pre-renal etiology - likely poor forward flow (evident by CXR,
elevated bnp and decreased bs). Patient without h/o losses
(n/v/d, bleed) furthermore BPs 130s-140s. Diuresis with lasix
60mg IV initially. No further diuresis during hospitalization,
during which timecreatinine declined from 2.2-2.3 to 1.5. She
was set up with nephrology follow up appointment through [**Location (un) 2274**].
.
# IDDM c/b neuropathy: patient was continued on home 17U lantus
+ SS initially. FS were persistently elevated, so on [**2-7**]
evening dose of lantus was increased to 20U, which patient
tolerated well.
.
# Right foot gangrene: Pt with chronic PVD (s/p L BKA [**2176**]). She
has ulcers on R foot. Vascular surgery team followed her while
in-house; they did not think that it was infected. They wrapped
the foot. Arterial non-invasive studies demonstrated patent
popliteal and PT arteries on the right with known moderate RLE
occlusive disease.
.
INACTIVE ISSUES
.
# Systolic and Diastolic CHF. Last TTE [**8-4**] with Normal left
ventricular cavity size with moderate global hypokinesis (EF
30-35%). Right ventricular cavity enlargement with free wall
hypokinesis. Mild-moderate mitral regurgitation. At the time of
admission there was evidence of heart failure on exam, lab and
imaging data. ?secondary to medication change vs ischemia in
setting of troponin elevation (c/w baseline) though EKG without
ischemic changes. Reinstated diuresis with lasix IV 60mg; goal
-500cc-1L. Digoxin level 1.0 so cont on digoxin and carvedilol.
A repeat TTE this admission demonstrated her cardiac function to
be globally stable. She will likely benefit from ACE-inhibitor
or [**Last Name (un) **] when her renal function stabilizes.
.
# CAD s/p CABG: [**2172**] with LIMA -> LAD and vein graft to [**Year (4 digits) 11641**],
STEMI [**2174**] s/p stents in left anterior descending and [**Year (4 digits) 11641**] art.
She did not complain of chest pain on admission or during her
stay. Biomarkers with trop 0.04, flat MB. Cont ASA and Plavix.
TTE revealed stable cardiac function w/r/t her previous study.
.
# Depression/Anxiety: Effexor, Wellbutrin, and ativan held
initially given her lethargy. Effexor and Wellbutrin were
reinstated, but the ativan was d/c'd given concerns about
somnolence.
.
TRANSITIONAL ISSUES
-Monitor volume status and adjust diuretics accordingly
-Watch renal function following re-initiation of torsemide
(Creatinine 1.5 on last check here)
-Follow-up BUN: BUN had been rising over the last several weeks,
up to 90s, but was decreasing in the last few days here; 87 on
last check.
-Follow digoxin level in light of fluctuating renal function
-Trend Finger sticks to confirm that new dose of 20U lantus at
bedtime + ISS controls sugars well
-Follow up regarding patient's continuing need for depression
medications that may potentially contribute to her episodic
lethargy
-Consider ACE/[**Last Name (un) **] therapy when renal function stabilizes
Medications on Admission:
1. bupropion HCl 100 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO BID (2 times a day).
2. gabapentin 400 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
3. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Four (4)
Capsule, Ext Release 24 hr PO DAILY (Daily).
5. digoxin 0.0625 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
8. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
sob/wheeze.
11. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours): for 14 days. (finished)
14. Insulin lantus 100units/ml- 17 units every night, prior to
bed.
15. Insulin 100 unit/mL Solution Humalog(Standing Dose in
addition to sliding scale below))
Discharge Medications:
1. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
Daily PRN as needed for Constipation.
2. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
Units Injection TID (3 times a day).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6
hours) as needed for SOB.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
7. atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
9. digoxin 125 mcg Tablet Sig: One half Tablet PO DAILY (Daily).
10. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): Hold for SBP < 100 or HR < 50.
11. bupropion HCl 100 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO BID (2 times a day).
12. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Four (4)
Capsule, Ext Release 24 hr PO DAILY (Daily).
13. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID (3 times a day) as needed for abd pain,
bloating.
14. gabapentin 300 mg Capsule Sig: One (1) Capsule PO QHS (once
a day (at bedtime)).
15. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Nursing & Therapy Center - [**Location 1268**] ([**Location (un) 86**] Center
for Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
unresponsiveness
acute on chronic kidney injury
peripheral vascular disease
congestive heart failure
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Intermittently lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Ms. [**Known lastname 91333**],
It was a pleasure caring for you during your stay in the
hospital. You were admitted following an episode of
unresponsiveness. An extensive workup including blood tests and
radiologic imaging did not reveal a serious health problem that
might have caused you to lose consciousness. Fortunately, you
improved with time. During your stay we noted that your kidney
function had declined a bit, but this also improved before your
discharge.
.
During your stay we adjusted some of your medications (changes
noted below). The medical team at your rehabilitation facility
will continue to evaluate your need for these changes, making
adjustments as necessary. Given your changing renal function,
your medical team should also check your blood level of digoxin
regularly.
.
Changes to your medications at home:
1. INCREASE Insulin glargine (Lantus) to 20 units before bedtime
2. DECREASE gabapentin (neurontin) to 300 mg before bedtime
3. INCREASE torsemide to 40 mg each morning
4. DISCONTINUED ativan
Followup Instructions:
Name: [**Last Name (LF) 38584**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Specialty: INTERNAL MEDICINE
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3530**]
**Please call your insurance and advise them that Dr [**Last Name (STitle) **] is
your PCP.**
**Please discuss with the staff at the facility the need for a
follow up appointment with your PCP when you are ready for
discharge.**
.
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Specialty: NEPHROLOGY
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2263**]
Appointment: TUESDAY [**2-27**] AT 10:20AM
**PLEASE CONTACT YOUR PCP FOR [**Name Initial (PRE) **] REFERRAL FOR THIS APPOINTMENT.**
|
[
"V45.02",
"362.01",
"428.0",
"300.00",
"403.90",
"V45.81",
"250.62",
"584.9",
"357.2",
"V58.67",
"707.14",
"493.90",
"428.42",
"V49.75",
"250.42",
"250.52",
"583.81",
"440.24",
"311",
"412",
"585.9",
"348.39",
"782.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.49"
] |
icd9pcs
|
[
[
[]
]
] |
15665, 15825
|
7628, 12915
|
333, 339
|
15970, 15970
|
4060, 5117
|
17217, 18182
|
3232, 3347
|
14238, 15642
|
15846, 15949
|
12941, 14215
|
16165, 16980
|
17001, 17194
|
3362, 4041
|
272, 295
|
367, 2086
|
5126, 7605
|
15985, 16141
|
2108, 2963
|
2979, 3216
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,145
| 149,625
|
45193
|
Discharge summary
|
report
|
Admission Date: [**2104-10-30**] Discharge Date: [**2104-12-13**]
Date of Birth: [**2027-6-16**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine / Lactose / Sulfa (Sulfonamide
Antibiotics) / Aspirin / Albuterol / Morphine
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
dysphagia, chronic cough
Major Surgical or Invasive Procedure:
EGD
Bronchoscopy
History of Present Illness:
77yo with no significant PMH with chronic cough x 2 months who
has been undergoing work-up by GI and Pulmonary for possible
neoplasm and TE-fistula, now being admitted for observation
after unsuccessful EUS re-look today.
.
Story starts in late [**Month (only) 216**], when she began devloping cough and
dysphagia for solids associated with intermittent sharp pains
radiating to the back as well as belching; she also notes having
anorexia. The cough was worked-up by her PCP with concerns for a
pulmonary infectious process; she underwent a course of
levofloxacin, a CXR, cardiac ECHO, and CT-Chest on [**10-7**] which
showed, among other findings, extensive mediastinal LAD and
ground glass opacities. She subsequently underwent GI work-up
with EGD in late [**Month (only) 359**] followed by the EGD today. Through this
interval, her symptoms have worsened and as a result of her
dysphagia and anorexia she has had an involuntary 20lbs weight
loss.
.
Findings from EGD today [**2104-10-30**]:
Esophageal/pleural fistula on EGD today. Large cavitation seen,
to be fistulizing into lung, on endoscopy today. Mucosa is
spared, unlike usually with Ca. DDx: adenoCa (GI vs lung) on
differential, but could also be the reverse with GI penetrating
to the lung.
.
Previous EGDs:
[**2103-8-3**]
Large hiatal hernia
Polyps in the fundus
Small nodular raised lesion with possible erosion on top, no
stigmata or visible vessel noted in the duodenum
Otherwise normal EGD to third part of the duodenum
.
[**2103-9-11**]
A medium size hiatal hernia was seen.
Multiple gastric polyps seen in the fundus and body
A small nodular submucosal lesion was seen in the duodenal bulb
with a small central raised area. Two cold forceps biopsies were
performed using a jumbo forcep for histology.
A 0.6cm X 0.4cm sub-mucosal lesion was seen in the duodenal
bulb, originating from the muscular layer.
Differential diagnosis includes GIST, Leiomyoma, Sarcoma
.
[**2104-10-16**]
Tubular sub-epithelial mass / buldge in the upper third of the
esophagus.
Food impaction in the mid and lower esophagus - this was pushed
into stomach. Assessment of esophageal wall could not be made
due to debris coating esophageal wall.
(foreign body removal)
Otherwise normal EGD to third part of the duodenum
.
[**2104-10-16**]
Food in the lower third of the esophagus
Mass in the middle third of the esophagus
The food bolus was unable to be removed due to patient poor
tolerance of procedure with desaturation of O2. Patient will
need procedure with anesthesia
Otherwise normal EGD to lower third of the esophagus
.
CT Chest [**2104-10-7**]:
1. Widespread new compared to prior radiograph areas of
peribronchovascular ground-glass opacities. Differential
diagnosis would include cryptogenic organizing pneumonia,
vasculitis, infection (less likely). Given the lack of those
abnormalities on the recent chest radiograph, neoplasm is
unlikely.
2. Huge hiatal hernia containing most of the stomach. Most
likely loculated peritoneal effusion at the level of the hiatus
as described.
3. Extensive mediastinal lymphadenopathy including right upper
paratracheal area, most likely reactive to the parenchymal
process.
4. Evidence of air trapping especially on the left that might be
related to narrowing of the left main bronchus by the large
hernia. Tracheomalacia is also suspected.
5. Bilateral pleural effusions, most likely secondary to the
parenchymal
process.
6. Small liver hypodense lesion, most likely cysts.
Past Medical History:
--hiatal hernia
--GERD
--allergies
--h/o asthma not currently treated
Social History:
-Smoking/Tobacco: Quit smoking about 50 years ago and had smoked
for
about 10 years in her 20s
Family History:
She does not have any first-degree relatives she is aware of who
have any pulmonary diseases.
Physical Exam:
VS: As above
GEN: AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: RRR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, CTAB no crackles or wheezes
Abd: soft, NT, +BS. no rebound/guarding. neg HSM. neg [**Doctor Last Name 515**]
sign.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes or bruising
Neuro/Psych: Grossly non-focal
Pertinent Results:
Admissions:
[**2104-10-30**] 07:35PM GLUCOSE-95 UREA N-11 SODIUM-138 POTASSIUM-3.7
CHLORIDE-102 TOTAL CO2-24 ANION GAP-16
[**2104-10-30**] 07:35PM WBC-8.0 RBC-3.85* HGB-11.3* HCT-33.5* MCV-87
MCH-29.5 MCHC-33.8 RDW-14.4
[**2104-10-30**] 07:35PM PLT COUNT-431
Reports:
CT abdomen/pelvis/chest ([**11-13**])
IMPRESSION:
1. Extensive esophageal mass abutting the pulmonary artery, left
atrium and aortic arch with circumferential thickening of the
esophagus and proximal air-fluid levels.
2. Extensive paraesophageal, mediastinal and hilar adenopathy.
3. Left upper lobe pulmonary nodule.
4. Right lower lobe pulmonary embolus
5. Liver metastases.
6. Metastatic retroperitoneal adenopathy.
7. extensive subcutaneous edema and gas formation within the
anterior
abdominal wall on left side in the region of the J-tube (series
301B image 59) concerning for gas-forming infection vs tube
leakage.
[**11-18**] abdominal tissue bx
Left abdominal wall:
Skin and subcutaneous tissue with focal fat necrosis and acute
and chronic inflammation.
[**11-23**] Head CT
No acute intracranial hemorrhage or mass effect. Partial
opacification of the mastoid air cells, which is new since the
prior study and may be related to recent intubation. MR can be
considered for better
assessment of parenchymal abnormalities related to
metastases/infarction, if not CI.
Micro:
[**2104-12-10**] CATHETER TIP-IV WOUND CULTURE-FINAL
{STAPHYLOCOCCUS, COAGULASE NEGATIVE}
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ 8 I
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ 1 S
[**2104-12-10**] BLOOD CULTURE Blood Culture,
Routine-PRELIMINARY {STAPHYLOCOCCUS, COAGULASE NEGATIVE};
Anaerobic Bottle Gram Stain-FINAL
[**2104-12-10**] URINE URINE CULTURE-yeast
[**2104-12-7**] BLOOD CULTURE Blood Culture, Routine-neg
[**2104-12-7**] URINE URINE CULTURE-negative
[**2104-11-26**] BLOOD CULTURE Blood Culture,
Routine-{STAPHYLOCOCCUS, COAGULASE NEGATIVE}; Anaerobic Bottle
Gram Stain-FINAL INPATIENT
[**2104-11-14**] BLOOD CULTURE Blood Culture, Routine-neg
[**2104-11-14**] URINE URINE CULTURE-neg
[**2104-11-14**] TISSUE GRAM STAIN-FINAL; TISSUE-FINAL
{ENTEROCOCCUS SP., ENTEROCOCCUS SP., STAPHYLOCOCCUS, COAGULASE
NEGATIVE}; ANAEROBIC CULTURE-FINAL {BACTEROIDES FRAGILIS GROUP}
INPATIENT
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
| ENTEROCOCCUS SP.
| |
STAPHYLOCOCCUS, COAGULASE N
| | |
AMPICILLIN------------ <=2 S <=2 S
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- <=0.25 S
PENICILLIN G---------- 8 S 4 S
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ 1 S 1 S 2 S
ANAEROBIC CULTURE (Final [**2104-11-18**]):
BACTEROIDES FRAGILIS GROUP. SPARSE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
310-4665R
[**2104-11-14**].
[**2104-11-14**] SWAB GRAM STAIN-FINAL; WOUND CULTURE-FINAL;
ANAEROBIC CULTURE-FINAL {BACTEROIDES FRAGILIS GROUP}
[**2104-11-13**] BLOOD CULTURE Blood Culture, Routine-neg
[**2104-11-12**] BLOOD CULTURE Blood Culture, Routine-neg
[**2104-11-12**] BLOOD CULTURE Blood Culture, Routine-neg
[**2104-11-12**] BLOOD CULTURE Blood Culture, Routine-neg
[**2104-11-12**] URINE URINE CULTURE-neg
[**2104-11-12**] BLOOD CULTURE Blood Culture, Routine-neg
[**2104-11-9**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2104-11-2**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2104-10-31**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL;
RESPIRATORY CULTURE-FINAL; FUNGAL CULTURE-FINAL; ACID FAST
SMEAR-FINAL; ACID FAST CULTURE-PRELIMINARY INPATIENT
[**2104-10-31**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2104-10-31**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2104-10-31**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2104-10-31**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
Brief Hospital Course:
77yo with no significant PMH with chronic cough x 2 months who
has been undergoing work-up by GI and Pulmonary for possible
neoplasm and TE-fistula, found to have esophageal adenocarcinoma
on pathology.
.
# Respiratory distress - Etiology includes post-procedural
laryngospam vs. paradoxical contraction of vocal cords vs. mass
compression by the esophageal mass. Lung exam indicated insp.
And exp. rhonchi which could indicate extrinsic compression by
the esophageal mass on her airways. Had been on bipap
intermittently alternating with Heliox, however needed to be
intubated on [**11-13**] due to respiratory distress and the need for
a CT scan to assess for necrotizing faciitis (was unable to lay
down due to her resp. distress). An element of agitation/anxiety
/delirium intermittently contributed to her respiratory
distress, and was treated with benzo's PRN initally which was
later transitioned to standing Haldol. Trach was discussed with
the family, though not pursued, especially given grave prognosis
with metastatic adenocarcinoma. She was not able to be weaned
from the vent, likely related to her esophageal mass and ?
compression on airway. She was not a candidate for tracheal
stent given poor overall prognosis.
.
# Necrotizing Fasciitis: Pt had necrotizing faciitis at J-tube
site that needed surgical debridement. A wound vac was placed.
Pt was started on TPN for nutrition. The wound vac was changed
at regular intervals. Treated with a course of tigecycline.
Patient received intermittent fentanyl with wound vac changes.
.
#Delirium: The patient at times exhibited increasing delirium,
including agitation, anxiety and confusion. Probable causes
include ICU delirium and anxiety related to her diagnosis.
Following transfer from SICU, unclear what her neurological
status was, though neuro workup was not pursued given extremely
poor prognosis and no predicted change in management based on
outcome. Large component of altered mental status likely
delirium (patient not reliably following commands or responsive
even when off sedation).
.
#Hypotension: Pt febrile with elevated WBC in setting of
hypotension to systolic 80s. Hypotension most likely [**1-29**]
sepsis. Fistulogram showed patent J-tube track. Treated for
cellulitis with daptomycin, tigecycline, clindamycin, and
ciprofloxacin initially, then finished course of tigecycline for
necrotizing fasciitis. Patient remained on maximal levophed
throughout her ICU stay and through the end of her life, though
no other pressors were started/no escalation of care after
discussion w/ family. Of note, patient also had CVL infection
with bacteremia (MRSA) on [**12-10**], but not treated given no
escalation of care per goals of care discussion at that point.
.
#Esophageal Adeniocarcinoma: Known esophageal/tracheal mass s/p
EGD and bronch with Bx respectively. Biopsies have come back as
adenocarcinoma, however stains are not fitting consistent
picture for clear diagnosis. Underwent a CT torso for the
question of necrotizing faciitis but also staged her neoplasm as
well. Noted to be extensive. After extensive conversations
involving palliative care, oncology, surgery, interventional
pulm, ethics, and the MICU team, patient was DNR/DNI (not
indicated) and no escalation of care. She expired on [**2104-12-13**].
.
# Pulmonary embolism: Patient noted to have PE during course,
she was initially on anticoagulation, but was stopped given
BRBPR. She was not a candidate for IVC filter given poor overall
prognosis.
Medications on Admission:
--azelastine 205.5 mcg (15%) spray for allergies
--fexofenadine 60mg [**Hospital1 **]
--omeprazole 10mg suspension 20mg [**Hospital1 **]
--pantoprozole 40 mg EC [**Hospital1 **]
--Zyrtec 10mg daily prn
--Dextromethorphan-guafenesin
--Viactiv
--Zadator eye drops
--Artificial tears
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"427.81",
"276.1",
"486",
"787.20",
"682.2",
"289.81",
"780.09",
"276.0",
"276.2",
"530.6",
"196.1",
"530.81",
"415.19",
"530.89",
"427.31",
"038.9",
"553.3",
"150.3",
"783.0",
"519.19",
"276.7",
"285.22",
"V49.86",
"569.61",
"995.92",
"569.3",
"557.9",
"V15.09",
"197.7",
"785.52",
"578.1",
"518.5",
"478.75",
"511.9",
"728.86"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"46.39",
"83.65",
"83.45",
"38.93",
"96.72",
"96.04",
"40.11",
"99.15",
"50.12",
"46.51",
"86.22",
"54.25",
"86.28"
] |
icd9pcs
|
[
[
[]
]
] |
13103, 13112
|
9233, 12740
|
393, 411
|
13163, 13172
|
4640, 9210
|
13228, 13374
|
4134, 4229
|
13071, 13080
|
13133, 13142
|
12766, 13048
|
13196, 13205
|
4244, 4621
|
329, 355
|
439, 3913
|
3935, 4006
|
4022, 4118
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,924
| 154,046
|
11154
|
Discharge summary
|
report
|
Admission Date: [**2111-12-11**] Discharge Date: [**2111-12-16**]
Date of Birth: [**2049-11-22**] Sex: F
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a 62-year-old woman with
a history of insulin-dependent diabetes mellitus, with a
history of postprandial epigastric pain.
In the recent past she had a markedly positive exercise
tolerance test which prompted cardiac catheterization
revealing severe left main coronary artery disease. The
patient denies any history of orthopnea or paroxysmal
nocturnal dyspnea. The patient does have occasional lower
extremity edema which was thought to be secondary to her use
of calcium channel blockers. She denies any history or
symptoms of cerebrovascular accident, transient ischemic
attack or atrial fibrillation. She denies claudication.
PAST MEDICAL HISTORY:
1. Diabetes.
2. High cholesterol.
3. Hypertension.
PAST SURGICAL HISTORY: She is status post total abdominal
hysterectomy/bilateral salpingo-oophorectomy
PHYSICAL EXAMINATION ON PRESENTATION: General appearance
revealed well-appearing, in no distress, comfortable. HEENT
revealed extraocular muscles were intact. Pupils were equal,
round, and reactive to light and accommodation. No carotid
bruits. Pulmonary was clear to auscultation bilaterally.
Heart had a regular rate and rhythm. No murmurs. Abdomen
was obese, soft and nontender. Extremities were warm. No
edema. Palpable pulses in all extremities. No varicosities.
The patient had an intra-aortic balloon pump in place which
was placed in the catheterization laboratory on the day of
admission.
RADIOLOGY/IMAGING: Coronary angiography findings revealed a
right-dominant system with significant obstructive left main
coronary artery disease. There was a focal 90% ostial
stenosis. The left anterior descending artery and circumflex
were without significant stenosis. Right coronary artery had
a tubular 50% proximal stenosis followed by a middle 30%
stenosis. Resting hemodynamics revealed elevated left-sided
filling pressures. The left ventricular end-diastolic
pressure was 15 mmHg, consistent with mild diastolic
dysfunction. There was no significant pressure gradient
across the aortic valve. Left ventriculography revealed
hypokinesis of the inferior and posterobasal walls. No
significant mitral regurgitation was noted. Calculated left
ventricular ejection fraction was 49%. Intra-aortic balloon
pump was placed as a result of significant obstructive left
main coronary artery disease. Placement of this pump
revealed appropriate diastolic augmentation of blood
pressure.
Exercise tolerance test: Impression was a very limited
exercise tolerance; test terminated secondary to hypotensive
blood pressure response in the presence of a marked diffuse
ST segment changes which persisted until later recovery.
LABORATORY DATA ON PRESENTATION: Chemistry revealed sodium
of 141, potassium 3.6, chloride 106, bicarbonate 30, BUN 10,
creatinine 0.8, glucose 129. Complete blood count with a
white blood cell count of 5.1, hematocrit 40.8,
platelets 283. Coagulations were PT 12.7, PTT 30.2.
HOSPITAL COURSE: The patient was admitted on the same day
of her cardiac catheterization and was brought to the
operating room on a semi-emergent basis. Dr. [**Last Name (STitle) 70**]
performed coronary artery bypass graft on three vessels. He
anastomosed the left internal mammary artery to the left
anterior descending artery. A saphenous vein graft was used
as a conduit for bypass to both the obtuse marginal and the
right coronary artery. Please see previously dictated
Operative Note for more details.
The patient tolerated the procedure well and was transferred
to the Intensive Care Unit on a Neo-Synephrine and propofol
drip.
The patient had a relatively uncomplicated postoperative
course. She was reversed and extubated on postoperative day
one. Her intra-aortic balloon pump was also discontinued on
postoperative day one. Once she was extubated she began to
tolerate a regular diet in the Intensive Care Unit.
On postoperative day two, she was transferred from the
Intensive Care Unit to the patient care floor. Her chest
tube was removed in the Intensive Care Unit prior to transfer
to the floor. Her cardiac pacing wires were removed on
postoperative day three as was her Foley catheter.
On postoperative day three, the patient was noted to have a
blood sugar of 405. Because of this, her morning dose of
Lente was changed from 30 units to 35 units, and she was put
on a more aggressive insulin sliding-scale. Also, the [**Hospital **]
Clinic was consulted. Follow-up blood sugars were in a
controlled range, and she had reasonable blood sugar control
after this event.
On postoperative day five, the patient was ambulating at
level V and tolerating diet. Pain was controlled. Blood
sugars were controlled, and was urinating on her own and was
agreeable with going home.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: The patient was to be discharged home.
MEDICATIONS ON DISCHARGE:
1. Lopressor 50 mg p.o. b.i.d.
2. Lasix 20 mg p.o. b.i.d. times one week.
3. Potassium chloride supplements 20 mEq p.o. b.i.d. while
on Lasix.
4. Percocet one to two tablets p.o. q.4-6h. p.r.n.
5. Colace 100 mg p.o. b.i.d. while on Percocet.
6. Aspirin 81 mg p.o. q.d.
7. Ibuprofen 600 mg p.o. q.6h. with food p.r.n. for pain.
8. NPH insulin; the patient had her insulin regimen altered
by the [**Hospital **] Clinic. Their recommendations were to increase
her a.m. dose of NPH from 30 units to 35 units. Her evening
dose will remain at 20 units. In addition, she will be on a
pre-breakfast and pre-dinner sliding-scale of regular
insulin. For blood sugar of 100 to 150 she was to take
2 units of regular insulin, 151 to 200 she was to take
3 units, 201 to 250 she was to take 4 units, 251 to 300 she
was to take 5 units, 301 to 350 she was to take 6 units, 351
to 400 she was to take 7 units. This was discussed with the
patient and [**Last Name (un) **] also provided teaching. It was confirmed
that the patient understood her current regimen of insulin
that she will be discharged home on.
DISCHARGE DIAGNOSES: Status post coronary artery bypass
graft times three.
DISCHARGE FOLLOWUP: The patient was to see her primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 35916**], in three weeks. The patient was to
see Dr. [**Last Name (STitle) 70**] back in clinic in six weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 6355**]
MEDQUIST36
D: [**2111-12-16**] 12:19
T: [**2111-12-18**] 14:22
JOB#: [**Job Number 35917**]
(cclist)
|
[
"V15.82",
"530.81",
"414.01",
"250.00",
"429.9",
"272.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"37.61",
"37.22",
"36.15",
"88.72",
"39.61",
"88.53",
"42.23",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
6218, 6273
|
5087, 6195
|
3152, 4952
|
928, 3133
|
4967, 5061
|
6295, 6828
|
183, 827
|
849, 904
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,299
| 148,291
|
46742
|
Discharge summary
|
report
|
Admission Date: [**2100-8-3**] Discharge Date: [**2100-8-11**]
Date of Birth: [**2038-4-20**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Oxycontin
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
62 yo M w/ Hemoptysis x 3 days
Major Surgical or Invasive Procedure:
Bronchoscopy with placement of Y-stent to trachea.
Argon Plasma Laser cautery of active bleeding.
History of Present Illness:
62 year old M with history of SCC lung s/p LUL and partial LLL
lobectomy [**7-/2098**], no chemo or radiation who initially presented
to [**Hospital6 33**] [**2100-8-3**] with hemoptysis. Patient states
he had developed a cough and chest congestion w/o fevers. PCP
prescribed [**Name9 (PRE) **] around [**7-24**]. Then around [**8-1**] or so, he noticed
some blood in his sputum. This increased in amount until [**8-4**]
when his wife was concerned enough to bring him to Southshore's
ER. CT showed a mass involving right lateral wall of proximal
trachea pushing carina anteriorly. Bronch at [**Hospital 2079**] hospital
showed blood in trachea and tumor on right lateral tracheal
wall, compromising the terminal trachea and proximal main stem
bronchi. Biopsies were taken and BAL GS showed few polys and
rare GPC. Post-bronch, his O2sats dropped to 70-80s in the
setting of hemoptysis, prompting intubation and transfer to
[**Hospital1 18**].
Past Medical History:
PMH:
1) squamous cell left lung CA dx [**2098**], w/ left upper and partial
lower lobectomy [**7-/2098**], no chemotherapy or radiation
2) DM2
3) HTN
4) CAD s/p four stents in [**2096**]
5) IBD
Social History:
lives with wife. former [**Name2 (NI) 1818**]. no etoh.
Family History:
hx of [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) **] disease, cad
Physical Exam:
VITALS: T=98.5, BP=120s/80s, P=65, O2sat=100% on vent
GEN: intubated, sedated
HEENT: PERRL, edema around eyes, MM dry, no lad, no JVD
CV: rrr, nl s1/s2
PULMO: coarse breath sounds b/l
GI: bs+, nt, nd
EXT: warm, 2+ DP/PT
NEURO: responds to painful stimuli
Pertinent Results:
LABS ON ARRIVAL TO [**Hospital1 18**] 9pm:
pH 7.38, pCO2 45, pO2 218, HCO3 28, BaseXS 1
Type:Art; Intubated; FiO2%:60; Rate:12/; TV:650; PEEP:8;
Temp:36.9
K:4.0 freeCa:1.14
WBC 13.2, Hct 36.7, Plt 292, N:77.5 L:17.7 M:4.4 E:0.3 Bas:0.1
PT: 12.2 PTT: 29.1 INR: 1.0
Chest CT [**2100-8-5**]
IMPRESSION:
1. Paratracheal and subcarinal masses within the mediastinum
invading the mid thoracic trachea and distal trachea, carina and
mainstem bronchi. There is marked narrowing of the tracheal and
right and left main stem bronchial lumens due to invasion.
Findings favor secondary invasion of the airway from the
mediastinal nodal masses rather than a primary airway neoplasm.
2. Consolidation within the left lower lobe, likely representing
aspiration, infection, or hemorrhage in the setting of
hemoptysis.
3. Status post left upper lobectomy and wedge resection of the
left lower
lobe.
CXR [**8-9**]:
Increased density involving the entire left hemithorax is
suggestive of left pleural effusion. Associated atelectatic
changes are suspected in the left upper lobe and the left lower
lobe. The right lung is clear. There is no evidence of
pneumothorax.
IMPRESSION: Increasing left pleural effusion. No evidence of
pneumothorax.
[**2100-8-11**]: Fluoro-guided PICC line placement:
IMPRESSION: Successful placement of a 35 cm 4-French single
lumen Vaxcel PICC in the right brachial vein. Tip is in the SVC.
The line is ready for use.
Path from [**2100-8-4**] bronch bx:
SPECIMEN SUBMITTED: TRACHEAL TUMOR (PERM) AND (FROZEN) (3
JARS).
Procedure date Tissue received Report Date Diagnosed
by
[**2100-8-4**] [**2100-8-4**] [**2100-8-9**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/cma??????
DIAGNOSIS
A. Tracheal tumor 1: Combined Squamous cell-Small cell
carcinoma, invasive (see note).
B. Tracheal tumor 2: Combined Squamous cell-Small cell
carcinoma, invasive (see note).
C. Tracheal tumor 3: Combined Squamous cell-Small cell
carcinoma, invasive (see note).
Note:
1) Immunostains for P63, chromogranin (focal), synaptophysin and
TTF-1 are all positive in subsets of the tumor cells.
2) An in-situ squamous carcinoma/dysplasia is present suggesting
a separate primary.
3) Slides were reviewed with Dr. [**Last Name (STitle) **]. [**Doctor Last Name **].
Clinical: None given.
Gross: The specimen is submitted in three parts. Part 1 is:
tracheal tumor. Part 2 is: tracheal tumor. Part 3 is: tracheal
tumor.
Part 1 is received fresh in the O. R. and consists of multiple
fragments of tan and red soft tissue aggregate measuring 1.4 x
1.2 x 0.3 cm. The specimen is entirely submitted for frozen
sectioned, and frozen section diagnosis by Dr. [**Last Name (STitle) **] is:
"carcinoma; foci of non-small cell carcinoma present; component
of small round blue cells also present. (Lymphoid cells vs.
small cell component); final diagnosis pending permanent
sections." The frozen section remnant is entirely submitted in
A.
Part 2 is labeled "tracheal tumor" and consists of a 1.1 x 0.2
cm aggregate of clotted blood and pink tissue fragments. The
specimen is entirely submitted B.
Part 3 is labeled "tracheal tumor" and consists of multiple
small fragments of tan brown blackened tissue aggregating 1.0 x
1.0 x 0.5 cm, entirely submitted in C.
[**2100-8-5**] 10:08 am BRONCHOALVEOLAR LAVAGE
**FINAL REPORT [**2100-8-9**]**
GRAM STAIN (Final [**2100-8-5**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
RESPIRATORY CULTURE (Final [**2100-8-9**]):
10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML..
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy. .
Please contact the Microbiology Laboratory ([**7-/2401**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
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
Urine cx [**2100-8-5**] no growth
Blood cx [**8-8**], [**8-9**] NGTD
Blood cx [**8-5**] negative
Brief Hospital Course:
A/P: 65 y/o M w/ h/o CAD, T2DM, htn, and squamous cell CA of
left lung admitted to [**Hospital 2079**] Hospital [**8-3**] w/ hemoptysis d/w
lung CA s/p intubation for worsening hemoptysis/hypoxia,
extubated [**8-6**] and currently stable on 2 L NC w/o further
hemoptysis.
# Hemoptysis: Likely due to malignant mass. S/p argon laser tx
to invading tumor [**8-4**]. Hct stable w/o transfusion since [**8-4**].
Hematocrit 28.1 on day of discharge.
.
# Lung cancer: Patient underwent bronchoscopy for bx/tx/dx and
path c/w recurrent SCC. Chest CT was repeated here and shows a
paratracheal and subcarinal mass invading the right and left
mainstem bronchi. He had a Y-tube stent placed to maintain
patency of the airways. CEA 4.0. Thoracic surgery was consulted
and deemed Mr. [**Known lastname **] not an operable candidate. Medical
oncology and radiation oncology consulted during this admission.
Plan for chemoradiation. Patient wishes to do radiation
treatments at [**Hospital3 3583**]. Appointment made for him to see
Dr. [**Last Name (STitle) 99212**]. Medical oncology here will be contacting patient
with his appointment with them. He has been scheduled for an
outpatient PET scan for staging.
.
# MRSA pneumonia: Patient w/ hypoxia on presentation. Extubated
[**2100-8-6**] but w/ persistent O2 requirement. Patient spiked while in
house and was started on levofloxacin. He continued to spike on
this antibiotic. Subsequently, sputum cx from BAL grew out MRSA.
Patient's interventional pulmonologist, Dr. [**First Name (STitle) **] [**Name (STitle) **], saw the
patient during his stay and attempted ultrasound thoracentesis
of patient's left pleural effusion. There was not enough flood
to permit a tap. He will f/u with Mr. [**Known lastname **] as an outpatient.
Blood cx from [**8-5**] are negative and subsequent cx from [**8-8**] and
11 are NGTD. Plan for 14 days total of vancomycin +
levofloxacin. PICC placed by IR. Patient discharged w/
prescription for home O2, in addition to guaifenesin.
.
# GI bleeding: Patient had increasing diarrhea in the ICU. He
has a h/o IBD and states this has happened to him in the past.
However, he also had an episode of bloody diarrhea
(approximately 1 teaspoon). Hct remained stable. No transfusions
were necessargy. ASA initially held but restarted without
issues. Plan for f/u w/ outpatient PCP to consider colonoscopy.
Patient d/c home on qd PPI.
.
# Htn: Home bp meds restarted following extubation and patient's
bp has been well-controlled.
.
# T2DM: Well-controlled blood sugars on home glyburide.
.
# CAD: No c/o chest pain this admission. Patient continued on
his home ASA, statin, BB, and ACE. No CHF on CXR/exam.
.
# Crohn's: Stools are loose. No antibx within past 3 months.
Continue asacol and azathioprine.
.
# PPX: sq heparin, PPI
.
# FEN: IVFs (BUN/creat>20), phos repleted this AM, DM/cardiac
diet
.
# Full code
.
# Access: central line in ICU, d/c home w/ PICC
.
# Dispo: home w/ services (IV antibx, PICC care, O2)
Medications on Admission:
--asacol 400 mg [**Hospital1 **]
--nifedical 60 mg QD
--azathioprine 25 mg [**Hospital1 **]
--uniretic 15/12.5 QD
--glyburide 10 mg QHS
--coreg 18.75 mg [**Hospital1 **]
--avandamet 4/500, 2 tabs daily
--lipitor 40 mg QD
--diovan 80 mg QHS
--aspirin 162 mg QD
Discharge Medications:
1. Moexipril 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
3. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 11 days.
Disp:*11 Tablet(s)* Refills:*0*
5. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO bid () for 11 days.
Disp:*44 Tablet Sustained Release(s)* Refills:*0*
6. Azathioprine 50 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
7. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
9. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
11. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous Q 12H (Every 12 Hours) for 25 doses.
Disp:*25 gram* Refills:*0*
12. PICC line care
per protocol
13. BUN, creatinine
please check in 1 week and call to DR. [**Last Name (STitle) 57303**],[**First Name3 (LF) **]
[**Telephone/Fax (1) 57304**]
14. oxygen
2L continuous home O2
15. Carvedilol 6.25 mg Tablet Sig: Three (3) Tablet PO twice a
day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] home therapies
Discharge Diagnosis:
Primary diagnoses:
Non-small cell lung cancer
Secondary Diagnoses:
MRSA Pneumonia
gastrointestinal bleeding
Discharge Condition:
Desaturations to 86% with ambualtion on room air. No coughing of
blood. No gross blood in stool.
Discharge Instructions:
Please call your doctor or go to the emergency room if you have
recurrent blood in your sputum, blood in your stool, worsening
shortness of breath, or temperature greater than 101.
Followup Instructions:
You have a PET scan scheduled at the [**Country 3867**] Hospital,
Nuclear Medicine, on Wednesday, [**8-18**], at 1210.
Do not eat or drink anything besides water for 6 hours prior to
the appointment, no strenuous exercise, or sugary food for 24
hours.
You have an appointment with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 99213**] on Tuesday [**8-17**] at 1200.
You have an appointment to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 99212**] at [**Hospital1 3325**] to discuss radiation therapy of your lung cancer on
[**2100-8-16**] at 10:30 AM. Address: [**First Name5 (NamePattern1) 46**] [**Last Name (NamePattern1) **] Cancer
Center, [**Location (un) 81195**], Exit 5. Phone: ([**Telephone/Fax (1) 99214**]
Your Medical Oncologist and Pulmonologist will contact you
regarding appointments.
Please call your gastroenterologist, Dr. [**Last Name (STitle) 99215**] [**Name (STitle) **] at [**Hospital **]
Medical Clinic in [**Location (un) 38**] for follow-up of your bloody bowel
movement while in the hospital.
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14,651
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28186
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Discharge summary
|
report
|
Admission Date: [**2161-3-1**] Discharge Date: [**2161-3-10**]
Date of Birth: [**2091-11-14**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5123**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
69 y/o F with hx of NSCLC in L lung, known LLE DVT on coumadin,
presents today with new onset chest pain. Approximately 2 days
ago, she started having pleuritic chest pain.
.
Of note, she has a hx of PE diagnosed in [**2158**] and has been on
coumadin since that time. She had held her coumadin 4 days
prior to a lymph node biopsy on [**2-10**]. The coumadin was
restarted the day after the biopsy, and on that day she noted
redness and swelling in her RLE. She was admitted [**2-19**] and
treated for RLE cellulitis with vanco/keflex. She was also
found to have LLE DVT. The thought was that it likely occurred
while she was off her coumadin, so it was not considered a
treatment failure and she was continued on her coumdain, as she
was appropriately therapeutic. She was discharged [**2-23**].
.
In the ED, initial vs were T 98.9, p 86, bp 125/72, r 20, 100%
on 3L. Patient was given vanco, ceftriaxone, levofloxacin. She
had a head CT that was negative. Vascular surgery was consulted
and plans to place an IVC filter tomorrow morning.
.
On the floor, she is complaining of SOB and L sided chest pain.
She is hemodynamically stable. She wears home O2 since [**2157**].
She has no other complaints. No headaches, fevers, chills.
Does have chronic productive cough.
Past Medical History:
PMH:
Hypertension - diagnosed 25 years ago
Hyperlipidemia
hearing loss
chronic diastolic heart failure
lung/thyroid cancer s/p resection
[**2159-3-28**] CT scan --> pulmonary embolism; started coumadin
Hypothyroid
Pulmonary hypertension
Left ventricular hypertrophy
.
ONCOLOGIC HISTORY:
- [**11-2**] - increased SOB --> CXR with RUL opacity, CTA with 1.7 x
2.1 cm spiculated right apical lung mass was noted, also found
to have left sided thyroid mass with mass effect and tracheal
narrowing.
- [**11-2**] - CT scan of the abdomen that showed innumerable
low-density lesions in the liver for which MRI was recommended
- [**11-2**] negative bone scan
- [**11-2**] thyroid ultrasound with FNA biopsy that was
nondiagnostic.
- [**11-2**] PET/CT intensely FDG-avid right apical spiculated nodule
measuring 2.4 x 1.7 cm with an SUV max of 15.8. Also noted was
an FDG-avid 5-mm left upper lobe nodule. There was no evidence
of hilar or mediastinal lymphadenopathy and her thyroid lesion
was not FDG avid.
- repeat thyroid biopsy was unremarkable.
- [**2158-1-10**] left total thyroidectomy and right subtotal
thyroidectomy, wedge resection of a right upper lobe nodule
given her poor lung function as well as mediastinal lymph node
dissection.
- Pathology from lung revealed a 1.9 cm grade II adenocarcinoma
staged as a T1, N0.
- Note was also made of a micropapillary 0.1 cm thyroid cancer
confined to the thyroid.
- followed with frequent imaging
- [**2159-3-28**] CT scan --> pulmonary embolism, and she was
subsequently started on Coumadin for anticoagulation.
- follow up CT scans every three months.
-[**8-5**] a right lower lobe nodule and a 3-mm right middle lobe
nodule concerning for metachronous lung cancer was noted.
- PET/CT right lower lobe non-FDG avid lesion, but there was
some concern for a bronchoalveolar carcinoma upon the read of
that scan.
- [**12-6**] Repeat CT scan with right middle lobe nodule measuring
now
8.9 mm and a right lower lobe opacity concerning for
bronchoalveolar carcinoma.
- [**2160-1-8**] PET/CT on [**2160-1-8**], which revealed two suspicious
right lung lesions that were noted on the CT scan on [**2159-12-19**],
both with increased FDG avidity that was new from prior scans
and felt very suspicious for malignancy
- [**5-6**] CT interval progression in the right middle lobe lesion,
A slowly growing lesion in the left lower lobe suspicious for
bronchoalveolar cancer with significant soft tissue component,
Left axillary and mediastinal lymphadenopathy, Equivocal
findings in the adrenals.
.
PAST SURGICAL HISTORY:
# Hysterectomy age 18
# [**2158-1-10**] left total thyroidectomy and right subtotal
thyroidectomy, wedge resection of a right upper lobe nodule
given her poor lung function as well as mediastinal lymph node
dissection. (Pathology from lung revealed a 1.9 cm grade II
adenocarcinoma staged as a T1, N0. Note was also made of a
micropapillary 0.1 cm thyroid cancer confined to the thyroid.)
# [**2161-2-10**]: L axillary LN biopsy metastatic lung cancer
Social History:
Exsmoker, lives alone in her ground floor apartment. Uses O2
prn. Mobilizes with walker and cane. Friends do errands for her.
Does not get out of the house. Gets SOB walking minimal
distances. Does not drink ETOH or use illicits.
Family History:
No history of clotting disorders.
Physical Exam:
Vitals: T: 97.2 BP: 135/63 P: 94 R: 20 O2: 98% on 3L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
CTA CHEST
FINDINGS: There are large filling defects within the right main
pulmonary
artery extending into the right lower lobe subsegmental arteries
and right
middle lobe segmental arteries. Filling defects within the left
lower lobe
segmental and subsegmental arteries as well left upper lobe
segmental artery are noted. There has been interval development
of patchy opacity within the left upper lobe (3, 25). This may
represent developing infection versus pulmonary infarct. There
has been interval development of small left pleural effusion.
Large right upper lobe mass measures 3.7 x 3.2 cm, increased
when compared to prior exam. Additional pulmonary nodules are
similar in appearance. Patient is status partial right lung
resection. There is patchy opacity in the left lung base, which
also may represent atelectasis versus developing pulmonary
infarct. There are coronary artery calcifications. There is no
pericardial effusion.
There is massive left axillary and left subpectoral
lymphadenopathy, partially imaged. For example, there is a 3.7
cm lymph node in short axis diameter within the left axilla.
Enlarged lymph nodes within the mediastinum including a
subcarinal lymph node measuring 2.6 x 2.2 cm is also identified,
similar in
appearance. Calcifications of the arch of aorta and its branches
arnoted.
Limited views of the upper abdomen are noncontributory, except
to note a
subcentimeter hypodense lesion within the liver (2, 52), better
seen on prior CT scan.
IMPRESSION:
1. Bilateral segmental and subsegmental pulmonary emboli which
extend into
the right main pulmonary artery.
2. Interval development of patchy opacity in the left upper lobe
and left
lung base, which may represent new infectious process versus
developing
pulmonary infarcts.
3. Small left pleural effusion.
4. Interval increase in pulmonary nodules and masses.
5. Extensive lymphadenopathy in the left axilla and mediastinum,
similar in appearance.
.
.
LE U/S:
FINDINGS: The right common femoral vein, superficial femoral
vein, greater
saphenous vein and calf veins are patent with appropriate
direction of flow and compressibility. However, the right
popliteal vein is enlarged with echogenic material within the
lumen and absence of flow or compressibility. These findings
are compatible with an occlusive thrombus. This is new when
compared to the prior study.
.
The left common femoral vein, superficial femoral vein and
greater saphenous veins are patent with appropriate direction of
flow, compression and augmentation. There is a filling defect
within the left popliteal vein
without compressibility, however, a small amount of flow is
identified.
Findings are compatible with a nonocclusive thrombus within the
left popliteal vein. The left calf veins are patent.
.
IMPRESSION:
1. Interval development of occlusive thrombus within the right
popliteal
vein.
2. Nonocclusive thrombus in the left popliteal vein, as seen on
the prior
study.
Brief Hospital Course:
This is a 69 year old female with a history of metastatic NSCLC,
deep vein thrombosis on coumadin with therapeutic INR admitted
with pleuritic chest pain found to have bilateral pulmonary
segmental and subsegmental emboli.
.
# PULMONARY EMBOLISM: She was found to have a recurrent
thromboembolism on coumadin. Her coumadin was held given
therapeutic failure. She was started on a heparin drip and
transitioned to lovenox. An IVC filter was placed without
complication. She remained hemodynamically stable and was
satting well in the mid to high 90s at her baseline oxygen
requirement of 3L. She will need lifelong anticoagulation with
Lovenox and it took several days to ensure that she would have a
supply as an outpatient. Lovenox teaching was performed.
.
# INFILTRATE: There was a questionable infiltrate found on the
admission CT scan. She was started on broad spectrum antibiotics
but remained afebrile without clinical evidence of infection so
her antibiotics were stopped on hospital day 2. Blood cultures
from admission remained negative.
.
# HEMOPTYSIS: She reported intermittent teaspoon size hemoptysis
in the setting of a supratherapeutic INR. She received vitamin
K. Her hematocrits were trended and remained stable.
.
# NSCLC: The oncology service was consulted regarding the
management of her metastatic disease. She was continued on
folate and a chemo port was placed on [**3-6**]. She is due to start
chemotherapy with pemetrexed as an outpatient. Decadron 4mg [**Hospital1 **]
was started as pre-treatment for chemo.
.
# DIASTOLIC CHF: She appeared euvolemic on exam and had no
increased O2 requirement with mild bilateral pedal edema likely
secondary to her known DVTs. She was continue on her home
metoprolol and lisinopril, but her home furosemide was held and
not restarted upon discharge.
.
# HYPERTENSION: Her home metoprolol and lisinopril were
continued. Her home nifedipine was initially held, but
restarted prior to discharge. Her home Lasix was held her whole
admission and not restarted upon discharge.
.
# HYPERLIPIDEMIA: She was continued on her home dose of statin.
.
# Hypothyroid: She was continued on her home dose of
levothyroxine.
.
#. Anemia. Appears to be secondary to chronic inflammation.
.
#. Communication: Patient
.
#. Code: Confirmed full code.
Medications on Admission:
Albuterol Sulfate [ProAir HFA] PRN
Dexamethasone 4mg then taper for nausea
Folic Acid 1 mg daily
Furosemide [Lasix] 160 mg [**Hospital1 **]
Potassium Chloride 20 meq daily
Levothyroxine 112 mcg daily
Lisinopril 20 mg daily
Lovastatin 40 mg daily
Metoprolol Tartrate [Lopressor] 75 mg [**Hospital1 **]
Nifedipine 60 mg daily
Prochlorperazine Maleate 5 mg q6hrs PRN
Sulfamethoxazole-Trimethoprim DS 2 tabs [**Hospital1 **]
Warfarin [Coumadin] 5 mg daily
Guaifenesin [Mucinex] 1200 mg [**Hospital1 **] PRN
Senna 8.6 mg daily PRN
Discharge Medications:
1. Lovenox 120 mg/0.8 mL Syringe Sig: One [**Age over 90 **]y (120)
mg Subcutaneous twice a day for 3 doses.
Disp:*3 syringes* Refills:*0*
2. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*2*
3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Lovastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
9. Nifedipine 60 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
10. Prochlorperazine Maleate 5 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Pulmonary embolism, Deep venous thromboses
.
Secondary diagnoses:
Metastatic non small cell lung cancer
Hypertension
Hyperlipidemia
Hearing loss
Chronic diastolic heart failure
h/o pulmonary embolism
Hypothyroidism
Pulmonary hypertension
Left ventricular hypertrophy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to [**Hospital1 69**] for
evaluation of chest pain and coughing up blood. You were found
to have clots in your lungs and in your legs even though you
were on Coumadin at home. A filter was placed to help prevent
future clots from traveling to your lungs. You were started on
a heparin drip and transitioned to Lovenox and your symptoms
improved. You also had a port placed in the right side of your
chest so that you can start your chemotherapy as an outpatient.
You will need to continue dexamethasone and Lovenox as an
outpatient.
.
AT YOUR ONCOLOGY APPOINTMENT TOMORROW SOMEONE WILL DELIVER YOUR
LOVENOX. IF YOU HAVE ANY PROBLEM GETTING THIS CALL [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] MD AND HAVE HER PAGED AT [**Telephone/Fax (1) 2756**].
.
The following changes have been made to your home medication
regimen:
- You should stop your home Lasix (furosemide), Coumadin
(warfarin), Bactrim (sulfamethoxazole/trimethoprim), and
potassium
- You should start dexamethasone 4mg twice daily
- You should continue on Lovenox 120mg twice daily indefinitely
.
The following medications were continued:
-albuterol
-folic acid 1mg daily
-lisinopril 20mg daily
-lovastatin 40mg daily
-metoprolol 75mg (three 25mg pills) twice a day
-nifedipine 60mg daily
-prochlorperazine 5mg every 6 hours as needed for nausea
-senna
-tylenol as needed for pain
-levothyroxine 112mcg daily
Followup Instructions:
Please follow-up with all of your outpatient medical
appointments listed below:
.
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2161-3-11**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10384**], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
**** AT THIS APPOINTMENT, SOMEONE WILL DELIVER YOUR LOVENOX IF
HAVE HER PAGED AT [**Telephone/Fax (1) 2756**].
.
1. Department: [**Telephone/Fax (1) 706**]
When: THURSDAY [**2161-3-12**] at 1 PM
With: [**Year (4 digits) 706**] [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
2. Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2161-3-19**] at 2:30 PM
With: [**First Name8 (NamePattern2) 251**] [**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
.
3. Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2161-3-19**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 15105**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"V10.87",
"786.3",
"428.0",
"401.9",
"415.19",
"272.4",
"197.0",
"453.40",
"428.32",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.07",
"88.51",
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
12547, 12605
|
8501, 10808
|
326, 332
|
12916, 12916
|
5532, 8478
|
14539, 15929
|
4942, 4977
|
11384, 12524
|
12626, 12671
|
10834, 11361
|
13099, 14516
|
4224, 4678
|
4992, 5513
|
12692, 12895
|
276, 288
|
360, 1641
|
12931, 13075
|
1663, 4201
|
4694, 4926
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,432
| 156,178
|
48580
|
Discharge summary
|
report
|
Admission Date: [**2167-11-4**] Discharge Date: [**2167-11-13**]
Date of Birth: [**2095-3-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
1.Bentall procedure with a 29-mm [**Company 1543**] Freestyle
aortic valve bioprosthesis with coronary button
reimplantation. Valve data is the following: Serial
#[**Serial Number 102216**].
2. Replacement of ascending aorta and hemi-arch using a 30-
mm Vascutek Dacron tube graft with deep hypothermic
circulatory arrest.
History of Present Illness:
72 year old male presented to OSH with chest pain that started
as severe pain that lasted 30 minutes and then decreased to mild
and called his PCP who referred him to the ED. In triage he had
sudden chest pain, became diaphoretic and pale with hypotension
of Systolic pressure documented at 60. He received IV fluids
and transferred to cardiac cath lab for emergent catheterization
that revealed dilated aorta. He was then transferred to [**Hospital1 18**]
for evaluation which he was brought into the ED, CTA and labs
obtained and emegerently to the operating room for ascending
aorta replacement.
Past Medical History:
Hypertension
Prostate CA
Past Surgical History
Seed implants for prostate CA
Social History:
Race: hispanic
Lives with: spouse
Family History:
NC
Physical Exam:
Admission Physical Exam
Pulse: 64 Resp: 22 O2 sat: 100% on NRB
B/P SBP 100's bilateral
General: on 100% NRB calm
Skin: Dry [x] intact [x]
HEENT: Pupils equal in size
Chest: Lungs clear bilaterally [x] anterior on 100% NRB
Heart: RRR [x] Irregular [] Murmur none
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] no palpable masses
Extremities: Warm [x], Edema none
Neuro: awakes to voice oriented x3
Pulses:
Femoral Right: sheath Left: +1
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +1 Left: +1
Carotid Bruit Right:none Left: none
Pertinent Results:
[**2167-11-12**] 04:50AM BLOOD WBC-9.0 RBC-3.83* Hgb-11.5* Hct-33.4*
MCV-87 MCH-30.1 MCHC-34.6 RDW-14.5 Plt Ct-346
[**2167-11-6**] 03:07AM BLOOD WBC-8.8 RBC-2.76* Hgb-8.6* Hct-24.2*
MCV-88 MCH-31.2 MCHC-35.6* RDW-15.1 Plt Ct-145*
[**2167-11-4**] 02:30PM BLOOD WBC-19.1*# RBC-4.36* Hgb-13.3* Hct-37.8*
MCV-87 MCH-30.4 MCHC-35.1* RDW-14.9 Plt Ct-254
[**2167-11-11**] 09:41AM BLOOD PT-13.8* PTT-30.4 INR(PT)-1.2*
[**2167-11-4**] 02:30PM BLOOD PT-12.9 PTT-22.9 INR(PT)-1.1
[**2167-11-12**] 04:50AM BLOOD Glucose-96 UreaN-41* Creat-1.3* Na-143
K-3.6 Cl-107 HCO3-25 AnGap-15
[**2167-11-4**] 02:30PM BLOOD Glucose-137* UreaN-20 Creat-1.3* Na-136
K-4.0 Cl-105 HCO3-19* AnGap-16
[**2167-11-6**] 03:16PM BLOOD ALT-16 AST-50* LD(LDH)-289* AlkPhos-53
Amylase-73 TotBili-0.6
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 102217**] (Complete)
Done [**2167-11-4**] at 8:17:39 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2095-3-15**]
Age (years): 72 M Hgt (in): 67
BP (mm Hg): 80/60 Wgt (lb): 178
HR (bpm): 72 BSA (m2): 1.93 m2
Indication: emergency aortic dissection
ICD-9 Codes: 441.2, 423.9, 424.1
Test Information
Date/Time: [**2167-11-4**] at 20:17 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3893**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2010AW04-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Sinus Level: *4.5 cm <= 3.6 cm
Aorta - Ascending: *4.5 cm <= 3.4 cm
Findings
The NG tube could not be passed into the stomach. The TEE probe
was felt to be tight beyond 30cm at incisors. No further
attempts to pass it lower esophagus or transgastric. Therefore
limtied imaging was performed.
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color Doppler.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Moderately dilated aortic sinus. Dilated sinuses of
Valsalva. Focal calcifications in aortic root. Moderately
dilated ascending aorta. Normal aortic arch diameter. Normal
descending aorta diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Moderate (2+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: Moderate pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient. See Conclusions for post-bypass data
Conclusions
PRE-BYPASS:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage.
No atrial septal defect is seen by 2D or color Doppler.
Right ventricular chamber size and free wall motion are normal.
The aortic root is moderately dilated at the sinus level. The
sinuses of Valsalva are dilated. The ascending aorta is
moderately dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Moderate (2+)
aortic regurgitation is seen. The aortic regurgitant jet was
centra. An elaborate attempt was made to elucidate the
dissection flap. However, this was not well visualilzed. This
finding was conveyed to surgeons.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is a moderate sized pericardial
effusion.
There was moderate pericardial effusion causing hemodynamic
disturbances in the form of mild hypotension. NO further
attempts made to characterize tamponade effects.
Dr.[**Last Name (STitle) 914**] was notified in person of the results on [**Known firstname 3924**]
[**Known lastname **] before surgical incision..
POST-BYPASS:
Patient on small dose of phenylephrine.
Intact thoracic aorta and the graft.
Normal biventricular systolic function. LVEF 55%.
Trivial MR.
The new stentless bioprosthesis is well visualized, well seated
with a small central regurgitant jet. No gradients done due to
inability to pass the probe into the stomach.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2167-11-4**] 20:26
?????? [**2160**] CareGroup IS. All rights reserved.
Brief Hospital Course:
On [**11-4**]/2010Mr.[**Known lastname **] was taken to the operating room and
underwent an emergent Bentall Procedure (#29 mm [**Company 1543**]
Freestyle Porcine Aortic Valve/root and Replacement of aortic
hemi-arch with #30mm Gelweave sidearm graft with Dr.[**Last Name (STitle) 914**].
Circulatory arrest time=22 minutes, Cross clamp time=150
minutes, and Cardiopulmonary Bypass time=187 minutes.Please
refer to the operative report for further details. He tolerated
the procedure well and was transferred to the CVICU intubated
and sedated. He awoke neurologically intact but required
Precedex for extubation. POD#1 he was extubated without
difficulty. Postoperative confusion and agitation was treated
with Haldol and Zyprexa, all narcotics were discontinued. He
remained in the CVICU until his mental status improved. All
lines and drains were discontinued in a timely fashion.
Beta-blocker/Statin/Aspirin/ and diuresis were initiated. POD#6
Mr.[**Known lastname **] went into postoperative rapid atrial fibrillation that
was treated with Amiodarone and increased Beta-blocker and
ultimately converted to normal sinus rhythm. [**11-11**] Psychiatry and
social work was consulted to evaluate postoperative confusion
with hallucinations. Recommendations appreciated. POD#7 he was
transferred to the sterp down unit for further monitoring.
Physical Therapy was consulted for evaluation of strength and
mobility. The remainder of his postoperative course was
essentially uneventful. His mental status returned to baseline.
POD# 9 Dr.[**Last Name (STitle) 914**] cleared him for discharge to home with
Visiting Nurse services. All follow up appointments were
advised.
Medications on Admission:
Atenolol 25 mg daily
Hydrochlorothiazide 25 mg daily
Protonix 40 mg daily
Aspirin 325 mg daily
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
2. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours) as needed for pain.
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): x 7 days, then decrease to 200 mg po once daily .
Disp:*60 Tablet(s)* Refills:*2*
6. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*2*
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Acute type A aortic dissection/ Ascending aortic aneurysm/ Mild
to moderate aortic insufficiency/ Aortic root aneurysm/ Aortic
arch aneurysm.
-s/p Bentall procedure with a 29-mm [**Company 1543**] Freestyle aortic
valve bioprosthesis with coronary button reimplantation. Valve
data is the following: Serial#[**Serial Number 102216**]. Replacement of
ascending aorta and hemi-arch using a 30- mm Vascutek Dacron
tube graft with deep hypothermic circulatory arrest on [**2167-11-4**].
-Hypertension
Prostate CA
Past Surgical History
Seed implants for prostate CA
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral Analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Trace
lower extremity edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon:Dr.[**Last Name (STitle) 914**] # [**Telephone/Fax (1) 170**], appointment arranged for
[**2167-12-1**] at 2 pm
Cardiologist:Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1159**], appointment was arranged for [**12-22**], [**2167**] at 11:30 AM. #[**Telephone/Fax (1) 6256**]
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) 16412**] in [**2-14**] 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:[**2167-11-13**]
|
[
"997.1",
"424.1",
"518.0",
"441.01",
"V10.46",
"997.4",
"427.31",
"560.1",
"285.9",
"293.0",
"E878.2",
"423.9",
"348.30",
"518.5",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"38.45",
"39.61",
"36.2"
] |
icd9pcs
|
[
[
[]
]
] |
10296, 10355
|
7341, 9012
|
333, 680
|
10964, 11213
|
2160, 7318
|
12137, 12800
|
1481, 1485
|
9158, 10273
|
10376, 10943
|
9038, 9135
|
11237, 12114
|
1500, 2141
|
282, 295
|
708, 1313
|
1335, 1413
|
1429, 1465
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,767
| 149,211
|
52182
|
Discharge summary
|
report
|
Admission Date: [**2142-4-16**] Discharge Date: [**2142-4-22**]
Date of Birth: [**2074-9-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
67M with CAD
Major Surgical or Invasive Procedure:
CABG x 3 ([**Female First Name (un) 899**]>LAD, SVG>OM, SVG>PDA)
History of Present Illness:
67 yo male, had 3 vessel cabg on [**4-16**]. CAD found during work up
for penile cancer. Plans to move on to penectomy. Type 2 dm, A1C
6%. Creat 1.5
Past Medical History:
NIDDM
HTN,
^chol.
CRI
penile carcinoma
obesity
severe claustrophobia
Social History:
+ TOB 1 PPD x 50 yrs
ETOH 3 drinks/ week
Physical Exam:
GEN: NAD
CV:RRR
Chest: CTA B
ABD: soft, NT,
EXT: + pulses
INC: CDI, no drainage, no erythema
Pertinent Results:
[**2142-4-16**] 12:11PM freeCa-1.23
[**2142-4-16**] 12:11PM HGB-11.4* calcHCT-34
[**2142-4-16**] 12:11PM GLUCOSE-93 NA+-138 K+-4.9
[**2142-4-16**] 12:11PM TYPE-ART PO2-331* PCO2-39 PH-7.35 TOTAL
CO2-22 BASE XS--3 INTUBATED-INTUBATED VENT-CONTROLLED
[**2142-4-16**] 02:23PM HGB-8.6* calcHCT-26
[**2142-4-16**] 02:23PM GLUCOSE-105 K+-6.4*
[**2142-4-16**] 02:23PM TYPE-ART PO2-471* PCO2-35 PH-7.45 TOTAL
CO2-25 BASE XS-1
[**2142-4-16**] 03:05PM HGB-8.8* calcHCT-26
[**2142-4-16**] 03:05PM GLUCOSE-137* K+-7.2*
[**2142-4-16**] 03:57PM HGB-8.6* calcHCT-26
[**2142-4-16**] 03:57PM GLUCOSE-122* NA+-135 K+-5.0
[**2142-4-16**] 03:57PM TYPE-ART PO2-293* PCO2-41 PH-7.34* TOTAL
CO2-23 BASE XS--3 INTUBATED-INTUBATED VENT-CONTROLLED
[**2142-4-16**] 05:05PM FIBRINOGE-223
[**2142-4-16**] 05:05PM PT-13.3* PTT-30.4 INR(PT)-1.2*
[**2142-4-16**] 05:05PM PLT COUNT-191
[**2142-4-16**] 05:05PM WBC-17.2*# RBC-3.50* HGB-10.2* HCT-30.9*
MCV-88 MCH-29.2 MCHC-33.0 RDW-14.8
[**2142-4-16**] 05:05PM CALCIUM-8.5 PHOSPHATE-1.3* MAGNESIUM-2.8*
[**2142-4-16**] 05:05PM GLUCOSE-90 UREA N-27* CREAT-1.5* SODIUM-137
POTASSIUM-4.8 CHLORIDE-110* TOTAL CO2-20* ANION GAP-12
[**2142-4-16**] 05:28PM freeCa-1.30
[**2142-4-16**] 05:28PM O2 SAT-98
[**2142-4-16**] 11:52PM TYPE-ART PO2-114* PCO2-43 PH-7.26* TOTAL
CO2-20* BASE XS--7
[**2142-4-16**] 11:52PM GLUCOSE-128* K+-4.8
[**2142-4-16**] 11:52PM freeCa-1.16
[**2142-4-16**] 09:28PM TYPE-MIX TEMP-35.9 PO2-39* PCO2-49* PH-7.24*
TOTAL CO2-22 BASE XS--6
Brief Hospital Course:
Pt received a Coronary artery bypass graft x3, left internal
mammary artery to left anterior descending artery and
saphenous vein grafts to posterior descending artery and
obtuse marginal artery on [**2142-4-16**]. Patient did weel post op.
transfered to the floor on POD 2.[**Last Name (un) **] was consulted for
glucose control.Patient went into a-fib on POD 3 and treated
with an Amio drip and pt went back to NSR.Pt was placed on po
Amio.remained in NSR and was D/C'd on [**2142-4-22**].
Medications on Admission:
Metformin 850", [**Last Name (un) **] 4/240 mg', Glyburide 2.5', Toprol XL 100',
Crestor 10', Tricor 145', ASA 325'
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (once) for 1
doses.
Disp:*30 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
8. Fenofibrate Micronized 48 mg Tablet Sig: One (1) Tablet PO
daily ().
Disp:*30 Tablet(s)* Refills:*2*
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
11. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO
DAILY (Daily) for 1 weeks: take with lasix.
Disp:*8 Packet(s)* Refills:*0*
12. Glimepiride 2 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. [**Last Name (un) **] 4-240 mg Tab, Multiphasic Release 24 HR Sig: One (1)
Tab, Multiphasic Release 24 HR PO once a day.
Disp:*30 Tab, Multiphasic Release 24 HR(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
care group
Discharge Diagnosis:
CAD
NIDDM
HTN
^chol.
CRI, penile carcinoma, obesity, severe claustrophobia
Discharge Condition:
GOOD
Discharge Instructions:
no creams, lotions or powders to any incisions
no lifting > 10# for 10 weeks
ma y shower, no bathing or swimming for 1 month
Followup Instructions:
Dr [**Last Name (STitle) 914**] 1- 2 weeks
Dr [**Last Name (STitle) 1147**] 1 week
[**Last Name (un) **] 1 week
Completed by:[**2142-4-22**]
|
[
"997.1",
"414.01",
"187.4",
"250.00",
"401.9",
"585.9",
"427.31",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"36.15",
"37.78",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
4699, 4740
|
2397, 2891
|
333, 399
|
4860, 4866
|
856, 2374
|
5039, 5184
|
3058, 4676
|
4761, 4839
|
2917, 3035
|
4890, 5016
|
743, 837
|
281, 295
|
427, 577
|
599, 670
|
686, 728
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,472
| 142,131
|
11080
|
Discharge summary
|
report
|
Admission Date: [**2185-3-11**] Discharge Date: [**2185-3-20**]
Date of Birth: [**2109-8-31**] Sex: M
Service: C-MED
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 35787**] is a 75-year-old
gentleman with a past medical history of aortic valve
replacement in [**2181**] (for aortic stenosis) complicated by
culture-negative endocarditis in [**2183**] (requiring a redo
aortic valve replacement homograft in [**2183**]).
The patient presented to an outside hospital with a 1-week to
2-week history of fatigue and occasional brief episodes of
shortness of breath. He denied any associated chest pain and
reported that the shortness of breath was unrelated to
exertion with lasted only a few seconds and improved when he
took a few deep breaths.
The patient also notes that his family has commented on his
decreased appetite for the last two days; although, he feels
that his appetite and oral intake have not significantly
changed. He describes occasional orthopnea. No paroxysmal
nocturnal dyspnea. Occasional ankle swelling. No
palpitations. No lightheadedness or dizziness.
The patient denies fevers, sweats, chills, or weight loss.
He reports a dry nonproductive cough. He denies hemoptysis.
He denies abdominal pain, nausea, or vomiting; although, this
had been noted at the outside hospital. He denies dysuria or
changes in urinary habits. No visual changes. No skin
changes or rashes.
PAST MEDICAL HISTORY:
1. Aortic stenosis; status post porcine valve replacement in
[**2181**]. Aortic valve culture-negative endocarditis in [**2183-8-6**]; status post aortic valve replacement redo.
2. Abdominal aortic aneurysm; status post repair at
[**Hospital6 1129**] in [**2183-11-6**].
3. Postural hypotension.
4. Chronic renal failure (with a baseline of 1.8 to 2.2).
5. B12 deficiency.
6. Depression.
MEDICATIONS ON ADMISSION: Medications at home included
vitamin B12 tablets.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is married. He lives at home
with his wife. [**Name (NI) **] has three children. He is retired. A
former smoker of one pack per day times 20 years; he quit 17
years ago. He denies ethanol or intravenous drug abuse.
PHYSICAL EXAMINATION ON PRESENTATION: Examination revealed
temperature was 96.9, heart rate was 76, blood pressure was
130/62 left and 130/60 right, oxygen saturation was 97% on
room air, and respiratory rate was 24. In general, the
patient appeared mildly short of breath; otherwise
comfortable. Head, eyes, ears, nose, and throat examination
revealed mild conjunctival pallor. Sclerae were anicteric.
Pupils were equal, round, and reactive to light and
accommodation. No conjunctival hemorrhages. Mucous
membranes were moist. No oral lesions. The neck was supple
with marked jugular venous distention to the angle of the
jaw. Heart was regular in rate and rhythm. Normal first
heart sounds and second heart sounds. A [**2-8**] diastolic murmur
at the aortic area; a 2/4 systolic ejection murmur at the
apex. Lung examination revealed thin bibasilar crackles. No
wheezing. The abdomen was soft, nontender, and nondistended.
No hepatosplenomegaly. Normal active bowel sounds. No
clubbing, cyanosis, or edema. No stigmata of endocarditis.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on
admission from the outside hospital revealed hematocrit was
32.7, white blood cell count was 4.5, platelet count was 120,
and mean cell volume was 85.1. Differential on the white
count revealed 62 polys, 23 lymphocytes, 11 monocytes, and
1.7 eosinophils. Iron was 36, total iron-binding capacity
was 274, B12 was 909. Chemistry was significant for a
creatinine of 1.8. AST was 26, ALT was 55, alkaline
phosphatase was 280. Glutamyltransferase was 159. Total
bilirubin was 1.3. Amylase was 46 and lipase was 32.
Albumin was 3.9. Total protein was 7.2. Thyroid-stimulating
hormone was 2.89.
PERTINENT RADIOLOGY/IMAGING: Imaging from the outside
hospital with abdominal ultrasound on [**2185-3-11**] (status
post abdominal aortic aneurysm repair) with patent bifurcated
graft, maximal diameter of the aneurysmal sac was 4.5 cm
(which was decreased when compared with the prior study from
[**2183-9-19**]). No large periaortic collection visible.
Echocardiogram on [**2185-3-11**] revealed preserved left
ventricular function, new 3+ aortic insufficiency, new 3+
mitral regurgitation; old 4+ tricuspid regurgitation with
elevated pulmonary artery systolic pressure at 80 mmHg.
A chest x-ray on [**2185-3-10**] revealed no infiltrates or
edema. Small bilateral pleural effusions, cardiomegaly,
dual-chamber pacing wires and sternotomy wires in place and
unchanged.
IMPRESSION: This is a 75-year-old gentleman with a history
of aortic valve replacement times two with a history of
culture-negative endocarditis; now with new 3+ aortic
insufficiency compared to a prior echocardiogram. Given
history, his presentation was worrisome for endocarditis;
although, he denied any infectious-type symptoms and per
outside hospital records was afebrile and all blood cultures
were negative. However, this is not surprising in light of
the patient's culture-negative endocarditis in [**2183**].
HOSPITAL COURSE BY ISSUE/SYSTEM:
1. NEW 3+ AORTIC INSUFFICIENCY: The patient appeared
euvolemic on admission and throughout his hospital course
without evidence of heart failure.
Therefore, for his aortic insufficiency, he was not actively
diuresed, but he was placed on afterload reduction.
Initially, the patient was placed on an ACE inhibitor. He
was given captopril which was titrated up to 37.5 mg t.i.d.
which he tolerated well (from a blood pressure standpoint).
However, by [**2185-3-14**], his creatinine had gone from 1.8
on admission to 2. On [**3-15**], his creatinine was 2.3.
Therefore, it was decided on [**2185-3-14**] to stop the
captopril for fear of worsening renal function and to
substitute this with hydralazine 50 mg p.o. t.i.d. for
afterload reduction.
To further evaluate the patient's aortic valve, a
transesophageal echocardiogram was performed. The
transesophageal echocardiogram was performed on [**2185-3-14**] and showed an left ventricular ejection fraction of 40%
to 45%. The left atrium was said to be mildly dilated. The
right atrium was normal in size. The left ventricular wall
thickness and cavity size were normal. Overall left
ventricular systolic function was mildly depressed. The
right ventricular wall thickness was normal. The right
ventricular chamber was markedly dilated with severe global
right ventricular free wall hypokinesis and abnormal septal
motion/position. The aortic valve was said to have a small
vegetation. No aortic valve abscess was seen.
Moderate-to-severe 3+ aortic regurgitation. Motion of the
aortic prosthesis leaflets and poppet were abnormal. The
mitral valve leaflets were severely thickened and deformed.
There was said to be a probable vegetation on the mitral
valve with 1+ mitral regurgitation. The tricuspid valve
leaflets were mildly thickened. No mass or vegetation.
Tricuspid regurgitation of 3+. The pulmonic valve was
normal. No pericardial effusion.
After these results returned, it was decided to consult the
Infectious Disease Service to help with management. Since
admission, the patient had not been placed on intravenous
antibiotics as he was afebrile with no growth from any blood
cultures.
The Infectious Disease Service was consulted on the day of
the transesophageal echocardiogram results. Their impression
was that the patient could be infected with an indulin
infection causing culture-negative endocarditis such as
Brucella, or Q fever, histoplasmosis, Whipple's disease, or
one of the hacek organisms.
They agreed that the patient should not be placed on
antibiotics, and that instead they would not place the
patient on antibiotics until just prior to his aortic valve
repair by Cardiothoracic Surgery.
They suggested the following serologies be checked:
(1) Bartonella antibody; (2) Lyme serologies; (3) rapid
plasma reagin; (4) mycoplasma hominis antibody, (5)
Chlamydia psittaci antibody; (6) Brucella abortus antibody;
and (7) Coxiella burnetii antibody. They also recommended
sending a urine histoplasmosis antigen.
At the time of cardiac surgery, they recommended that the
valve be sent for many studies; including Tropheryma
whippelii PCR, and the valve should be sent for routine Gram
stain culture, fungal cultures, and mycobacteria cultures; as
this had not been done in [**2183**] when the patient had
culture-negative endocarditis.
The Infectious Disease team felt that the patient would
benefit from going to cardiac surgery sooner rather than
later so that actual valve tissue could be obtained and sent
for the PCR and cultures they recommended, as they felt the
diagnosis would most likely be obtained from getting valve
tissue itself.
Cardiothoracic Surgery was consulted. They felt that the
patient should have repair of his aortic valve and possible
mitral valve as well. Before cardiothoracic surgery, they
requested that the patient be seen by the Dental Service so
that if he had any signs of infection in his gums this would
be dealt with prior to surgical intervention.
Therefore, the patient was seen by the Dental Service, who
stated that the patient had a large distal caries on tooth
number two, and tooth number nine had the beginning of a
caries with no pulp invasion.
Oral Surgery saw the patient on [**2185-3-16**] and decided to
remove tooth number two at the bedside. They felt that tooth
number nine would not be an infectious risk, as it was not
invading the pulp and therefore felt this tooth did not need
to be intervened upon. The patient had his tooth removed at
the bedside on [**2185-3-17**] without complications.
Per Cardiothoracic Surgery recommendations, the patient went
for cardiac catheterization as part of his preoperative
workup on [**2185-3-17**]. The cardiac catheterization showed
no evidence of coronary artery disease with clean coronary
arteries; however, this procedure was complicated by a
decrease in cardiac output and pulmonary edema.
Secondary to the decline in cardiac output and pulmonary
edema, the patient required a transfer to the Coronary Care
Unit and initiation of dobutamine and nitroglycerin drips.
The patient was in the Coronary Care Unit from [**2185-3-17**]
to [**2185-3-19**] and was transferred back to C-MED on [**2185-3-19**]. During his Coronary Care Unit stay, he was
diuresed with intravenous Lasix. A Swan-Ganz catheter was
placed to adequately measure hemodynamics. For afterload
reduction, the patient was continued on hydralazine and
started on Isordil. He was weaned off the nitroglycerin
drip, and he was weaned off the dobutamine by [**2185-3-19**].
The patient remained afebrile in the Coronary Care Unit. His
blood cultures remained negative.
2. INFECTIOUS DISEASE ISSUES: As stated previously, the
patient had culture-negative endocarditis in [**2183**], and it was
felt that the endocarditis at this time was either due to an
indulin infection (such as those mentioned previously,
including Whipple's disease or Brucella), or the patient
could have noninfectious endocarditis (such as from a
malignancy).
For the concern of endocarditis caused by some type of
malignancy, the patient had a chest, abdominal, and pelvic
computed tomography scan that showed no evidence of
malignancy and no abnormal lymph nodes (i.e., no lymph node
enlargement meeting pathologic criteria). The serologies
that were sent with the help of the Infectious Disease
Service were all pending on the day of discharge.
Infectious Disease recommended that the patient only have
antibiotics on call to the operating room and in the
immediate postoperative setting so that the organism could be
isolated from the valvular tissue after surgery. They
recommendations included vancomycin 1 g, ceftriaxone 1 g
intravenously q.24h., and gentamicin 1 mg/kg q.8h. They
recommended that all of these antibiotics be started
intraoperatively and should be continued postoperatively and
modified depending on the culture and serology data. They
also recommended that the valve tissue be sent u formalin to
pathology and also fresh for Gram stain and culture, fungal
culture, whippelii PCR, Bartonella PCR if the Bartonella PCR
came back positive; and lastly, that the valve be sent for
LBS/RNA/PCR.
At the time of this dictation, the following laboratory
results were back:
1. Mycoplasma culture of the urine was negative.
2. Bartonella blood cultures was still pending.
3. All regular blood cultures showed no growth.
4. Mycobacterial cultures were negative.
5. Lyme serology was negative (by Western blot).
6. Cardiolipin antibody was pending for the question of
marantic endocarditis.
The following chlamydia pneumonia serology was returned:
1. The chlamydia pneumonia immunoglobulin M was less than
1:16, which his normal.
2. The chlamydia pneumonia immunoglobulin G was 1:128, which
was high (less than 1:32 is normal).
3. The chlamydia pneumonia immunoglobulin A was 1:128 and
less than 1:16 is normal.
The interpretation of this test was that immunoglobulin M
titers of 1:16 or greater are indicative of recent infection.
Immunoglobulin G titers of 1:32 or greater may indicate past
exposure to a particular species. Titers of 1:128 or less
may be due to cross-reactive antibody or a nonspecific
stimulation of chlamydial antibody. Immunoglobulin G titers
in recently infection individuals are usually greater than or
equal to 1:512. Immunoglobulin A titers may be elevated in
recurrent or chronic infection and may be helpful in
identifying the infecting species of chlamydia when
cross-reactive immunoglobulin G is present.
The Q fever immunoglobulin G phase I titer was negative, as
was the phase II titer. The Brucella abortus immunoglobulin
G and immunoglobulin M were both within normal limits (i.e.,
negative). Chlamydia psittaci immunoglobulin M was negative,
immunoglobulin G negative, and immunoglobulin A negative.
Tests for Bartonella [**First Name9 (NamePattern2) 35788**] [**Last Name (un) 7570**] immunoglobulin
G/immunoglobulin M antibody panel were all negative. The
tests for Bartonella [**Last Name (un) 35788**] immunoglobulin G screen was
positive. Histoplasma antigen was negative at 0.76 (less
than 1 is said to be negative).
DI[**Last Name (STitle) 408**]E INSTRUCTIONS/FOLLOWUP: The patient was discharged
to home on [**2185-3-20**] after being transferred back to the
C-MED Service from the Coronary Care Unit on [**2185-3-19**].
He was ambulating without difficulty. He was normotensive.
There were no signs of congestive heart failure. The
following followup was put in place for the patient.
1. The patient was to follow up with his cardiologist (Dr.
[**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**]) on Wednesday, [**3-23**], on the seventh floor of
the [**Last Name (un) 469**] Building at 12 noon.
2. The plan was for the patient to have aortic valve
replacement on Monday, [**4-4**], with Dr. [**Last Name (Prefixes) **].
DISCHARGE DIAGNOSES:
1. Endocarditis of the aortic valve; recurrent.
2. Congestive heart failure secondary to aortic
insufficiency.
MEDICATIONS ON DISCHARGE: (The patient's discharge
medications were as follows)
1. Hydralazine 50 mg p.o. t.i.d.
2. Lopressor 12.5 mg p.o. b.i.d.
3. Isosorbide dinitrate 20 mg p.o. t.i.d.
4. Lasix 20 mg p.o. q.d.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. [**MD Number(1) 5226**]
Dictated By:[**Last Name (NamePattern1) 5851**]
MEDQUIST36
D: [**2185-3-22**] 15:26
T: [**2185-3-22**] 16:50
JOB#: [**Job Number 35789**]
|
[
"585",
"396.3",
"428.0",
"397.0",
"421.0",
"V42.2",
"398.91",
"521.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"88.52",
"23.09",
"88.55",
"37.21",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
15178, 15292
|
15319, 15792
|
1873, 1962
|
5264, 15157
|
167, 1429
|
1451, 1847
|
1979, 5230
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,040
| 157,839
|
23584
|
Discharge summary
|
report
|
Admission Date: [**2147-2-23**] Discharge Date: [**2147-2-27**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9554**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
This is a 85 who has history of hypertension and anemia who
presented to [**Hospital 8**] hospital with acute dyspnea. She arrived
in [**Hospital1 60375**] ED looking pale and diaphoretic using her
accessory muscles to breathe.
On arrival, she was found to be confused and agitated. Initial
blood gas showed 7.08/74/93. Her presentation BP was 212/86, P
112-120, R26-40 and 93% on NRB. She was found to have crackles
diffusely and 2+ leg edema. EKG was done that showed LLLB with
STE anterolaterally. CXR compatible with CHF. She was intubated
with repeat blood gas of 7.33/42/371. She recieved IV nitro, IV
heparin, IV [**Last Name (LF) 60376**], [**First Name3 (LF) **], IV lopressor 5 x1, IV lasix 100mg
trp 0.09
According to a family member, she has been intermittently short
of breath for a month and claims that it is relieved by
inhalers. At baseline, she is able to climb up a flight of
stairs without problem. Lately, her daughter noted subjectively
more shortness of breath. SHe might have been more tired in the
recent while. According to the daughter, she has no
orthopnea/PND. SHe has leg edema for several months and has been
worsening for a month. She denies orthostatic hypotension.
Past Medical History:
1 hypertension
2 anemia refused colonoscopy x 2 years; on Fe pills
3 emphysema
4 urinary incontinence x 3 years
5 cataract
6 GERD
Social History:
ex smoker; [**12-4**] ppd x 40 years, quit 15years ago
no ETOH
Family History:
MI in mother
Physical Exam:
98.3 140/59 73 18 96%RA
Gen-resting comfortably in no acute distress
HEENT-PERRL, EOMI, anicteric, OPC, MMMI
CV-RRR, 3/6 SEM radiating to carotids at RUSB, +A2
resp-faint bibasilar inspiratory crackles b/[**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 103**]-soft, NT/ND, +BS
ext-in [**Male First Name (un) **] hose, no c/c/e, pulses 2+ b/l
neuro-AOx3, MAEW, no dysarthria, ambulatory
Pertinent Results:
[**2147-2-23**] Admission Labs:
WBC-9.2 RBC-3.63* Hgb-8.5* Hct-26.0* MCV-72* MCH-23.3* MCHC-32.6
RDW-15.2 Plt Ct-251 Neuts-87.3* Bands-0 Lymphs-8.5* Monos-3.3
Eos-0.7 Baso-0.2
PT-13.8* PTT-59.8* INR(PT)-1.2
Glucose-93 UreaN-26* Creat-1.1 Na-142 K-3.9 Cl-110* HCO3-23
AnGap-13
ALT-22 AST-59* CK(CPK)-79 TotBili-0.4
CK-MB-4 cTropnT-0.08*
Albumin-3.3* Cholest-209*
Triglyc-40 HDL-88 CHOL/HD-2.4 LDLcalc-113
.
[**2147-2-27**] Discharge Labs:
WBC-5.3 RBC-4.34 Hgb-10.2* Hct-32.3* MCV-74* MCH-23.6* MCHC-31.8
RDW-16.0* Plt Ct-238
BLOOD Glucose-96 UreaN-17 Creat-0.9 Na-138 K-4.2 Cl-106 HCO3-25
AnGap-11
Calcium-9.3 Phos-2.3* Mg-2.0
.
Cath [**2147-2-23**]:
CO/CI 4.65/3.09
PCWP 17 CVP 11 PA 35/17
LMCA:mild disease
LAD:60% after D1, 50% after large D1
LCx: mild disease
RCA-40% mid RCA, 90% PL branch
DES in PL
.
Echocardiogram [**2147-2-24**]:
EF>65%, severe AS with area 0.8
.
EKG:NSR at 55bpm, left axis, STE in V1-V4 and 2, 3 VF, LBBB
.
CXR PA/Lat [**2147-2-27**]:
Small posterior stable effusions versus pleural thickening.
Resolving small pulmonary edema.
No pneumonia or CHF.
.
CXR portable [**2147-2-24**]:
? opacity near RLL effusion. ? pneumonia.
Brief Hospital Course:
85 year old with history of hypertension presented to the OSH
with acute pulmonary edema secondary to hypertension in the
setting of aortic stenosis. She is now post drug eluting stent
to rPL. She will continue on aspirin, lipitor, and plavix for 9
months with follow up in the cardiology clinic. Echocardiogram
was performed on [**2147-2-24**] which showed EF>65% and severe aortic
valve stenosis. She was started on low dose losartan given that
she has aortic stenosis and did not tolerate lisinopril. Beta
blockade was deferred as it will reduce inotropy and was thought
to be deleterious given the aortic stenosis. Hydrochlorothiazide
was started for continued diuresis for goal of euvolemia.
Patient and family was given the option of valvular replacement
decided to be DNR/DNI.
.
Cardiac: Patient had coronary artery disease and underwent
catheterization with intervention (DES in rPL). There was no
evidence of MI on ECG and cycled cardiac enzymes were flat.
Medical management includes [**Date Range **], lipitor, losartin, and plavix
for 9 months. She presented with CHF and required brief
intubation for pulmonary edema. Echocardiogram [**2147-2-24**] revealed
EF>65% with severe aortic valve stenosis (area 0.8). Beta
blockade is deferred given the severity of aortic stenosis
(would prefer to have the inotropy). Also, vasodilators and
preload reduction should be avoided. Valve replacement surgery
was refused. She will continue HCTZ for a goal of euvolemia. The
patient remained in normal sinus rhythm and was without adverse
events on telemetry monitoring.
.
Bacteremia: Patient developed ceftriaxone sensitive S.
pneumoniae bacteremia identified when one of four blood culture
bottles was positive. The remaining 3 bottles have no growth to
date. The likely source is the lung with CXR on [**2-24**] post
extubation suggestive of a right lower lobe opacity near an
effusion. Repeat CXR on day of discharge was negative for
pneumonia or CHF. She received 3 days of vancomycin and was
switched to ceftriaxone IV after sensitivities came back. She
will continue a 2 week course of ceftriaxone via midline access
at rehab. Pneumovax was administered.
.
Chronic Anemia: The patient has a known iron deficiency anemia
for which she takes iron supplementation and has refused
colonoscopy. Hematocrit was stable at discharge. It decreased
post cath and required transfusion of PRBCs to return to goal of
over 30.
.
Prophylaxis: Continue subcutaneous heparin and protonix.
.
Pt was discharged to rehab in stable condition for physical
therapy and IV antibiotics. She was ambulating with assistance
and tolerating a cardiac healthy diet.
Medications on Admission:
vasotec which she stopped 6 months ago.(was on atenolol before)
prilosec and [**Month/Year (2) **] which she takes intermittently
NKDA
Discharge Medications:
1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
5. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
ml Injection TID (3 times a day).
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
7. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Ceftriaxone Sodium 1 g Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours) for 2 weeks.
10. Losartan Potassium 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
coronary artery disease
aortic stenosis
other:
hypertension
chronic iron deficiency anemia
emphysema
urinary incontinence
cataract
Discharge Condition:
stable
Discharge Instructions:
Please return to the hospital or call your doctor if you have
chest pain/shortness of breath/dizziness or if there are any
concerns at all.
Please take all prescribed medication especially the medication
by the name of PLAVIX. You should not stop that medication under
any circumstances unless you have spoken to your cardiologist.
This medication is very important to prevent another heart
attack.
Followup Instructions:
Please call ([**Telephone/Fax (1) 2037**] to schedule an appointment with a
cardiologist at [**Hospital1 18**]. You should see a cardiologist within one
month of your discharge
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]
|
[
"530.81",
"790.7",
"518.81",
"280.9",
"402.91",
"424.1",
"414.01",
"492.8",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.01",
"88.56",
"96.71",
"99.20",
"88.52",
"37.23",
"36.07",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
7252, 7322
|
3410, 6059
|
282, 308
|
7497, 7505
|
2236, 2252
|
7953, 8259
|
1787, 1801
|
6244, 7229
|
7343, 7476
|
6085, 6221
|
7529, 7930
|
2674, 3387
|
1816, 2217
|
223, 244
|
336, 1538
|
2268, 2658
|
1560, 1691
|
1707, 1771
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,599
| 106,889
|
33360
|
Discharge summary
|
report
|
Admission Date: [**2119-8-22**] Discharge Date: [**2119-8-29**]
Date of Birth: [**2063-10-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Glucotrol
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
exertional dyspnea/ abnormal exercise stress test
Major Surgical or Invasive Procedure:
cardiac catheterization
Coronary Artery Bypass Grafting x 3 (LIMA-LAD,SVG-OM, SVG-dRCA),
Resection of left atrial appendage, Partial Maze [**2119-8-25**]
Left heart catheterization and coronary angiography [**2119-8-23**]
History of Present Illness:
This is a 55 year old male who has a history of atrial
fibrillation, hypertension, hyperlipidemia and diabetes who was
cardioverted in the spring of [**2118**] He reverted to atrial
fibrillation in [**Month (only) 216**] and has developed shortness of breath on
exertion.
He underwent a nuclear stress test on [**2119-8-14**] where he was able
to exercise 4 minutes 15 seconds on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol to a peak
heart rate of 96 and stopped due to chest pain and dyspnea. He
achieved 58% of maximum predicted heart rate, the EF was 64%.
Nuclear imaging demonstrated a reversible defect but the test
was thought to be suboptimal. He underwent an echo which showed
normal biventricular size and systolic function, no valve
abnormalities, but did have moderately severe left atrial
dilatation. He was told to take his last dose of coumadin on
[**2119-8-17**] and he was found to have a creatinine of 1.9 and is
being admitted for prehydration in preparation for cath
tomorrow.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope
or presyncope. Patient does report DOE and chest tighntess with
exertion.
Past Medical History:
Cardiac Risk Factors:
Diabetes Mellitus
Dyslipidemia
Hypertension
Obesity
Other Past History:
AFIB
s/p Rhinoplasty
osteoarthritis
Social History:
Social history is significant for the absence of current tobacco
use. There is social alcohol use.
retired US Army- 20 years
Family History:
There is no family history of premature coronary artery disease
or sudden death. Mother had DM and CAD, Father had rheumatic
fever.
Physical Exam:
Alert and oriented
HEENT- unremarkable
Lungs- sl. decreased breath sounds at bases.No rales or rhonchii
Cor- SR at 80. BP 110-120/60s
Exts- 1+ leg edema. Wounds clean and dry. Venous stasis changes
pretibially- bilaterally
Wounds- cleans and dry. Sternum stable.
Pertinent Results:
[**2119-8-22**] 06:49PM PT-13.3 PTT-24.8 INR(PT)-1.1
[**2119-8-22**] 06:49PM GLUCOSE-97 UREA N-14 CREAT-1.5* SODIUM-137
POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-29 ANION GAP-13
[**2119-8-22**] 06:49PM WBC-6.6 RBC-4.44* HGB-13.2* HCT-39.4* MCV-89
MCH-29.8 MCHC-33.6 RDW-13.5
[**2119-8-22**] 06:49PM PLT COUNT-224
Brief Hospital Course:
Mr. [**Known lastname 77427**] was admitted for hydration and cardiac
catheterization. catheterization on [**8-23**] demonstrated
triple vessel disease with preserved left ventricular function.
He had venous stasis changes with mild cellulitis of the lower
legs (pretibial) and was kept in house for antibiotics and vein
mapping. Unasyn was begun for the cellulitis, which improved
somewhat preoperatively.
On [**8-25**] he went to the operating room where coronary
revascularization, a partial Maze and left atrial ligation was
performed (se operative note for details).He weaned from
cardiopulmonary bypass on Neo-Synephrine and Propofol easily. He
remained stable on transfer to the ICU and was extubated easily
on the day of surgery and pressors were weaned to off.
He was transferred to the floor on POD 2. His CTs were removed
on POD 2 and pacing wires and right leg JP drain on POD3. He was
begun on diuretics, his Statin was resumed as was his Atenolol.
He reverted to AF at a controlled rate. Coumadin was resumed for
his rhythm.
At discharge wounds are healing well, the pretibial cellulitis
has resolved and his venous stasis changes are at baseline
according to the patient. He is ambulatory and is returning home
with VNA assistance.
Medications, instructions and follow up directions have been
discussed with him. His Coumadin will be controlled by Dr.
[**Last Name (STitle) 23956**] as before hospitalization.(stopped [**8-28**])
Medications on Admission:
Metformin 1000mg [**Hospital1 **], Atenolol 50mg QD, Lisinopril 40mgQD,
Sotalol 80mgQD,HCTZ 25mgQD, Actos 30mgQD, Glyburide 10mgQD,
Zocor 40mgQD, Disalcid 500mg prn, Androgel 5mgQD, ASA 325mgQD,
Lantus insulin 26-30 units QHS
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours).
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
9. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Metformin 500 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*2*
12. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Warfarin 2.5 mg Tablet Sig: as directed Tablet PO once a
day: daily dose as directed.
Disp:*100 Tablet(s)* Refills:*2*
14. Lantus 100 unit/mL Solution Sig: 26-30 units Subcutaneous
at bedtime.
Disp:*1 * Refills:*2*
15. androgel Sig: One (1) 5 mgm Topical once a day.
Disp:*1 * Refills:*2*
16. Hydroxyzine HCl 10 mg Tablet Sig: One (1) Tablet PO every
4-6 hours as needed for itching.
Disp:*50 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
Diversified VNA [**Location (un) 1157**]
Discharge Diagnosis:
Coronary artery disease
diabetes mellitus
obesity
atrial fibrillation
hypertension
s/p coronary artey bypass grafting, resection Left atrial
appendage,partial MAZE
hyperlididemia
Discharge Condition:
good
Discharge Instructions:
No driving for 4 weeks and off all narcotics
No lifting more than 10 pounds for 10 weeks
Shower daily, no baths or swimming
no lotions, creams or powders to incisions
take all medications as prescribed
report any drainage from or redness of incisions
report any temperature greater than 101
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr.[**Last Name (STitle) 23956**] in [**1-8**] weeks
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 25270**] in [**1-8**] weeks
Completed by:[**2119-8-29**]
|
[
"715.90",
"585.9",
"428.30",
"278.00",
"401.9",
"459.81",
"428.0",
"250.00",
"427.31",
"682.6",
"272.4",
"414.01",
"707.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"88.56",
"36.12",
"36.15",
"39.61",
"37.33",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
6787, 6858
|
3242, 4695
|
326, 551
|
7081, 7088
|
2903, 3219
|
7427, 7678
|
2470, 2604
|
4971, 6764
|
6879, 7060
|
4721, 4948
|
7112, 7404
|
2619, 2884
|
237, 288
|
579, 2158
|
2180, 2312
|
2328, 2454
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,969
| 140,017
|
40228+58357
|
Discharge summary
|
report+addendum
|
Admission Date: [**2177-4-5**] Discharge Date: [**2177-4-6**]
Date of Birth: [**2128-3-23**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Epistaxis
Major Surgical or Invasive Procedure:
endoscopy
History of Present Illness:
49 year old male with history of EtOH cirrhosis c/b hepatic
encephalopathy and varices with most recent MELD of 20 prsented
to the ED from his nursing home with c/o hematemesis. Pt states
that around 1100 at the grocery store this morning he became
nauseated and vomited [**1-13**] cup of bright red blood. Few minutes
later he had heavy nosebleeding which took 15 minutes to abate.
No additional epsistaxis/hematemesis or N/V since then. Denies
any BRBPR/dark stools or abd pain. States he is slightly
lightheaded, but otherwise has no complaints. He states he has
had several nosebleeds in the past and notes 2 episodes of
hematemesis previously. He underwent EGD [**2177-1-17**] at [**Hospital1 1474**] that
showed severe portal gastropathy and grade F1 esophageal
varicies. He was also seen in the [**Hospital1 1474**] ED with BRBPR [**2177-2-22**]
and was found to have mild diverticulosis and grade 1 internal
hemorrhoids. He did not require transfusion on that admission,
at which time HCT was 30.
.
Of note, he was recently admitted [**Date range (3) 88313**] for hepatic
ecephalopathy, the precipitant of which remains unclear. HCT at
the time of d/c was 25.4. The pt was continued on his home
Lactulose and Rixafimin and was sent home with a 10d course of
Cipro for presumed GI infection - blood and urine Cx were
negative. On that admission he was transfused 1U pRBCs for HCT
of 22, which was felt to be [**2-13**] ESLD, possibly c/b bone marrow
process given concurrent Leukopenia and history of aplastic
anemia. His HCT increased appropriately and there was no e/o
GIB. On his most recent admission to [**Hospital1 18**], RUQ ultrasound
showed no ascites, patent portal vein with reversal of flow and
large varicies in the midline, concerning for RP portosystemic
shunt. Last drink was [**2175**].
.
In the ED, initial VS were:
T 98.8 HR 84 BP 150/72 RR 16 O2 Sat 100%
Labs were notable for HCT 24.6 (baseline 22-30, 25.4 at last
d/c), INR 1.7, Plt 62. Liver was consulted and recommended
Octreotide, Pantoprazole gtt and Ceftriaxone. Stool guiac was
negative and NG lavage was not performed given stable HCT. Liver
ultrasound was performed and showed no ascites. 18G PIV x2 were
placed and the pt was admitted to the MICU.
.
On arrival to the MICU, initial VS were:
T 98 BP 140/70 HR 78 RR 14 O2 Sat 98% RA
He endorsed mild lightheadedness, but otherwise had no
complaints.
Past Medical History:
- EtOH cirrhosis; complicated by hepatic encephalopathy,
esophageal varices (no EGD on record, only per patient report),
and jaundice
- Aplastic anemia (per pt, diagnosed in [**State 108**] several years
ago)
- Insulin-dependent diabetes mellitus
- Chronic kidney disease
- Hypertension
- Breast surgery ([**Hospital3 **] - [**2175-11-15**]) with resultant
hematoma evacuation x 2
Social History:
H/o EtOH abuse, quit in [**2175-12-13**]. Non-smoker, no h/o IVDU.
Currently residing at a [**Hospital **] nursing home because had a
violent episode while encephalopathic that he does not recall.
Prior to this was living with his mother.
Family History:
Father died of alcohol cirrhosis. Extended family members had
CVAs, age 55, 57.
Physical Exam:
Admission Exam:
T 98 BP 140/70 HR 78 RR 14 O2 Sat 98% RA
General: Alert, oriented, no acute distress
HEENT: Scleral icterus, MMM
Neck: Supple, JVP below the clavicle
CV: RRR, normal s1/s2, no s3/s4, II/VI systolic murmur heard
throughout the precordium, no rubs or gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: well healed abd scar, soft, non-tender, non-distended,
bowel sounds present, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, + leukonychia
Neuro: A/Ox3, CNII-XII intact, non focal
Discharge exam:
HR 74, BP 130/70s, satting 100%RA
NAD comfortable
Cardiac: systolic murmur left sternal border
Skin: [**Doctor First Name **] nails
Pulm: ctab no crr
Abd: soft, non distended, no ascites, no caput
Ext: no pedal edema
Pertinent Results:
Admission Labs:
[**2177-4-5**] 06:25PM BLOOD WBC-3.9* RBC-2.58* Hgb-8.2* Hct-24.6*
MCV-96 MCH-32.0 MCHC-33.5 RDW-16.6* Plt Ct-62*
[**2177-4-5**] 06:25PM BLOOD PT-18.4* PTT-31.8 INR(PT)-1.7*
[**2177-4-5**] 06:25PM BLOOD Glucose-195* UreaN-40* Creat-1.5* Na-136
K-4.4 Cl-104 HCO3-18* AnGap-18
[**2177-4-5**] 06:25PM BLOOD ALT-35 AST-69* AlkPhos-91 TotBili-5.4*
[**2177-4-5**] 06:25PM BLOOD Albumin-4.2 Calcium-9.1 Phos-4.0 Mg-2.0
[**2177-4-6**] 12:28AM BLOOD Lactate-1.4
Discharge Labs:
[**2177-4-6**] 11:15AM BLOOD WBC-2.9* RBC-2.57* Hgb-8.4* Hct-24.9*
MCV-97 MCH-32.8* MCHC-33.9 RDW-16.6* Plt Ct-56*
[**2177-4-6**] 11:15AM BLOOD Glucose-100 UreaN-35* Creat-1.3* Na-135
K-4.0 Cl-106 HCO3-17* AnGap-16
[**2177-4-6**] 11:15AM BLOOD ALT-47* AST-94* AlkPhos-95 TotBili-5.3*
[**2177-4-6**] 11:15AM BLOOD Calcium-9.3 Phos-3.6 Mg-2.0
Upper Endoscopy [**2177-4-6**]: portal gastropathy. No esophageal
varicse appreciated
Brief Hospital Course:
Primary Reason for Admission: 49 y/o man with EtOH cirrhosis
(MELD 20), c/b varicies and hepatic encephalopathy admitted to
the MICU for concern for variceal bleed vs epistaxis.
.
Active Problems:
.
# Epistaxis: Upper endoscopy negative for any varices, no active
bleeding. HCT stable, stool guiac negative. Initialy gave 1 dose
of ceftriaxone, pantoprazole and octreotide gtt which was
stopped when variceal bleed was ruled out.
Chronic Problems:
# Stage III CKD: Cr 1.5 on admission, which is his baseline.
Likely hypertensive nephropathy given absence of protein on UA,
though his DM may be contributory. ACEI was d/c'ed on last
admission for hyperkalemia. Resume ACE-I outpatient when pt's
lytes are stable.
# Pancytopenia: Thrombocytopenia likely related to ESLD and
splenic sequestration given splenomegaly noted on recent abd
ultrasound. Anemia likely multifactorial given h/o aplastic
anemia, chronic disease and GIB. At baseline.
# Hepatic Encephalopathy: Currently A/Ox3, no asterexis.
Continued rifaximin and lactulose.
# IDDM: On last admission, [**Last Name (un) **] was consulted and recommended
40U Lantus qhs and ISS. Continued home regimen.
Medications on Admission:
1. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
3. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. ascorbic acid 250 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO DAILY (Daily).
7. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. lactulose 10 gram/15 mL Syrup Sig: Sixty (60) ML PO QID (4
times a day): Take AT LEAST 4 times daily to have AT LEAST [**3-16**]
bowel movements daily.
9. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 8 days: Last day [**2177-4-11**].
10. Lantus 100 unit/mL Solution Sig: Fifty Two (52) units
Subcutaneous at bedtime.
11. Humalog 100 unit/mL Solution Sig: Per Attached Sliding Scale
Subcutaneous four times a day.
Discharge Medications:
1. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
3. nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
6. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
9. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days: Last day [**2177-4-11**].
10. insulin glargine 100 unit/mL Solution Sig: 40 u Subcutaneous
at bedtime: qhs.
11. Humalog 100 unit/mL Solution Sig: One (1) Subcutaneous as
directed: insulin sliding scale .
Discharge Disposition:
Extended Care
Facility:
Roscommon [**Hospital 1268**] Extended Care Center
Discharge Diagnosis:
Epistaxis
Portal hepatic gastropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital for a bleed. It was found that you had
a nose bleed. You had a scope to see if you had esophageal
varices and you do not have any. You did not have any signs of a
bleed in the gut track.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2177-5-12**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD [**Telephone/Fax (1) 8770**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: TRANSPLANT
When: TUESDAY [**2177-5-13**] at 8:00 AM
With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
Name: [**Known lastname 8180**],[**Known firstname **] Unit No: [**Numeric Identifier 14001**]
Admission Date: [**2177-4-5**] Discharge Date: [**2177-4-6**]
Date of Birth: [**2128-3-23**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3727**]
Addendum:
Pt takes lactulose 60 ml four times a day. thanks
Discharge Disposition:
Extended Care
Facility:
Roscommon [**Hospital 205**] Extended Care Center
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3728**] MD, [**MD Number(3) 3729**]
Completed by:[**2177-4-6**]
|
[
"585.9",
"V49.83",
"V11.3",
"585.3",
"784.7",
"403.90",
"286.9",
"530.10",
"456.21",
"284.19",
"537.89",
"571.2",
"284.9",
"572.2",
"572.3",
"250.40",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
10195, 10428
|
5289, 6454
|
312, 323
|
8561, 8561
|
4348, 4348
|
8948, 10172
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3418, 3499
|
7496, 8380
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8501, 8540
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6480, 7473
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|
4836, 5266
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3514, 4095
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4111, 4329
|
263, 274
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351, 2740
|
4365, 4819
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8576, 8688
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2762, 3144
|
3160, 3402
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,326
| 105,975
|
45305
|
Discharge summary
|
report
|
Admission Date: [**2154-6-20**] Discharge Date: [**2154-7-11**]
Service: MEDICINE
Allergies:
Sulfonamides
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
L5/S1 laminectomy
History of Present Illness:
[**Known firstname 18882**] [**Known lastname 79357**] is an 83-year-old woman with a history of CLL
and is status post high grade MRSA bacteremia causing L5/S1
osteomyelitis with extension into epidural space, requiring
admission in [**4-23**]. The patient is now status post 6 weeks of
vancomycin and over 2 weeks of linezolid. She has had ongoing
low back and leg pain which has not improved. She was referred
by Dr. [**Last Name (STitle) 17444**] (ID) for further pain control and a repeat MRI. Her
last MRI was approximately 3 wks ago without significant change.
The patient is unable to give an accurate history because "the
pain so bad, don't ask me any questions." She denies any chest
pain, SOB, or other symptoms. She relates pain "through my legs
and low back," which may have been worse over the past day or
so. She does not give a recent history of falls. She refuses to
answer any further questions.
In the ED, the patient had an L-MRI without significant change
from prior. She was given Dilaudid for pain control.
Past Medical History:
CLL
PVD s/p L [**Doctor Last Name **]/PT [**Name (NI) **] and L jump bypass from PT to plantar artery
CAD 3VD, s/p stent x2 [**10-21**]; p-MIBI [**1-23**] fixed, unchanged
moderate defect.
HTN
Dyslipidemia
Chronic right foot ulcer
Social History:
Widowed, lives alone, and has one daughter. [**Name (NI) **] tobacco/alcohol.
Had been independent with her ADLs prior to osteomyelitis.
Family History:
NC
Physical Exam:
VITALS: T=98.5, BP=121/88, HR=60, RR=16, O2=94% on RA
GEN: Pt moving and moaning, "I need more pain meds"
HEENT: Nonicteric, mucous membranes moist
CV: RRR, II/VI SEM
PULM/Back: CTA bilaterally; no spinal/paraspinal tenderness
ABD: Soft, NT, ND
EXT: No LE edema
NEURO: Uncooperative with exam; CN's intact, moving all 4
extremities with grossly normal strength/sensation; negative
straight leg raise
Pertinent Results:
WBC-66.5* RBC-3.76* Hgb-10.9* Hct-32.8* MCV-87 MCH-28.9
MCHC-33.1 RDW-14.9 Plt Ct-183
Neuts-10* Bands-2 Lymphs-86* Monos-1* Eos-0 Baso-0 Atyps-1*
Metas-0 Myelos-0 Other-0
Plt Smr-NORMAL Plt Ct-183
ESR-10
Glucose-99 UreaN-20 Creat-1.0 Na-138 K-4.2 Cl-103 HCO3-22
AnGap-17
Calcium-9.6 Phos-2.6* Mg-1.7
U/A: Sp [**Last Name (un) **] 1.015, pH 5.0, small leuks, 3 WBCs, otherwise
negative
Lumbar MRI on admission: IMPRESSION: Osteomyelitis and discitis
at L5-S1, with slight interval increase in irregularity and T2
hyperintensity within the L5-S1 disc space in comparison with
[**2154-5-7**]. Probable mild increase in enhancing epidural
soft tissue, posterior to L5 through S3 vertebrae without
evidence of canal stenosis. Persistent enhancing soft tissue
within the right psoas, anterior to the L5-S1 interspace, and
surrounding the L5 nerve roots bilaterally.
Angio [**7-4**]: Successful placement of a 40-cm total length right
basilic single lumen PICC with tip in the SVC
Brief Hospital Course:
1. L5/S1 Osteomyelitis: The patient was admitted for evaluation
and treatment of her severe low back pain. She was started on
opiate analgesia in addition to Neurontin. She was started on
Linezolid and then switched to Vancomycin IV for concern about
continuing osteomyelitis. Repeat lumbar MRI was performed and
compared with her study from six week prior; there was note of
continued osteomyelitis and discitis at L5-S1, with slight
interval increase in irregularity and T2 hyperintensity within
the L5-S1 disc space. There was probable mild increase in
enhancing epidural soft tissue, posterior to L5 through S3
vertebrae and persistent enhancing soft tissue within the right
psoas. ESR was 10. CRP was 0.82. Orthopedics and Infectious
Disease were consulted. It was determined that she would need
surgical debridement. Following cardiac clearance and
catheterization, she went to the OR and underwent a L5/S1
laminectomy on [**2154-7-1**]. Cultures from the site were obtained and
were negative except for trace growth of coag negative staph.
She was on antibiotics at the time of the surgery. The pathology
revealed bony changes consistent with chronic osteomyelitis.
Post surgery, she continued to note back pain. She was
maintained on vancomycin which was dosed by levels. A PICC line
was placed for long term IV antibiotic treatment. She will
likely require at least six weeks of antibiotics following
surgery. Her ID doctor, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17444**], wil contact her for a
follow-up appointment.
2. Acute renal failure: The patient's creatinine was 0.6 on
admission. She had a hypotensive episode prior to surgery which
resulted in a MICU admission. Her Cre rose at that time and it
was felt to be prerenal azotemia. Her creatinine then improved.
The day after her surgery, she was again noted to be
hypotensive. This was thought secondary to post-operative
hypovolemia. She received IV fluids with normalization of her
blood pressure. Her creatinine subsequently rose to a high of
1.6. This was thought to be secondary to ATN from her
hypotensive episode. Her ACE inhibitor was held. Her creatinine
slowly improved. Her ACEI was then restarted.
3. NSTEMI/CAD: Patient had known CAD. She also had a hypotensive
episode prior to surgery. During this time, she required MICU
admission for IV fluids and monitoring. She had a small NSTEMI
at that time. She was treated conservatively. When surgery was
deemed necessary cardiology was consulted for cardiac clearance.
She underwent persantine mibi which demonstarted a moderate
fixed inferior wall defect that was unchanged from prior study.
She also had global hypokinesis. Based on these results, the
patient went to cardiac catheterization. On cath, her RCA was
known to be proximally occluded, and thus was not selectively
engaged. The LAD had patent proximal- to mid-vessel stents, and
mild diffuse disease up to 40% otherwise. The Left circumflex
had a 40% proximal lesion, and was then occluded in the
mid-portion. A large OM1 branch had a 50% lesion proximally.
There was a 15-mmHg gradient across the aortic valve during
simultaneous measurement of central arterial and LV pressures,
consistent with mild aortic stenosis. In all, she had Two VD,
patent LAD stents, and mild AS. No interventions were performed
ID had recommended that no stents be deployed as the plavix
requirement would have delayed her necessary back surgery. POBA
would have been performed, but there were no lesions amenable to
this treatment. The patient was restarted on her aspirin post
surgery.
4. Congestive heart failure: Following her surgery and her acute
renal failure episodes, the patient was noted to have worsening
oxygenation and she developed SOB. Chest x ray revealed
congestive heart failure. She was treated with lasix with
improvement in her breathing and oxygenation.
5. Peripheral vascular disease: the patient complained of severe
pain in her lower extremities. The etiology of which was not
clear. The nerve roots did not appear to be infringed upon on
her MRI. She has known severe PVD and is s/p left fem-[**Doctor Last Name **] bypass
graft. She has had problems since that time. Vascular surgery
was consulted to see if the PVD was contribing to her pain. They
felt that she continues to have severe PVD and requires
additional vascular interventions, but that her PVD was not the
etiology of her leg pain.
6. Back and lower extremity pain: the patient was noted to have
severe low back pain and bilateral lower extremity pain. The
etiology was not clear. It could not clearly be attributed to
the osteomyelitis or the PVD. She was maintained on fentanyl
patch, neurontin, and po opiates. This still only provided
moderate pain control. On [**7-5**] she had acute change in mental
status and was arousable only to sternal rub. She had a head CT
that did not show a bleed. She was given narcan with some
improvement in her mental status. She slowly became more alert
and back to her baseline. The etiology of her depressed mental
status is likely multifactorial and included excessive sedation
from opiates and delirium. The fentanyl patch was decreased and
her po opiates were decreased.
7. CLL: The patient has a chronically elevated WBC count in the
20s. Heme/onc was consulted to ensure no additional treatment
was needed perioperatively. IVIG was considered, but given its
potential toxicities, it was held. Her CLL was not an active
issue during her hospitalization.
8. Hallucinations: In addition to her depressed mental status,
the patient suffered from hallucinations. She described seeing
bugs and other animals. These hallucinations were felt to be
opiate induced and improved with Haldol.
9. Anemia: The patient's hematocrit was noted to be dropping
post operatively. She required 4 units of PRBCs. A CT abdomen
was performed to exclude retroperitoneal bleed. This was
negative. She had trace OB positive stool from below. NG lavage
was negative. GI was consulted and EGD was considered, but was
deferred given her delerium. Hemolysis and DIC labs were
negative. The patient's blood counts then stabilized. The cause
of her drop in her hematocrit was not found. She should have a
colonoscopy as an outpatient if her clinical course goes well.
10. Thrombocytopenia: the patient's platelet counts dropped
during her admission. HIT antibody was sent and was negative.
Her platelet count then slightly improved. It was thought that
the Linezolid may have caused some of her thrombocytopenia.
11. Fevers: The patient had low-grade fevers post operatively.
She had chest x-rays which showed only CHF. Blood cultures were
negative. Urine culture demonstrated yeast, which was thought to
be contamination from tinea cruris. She was treated with topical
antifungal treatment for that as well as four days of po
fluconazole. She was also treated with cipro to complete an
8-day course for possible pneumonia.
12. Skin breakdown: The patient had mild skin breakdown on
sacrum and left elbow. Thought to be pressure-induced decubiti.
She was given an air mattress and wound care was consulted. She
had duoderms placed on her sacrum. She had had prophylaxis
instituted to prevent heel ulcerations as well.
13. Full code
Medications on Admission:
Plavix 75mg PO QD
Isosorbide Mononitrate 60 mg QD
Amlodipine 10mg QD
Besylate 10 mg QD
Quinapril 10 mg QD
ASA 325 mg QD
Protonix 40mg QD
Percocet prn
Lipitor 80mg QD
Metoprolol 75mg [**Hospital1 **]
Linezolid 600mg [**Hospital1 **]
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).
2. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed for constipation.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: 1.3333 Tablet,
Sublinguals Sublingual PRN (as needed) as needed for chest pain.
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
10. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Quinapril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
14. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours) as needed for Leg/back pain.
15. Oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4-6H (every 4 to
6 hours) as needed: Hold for confusion/oversedation.
16. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
17. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for Yeast in groin.
19. Vancomycin 1,000 mg Recon Soln Sig: Seven [**Age over 90 1230**]y
(750) mg Intravenous once a day: Please check trough after 2nd
dose and fax to Dr. [**Last Name (STitle) 17444**] at [**Telephone/Fax (1) 1419**]. First dose given [**7-12**]
at noon.
Discharge Disposition:
Extended Care
Facility:
Bear [**Doctor Last Name **] Nursing Center - [**Location (un) 2199**]
Discharge Diagnosis:
L5/S1 osteomyelitis
Acute renal failure due to acute tubular necrosis
NSTEMI
CAD
CLL
Delerium
Sacral decubiti
CHF
PVD
Back and lower extremity pain
Anemia
Thrombocytopenia
Fevers of unclear etiology
Discharge Condition:
The patient is able to pivot with assistance. She is requiring
2L of oxygen at rest. She is alert with occasional confusion.
Discharge Instructions:
Multiple medication changes have been made, please see
accompanying medication sheet for accurate list.
Weigh yourself daily.
Adhere to 2 gram sodium/day diet.
Please return to the ED if you have fevers, chills, inability to
tolerate medications or if you have worsening weakness or
decreased sensation in your legs.
Followup Instructions:
-- You have an appointment with your orthopedic surgeon, Dr.
[**First Name8 (NamePattern2) **] [**Name (STitle) 1022**], [**Street Address(2) 96781**], [**Location (un) **], [**Location (un) **] [**Numeric Identifier 822**],
Phone: [**Telephone/Fax (1) 7807**]. Day/time: [**7-17**], 3:45 p.m.
-- You will need to follow up with your infectious disease
doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17444**], in four weeks. He will contact you with
appointment information. The [**Hospital **] Clinic's phone number is ([**Telephone/Fax (1) 10**].
-- Please call your PCP for an appointment one week after
leaving the rehab hospital.
Completed by:[**2154-7-11**]
|
[
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icd9cm
|
[
[
[]
]
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[
"03.4",
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icd9pcs
|
[
[
[]
]
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12708, 12805
|
3176, 10420
|
229, 248
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13048, 13174
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2175, 2573
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180, 191
|
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2587, 3153
|
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|
1579, 1720
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,900
| 168,873
|
50044
|
Discharge summary
|
report
|
Admission Date: [**2196-10-16**] Discharge Date: [**2196-10-28**]
Date of Birth: [**2142-12-26**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old
female with a history of coronary artery disease (status post
myocardial infarction times two and left anterior descending
artery stent), end-stage renal disease (on peritoneal
dialysis secondary to antineutrophil cytoplasmic antibody
positive glomerulonephritis, status post transplant in [**2189**] which
failed), and hypertension who was admitted to the Medical
Intensive Care Unit for worsening shortness of breath,
increased edema, and decreased oxygen saturations thought
secondary to malfunctioning peritoneal dialysis catheter.
The patient reports that the peritoneal dialysis catheter had
decreased drainage over the last two to three days prior to
admission.
REVIEW OF SYSTEMS: Review of systems at the time of Medical
Intensive Care Unit admission was only positive for a slight
cough with minimal clear sputum. Otherwise, no nausea,
vomiting, or diarrhea. No fevers or chills. No chest pain.
No palpitations. No dizziness. No pain or drainage at the
catheter site.
Initially, in the Emergency Department, the patient was found
to have oxygen saturation on room air of 92%. The patient
was treated with 40 mg of intravenous Lasix and a
nitroglycerin drip with a decrease in her blood pressure.
The patient was then started on [**Hospital1 **]-level positive airway
pressure with correction of her oxygen saturations. The
patient was admitted to the Medical Intensive Care Unit for
catheter placement for hemodialysis for hypervolemia and
peritoneal cultures were obtained.
In the Medical Intensive Care Unit, a hemodialysis catheter
was placed and the patient received hemodialysis on the
evening of [**10-16**] and in the morning of [**10-17**].
The Renal team recommended giving the patient lactulose 30 mL
by mouth q.6h. times 24 hours for repositioning of the
peritoneal dialysis catheter and a repeat abdominal x-ray on
[**10-18**] in the morning to assess repositioning (the
dialysis catheter was possibly positioned too high in the
abdomen).
The patient was transferred to the Medicine Service today for
further management.
Currently, the patient is without complaints. She denies any
shortness of breath, chest pain, nausea, or vomiting. She
was given Kayexalate to decrease her potassium and now with
complaints of mild gassy pain. The patient had a low-grade
temperature of 100.2 degrees Fahrenheit with no chills. She
does have a cough with clear sputum. Otherwise, review of
systems was negative. The patient had eight bowel movements
today after Kayexalate.
PAST MEDICAL HISTORY:
1. End-stage renal disease (on peritoneal dialysis for the
last two to three years). This secondary to positive
antineutrophil cytoplasmic antibody and positive
glomerulonephritis status post transplant in [**2189**] which
failed. The patient was temporarily switched from peritoneal
dialysis to hemodialysis in [**2196-8-24**] secondary to
ventral hernia repair.
2. Coronary artery disease; status post myocardial
infarction times two with stents to the left anterior
descending artery.
3. Hypertension.
4. Hypercholesterolemia.
5. Scleroderma.
6. Chronic right upper lobe mass.
7. Claudication.
8. Gastrointestinal bleed secondary to anticoagulation.
9. Cardiomyopathy.
10. Status post ventral hernia repair.
MEDICATIONS ON ADMISSION: (Medications prior to admission
included)
1. Zestril 5 mg by mouth once per day.
2. Lipitor 20 mg by mouth once per day.
3. Calcitriol.
4. Iron supplements 325 mg by mouth once per day.
5. Nephrocaps.
6. Epogen.
7. Senna.
8. Colace.
9. Lactulose as needed.
10. Renagel.
11. Toprol-XL.
12. Potassium supplements 10 mEq by mouth once per day.
MEDICATIONS ON TRANSFER: (Medications on transfer to the
floor included)
1. Colace 100 mg by mouth twice per day.
2. Senna one to two tablets by mouth twice per day.
3. Doxercalciferol 2.5 mcg by mouth every day.
4. Iron supplements 325 mg by mouth once per day.
5. Sevelamer 800 mg by mouth three times per day.
6. Nephrocaps one tablet by mouth once per day.
7. Protonix 40 mg by mouth once per day.
8. Atorvastatin 20 mg by mouth once per day.
9. Toprol-XL 25 mg by mouth once per day.
10. Epogen 15,000 units two times per week (on Sunday and
Tuesday).
11. Calcium carbonate 1250 mg by mouth three times per day
12. Lisinopril 5 mg by mouth once per day.
13. Lactulose 30 mL by mouth four times per day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives with her husband and two
children. She smokes one half of a pack of cigarettes per
day. Still with occasional alcohol use. No intravenous drug
abuse.
FAMILY HISTORY: Family history was noncontributory.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed the patient's temperature was 101.2 degrees
Fahrenheit, her blood pressure was 145/78 (with a range of
112 to 145/55 to 78), her heart rate was 68 to 84, her
respiratory rate was 16 to 22, and her oxygen saturation was
97% on room air. In general, the patient was alert and
oriented times three. She was sitting comfortably and
eating. She was in no apparent distress. Head, eyes, ears,
nose, and throat examination revealed pupils were equal,
round, and reactive to light. The extraocular movements were
intact. The oropharynx was clear. No lesions. No exudates.
The mucous membranes were moist. The neck was supple and
nontender. No jugular venous distention. No
lymphadenopathy. Pulmonary examination revealed bibasilar
crackles. Cardiovascular examination revealed a regular rate
and rhythm. No murmurs, rubs, or gallops. The abdomen was
soft, mildly distended, nontender, with positive peritoneal
dialysis catheter in place with no drainage. There were
normal active bowel sounds. Extremity examination revealed
needed. No calf tenderness. Dorsalis pedis and posterior
tibialis pulses were present bilaterally in the lower
extremities. Positive contractures in the left and right
hands and feet; consistent with scleroderma.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on
admission revealed the patient's white blood cell count was
8.9, her hematocrit was 28.1, and her platelets were 152.
The patient's sodium was 139, potassium was 5.1 (this sample
was hemolyzed; previous sample was 4.2 just a few hours
prior), chloride was 101, bicarbonate was 26, blood urea
nitrogen was 43, creatinine was 10.3, and blood glucose was
87. Her calcium was 8.6, her magnesium was 2.3, and her
phosphorous was 5.4. Hepatitis B surface antigen was
negative. Her creatine kinases were 56 and 48. Her troponin
was 0.12 and 0.15. Her lactate level was 1.5. Peritoneal
dialysis catheter fluid showed Gram stain with 2+
polymorphonuclear leukocytes, no microorganisms, and the
culture was pending.
ASSESSMENT: The patient is a 53-year-old female with a
history of coronary artery disease and end-stage renal
disease (on peritoneal dialysis) who was admitted for
pulmonary edema to the Medical Intensive Care Unit. This was
most likely secondary to malpositioned peritoneal dialysis
catheter. The patient was transferred to the Medicine floor
for further management.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. MALPOSITIONED PERITONEAL DIALYSIS CATHETER ISSUES: The
Renal Service was consulted and followed the patient closely.
A repeat abdominal x-ray after the morning of transfer on
[**10-18**] did not show improvement in the positioning of
the peritoneal dialysis catheter; although, the catheter had
indeed moved from the upper abdomen to the lower abdomen.
Lactulose 30 mL by mouth four times per day was initially
given to increase gut motility in the hopes that the
peritoneal dialysis catheter would reposition itself, but
this was subsequently decreased in frequency of dosing and
was only used as needed for constipation after it was shown
to not be effective in repositioning the catheter.
Transplant Surgery Service was consulted to assess the
necessity for surgical repositioning of the catheter, and
they determined that the patient would most likely need
repair laparoscopically or by an open procedure.
The patient was tentatively scheduled for repositioning of
this catheter on [**10-19**]; however, it was found that her
peritoneal fluid may indicate possible peritonitis (described
further below). Because of the concern for infection, the
patient's surgery was postponed; presumably until the
infection would clear. However, the patient waited for over
one week to have the peritoneal dialysis catheter
repositioned. It was eventually determined that the patient
would not be able to have the peritoneal dialysis catheter
repositioned during this hospital admission since the
Transplant Surgery schedule could not allow for this.
Thus, the patient was discharged with a Perm-A-Cath in place
and was scheduled at the time of discharge for Wednesday,
[**11-2**], at 11:45 a.m. for peritoneal dialysis catheter
adjustment to be done immediately after her hemodialysis
treatment. The patient was instructed that should would have
to keep nothing by mouth after midnight on the Tuesday prior
to this surgery.
2. END-STAGE RENAL DISEASE ISSUES: The patient's Quinton
catheter was pulled soon after her transfer to the Medicine
floor in anticipation of peritoneal dialysis catheter
adjustment which was thought to be performed in one to two
days after her transfer to the floor.
However, with the development of the patient's positive cell
count for peritonitis in her peritoneal fluid (to be
described below), the patient's surgery was postponed to an
indefinite date, and the patient had a temporary right
internal jugular line placed by Interventional Radiology.
When it became evident that the patient would not be
receiving transplant surgery until an outpatient, she had
this line removed by Interventional Radiology and a new
Perm-A-Cath was placed. The patient was discharged with the
new Perm-A-Cath tunneled catheter, and she had a hemodialysis
appointment scheduled for Monday, [**10-31**], at 4:30 p.m.
and on Wednesday, [**11-2**], at 6:30 a.m.
In the meantime, the patient was continued on her Nephrocaps,
doxercalciferol, and sevelamer. Her renal function remained
stable throughout her hospital course.
3. INFECTIOUS DISEASE/PERITONITIS ISSUES: On transfer to
the Medicine floor, the patient spiked a temperature to 101
degrees Fahrenheit; although she appeared clinically stable.
Her abdominal examination remained benign. She was given one
dose of gentamicin and vancomycin, and blood cultures were
sent.
The peritoneal dialysis fluid that was sent from the Medical
Intensive Care Unit showed no organisms on culture and never
had any growth. However, a cell count could not be added
since it was not initially sent for, and the laboratory
stated that the specimen was too old to have an additional
cell count added on.
Thus, the patient had peritoneal fluid removed from the
peritoneal dialysis catheter on [**10-18**] during her
hemodialysis treatment. This peritoneal dialysis fluid
revealed a very high white blood cell count of 4775 cells, 30
red blood cells, 72% polys, 8% lymphocytes, 9% monocytes, and
1% eosinophils. The peritoneal dialysis fluid from the same
date still revealed nothing on culture.
This increased white blood cell count was worrisome for
peritonitis secondary to her peritoneal dialysis catheter,
even though the patient showed no clinical signs of
peritonitis.
Transplant surgery was temporarily postponed for the
malpositioned peritoneal dialysis catheter, and the patient
was started empirically on cefazolin and ceftazidime for
empiric coverage; recommended by the Renal Service for
peritonitis secondary to peritoneal dialysis catheter.
The patient was given antibiotics for a total of seven days,
and the repeat fluid count on [**10-20**] showed a
significantly decreased white blood cell count of 145 and
still no growth on cultures.
On the fifth day of treatment with cefazolin and ceftazidime,
the patient then began to manifest a generalized rash
consistent with a drug rash. The cephalosporins were
discontinued secondary to a presumed allergy, and the patient
was given one dose of vancomycin for empiric coverage and was
started on levofloxacin to finish a total of a 10-day course
(she was given one dose of vancomycin and her levels remained
therapeutic and she was given five more days of by mouth
levofloxacin). The patient remained afebrile, and her rash
soon resolved. The patient completed her entire course of
antibiotics prior to discharge.
4. HYPERTENSION ISSUES: The patient's blood pressures
remained in a good range, and the patient was temporarily
taken off her metoprolol and lisinopril when she demonstrated
lower blood pressures during hemodialysis. These medications
will likely be held until the patient is placed back on
peritoneal dialysis, and they can be added on in the
outpatient setting.
5. ANEMIA ISSUES: The patient continued to have a baseline
low hemoglobin and hematocrit. She was continued on her iron
supplements, Epogen, and vitamin C was added to increase iron
absorption.
The Renal team was asked whether we should consider
increasing the dosage of Epogen she was given twice weekly,
but the Renal team suggested that this be considered as an
outpatient.
6. ELECTROLYTE ISSUES: The patient's electrolytes remained
stable after her hemodialysis treatments. She was continued
on sevelamer for phos-binding which was increased to 1600 mg
by mouth three times per day. Calcium carbonate tablets were
discontinued since her calcium was high.
7. CORONARY ARTERY DISEASE ISSUES: The patient had slightly
elevated troponin levels upon transfer to the Medicine floor
which was thought likely secondary to the patient's renal
insufficiency. The patient showed no electrocardiogram
changes. She had one episode of chest pain, and an
electrocardiogram at that time showed slightly more prominent
ST-T wave changes. However, given that the patient's pain
was not typical angina for her, and since she had a negative
stress echocardiogram in [**2196-1-23**] (and per Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] has had a more recent negative echocardiogram), a
further workup was deferred at that time. The patient
remained asymptomatic for the rest of her hospitalization
with no further episodes of chest pain.
8. PULMONARY EDEMA ISSUES: The patient's pulmonary edema
resolved after transfer to the Medicine floor from the
Medical Intensive Care Unit. The patient remained in good
pulmonary status and had good oxygen saturations during her
entire hospitalization. The pulmonary edema seemed to have
resolved after diuresis with Lasix in the Medical Intensive
Care Unit.
DISCHARGE DISPOSITION: The patient was discharged after her
last hemodialysis appointment on [**10-28**]. The patient was
to have appropriate followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and
hemodialysis appointment scheduled on Monday, [**10-31**] as
well as Wednesday, [**11-2**] with presumed peritoneal
dialysis catheter adjustment on Wednesday, [**11-2**], after
hemodialysis.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: The patient's discharge status was to
home.
DISCHARGE DIAGNOSES:
1. Congestive heart failure exacerbation secondary to
peritoneal dialysis catheter malfunction.
2. Peritonitis.
3. End-stage renal disease (now on hemodialysis).
4. Scleroderma.
5. Coronary artery disease.
6. Hypertension.
7. Hypercholesterolemia.
8. Anemia.
9. Chronic right upper lobe mass.
MEDICATIONS ON DISCHARGE:
1. Atorvastatin 20 mg by mouth once per day.
2. Protonix 40 mg by mouth once per day.
3. Vitamin B complex/vitamin C/folic acid 1-mg tablet one
tablet by mouth every day.
4. Iron sulfate 325 mg by mouth once per day.
5. Senna one tablet by mouth twice per day.
6. Colace 100 mg by mouth twice per day.
7. Sevelamer 1600 mg by mouth three times per day.
8. Doxercalciferol 2.5 mcg by mouth every day.
9. Epogen 15,000 units twice per week (on Sunday and
Tuesday).
10. Lactulose 30 mL by mouth twice per day as needed (for
constipation).
11. Vitamin C 500 mg by mouth once per day.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] at the [**Hospital6 733**] on [**2196-11-7**] at
9:50 a.m.
2. The patient was scheduled for dialysis at [**Location (un) **]
[**Location (un) 4265**] on Monday, [**10-31**], at 4:30 p.m. and on Wednesday,
[**11-2**], at 6:30 a.m. The patient was scheduled for
surgery to readjust the peritoneal dialysis catheter at 11:45
a.m. directly after dialysis on Wednesday, and the patient
was instructed to remain nothing by mouth after midnight on
Tuesday night.
3. The patient was instructed to hold her blood pressure
medications while she is on hemodialysis and then restart
once she is back on peritoneal dialysis.
4. The patient was instructed to stop her calcium carbonate
medication since she had high calcium levels.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1879**], M.D. [**MD Number(1) 14612**]
Dictated By:[**Name8 (MD) 10397**]
MEDQUIST36
D: [**2196-11-7**] 13:08
T: [**2196-11-10**] 08:41
JOB#: [**Job Number 104501**]
|
[
"996.56",
"425.4",
"E879.1",
"285.9",
"710.1",
"428.0",
"567.9",
"403.91",
"996.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"97.82",
"93.90",
"54.95",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
14941, 15351
|
4812, 7335
|
15487, 15790
|
15817, 16417
|
3472, 3835
|
16450, 17564
|
7369, 14916
|
15366, 15466
|
879, 2691
|
159, 859
|
3861, 4605
|
2714, 3446
|
4622, 4794
|
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